Huntington Manor

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Angelica Boyles conducted a health and safety visit for one resident relocated from New World Villa North. LPA was welcomed by, and identified herself to Lynn Drummond, Chief Operating Officer and discussed the purpose of the visit. LPA conducted a brief tour and spoke with residents and staff. LPA observed medication for the relocated resident was locked and centrally stored. LPA also reviewed the relocated resident's records. LPA did not observe any health or safety concerns. No deficiencies were cited during today's visit. An exit interview was conducted with Lynn Drummond, Chief Operating Officer to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Sep 14, 2026

Allegation investigated: Facility fire alarm service was terminated

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced visit to initiate a complaint investigation regarding the above-mentioned allegation. LPA identified herself and met with staff Gerald Madla. Chief Operating Officer Lynn Drummond later joined the visit and LPA discussed the purpose of the visit and elements of the complaint. The Reporting Pary provided the Department with a letter from a fire alarm service company dated June 29, 2026 which stated that based upon failure to pay past due invoices the fire alarm monitoring and testing services would be discontinued by July 30, 2026. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) Staff provided LPA with email records that revealed the Administrator followed up with the fire alarm service company to prevent the cancellation. A representative from the company confirmed via email to the Administrator that the facility account had been brought current and the cancellations have stopped. Further records confirmed the facility payment to the fire alarm service company was processed and approved on July 8, 2026. The Department has investigated the above-mentioned allegation. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate this allegation and therefore deemed unsubstantiated. An exit interview was conducted with Chief Operating Officer Lynn Drummond, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 13, 2026 · control 08-AS-20260708151816

Allegation investigated: Unlawful eviction Staff are retaliating against resident Staff are not meeting residents needs

Licensing Program Analyst (LPA) Becky Kennedy conducted an unannounced complaint visit to the facility to deliver findings on the above allegations. LPA was granted entry to the facility by Lynn Drummond, Cheif Operating Officer after identifying herself and explaining the reason for the visit. The Department’s investigation consisted of a tour of the facility, review of facility records, and interviews of facility staff and outside sources. It was alleged that the resident was evicted from the facility unlawfully. The investigation revealed that on 5,10,2024 an email was sent to the family of a Resident 1 (R1) that appeared to be a 30-day notice of eviction. The investigation did not reveal any reappraisal in support of the eviction. Interviews did not reveal any additional information about the email or what happened afterword. The investigation did reveal that R1 continued to reside at the facility beyond 30 days following the email and was residing at the facility at least as late as 9-15-24. Unsubstantiated Although the email that appeared to be on the surface an eviction notice, no eviction was pursued. This allegation is Unsubstantiated. It was further alleged that the eviction was in retaliation for the family expressing their concerns regarding the care R1 was provided. As R1 was not evicted this allegation is also Unsubstantiated. Lastly it was alleged that the facility staff are not meeting R1's needs. Interviews revealed that R1 was challenging to care for due to R1’s behaviors. Interviews revealed that despite R1’s behaviors, care was provided to R1. This allegation is Unsubstantiated. Based on the evidence obtained during the complaint investigation, the allegations above are UNSUBSTANTIATED, meaning there isn’t enough evidence to prove a violation occurred. An exit interview was conducted at the conclusion of the visit, A copy of this report and licensee rights are left at the facility.the state’s words, verbatim · CDSS document, Jun 29, 2026 · control 08-AS-20240611161835

Allegation investigated: Staff did not answer resident's call button in a timely manner. Staff did not clean resident's room as often as needed. Staff spoke disrespectfully about resident. Facility has not provided a written statement of rate increases. Facility has not provided a copy of the updated admissions agreement. Facility did not meet resident's dietary needs.

Licensing Program Analyst (LPA) Becky Kennedy conducted an unannounced complaint investigation visit to the facility in order to deliver findings on the above allegations. LPA was granted entry to the facility by Lynn Drummond, Cheif Operating Officer, after identifying herself and explaining the reason for the visit. It was alleged regarding Resident 1 (R1) that: • Staff did not answer resident's call button in a timely manner. • Staff did not clean resident's room as often as needed. • Staff spoke disrespectfully about resident. • Facility did not meet resident's dietary needs. Unsubstantiated The Department’s investigation consisted of a tour of the facility, a review of facility records, and interviews of facility staff. The investigation revealed that the facility has no record of R1 residing at the facility. Staff members interviewed who worked at the facility at the time of the allegations have no recollection of R1. Interviews revealed that when a resident activates their call button, staff respond immediately to resident or as soon as possible, resident’s rooms are cleaned daily, and deep cleaning is done weekly. Interviews did not reveal any concerns about residents being treated disrespectfully. Interviews with staff revealed that dietary concerns are accommodated at the facility. These allegations are Unsubstantiated. It was further alleged that: • Facility has not provided a written statement of rate increases. • Facility has not provided a copy of the updated admissions agreement. The allegations regarding the lack of written statement of rate increases and an updated admission agreement are also unsubstantiated as no records could be reviewed regarding R1 Based on the evidence obtained during the complaint investigation, the allegations above are UNSUBSTANTIATED, meaning there isn’t enough evidence to prove a violation occurred. An exit interview was conducted with Martha Villalvazo, Assistant to the Administrator; a copy of this report and Licensee's Rights (LIC9058) were provided.the state’s words, verbatim · CDSS document, May 28, 2026 · control 08-AS-20220831114557

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Required Annual Inspection. LPA identified himself and discussed the purpose of the visit with Chief Operating Officer (COO) Lynn Drummond. The facility is Licensed to serve 21 residents ages 60 and above; of whom all may be non-ambulatory, 12 bedridden residents, and 15 whom can be receiving Hospice services. LPA, accompanied by Med-Tech Gerald Madla toured the interior and exterior of the facility, and inspected every resident's room. The facility was clean and sanitary. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present. Hot water temperature was measured in the facility at an average of 113 degrees F. The ambient temperature inside the facility was measured at an average of 73 degrees F. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas. Their are no bodies of water on the premises. Per COO, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C] LPA reviewed multiple staff and resident records/files. LPA file review did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. During resident interviews it was revealed that a deficiency took place in regards to basic services. Based on interviews and LPA observation deficiency was observed and cited on the attached LIC 809D. An exit interview was conducted with Chief Operating Officer Lynn Drummond to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, May 27, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced Case Management Visit. LPA was greeted by and met with staff Lynn Drummond, to discuss the purpose of the visit. LPA was at the facility for a complaint investigation, when a violation was found after an interview with staff. Interviews revealed that on 05/07/2026 the facility received an eviction notice due to unpaid rent for the facility. LPA interviewed S1 and S2 who stated that residents were not notified of the eviction notice. Based on the Foreclosure Protection Act of 2011 and per HSC § 1569.686(a)(4), the licensee was required to provide notice to the Department, State Long Term Care Ombudsman, all residents, and if applicable, their legal representatives within two business days of receipt of a written notice of default of payment of rent described in Section 1161 of the Code of Civil Procedure. Therefore, a civil penalty of $100 per day is being assessed as required per HSC § 1569.686(c) commencing 05/07/2026, through 05/26/2026 totaling $1,900 and will continue up until the maximum amount of $2000 or when notification requirements are met. One(1) deficiency is additionally being cited per Health and Safety Code on the attached LIC 809-D. An exit interview was conducted with Chief Operating Officer Lynn Drummond, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 26, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.686(a)(4) · Plan of correction due date: Jun 12, 2026

(a) A licensee shall notify the department, State Long-Term Care Ombudsman, all residents, and, responsible party in writing, within two business days... (4)The licensee receives a written notice of default of payment of rent described in Section 1161 of the Code of Civil Procedure. This requirement was not met, as evidenced bythe state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Licensee agreed to notify all required agencies of the eviction notice and provide proof to LPA via email by POC due date.

Allegation investigated: Neglect resulted in serious injury Facility was not sanitary. Staff did not centrally store medication. Facility did not maintain a comfortable temperature for residents. Facility was in disrepair. Staff did not accord dignity to resident. Staff were not able to communicate with residents.

On 11/7/2025, LPA Grace Donato conducted a telephone interview with the facility to deliver findings. LPA spoke with Administrator, Zayden Chen and explained the purpose of the call. Regarding the allegation of neglect which resulted in serious injury, Reporting Party (RP) stated that staff will handle the residents in a rough manner. RP states, it has been observed that staff S1 is rough with residents. S1 does not handle residents with care and will toss them around. RP states, R1 have sustained multiple unexplained injuries and fractures in care. Staff do not communicate. RP states, R1 was in pain and took R1 to hospital. The doctor informed that R1 has sustained fractures to the wrist. During the investigation, staff members were interviewed, and records were reviewed. R1 was seen on 08/24/2023 by R1s doctor (DR), after R1 was referred from occupational therapy due to finding R1s left hand swollen. DR stated R1 had discoloration on both hands, R1 was able to move each finger without limitation or pain and was able to shake the Doctor’s hand without a problem and there was no decrease in the grip from R1s right hand. Unsubstantiated DR provided a splint/brace and R1s family declined to have surgery. Staff stated they never saw R1 fall only one time R1 slid out of his wheelchair and at that time R1 had no injuries. Staff did report R1 showed aggression and sometimes would hit the walls with R1s fists, but R1 never complained of any pain. Staff stated they did not see any swelling of R1s left wrist. The time and the date of injury could not be conclusively established as staff denied R1 had any falls while at the facility only the one time of sliding out of R1s wheelchair with no injuries. The cause of R1s fracture remains unknown and there is no evidence to prove the neglect/lack of care allegation. For the allegations of Facility was not sanitary and was in disrepair, the department conducted a visit on 8/7/2023 and found no evidence of immediate health and safety risks. Regarding the allegation of staff did not centrally store medication, all medications have proper logs for routine, PRN and controlled drugs. There were noted confirmations from med tech that the facility did receive medications for R1. For the allegation of facility did not maintain a comfortable temperature for residents, facility had scheduled maintenance checkup for air condition on 7/5/2023. A technician came to fix the air conditioner and was running during that time. Technician also came back on 7/19/2023 to fix another issue. Portable aircons were provided to residents’ rooms during this time. Regarding the allegation of Staff did not accord dignity to resident, staff members mentioned that they have not been rough with handling any resident nor have they seen other caregivers be rough with residents. Regarding the allegation of Staff were not able to communicate with residents, when the department conducted interviews to staff members, everyone was able to communicate and answer questions. Based on interviews and records review, the department has determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Report is reviewed and a copy is provided.the state’s words, verbatim · CDSS document, Nov 7, 2025 · control 08-AS-20230804114458

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conclude an annual licensing inspection that commenced on 9/18/2025. LPA identified themselves to Med-Tech Madla and met with Administrator Drummond and Licensee Chen to whom was explained the purpose of the visit. The facility is licensed to serve 21 residents; of which all may be non-ambulatory, 12 bedridden, and 15 whom can be receiving Hospice services. During today's visit LPA conducted a review of staff records. LPA observed all required forms were complete and up to date. The Administrator Certification, facility infection control plan, and liability insurance were all active. The facility’s last disaster drill was conducted on 7/1/2025. Facility staff were all cleared, had current CPR and First Aid certification, and required training. LPA, accompanied by Med-Tech Madla, conducted a facility tour that revealed resident rooms and bathrooms were equipped with required furnishings and safety precautions. The facility is equipped with a back-up generator. LPA observed the required postings. Hazardous materials, including but not limited to, medications and cleaning solutions were all secured in locked areas, passageways were free from obstructions. No deficiencies were cited during today's visit. This report was discussed with Licensee Chen. A copy of the report and License Rights (01/2016) will be provided at the conclusion of the visit, and signature on this form acknowledges receipt of the rights and a copy of this report.the state’s words, verbatim · CDSS document, Oct 10, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced case management visit for the continuation of the Annual Inspection that began on 9/18/2025. LPA was greeted by and identified herself to Caregiver Gadamer Galvez, to whom she explained the purpose of the visit. A facility tour was conducted on September 19, 2025, which revealed several violations, including but not limited to medications and toxins that were not centrally stored and/or locked, and were accessible to residents in care. Medications that were dispensed to Resident 1 (R1) while unsupervised, there were also entry, exits, and/or passageways that were obstructed. LPA also observed Resident 2 (R2) with a health condition that was not appropriately managed as well as waste that was not appropriately disposed of. During today’s visit, LPA discussed the issues with Caregiver Galvez who confirmed they would be taking immediate action to correct the violations and provide Community Care Licensing (CCL) with proof of correction. Due to time constraints the completion of the annual inspection will require additional visits. An exit interview was conducted with Caregiver Galvez and a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) will be provided at the conclusion of the visit. The signature below confirms receipt of the reports.the state’s words, verbatim · CDSS document, Sep 24, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced case management visit for the continuation of an Annual Inspection that began on 9/18/2025. LPA was greeted by, identified herself to, and was granted entry by Med-Tech Madla, to whom she explained the purpose of the visit. The facility is licensed to serve 21 residents, however, a review of the Resident Roster as well as a subsequent facility inspection revealed that 22 Residents were admitted to the facility. Room #4 was observed converted into a shared room which was observed to be occupied by two (2) residents (R1 and R2). A review of records also revealed that Resident #22 (R22), was admitted to the facility on August 12, 2025. It shall be noted that an application to increase the facility’s capacity was received by the Department and has been under review. During a visit to the facility on 8/14/2025, LPA Correia discussed the capacity increase with the Administrator who understood that the application was under review, and that the facility may not admit additional residents until the final License had been approved and granted by the Department. The Licensee visited the San Diego Regional Office on the following day and was reminded that the application was pending, and that the Licensee was not yet authorized to admit additional residents to the facility. While a review of records confirmed that a Fire Clearance had been granted for the additional residents, the License was not yet granted by the Department. Deficiencies were cited and listed on the attached 809(d), and further visits will be necessary to complete the annual inspection, which will be completed at a later date. An exit interview was conducted with Med-tech Gerlad Madla to whom a copy of this report, the LIC 809-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. The signature below confirms receipt of the reportsthe state’s words, verbatim · CDSS document, Sep 19, 2025

Type of visit: Case Management - Annual Continuation

See initial amended complaint with signatures, dated 9/19/2025*the state’s words, verbatim · CDSS document, Sep 19, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced Case Management Visit to cite a deficiency identified during a facility file review. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Drummond. During a facility file review, it was identified that the Limited Liability Corporation (LLC) had been suspended for non-payment as of May 1, 2025. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted Administrator, to whom a copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Sep 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87205(b) · Plan of correction due date: Sep 30, 2025

Governing Body (a) The licensee... shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This requirement was not met as evidenced by: A facility record review revealed the Limited Liability Corporation (LLC) was suspended for non-payment effective May 1, 2025. This poses a potential personal rights risk to 21 out of 21 residents in care.the state’s words, verbatim · CDSS document, Sep 18, 2025

Plan of correction: The Licensee agreed to pay the Federal Tax Buearu (FTB) fee to bring the LLC back into active status. The Licensee will provide CCL proof of payment by the POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced case management visit to deliver findings for an investigation that was initiated based on an incident originally reported to the Department in June of 2025. LPA Correia was greeted by Med-tech Madla, identified herself, and met with Administrator Drummond to whom it was explained the purpose for the visit. On June 24, 2025, the Department received a Special Incident Report regarding the hospitalization of a Resident (R1), who was found to have suffered an apparent medication overdose on the morning of 6/19/25. After a subsequent Health and Safety visit revealed R1 had a known history of suicidal ideation, the Department initiated a full investigation to determine whether facility neglect contributed to the incident. The Department’s investigation included a review of facility and hospital records, as well as interviews with staff and outside sources, including medical professionals and law enforcement. R1’s facility records indicated that they were admitted to the facility in November of 2024 with previous diagnoses that included suicidal ideation, Major Depressive Disorder, and bipolar disorder. Records found in the facility from R1’s prior Skilled Nursing Facility (SNF) corroborated that R1 had a history of suicidal ideation and required extensive assistance with Activities of Daily Living (ADLs), Medication Management, Safety Monitoring, and oversight of overall health status. A review of R1’s Hospice Care Plan dated 6/2/2025 and applicable through 6/23/2025 listed several comorbidities which included depression, and suicidal ideations. According to their pre-placement Appraisal conducted on 11/25/24, R1 had depression, and required assistance with medications, and observation for pain or depression. [Continued on LIC 809C] [Continuation of LIC 809] A review of Hospital records dated June 19, 2025, confirmed that R1 was brought in by ambulance after being found by their Hospice Nurse (OS1) with an altered level of consciousness, and three empty bottles of Benadryl. Law Enforcement records were also reviewed which corroborated that R1 was found with empty bottles of Benadryl, had a history of Suicidal Ideation, and that R1 was taken to the hospital on a 5150 hold. On 8/6/25, the Department interviewed the Administrator (ADM) as well as the facility staff that responded to the incident (S1 and S2). All three had worked in the facility for more than one year and were aware that R1 had a history of drug abuse and required medication management by facility staff. S1 observed R1 exhibiting signs of depression but was unaware of any suicidal ideation. S2 did not believe there was anything documented but clarified a hospice nurse had recently told them that R1 had thoughts of suicide. The Administrator (ADM) confirmed they were notified during R1’s admission that they had suicidal ideations, as well as a history of drug abuse and was drug seeking. When asked about the day of the incident, S2 and S3 explained that they responded to R1’s room after being alerted by R1’s Hospice Nurse (OS1) that R1 was in bed, difficult to wake and could not verbally respond. OS1, S2, and S3 discussed that R1 was likely suffering an overdose, as three (3) empty bottles of allergy medication were discovered next to the bed. After observing that R1 was lying in bed lethargic and unable to verbally respond, S1 called the facility administrator and R1s responsible person (OS2). S2 left the room to find the facility administrator (ADM), who was in their office with OS1. After observing OS1 phoning CVS and their supervisor, S1 resumed their duties shortly after. The Department interviewed ADM who corroborated that they first learned of the incident after being approached by OS1 in their office. ADM clarified that they themselves phoned 9-1-1 after learning that 9-1-1 had yet to be called. When asked for clarification by the Department, both S1 and S2 confirmed that they did not phone 9-1-1, and they believed that approximately 30 minutes had elapsed before the facility administrator eventually called 9-1-1. S2 further believed R1 was having a medical emergency and believed that OS1 should have called 9-1-1 the moment R1 was discovered. On 8/6/25, the Department interviewed Outside Source 1 (OS1), who confirmed that on the day of the incident, they arrived to R1’s room at approximately 11:35 am, and observed them leaning over, swaying next to their bed. R1 appeared disoriented, lethargic, and was unable to respond to questions. After checking R1’s vitals and placing them in their bed, OS1 observed three (3) empty bottles of allergy medication on R1’s bedside table. [Continued on LIC 809C] [Continuation of LIC 809C] As R1 could not be kept awake, OS1 alerted facility staff after which S1 and S2 responded. The next day, the Department further questioned OS1 regarding the timeline of events. OS1 could not confirm the amount of time that had elapsed, but believed that law enforcement arrived at 12:15pm, approximately 45 minutes after R1 was discovered. On 8/6/25, the Department interviewed R1 who confirmed that they had been taking the over the counter allergy medication for about six (6) months, and that they purchased the medication online, which was delivered along with snacks from CVS pharmacy. R1 believed the normal dosage was 2-3 pills, however they were taking six (6) pills before going to sleep. R1 could not confirm how many pills were taken before they were sent to the hospital, and believed they did not need to tell facility staff about the Benadryl as it was over-the-counter medication. During their interview with the department, ADM corroborated that prior to the incident regarding R1, there were no written policies in place regarding package deliveries, however staff have since been instructed to contact delivery personnel and observe packages for concerns. [See LIC 811 for list of confidential names] Based on interviews conducted and records reviewed, the preponderance of the evidence shows that facility staff were aware that R1 had suicidal ideation, required monitoring, and obtained and consumed medications they were not capable of self-managing, resulting in an overdose requiring hospitalization. Further evidence shows that facility staff did not immediately phone 9-1-1 for R1’s medical emergency. Two (2) Deficiencies are being cited in accordance with the California Code of Regulations, Title 22, Division 6, and listed on the 809 D. As the violation resulted in the illness of a resident, an immediate $500 civil penalty is hereby assessed per Health and Safety Code 1569.49 (see LIC 421IM, attached). It shall also be noted that additional civil penalties are under review by the Department and may be assessed at a later date. An exit interview was conducted with Administrator and a copy of this report, LIC 809D, LIC 421IM and Licensee/Appeals Rights (LIC 9058 01/16) will be provided at the conclusion of the visit. Signature below confirms receipt of the documents.the state’s words, verbatim · CDSS document, Sep 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 19, 2025

87464 Basic Services (f) Basic services shall at a minimum include (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on record review and interview, the licensee did not protect a resident (R1) from access to medications which resulted in overdose and hospitalization. This posed an immediate health, safety and personal rights risk to 1 of 21 Residents in carethe state’s words, verbatim · CDSS document, Sep 18, 2025

Plan of correction: Administrator agreed to identify and create a list of high-risk residents to ensure incoming packages are checked and logged by staff for any harmful items, including medications. Administrator will provide a copy of the log to CCL by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(g) · Plan of correction due date: Sep 19, 2025

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health… This requirement was not met as evidenced by: Based on record review and interview, facility staff did not immediately phone 9-1-1 when a resident (R1) was discovered experiencing a medical emergency, which posed an immediate health, safety and personal rights risk to 1 of 21 Residents in care.the state’s words, verbatim · CDSS document, Sep 18, 2025

Plan of correction: Administrator agreed to have facility staff attend training by a CCL approved vendor regarding when to seek immediate medical attention. Administrator will send date of training to CCL by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit for the facility for the annual required licensing inspection. LPA Correia was greeted by Med-tech Gerald Madla, identified herself, and explained the purpose of the visit. A short time later LPA met with Administrator Drummond The facility is Licensed to serve 21 residents ages 60 and above; of whom all may be non-ambulatory, 12 bedridden residents, and 15 whom can be receiving Hospice services. LPA Correia conducted a facility records review and a partial facility tour. An overall inspection of the facility began today however due to time constraints LPA was unable to complete the visit and will return later to conduct the remaining portion of this inspection. No deficiencies were cited during today's visit. This report was discussed with Administrator Drummond. A copy of the report and License Rights (01/2016) will be provided at the conclusion of the visit, and signature on this form acknowledges receipt of the rights and a copy of this report.the state’s words, verbatim · CDSS document, Sep 18, 2025

Allegation investigated: Facility has an accessible body of water. Licensee did not keep facility free from trip hazard. Facility is in disrepair.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to the facility to commence and conclude a complaint investigation. LPA was greeted by Caregiver Marissa Sabrino and Med-tech Gerald Madla identified herself, and was allowed entrance into the facility and later met with Administrator Lynn Drummond to whom was explained the purpose of the visit. The investigation included a facility tour, staff interviews, a facility records review, and secured photos. The facility is Licensed for 21 residents ages 60 and over, all of which may be non-ambulatory, 12 may be bedridden, and the facility is approved for 15 residents receiving Hospice care services. Staff interviews and a review of facility records revealed during today’s visit the census was 21 residents, which included four (4) that were receiving Hospice services and three (3) who were bedridden. Substantiated On August 5, 2025, the Department received a complaint that alleged the facility was in disrepair, the facility did not provide a safe environment, and the facility’s fishpond was enclosed by a dilapidated gate. During a facility tour, accompanied by Med-tech Madla, LPA observations corroborated several areas of disrepair at the facility, including damaged flooring in passageways which posed a fall risk to residents in care. LPA's observations also confirmed the gate in front of the facility’s fishpond was so severely deteriorated it was accessible to residents in care. Based on the investigation the allegations were determined to be SUBSTANTIATED. A substantiated finding means the preponderance of evidence was met. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiencies are being cited on the attached LIC9099D and plans of corrections were jointly developed with Administrator Drummond. An exit interview was conducted with the Administrator; a copy of this report and Licensee's Rights (LIC9058) will be provided. Additionally, it was alleged that staff did not ensure that food was adequately stored. During the facility tour LPA observed the food was properly stored and labeled with expiration dates. Based on the investigation a preponderance of evidence did not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator Drummond to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. This is an amended version of the original report dated August 14, 2025.the state’s words, verbatim · CDSS document, Aug 14, 2025 · control 08-AS-20250805124533

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(e)(2)(A) · Plan of correction due date: Aug 15, 2025

The licensee shall supervise...as needed...pursuant to Section 87457 or ...87463...when residents are in proximity to...Fishponds...licensee shall ensure...bodies of water are inaccessible through...fencing, covering, or other.. when not in...use by residents. This requirement was not met as evidenced by: A facility tour revealed the gate to a fishpond had deteriorated to a point of ability to access the body of water. This posed an immediate safety risk to 18:21 residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2025

Plan of correction: Staff boarded up the fishpond during site visit. Staff will be replacing the fence with a new gate by Monday August 18, 2025. And provide Licensing with proof of replacement.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(D)(6) · Plan of correction due date: Aug 15, 2025

The following space and safety provisions shall apply to all facilities: All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by: A facility tour revealed the flooring in the facility hallway into the main dining hall was damaged and buckled creating a trip hazard. This posed an immediate safety risk to 18:21 residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2025

Plan of correction: Licensee will temporarily fix the damaged areas with plywood in the interim of replacing the damaged floors. Licensee will provide proof of correction by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(D)(2) · Plan of correction due date: Sep 16, 2025

Personal Accommodations and Services: The following... safety provisions shall apply...The premises shall be maintained in... good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by: A facility tour revealed several areas of disrepair throughout the facility housing and grounds. This posed a potential safety and personal rights risk to 21:21 residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2025

Plan of correction: Licensee will contact maintenance to fix issues of disrepair throughout the facility by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced case management visit to conduct follow up regarding a self-reported incident of Resident #1 (R1)'s misuse of a medication. LPA was greeted by, identified herself to, and explained the purpose of the visit with Medtech Gerald Madla. Administrator Lynn Drummond arrived later during the visit. On June 24, 2025, the Department received an incident report that described that on June 19, 2025, R1 had consumed three bottles worth of over-the-counter allergy pills from a store. R1 was found to be lethargic and was taken to the hospital via emergency services. During today’s visit, LPA conducted a health and safety check, observed residents in care, and reviewed facility records. No deficiencies were cited on today’s date. An exit interview was conducted with Administrator Lynn Drummond, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Jun 25, 2025

Allegation investigated: Resident had an unwitnessed fall resulting in the resident being on the floor for an extended period of time Staff are not following the feeding/drinking care plan Staff are not ensuring the residents diapers are changed timely

Licensing Program Analyst (LPA) Ryan Fulton conducted an unannounced subsequent visit to deliver findings regarding the above allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Med Tech Gerald Mad. The Department's investigation consisted of LPA observations, interviews with facility staff, residents, and outside sources, as well as records reviews. It was alleged that the resident had an unwitnessed fall, resulting in the resident being on the floor for an extended period of time. It was reported that resident fell out of their bed and was left on the floor by staff members. Resident 5 (R5) is bedridden and needs to be rotated every two hours. However, after a review of R5's progress notes from the day the incident occurred at 10:05 am, staff did a round of checks and rotated R5 and did not note that the resident had a fall. Unsubstantiated At 11:15 am, the facility received a telephone call from the RP indicating that R5 was on the floor in their bedroom. At 11:15 am, staff entered R5's room and checked vitals and oxygen saturation. Staff interviews revealed that R5 was not on the floor when they did resident checks at 10:05 am. Staff also noted that the resident could not have been on the floor for long because a staff member walked by R5's room at 10:45 am and witnessed R5 still in bed. Since staff did regular checks on the resident that did not exceed 2 hours, this allegation is unsubstantiated. It was alleged that staff are not following the feeding /drinking care plan. It was reported that staff were feeding R5 incorrectly, causing them to throw up and choke. After reviewing R5's needs and service plan, as well as the physician's report, it was revealed that R5 is on a modified diet that involves pureed food to be administered when they are being fed. Progress notes for R5 revealed that facility staff were aware of R5's need for pureed food and were documenting what types of food and when R5 was being fed these meals. Progress notes also revealed that staff followed the one-on-one feeding instructions specified in the physician's report and the needs and service plan. Staff interviews revealed that staff had adequate training and knowledge on how to feed a resident who is on a puree diet. Staff explained at length the process and procedure for feeding a person on a puree diet. Resident interviews revealed that they had had no issues with receiving the correct modified diet plans from the staff at the facility. Based on interviews and records reviews, this allegation is unsubstantiated. Lastly, it was alleged that staff are not ensuring the residents' diapers are changed in a timely manner. It was specifically reported that R5 was being left in diapers that were soaked through on multiple occasions. After reviewing R5's physician's report, it was revealed that R5 required full assistance with incontinence and hygiene. LPA conducted a tour of the facility and did not observe any residents who needed to be changed and could not receive assistance. LPA also observed a resident using their call pendant for assistance with being changed, and staff assisted them in a timely manner. A records review of the progress notes for R5 revealed that from 7/01/2024 through 07/30/2024, staff did two-hour checks on R5 to ensure they were rotated and if needed, changed their diaper. Interviews with staff revealed that they were checking on R5 in the appropriate two-hour window. Based on LPA observations, records reviews and interviews, this allegation is unsubstantiated. This agency has investigated the complaint allegations, Resident had an unwitnessed fall resulting in the resident being on the floor for an extended period of time. Staff are not following the feeding/drinking care plan. Staff are not ensuring the residents diapers are changed timely. The Department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations occurred. Therefore, the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted, and the report along with licensee appeal rights (LIC 9058 03/22) reviewed with Med Tech Gerald Madlathe state’s words, verbatim · CDSS document, Jan 8, 2025 · control 08-AS-20240809113551

Allegation investigated: Neglect resulted in stage 4 pressure injury. Neglect resulted in multiple stage 2 pressure injuries. Licensee did not seek timely medical attention for resident.

Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to deliver investigative findings. LPA was granted entry into the facility and met with Tess Derafera, Administrator, to whom LPA disclosed the reason for the visit. Community Care Licensing (CCL) has investigated the above listed complaint allegations. The investigation consisted of a tour of the facility, review of facility and outside source records, and interviews of resident, staff, and outside sources. It was reported to Community Care Licensing that Resident 1 (R1) developed a stage 4 pressure injury and multiple stage 2 pressure injuries due to neglect by facility staff. According to evidence obtained during the investigation, R1 moved into the facility on 2/28/2020. In addition to services provided by facility staff, R1 hired two personal nurses (PN 1 and PN 2), as R1 required full assistance in care. Unsubstantiated On 7/7/2023, R1 started receiving hospice services. R1 continued to receive services from his/her two private nurses. Records reflect that on or about 8/5/2023, a hospice nurse noted that a red area was developing on R1’s buttocks. At the time of the observation, PN 2 was present and made aware of the red area. The nurses treated the area and decided to monitor it. On 8/17/2023, PN 1 was contacted by a hospice nurse and facility staff regarding the red area on R1’s buttocks. PN 1 informed the nurse and staff that he/she was out of town and provided instruction as to how to clean the wound. PN 1 made the nurse aware that he/she would be back that night and check and reevaluate the next day. The hospice nurse noted that upon assessing the red area, the wound was closed. The skin was peeled off from cleaning, and R1’s buttocks appeared to have a light yellow film. There was no drainage or sign of bleeding at the time. R1’s physician was made aware of the wound through photos that were sent by PN 1 and facility staff. On 8/18/2023, at or about 1:00 PM, PN 1 visited R1 and tended to R1’s wound. PN 1 was not aware that there was a deep abscess in the area and began to compress on it, at which time it excreted pus and bodily fluid. At this time, PN 1 called 911, paramedics arrived, and R1 was transported to a local hospital. Hospital records note that the physician reported the chief complaint to be an area of infection with purulent drainage to the right buttock. On 8/30/2023, R1 was discharged from the hospital to a skilled nursing facility. Interview of R1’s physician, conducted during the investigation, revealed that the abscess was unforeseen, and the facility’s caregivers had nothing to do with the development of the abscess. R1’s physician noted that R1’s complex medical conditions caused the abscess to develop without symptoms. R1’s physician made it clear that R1 did not have a pressure injury on the buttocks, as was reported, but had an abscess. R1’s physician also noted that facility staff communicated with the physician, as needed, regarding any questions or concerns relative to R1’s care, and facility staff provided excellent care to R1. One of R1’s hospice nurses also noted that the facility’s caregivers were well trained, provided extra care, did a really good job, and were able to take care of R1 with all the services he/she required. Relative to the report of R1 sustaining multiple stage 2 pressure injuries on ankles and feet, records reviewed during the investigation indicate that water blisters had developed on R1’s hands and feet; however, there was no evidence obtained to indicate that R1 sustained pressure injuries in any of those areas. The third allegation is that R1 did not receive timely medical attention. According to evidence obtained during the investigation, R1 had been receiving frequent care from hospice nurses and his/her private nurses, PN1 and PN 2. Prior to PN 1 compressing on the area that was later determined to be an abscess, there was no indication to facility staff that R1 had a sudden need for medical attention. At the time that PN 1 compressed and expressed fluid from the abscess, R1’s condition worsened which triggered the need for medical attention. At that time, PN 1 called 911 and had R1 transported to the hospital for medical care. Based on all of the foregoing, the above listed allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Tess Derafera, and copies of this report and Licensee/Appeal Rights (LIC 9058) were provided to the administrator at the conclusion of the visit. Administrator’s signature on this report acknowledges receipt of copies of the rights and report. Records reflect that on or about 8/5/2023, a hospice nurse noted that a red area was developing on R1’s buttocks. At the time of the observation, PN 2 was present and made aware of the red area. The nurses treated the area and decided to monitor it. On 8/18/2023, PN 1 visited R1 and tended to R1’s wound. PN 1 was not aware that there was a deep abscess in the area and began to compress on it, at which time it excreted pus and bodily fluid. At this time, PN 1 called 911, paramedics arrived, and R1 was transported to a local hospital. Hospital records note that the physician reported the chief complaint to be an area of infection with purulent drainage to the right buttock. The investigation did not yield evidence to conclude that there was a change in R1’s condition until PN 1 compressed the abscess which excreted bodily fluids in response to the compression. Records reviewed and interviews conducted during the investigation revealed that PN 1 has been granted durable power of attorney by R1. Accordingly, if notification was to be provided, it would have been provided to PN 1, who was present and actively involved when the identified change in R1’s condition occurred. Based on the foregoing, we have found that the complaint allegation is unfounded, meaning that the allegation is without a reasonable basis. Therefore, as to the above listed allegation, the facility is in compliance with Title 22 regulations at this time, and we have dismissed the complaint. An exit interview was conducted with Tess Derafera, Administrator, and copies of this report and Licensee Rights (LIC 9058) were provided to the administrator at the conclusion of the visit. Administrator's signature on this report acknowledges receipt of copies of the rights and report.the state’s words, verbatim · CDSS document, May 31, 2024 · control 08-AS-20230821153534

Allegation investigated: Neglect resulted in sexual abuse of resident

Licensing Program Analyst (LPA), Natasha Persaud Conducted an unannounced visit to conclude the investigation regarding the above-mentioned allegation. LPA met with Administrator, Tess Derafera. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged neglect resulted in sexual abuse of Resident #1 (R1). It was reported Resident #2 (R2) sexually assaulted R1. However, evidence obtained revealed R1 was not sexually assaulted by R2 but was sexually assaulted by Staff #1 (S1), which was reported to the facility on 10/25/23. R1’s Physician’s Report dated 05/04/23 indicated a diagnosis of Major Neurocognitive Disorder and R1 required assistance with bathing, dressing/grooming, toileting, and medication management. During R1’s interview they were qualified as alert and oriented and able to state pertinent details. Interviews were conducted with the staff members that were sexually harassed by S1. Staff #2 (S2) reported there was an incident when S2 was changing a resident’s diaper and S1 tried to kiss S2. Continued on an LIC 9099C. Substantiated Staff #3 (S3) reported S1 asked S3 to have sex, at first S3 thought S1 was joking around, but then S1 started to grab and touch S3. S3 also reported S1 sent nude photographs of themselves, and stalked S3 by going to their house. S3 also stated they were preparing lunch for the residents in the kitchen when S1 came up behind S3 and grabbed their breast on the left side. In addition, S1 pinned S3 up against the kitchen counter and blocked S3 from getting away from S1, then continued requesting S3 to meet up to have sex. S3’s interview revealed S1 told S3 they liked Resident #3’s (R3) face and the form of R3’s private part. Staff interviews indicated it was reported that S1 massaged R1’s breast and squeezed it then was about to move their mouth to R1’s breast when R1 pushed S1 away. The administrator’s interview revealed S1 was placed on administrative leave and later terminated on 11/01/2023. R1’s interview confirmed they were sexually harassed by S1. Evidence obtained revealed S1 sexually harassed multiple staff members at other facilities. S1 was also terminated at another facility for sexual harassment towards staff, which was documented and signed by S1 as acknowledgment and confirmation. Three (3) different females from three different facilities where S1 once worked who didn’t know each other were all able to confirm, S1 was sexually harassing them and touching them inappropriately. Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Tess Derafera whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Residents 1-3 and Staff 1-3].the state’s words, verbatim · CDSS document, May 2, 2024 · control 08-AS-20240201100243

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: May 2, 2024

Additional Personal Rights of Residents in Privately Operated Facilities: “…residents in privately operated residential care facilities shall have all of the following personal rights:…to be free from mental, physical, or sexual abuse.” This requirement is not met as evidenced by: Based on interviews the licensee did not protect 1 out of 21 residents in care from sexual abuse [R1] which posed an immediate safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 2, 2024

Plan of correction: Administrator stated Staff #1 was terminated on 11/01/23, which removed the immediate threat, POC corrected.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Haydee Jumulun. Administrator Tess Derarfera arrived shortly after. According to the facility’s license, the facility has a maximum capacity of twenty-one (21) residents, of whom twenty-one (21) may be non-ambulatory, of which 12 may be bedridden.. During today’s inspection, there were a total of (20) residents in care. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by Tess Derafera toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients were all compliant. There was at least 2 days supply of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters observed available to clients. Medications were labeled, as required, and stored in locked areas. (CONTINUED ON LIC809-C) [CONTINUED FROM LIC 809] No pools or bodies of water on the premises. According to Tess Derafera, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients. LPA interviews did not raise any licensing concerns. LPA reviewed multiple staff and client records. Files reviewed contained required documents. Confidential records were stored in locked areas. Tess Derafera presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Tess Derafera to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 25, 2024

Allegation investigated: -Staff did not address resident's medical condition timely -Staff did not ensure resident's call pendant was working -Staff did not address bed bug infestation

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above-mentioned allegation. LPA met with Administrator, Tess Derafera. During the investigation, the facility was briefly toured, records reviewed, and interviews with staff, residents, and outside sources. It was alleged that staff did not address Resident #1’s (R1) medical condition timely. R1’s Physician’s Report dated 09/26/22 indicated R1 was unable to handle their activities of daily living (ADL) such as toileting, showering, and dressing/grooming. R1’s Resident Appraisal dated 02/22/23 indicated R1 required full assistance with ADL's, had right side paralysis and was not mentally stable. The appraisal also stated R1 was verbally abusive with a tendency to become violent. The facility provided the following services to R1, bathing, grooming/dressing, help moving about the facility, eating, medications, and toileting as R1 was incontinent of both bowel and bladder. On 01/06/24, R1’s responsible party observed an infection located on R1’s chest area. The responsible party called 911 and R1 was transported to the hospital for evaluation. Continued on an LIC 9099C. Substantiated The hospital evaluated that R1 had mild erythema of an old chest scar that seemed to be very mild cellulitis. Also, R1 was diagnosed with a diffuse nonspecific rash that could be bed bugs versus nonspecific dermatitis. R1 was prescribed medications for the itch/bites. Staff interviews stated they provided R1 with dressing and showers but did not observe any bites on R1 on 01/05/24, 01/06/24, or 01/07/24. However, staff reported R1 was constantly itching and scratching their body. The administrator did not observe the bites or was notified by staff, as they were out on vacation during that period. It was also alleged staff did not address bed bug infestation. On 01/06/24, when R1 was transported to the hospital for a possible chest infection, it was identified that R1 was covered in bug bites. R1’s responsible party reported the bites to the licensee. On 01/09/24, R1’s responsible party and an outside source witnessed bed bugs on R1’s bed. On 01/09/24 R1’s mattress and recliner were disposed of. The staff stated they used Clorox wipes to wipe down R1’s furniture and washed the clothing R1 was wearing in bleach. Staff confirmed R1’s clothing in their drawers was not bagged up or washed in heat. Staff were not aware of universal precautions regarding bed bugs. The licensee stated a professional pest control company came to the facility on 01/10/24 and did not observe bed bugs. The pest control company documented on 01/10/24, no live activity or evidence of activity was seen; mattresses and other bed clothing were already discarded, and inspected area cleaned out, before visual inspection. The licensee’s interview revealed he did not witness bed bugs. However, R1’s items were already disposed of prior to licensee’s inspection on 01/10/24. It was also alleged the staff did not ensure R1’s call pendant was working. The administrator stated R1 throws their call button, and it breaks. R1 was given three (3) call buttons and destroyed all of them. Staff interviews indicated R1’s mental condition inhibits R1 from using the call button. Outside source interviews revealed when R1 had a call button but it did not work, as the outside source would push the button to try and alert staff but there was no response. R1’s responsible party also attempted to activate the call button on numerous occasions and did not work to alert staff. The administrator was not aware the call button was not operating, as it was not brought to her attention. It’s possible the button was broken due to R1 throwing it. However, staff did not ensure R1 was afforded the call button for assistance. Staff mentioned they observed the call button hanging from R1’s nightstand but also not aware the button was not working. Staff also stated they do not check or monitor the call buttons for residents. The facility is required to have a signal system as outlined in Title 22 Regulation, which shall operate from each resident's living unit. On 01/17/24, LPA toured R1’s bedroom and did not observe a call button. Continued on an LIC 9099C. Further staff interviews revealed the last time they observed the call button was approximately one (1) week prior to LPAs visit. Staff did not alert the administrator that R1’s call button was not working or present in their room. Based on LPA’s observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Tess Derafera whose signature below confirms receipt of these rights. The facility provided the following services to R1, bathing, grooming/dressing, help moving about the facility, eating, medications, and toileting as R1 was incontinent of both bowel and bladder. Staff interviews confirmed R1 was verbally abusive and violent, causing injury to staff. On 01/08/24, R1’s family member observed R1 calling for help as they already had bowel movement and smeared feces on their bed, and walls. R1 was identified with a medical condition that had R1 reach into their diaper after defecating and used their hand to smear the feces on themselves and items. Staff interviews confirmed R1 will reach into their diaper and smear their feces. Further staff interviews revealed R1 had multiple bowel movements a day, between four (4) to five (5) times a day. R1 did not have a regular bowl movement schedule, therefore, staff were unable to gauge when to the bowl movement and smearing of feces would occur. Staff stated they checked on R1 every 30 minutes. Additional staff interviews revealed they checked on R1 every two (2) hours. The administrator explained they do not provide one on one care to residents. Therefore, they cannot always know when R1 was going to have a bowel movement tin order to get to R1 prior to R1 smearing feces. Staff confirmed once observing R1 with feces, R1 was changed and showered more than their allotted shower days, which was twice a week. Staff confirmed R1 would typically receive four (4) or more showers a week due to wanting to ensure R1 was kept clean. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Tess Derafera whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Feb 5, 2024 · control 08-AS-20240109081821

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Mar 4, 2024

Observation of the Resident. The licensee shall ensure...residents are regularly observed for changes in physical...when such observation reveals unmet needs. When changes...are observed...the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews and records, the licensee did not ensure 1 out of 21 [R1] residents were observed for a medical condition requiring medical treatment, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 5, 2024

Plan of correction: Administrator stated she will conduct In-Service training regarding observations of the residents and reporting observations. Training is due by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(2) · Plan of correction due date: Mar 4, 2024

Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria: Facilities having more than one wing, floor or building shall be permitted to have a separate system in each, provided each meets the above criteria. This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not ensure 1 out of 21 [R1] residents call buttons were operable, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 5, 2024

Plan of correction: Administrator stated she will implement a new policy to ensure call buttons are operable and by having staff check/test the call buttons on an ongoing basis. The administrator also stated she will provide an In-Service training to staff regarding the call buttons. Proof of new policy and training are due by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Mar 4, 2024

Personal Rights of Residents in All Facilities. To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement is not met as evidenced by: Based on interviews, the licensee did not ensure 1 out of 21 [R1] residents were afforded healthful accommodations due to not following universal precautions for bed bug infestation, which poses a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Feb 5, 2024

Plan of correction: Administrator stated she will conduct In-Service training on universal precautions regarding bed bugs and provide proof of training by POC due date.