Huntington Terrace

Allegation investigated: Staff did not administer medication as prescribed.

On July 10, 2026 at approximately 2:45 PM, LPA Taylor Simerly and LPM Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA and LPM met with Timarie Morrisey Business Office Director. LPA and LPM explained the purpose of this visit. The Investigation consisted on: records reviews and residents interviews. Evaluation Report continues on LIC 9099-C... Substantiated Investigation Revealed the following: Allegation: Staff did not administer medication as prescribed. It was alleged that facility staff did not administer medications as prescribed. During the course of the investigation, LPA Lee reviewed facility records pertaining to resident medications. Based on incident reports provided by the facility on 05/22/2026, it was learned that three medication errors occurred during 2024. On 01/09/2024, 01/10/2024, 01/11/2024, and 01/13/2024, Resident 1 (R1) was administered an additional dose of Mirtazapine 30 mg. The medication was prescribed as one tablet by mouth at bedtime only; however, it was also administered in the morning. On 10/14/2024 at approximately 2:00 p.m., a medication technician reported to the Health Services Administrator (HSA) that Resident 2 (R2) had been administered the incorrect dosage of Atorvastatin. R2 received Atorvastatin 20 mg, however, the physician's order prescribed Atorvastatin 10 mg, one tablet by mouth at bedtime. On 05/01/2024 at approximately 9:00 p.m., Resident 3 (R3) was administered another resident's bedtime medications, including Ativan and Norco. LPA Lee also reviewed Medication Administration Records (MARs) for seven residents for May 2024 and identified two documentation discrepancies. Resident 4 (R4) was prescribed Ocean Blue Omega-3 2100 mg, one capsule by mouth daily, with a start date of 05/02/2024 and an end date of 10/10/2024. The MAR did not have staff initials from 05/02/2024 through 05/06/2024, and no documentation to explain the omission. Resident 5 (R5) was prescribed Methylphenidate 5 mg tablets, two tablets (10 mg) by mouth three times daily, with a start date of 02/29/2024 and an end date of 08/21/2024. The MAR contained no staff initials for the morning, noon, or evening medication passes on 05/02/2024 and from 05/06/2024 through 05/16/2024. No notes were documented explaining the missing entries. Evaluation Report continues on LIC 9099-C... Based on facility incident reports and the review of resident MARs, the investigation revealed medication administration errors, as a result, the allegation is found to be SUBSTANTIATED, meaning the allegation was found to be valid because the preponderance of evidence standard was met. The following deficiency was cited on the LIC 9099-D pursuant to Title 22, Division 6, of the California Code of Regulations and applicable Health and Safety Code sections. An exit interview was conducted, and a copy of the complaint report was provided via email to Timarie Morrisey Business Office Directorthe state’s words, verbatim · CDSS document, Jul 10, 2026 · control 22-AS-20240919164250

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 24, 2026

THIS DOCUMENT WAS AMENDED DUE TO INCORRECT CITATION. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This was not met as evidence by: Based on record review, the facility reported three medication errors. Additionally, a review of residents' MARs revealed multiple discrepancies involving three residents, indicating that medications were not administered in accordance with physicians' orders. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 10, 2026

Plan of correction: The Administrator shall conduct an in-service training regarding medication administration to ensure that residents' medications are administered in accordance with physicians' orders. Copies of the training materials and staff sign-in sheet shall be submitted to the LPM no later than 7/24/26 by 5:00 PM.

Type of visit: Required - 1 Year

On July 7, 2026, Licensing Program Analysts (LPAs) Brandon Lopez and Tran Nguyen made an unannounced visit to the facility to conduct the required annual inspection. LPAs were greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Emily Turner was present and assisted on today's visit. LPAs observed that Emily Turner has a valid Administrator certificate which expires on November 14, 2027. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for one hundred and eight five residents, of which thirty can be ambulatory, one hundred and fifty five can be non-ambulatory, and of which fifteen can be bedridden. The facility also has an approved hospice waiver for thirty residents. The facility is a three story commercial building with a center courtyard, and it serves both Assisted Living and Memory Care. LPAs, accompanied by the ED, conducted a tour of the interior portions of the facility. On today's visit, there were one hundred and sixty nine residents in care. LPAs observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPAs inspected a total of seventeen resident bedrooms, which consisted of bedrooms located on each floor and in both Assisted Living and Memory Care. LPAs observed each bedroom to be free of any hazards. LPAs observed each resident bedroom to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPAs observed resident beds to have clean linens and blankets. LPAs observed that each resident bedroom has a bathroom located in suite. LPAs inspected the resident bathrooms and observed them to be free of any hazards. LPAs observed resident bathrooms to be equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 109.2 and 119.1 degrees Fahrenheit. LPAs also tested the signal systems in resident bedrooms which tested operational. CONTINUED ON LIC809-C LPAs inspected the facility's commercial kitchen area and observed it be clean. LPAs observed the facility to have a minimum two day perishable and seven day non-perishable food supply on hand. LPAs observed the facility has a three day emergency food supply kept in the kitchen's pantry area. LPAs observed multiple fire extinguishers to be mounted on the walls across the facility on each floor. LPAs observed each fire extinguisher to be charged and serviced as of January 12, 2026. LPAs observed that the facility had their most recent fire inspection conducted on January 26, 2026. LPAs observed that the facility's fire sprinklers and smoke detectors tested operational during the inspection. LPAs observed the facility conducted their last emergency disaster drill on July 3, 2026. LPAs observed the centrally stored medication to be kept in locked medication carts located in the both Assisted Living and Memory Care. LPAs observed first aid kits to be stored in the medication room in Assisted Living and they had all the required components. LPAs observed all the facility's chemicals and toxins to be stored in a locked storage rooms. LPAs observed the facility has a three day emergency water supply stored in the maintenance room and at the bottom of each staircase. LPAs also observed the facility has an evacuation chair located at each staircase. LPAs observed all other common areas such as the dining rooms, activities rooms, fitness center, laundry rooms, and staff offices, to be clear of any hazards. LPAs, accompanied by the ED, conducted a tour of the exterior portions of the facility. LPAs observed the facility has outdoor areas for both assisted living and memory care. LPAs observed the exteriors to be free of any obstructions or hazards. LPAs observed shaded outdoor seating areas with furniture for resident use. LPAs tested the delay egress doors located on the exterior portions of Memory Care which tested operational. LPAs observed the facility has a pool and club house located on the southside of the property. LPAs observed the pool to be adequately fenced and kept locked for resident safety. LPAs observed the club house to be free of any hazards. LPAs reviewed the seventeen resident files. All the required documentation were present and current in the resident files reviewed. LPAs reviewed residents' medication and medication administration records. LPAs reviewed twelve staff files. All staff are background cleared and associated to the facility. Based on the observations made during today's visit, no deficiencies are being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with Executive Director Emily Turner and a copy of the report was provided at time of visit.the state’s words, verbatim · CDSS document, Jul 7, 2026

Allegation investigated: Facility is failing to meet residents' needs Insufficient staffing Staff engaged in a verbal altercation in the presence of residents

On 06/19/2026, Licensing Program Analyst (LPA) Pang Lee conducted a telephone meeting with Facility Designated Administrator (FDA) Emily Turner for the purpose of delivering the complaint findings regarding the allegation above. A brief interview was conducted with FDA Turner. It was alleged that facility failed to meet resident's needs and insufficient staff. During the investigation, Licensing Program Analyst (LPA) Pang Lee reviewed facility records and conducted interviews with staff, residents, and a resident’s responsible party. LPA Lee interviewed two of two facility staff members, both of whom denied the allegations. Attempts to interview eight additional staff members were unsuccessful. LPA Lee interviewed four of four residents, all of whom denied the allegations and reported no concerns related to the reported allegations. Attempts to interview twenty-six additional residents were unsuccessful. Additionally, LPA Lee was unable to contact facility staff who may have worked during the time the alleged incident occurred. CONTINUED LIC 9099-C Unsubstantiated LPA Lee also interviewed a resident’s responsible party, who denied the allegations and reported no concern regarding facility staff meeting their family member’s needs. The responsibility party stated that they had never observed their family members being left in soiled clothing, were satisfied with their family members’ placement at the facility and had not witnessed any of the alleged incidents. Based on the information obtained during the investigation, LPA Lee was unable to corroborate the allegations. It was alleged that Staff engaged in a verbal altercation in the presence of residents. During the investigation, Licensing Program Analyst (LPA) Pang Lee reviewed facility records and conducted interviews with facility staff, residents, and a resident’s responsible party. LPA Lee interviewed two of two staff members, both of whom denied the allegation. Attempts to interview eight additional staff members were unsuccessful. LPA Lee also interviewed four of four residents, all of whom denied witnessing staff engage in verbal altercations in the presence of residents. Attempts to interview twenty-six additional residents were unsuccessful. Additionally, LPA Lee was unable to contact staff members who may have been working at the time of the alleged incident. A resident’s responsible party was also interviewed and reported having no knowledge of, or having witnessed, any incidents involving staff verbal altercations in the presence of residents. Furthermore, a review of facility records revealed no incident reports or documentation supporting the allegation that staff engaged in verbal altercations in the presence of residents. Based on the information obtained during the investigation, LPA Lee was unable to corroborate the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did nor did not occur, therefore, the allegations are unsubstantiated. An Exit Interview was conducted with (FDA) Turner, and a copy of this report was provided to the facility via email. A certified copy will be sent to the facility mailing address.the state’s words, verbatim · CDSS document, Jun 19, 2026 · control 22-AS-20210913144414

Allegation investigated: Staff did not dispense resident's medication as prescribed by physicians.

On 06/19/2026, Licensing Program Analyst (LPA) Pang Lee conducted a telephone meeting with Facility Designated Administrator (FDA) Emily Turner for the purpose of delivering the complaint findings regarding the allegation above. A brief interview was conducted with FDA Turner. It was alleged that staff did not dispense resident's medication as prescribed by physicians. During the course of the investigation, LPA Lee reviewed facility records pertaining to resident medications. Based on incident reports provided by the facility on 05/22/2026, it was learned that three medication errors occurred during 2024. On 01/09/2024, 01/10/2024, 01/11/2024, and 01/13/2024, Resident 1 (R1) was administered an additional dose of Mirtazapine 30 mg. The medication was prescribed as one tablet by mouth at bedtime only; however, it was also administered in the morning. On 10/14/2024 at approximately 2:00 p.m., a medication technician reported to the Health Services Assistance (HSA) that Resident 2 (R2) had been administered the incorrect dosage of Atorvastatin. CONTINUED LIC 9099-C Substantiated R2 received Atorvastatin 20 mg, however, the physician's order prescribed Atorvastatin 10 mg, one tablet by mouth at bedtime. On 05/01/2024 at approximately 9:00 p.m., Resident 3 (R3) was administered another resident's bedtime medications, including Ativan and Norco. LPA Lee also reviewed Medication Administration Records (MARs) for seven residents for May 2024 and identified two documentation discrepancies. Resident 4 (R4) was prescribed Ocean Blue Omega-3 2100 mg, one capsule by mouth daily, with a start date of 05/02/2024 and an end date of 10/10/2024. The MAR did not have staff initials from 05/02/2024 through 05/06/2024, and no documentation to explain the omission. Resident 5 (R5) was prescribed Methylphenidate 5 mg tablets, two tablets (10 mg) by mouth three times daily, with a start date of 02/29/2024 and an end date of 08/21/2024. The MAR contained no staff initials for the morning, noon, or evening medication passes on 05/02/2024 and from 05/06/2024 through 05/16/2024. No notes were documented explaining the missing entries. Based on facility incident reports and the review of resident MARs, the investigation revealed medication administration errors, as a result, the allegation is found to be SUBSTANTIATED, meaning the allegation was found to be valid because the preponderance of evidence standard was met. The following deficiency was not cited as the same citation was already cited on complaint control number 22-AS-20240919164250. An exit interview was conducted with FDA Turner. A copy of this report was provided to the facility via email, and a certified copy will be mailed to the facility's address of record. However, both staff members reported that they were not employed at the facility during the COVID-19 pandemic and were therefore unable to provide information regarding the events referenced in the allegation. LPA Lee attempted to interview eight additional staff members; however, those attempts were unsuccessful. LPA Lee also interviewed three of three residents, none of whom were able to provide information regarding the facility's infection control practices during the time period relevant to the allegation. LPA Lee attempted to interview twenty-six additional residents; however, those attempts were unsuccessful. A review of facility records confirmed that the facility maintained an infection control plan. LPA Lee attempted to obtain additional information related to the allegation; however, records and information pertaining to the events that occurred during the COVID-19 pandemic were unavailable; therefore, based on the information obtained during the investigation, LPA Lee was unable to corroborate the allegation that staff did not follow infection control practices. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did nor did not occur, therefore, the allegations are unsubstantiated. An Exit Interview was conducted with (FDA) Turner, and a copy of this report was provided to the facility via email. A certified copy will be sent to the facility mailing address. It was alleged that staff left residents in the same clothing for extended periods of time, staff did not ensure that residents were appropriately dressed, staff left residents in wet briefs for extended periods of time, and staff did not provide adequate supervision, resulting in resident falls. During the investigation, Licensing Program Analyst (LPA) Pang Lee reviewed facility records and conducted interviews with staff, residents, and a resident's responsible party. LPA Lee interviewed two out of two facility staff members, who both denied the allegations. LPA Lee attempted to interview eight additional staff members; however, those attempts were unsuccessful. LPA Lee interviewed two of three residents in care, both of whom denied the allegations and reported no concerns regarding the allegations. Resident 1 (R1) stated that they were regularly changed and received showers twice weekly and has no concerns with the allegations. LPA Lee attempted to interview twenty-six additional residents; however, those attempts were unsuccessful. LPA Lee also interviewed a resident's responsible party, who denied the allegations, reported no concerns regarding the care and supervision provided by facility staff, and stated they were satisfied with their family member's placement at the facility. The responsible party further indicated they had not witnessed any of the alleged incidents. The investigation also revealed that R2 was receiving hospice services during the time of the complaint; however, hospice records were not available for review. Additionally, LPA Lee was unable to contact facility staff who may have worked during the time the alleged incidents occurred and was unable to interview R2. Additionally, a review of facility records revealed that the facility did not maintain documentation indicating when residents' clothing was changed, when residents were dressed, or when residents' briefs were changed. Therefore, LPA Lee was unable to verify through record review whether R1 did or did not receive these services as alleged. Therefore, LPA Lee was unable to corroborate the allegations. It was alleged that staff did not follow infection control practices. During the investigation, Licensing Program Analyst (LPA) Pang Lee reviewed facility records and conducted interviews with staff and residents. LPA Lee interviewed two of two facility staff members, both of whom denied the allegation and stated that they do follow infection control practices. CONTINUED LIC 9099-Cthe state’s words, verbatim · CDSS document, Jun 19, 2026 · control 22-AS-20240711091659

Allegation investigated: Facility staff did not ensure residents received assistance with PRN medications. Facility staff did not ensure residents were charge in accordance with the admission agreement.

Licensing Program Analysts (LPAs) Nancy Guillen and Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegations. LPAs were greeted and granted entry into the facility and explained the reason for the visit. It was alleged the facility did not assist resident with PRN medications and facility did not charge resident in accordance with the admission agreement. The investigation determined as follows: Regarding the allegation that facility did not provide assistance with PRN medications, it was reported staff denied assistance with application of ointment at the request of the resident who was unable to reach the affected area and is part of their care plan. Continued on LIC 9099C Unfounded Interviews with two out of four residents stated that they administer their own medication and have no issues. Both residents interviewed believe if they were to need additional help they would receive it from the staff. The two remaining residents interviewed receive medication assistance and do not report any problems or concerns. Three out of six staff stated they have not spoken to Resident 1(R1) regarding assistance with their medications and are unaware that they may require assistance. One of the three staff stated residents are assessed at least once a year or upon change of condition. The remaining three staff did not add anything relevant to the allegation. Record review revealed that R1's "Assessment for Medication Self Management" dated February 19, 2025 determined the resident is able to self manage their medications and states the resident can physically take/apply medications. R1's Physician Report dated August 25, 2025 indicated the resident is able to manage their own medications without any assistance. Care Plan completed on November 18, 2025 for R1 states resident is able to self administer medications. R1's billing statement for June 2026 does not indicate any additional fees for medication management. Regarding the allegation that facility did not charge in accordance with the admission agreement, it was reported residents are being charged for amenities they cannot use. Interview with four of the four residents stated that they are not charged a separate fee for the amenities such as the pool, putting green area or the club house. Per record review residents were notified on February 6, 2026 of the closed amenities with the most recent notice dated May 13, 2026 updating residents of continuing construction. Admission agreement for R1 dated January 18, 2025 and facility program do not have a separate charge for the amenities addressed above. R1's billing statement for June 2026 does not indicate any additional fees for amenities. Based on interviews and record review, the following allegations above, 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 the report was left with the facility representative. Six out of six staff stated the outside areas of the facility are cleaned every day including walkways. Four out of six staff stated that during heavy rains, if there are puddles, those are drained immediately by opening drain pipes or using a pump. Per record review, landscaping contract was signed May 14, 2026 and are required to provide services 24 times per year. LPAs observed the outside areas are clean and clear of hazards. Based on interviews and record review, the above allegation is therefore deemed unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of the report was left with the facility representative.the state’s words, verbatim · CDSS document, Jun 15, 2026 · control 22-AS-20260605140511

Allegation investigated: Staff is not able to meet resident's care needs. Staff does not respond to resident's call button in a timely manner. Staff left resident soiled for an extended period of time. Facility does not have adequate staffing resulting in children working as kitchen staff. Staff does not provide adequate food service. Facility heater is in disrepair resulting in gas leak. Facility outlets are in disrepair. Facility has pests.

On 06/19/2026, Licensing Program Analyst (LPA) Pang Lee conducted a telephone meeting with Facility Designated Administrator (FDA) Emily Turner for the purpose of delivering the complaint findings regarding the allegation above. A brief interview was conducted with FDA Turner. It was alleged that staff is not able to meet resident's care needs, staff left resident soiled for an extended period of time. During the investigation, Licensing Program Analyst (LPA) Pang Lee reviewed facility records and conducted interviews with staff, residents, and a resident’s responsible party. LPA Lee interviewed two of two facility staff members, both of whom denied the allegations. Attempts to interview eight additional staff members were unsuccessful. LPA Lee interviewed four of four residents, all of whom denied the allegations and reported no concerns related to the reported allegations. Resident 1 (R1) also denied the allegations, stating that the alleged incidents never occurred, that they did not recall any such events, and that they had no concerns regarding the facility's care and services. CONTINUED LIC 9099-C Unsubstantiated Attempts to interview twenty-six additional residents were unsuccessful. Additionally, LPA Lee was unable to contact facility staff who may have worked during the time the alleged incidents occurred. LPA Lee also interviewed a resident’s responsible party, who denied the allegations and reported no concern regarding facility staff meeting their family member’s needs. The responsible party stated that they had never observed their family member being left in soiled clothing, were satisfied with their family member’s placement at the facility and had not witnessed any of the alleged incidents. A review of facility records further revealed that the facility did not maintain documentation indicating when residents’ briefs were changed. As a result, LPA Lee was unable to verify through record review whether R1 did or did not receive the services referenced in the allegations. Based on the information obtained during the investigation, LPA Lee was unable to corroborate the allegations. It was alleged that staff do not respond to residents’ call buttons in a timely manner. During the investigation, Licensing Program Analyst (LPA) Pang Lee reviewed facility records and conducted interviews with staff, residents, and a resident’s responsible party. LPA Lee interviewed two of two facility staff members, both of whom denied the allegation and stated that staff respond to residents’ calls when assistance is requested. Attempts to interview eight additional staff members were unsuccessful. LPA Lee interviewed three of four residents, all of whom denied the allegation and reported no concerns regarding staff response times. The residents stated that staff respond when they activate their call pendants. Resident 1 (R1) stated that the call button system is working properly and that staff generally respond within 10 to 15 minutes. R1 reported having no concerns regarding staff response times. Attempts to interview twenty-six additional residents were unsuccessful. LPA Lee also interviewed a resident responsible party, who denied the allegation and reported no concern regarding staff responsiveness. The responsible party stated that staff typically respond within a couple of minutes and that, based on their observations, response times have not exceeded 15 minutes. Additionally, LPA Lee reviewed R1’s call pendant activity report for March 2026 through May 2026, which showed that R1 activated the call pendant seven times, with an average response time of 4 minutes and 8 seconds. LPA Lee also reviewed eight other residents call pendant activity report for March 2026 through May 2026 and it was learned that all the calls had an average between 2 minutes to seven minutes. Based on interviews and record review, LPA Lee was unable to corroborate the allegation that staff do not respond to residents’ call buttons in a timely manner. CONTINUED LIC 9099-C It was alleged that Facility does not have adequate staffing, resulting in children working as kitchen staff and staff do not provide adequate food service. During the investigation, Licensing Program Analyst (LPA) Pang Lee reviewed facility records and conducted interviews with staff and residents. LPA Lee interviewed two of two facility staff members, both of whom denied the allegations and stated that all kitchen staff are over the age of 18 and possess the appropriate training and experience. Attempts to interview eight additional staff members were unsuccessful. Additionally, LPA Lee was unable to contact facility staff who may have worked during the time the alleged incident occurred. LPA Lee interviewed three of four residents, all of whom denied the allegations and reported no concerns regarding underage kitchen staff or the adequacy of food services provided by the facility. Attempts to interview twenty-six additional residents were unsuccessful. LPA Lee reviewed the personnel files of three kitchen staff members, and it was learned that all three individuals were over 20 years of age and had at least two years of food service experience. Records further showed that all three staff members possessed valid food handler certificates. Based on interviews and record review, LPA Lee was unable to corroborate the allegations that the facility employed underage kitchen staff and that staff does not provide adequate food service. It was alleged that facility heater is in disrepair resulting in gas leak, facility outlets are in disrepair and that facility has pests. During the investigation, Licensing Program Analyst (LPA) Pang Lee reviewed facility records and conducted interviews with staff, residents, and a resident’s responsible party. LPA Lee interviewed two of two facility staff members, both of whom denied the allegation and stated that they have not heard or observed the facility’s heater is in disrepair and the facility having pest. Attempts to interview eight additional staff members were unsuccessful. Additionally, LPA Lee was unable to contact facility staff who may have worked during the time the alleged incident occurred. LPA Lee interviewed four of four residents, all of whom denied the allegation and reported no concerns regarding the facility having pest in the facility. Moreover, resident 1 (R1) denied the allegations. Attempts to interview twenty-six additional residents were unsuccessful. LPA Lee also interviewed a resident responsible party, who denied the allegations and reported not seeing any pest in the facility and in their family members room and has no concerns with the allegation. CONTINUED LIC 9099-C Additionally, LPA Lee reviewed facility records, and it was learned that the facility has had a contract with Western Exterminator Company since 2022 to current and that there was no break in services and that the facility was having pest services. Based on interviews and record review, LPA Lee was unable to corroborate the allegation that staff do not respond to residents’ call buttons in a timely manner. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did nor did not occur, therefore, the allegations are unsubstantiated. An Exit Interview was conducted with (FDA) Turner, and a copy of this report was provided to the facility via email. A certified copy will be sent to the facility mailing address.the state’s words, verbatim · CDSS document, Jun 14, 2026 · control 22-AS-20230425102858

Allegation investigated: Facility did not allow resident visitation

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegation received on December 16, 2025. LPA was greeted and granted entry into the facility and met with Business Office Manager (BOM) Timarie Breslin. LPA explained the reason for the visit. This Department has investigated the complaint alleging that facility did not allow resident visitation. Regarding the allegation the following was revealed: During the interviews with individuals eight of ten individuals denied the allegation. During the course of the interviews with residents, Resident 1 (R1) reported that her boyfriend, R7 is not being allowed to visit her. Per R1, her boyfriend gets upset when things do not go his way. During the investigation LPA reviewed the Huntington Terrace notification letters dated July 1, 2025, and September 3, 2025, for R7. Per letter dated July 1, 2025, it states yelling at another resident...amounts to harassment and is a violation of our House Rules. Per letter dated September 3, 2025, it states should you engage in any future conduct in violation of the community's written policies, CONTINUED ON LIC9099-C... Unsubstantiated we reserve the right to issue a new 30-Day Notice to Terminate. R7 moved out of Huntington Terrace on October 27, 2025. LPA also reviewed the Huntington Terrace notification letter dated November 6, 2025, for R7. Per letter, it states as a visitor you are required to sign in at the front desk...you refused to do so. Per letter it states, your recent visits to Huntington Terrace were disruptive and inappropriate towards other residents and staff. During the course of the of the interviews with staff, Staff 1 (S1) reported that no resident has complained about visitor being denied entrance. Per S2, R1 has not been denied visitors. S3 reported that the facility has not had an incident where R7 was denied visiting R1. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is 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 BOM Breslin, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 9, 2026 · control 22-AS-20251216152141

Allegation investigated: Facility has a bed bug infestation. Facility is not being maintained free of vermin.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on July 29, 2024. LPA was greeted and granted entry into the facility and met with Business Office Manager (BOM) Timarie Breslin. LPA explained the reason for the visit. This Department has investigated the complaint alleging that facility has a bed bug infestation. Regarding the allegation the following was revealed: During the course of the interviews with individuals nine of fourteen individuals interviewed denied the allegations. During the investigation LPA reviewed the Western Exterminator Summary of Service dated July 10, 2024, August 15, 2024, and August 23, 2024. Per Summary of Service dated July 10, 2024, under service description it states Bioremediation Ongoing Full Service maintenance and it states no activity noted. Per Summary of Service dated August 15, 2024, under service description it states Bioremediation Ongoing Full Service Maintenance and it states no activity noted. CONTINUED ON LIC9099-C... Unsubstantiated Per Summary of Service dated August 23, 2024, under service description it states General Pest Control Maintenance and it states no activity noted. During the course of the interviews with residents, Resident 1 (R1) through R4 reported that they have never seen bedbugs. During the interviews with staff, Staff 1 (S1) through S4 reported that the facility does not have a bed bug infestation. Regarding the allegation that facility is not being maintained free of vermin, the following was revealed: During the initial visit on August 5, 2024, and subsequent visit on December 22, 2025, LPA tour the facility and did not observe vermin and/or cockroaches throughout building. During the interviews with residents, R1 through R4 reported that they have never seen vermin, cockroaches and/or insects in the facility. During the course of the interviews with staff, S2 reported that she has never seen vermin or insects in the facility. Per S2, the residents' actions influence the facility having vermin. S3 stated that no staff or resident has complained about there being vermin in the facility. Per S3, pest control did not find any cockroaches. 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 BOM Breslin, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 22, 2025 · control 22-AS-20240729133827

Allegation investigated: Staff threatened to evict a resident in care.

Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent vist for the purpose of continuing the investigation and delivering the findings into the above allegation. LPA met with Business Office Manager (BOM) Timarie Morrissey and explained the reason for the visit. During the course of the investigation, LPA interviewed one resident, two staff, and a witness, and obtained the following documentation for review: Resident Rosters, Personnel Report, Staff Contacts, Face Sheet, Physician's Report, Admission Agreement, Resident Assessments/Needs and Services Plans, Narrative Charting, and Warning Notice involving Resident #1 (R1). The investigation revealed the following: The Department received said complaint on July 31, 2024. The complaint was initiated by LPA on August 8, 2024. Regarding the allegation, Staff threatened to evict a resident in care, it is alleged that a Registered Nurse (RN) and R1 was engaged in an interaction where an eviction threat was made to R1. The Narrative Charting revealed that RNs were a third-party contractor in 2024 to provide the facility support which was corroborated by one staff. Unsubstantiated Based on the review of the resident assessments, the resident assessment dated July 26, 2018 indicates R1 began receiving care at a level 5. However, LOC was reduced to a level 1 as per resident assessment dated October 25, 2022. It was noted on this assessment that the LOC was dropped after speaking to R1's wife. There was no signature obtained on this assessment. On November 22, 2022, LOC increased to a Level 3. It was noted on the assessment and narrative charting dated November 23, 2022 at 6:37pm that R1 refused to sign updated assessment. The records reveal that the signatures were not forged and was left blank. Therefore, this agency has investigated the complaint and based on the interviews which were conducted and the records that were reviewed, the following allegation, Resident's signature was forged on a document is deemed UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Executive Director Mike Marion, and a copy of this report was provided at exit. The witness who had observed the interaction reported that the RN did not issue threats, but instead explained to R1 that their behavior and actions could result in an eviction due to policy violations regarding medications. The witness indicated that R1 had immediately reached out to their attorney which aligns with the narrative charting noted on July 24, 2024 at 2:29pm. The charting documented that R1's attorney agreed to facilitate R1's return of their medications. One out of three staff confirmed that R1 had prior history of not returning their medications after leaving the community. Therefore, based on the interviews which were conducted and the records that were reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation, Staff threatened to evict a resident in care is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Mike Marion, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 22-AS-20240731232601

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose of issuing a deficiency in regards to complaint investigation control number: 22-AS-20240731232601. LPA met with Executive Director Mike Marion and explained the reason for the visit. The investigation in connection to the complaint mentioned above revealed that the level of care for Resident #1 (R1) was reduced from a level 5 to a level 1 on October 25, 2022 and increased to a level 3 on November 22, 2022. The facility failed to ensure that R1 was enabled to make informed decision and choices for their level of care. The investigation also revealed, based on the care assessments, the facility proceeded to provide a level of care that R1 had not signed for or consented to. Therefore, a deficiency is being cited on the attached LIC809-D. An exit interview was conducted with Executive Director Mike Marion, and a copy of this report including the LIC-811 and appeal rights were provided at exit.the state’s words, verbatim · CDSS document, Dec 2, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(7) · Plan of correction due date: Dec 9, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(7) To fully participate in planning their care...and involve persons of their choice in this planning. The licensee shall provide necessary information and support to ensure that residents... are enabled to make informed decisions and choices. This requirement was not met as evidenced by: Based on interview and record review, R1 was not enabled to make informed decisions and choices as facility proceeded to change R1's level of care without R1's consent on 10/25/22 and 11/22/22 which poses a potential Health, Safety, and/or Personal Rights risk to person in care.the state’s words, verbatim · CDSS document, Dec 2, 2025

Plan of correction: ED stated that they will submit a written plan to LPA by POC due date outlining the steps involved in the change in care which meets the regulations and specifying when to contact/obtain signatures from the residents and/or their respresentatives.

Allegation investigated: Multiple residents have an issue with roaches in their room patio are constantly subject to accumulated moisture and water facility has not had a driver and van for over a year Difficulty communicating with Administrator/General Manager Smoke alarms are going off in problematic manner

On this day Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced subsequent visit to deliver complaint investigation findings. LPA was granted entry by staff. LPA Tirre discussed purpose of the visit and allegations with Business Office Manager Timarie Morrissey The investigation consisted of staff and resident interviews and review of facility records. The Investigation was completed by department and revealed the following: On January 5, 2022, the department received allegations that Multiple residents have an issue with roaches in their room, patio are constantly subject to accumulated moisture and water, facility has not had a driver and van for over a year, and Difficulty communicating with Administrator/General Manager, and smoke alarms are going off in problamatic manner. Regarding the allegation multiple residents have an issue with roaches in their room, interviews were conducted with staff and residents, the following information was provided: Interviews conducted with staff have found that two of five staff members have not experienced any roaches at facility. CONTINUED ON 9099C Unsubstantiated Two of five staff members have not experienced any roaches at facility but stated that residents have complained about roaches and one staff stated they have witnessed roaches inside a residents room. Interviews with residents conducted have found that seven of ten residents have not experienced any roaches at facility. Three of Ten residents have experienced roaches inside their apartments located in cabinets, sinks and restrooms. The Three of Ten residents who have experienced roaches at facility all stated that facility has sent out exterminator to handle the issue and residents stated that roaches in their rooms have been terminated. Facility provided documentation invoices from Western Exterminator dated from 12/22/2020 to 11/14/2023 and records show company comes out monthly to conduct full service pest control maintenance. During investigation, LPA Tirre has not observed any roaches inside or outside facility during the following inspection dates: 1/12/2022, 10/22/2025, and 11/18/2025. Based on the information gathered during the investigation, the allegation Multiple residents have an issue with roaches in their room, the preponderance of evidence has not been met meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegation is deemed UNSUBSTANTIATED Regarding allegation patio are constantly subject to accumulated moisture and water, the department made observations and conducted interviews with staff & residents and the following information was provided. LPA Tirre conducted visits on 1/12/22, 10/22/25, and 11/18/25 and observed accumulated water on patio areas on 11/18/2025. During LPA’s visit on 11/18/2025 it was noted that the night before it rained. Facility interviews with staff revealed that Four of Five staff stated they have not experienced accumulated water or moisture in outside patio areas. One of five staff stated they have experienced accumulated water but also claimed that the water was a result of rain the night before. Interviews with residents state that five of ten residents don’t have patio areas while the other five residents stated that they have not had any issues with accumulated water or moisture in their patio areas. CONTINUED ON 9099C Based on the information gathered during the investigation, the allegation patio are constantly subject to accumulated moisture and water, has been determined the preponderance of evidence has not been met meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegation is deemed UNSUBSTANTIATED. Regarding the allegation facility has not had a driver and van for over a year, the investigation consisted of interviews and record review. Interviews with staff members stated that Six of Six staff stated that facility has never been without a driver and has transportation van and car available to take residents out on outings and errands. Staff 6 stated they have been facility driver since August 23, 2021. Interviews with residents state that six of ten residents have never had any issues regarding facility van. Four of ten residents stated that they don’t use facility van for transportation. Ten of ten residents stated that to their knowledge the facility van and driver have been available if needed. Records provided by facility show facility had a mileage log that was provided upon initial period of complaint from 1/4/2022 to 1/12/2022. Mileage log shows there have been eight visits during that time period. Additional Transportation Records where residents have signed out for outings show that from 1/2/2022 to 3/9/2022 facility had driver and used van everyday for the exception of five days where log shows that no residents went out of facility. Transportation log notes on two days (1/9/2022 and 2/4/2022) facility did not have any driver available for transportation. Based on information gathered by records reviewed and interviews conducted, the allegation facility has not had a driver and van for over a year was deemed UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported. Regarding Allegation difficulty communicating with Administrator/ General Manager, the investigation consisted of interviews and record review. Per staff interviews two of five staff stated they have not had any issues with Administrator in question, while two of five staff stated they did not work with Administrator in question. One of five staff stated that Administrator was difficult with residents and rude to others. Interviews with residents stated that nine of ten residents didn’t have any issues with staff members. One of ten residents stated that they witnessed rude behavior from Administrator. CONTINUED ON 9099C LPA conducted a record review on Administrator 1 (AD1) and found documentation that AD1 had a Team Member Action Plan dated 3/25/2022 where they were written up for numerous complaints regarding dismissive and unresponsive behaviors through their duties as Executive Director. LPA noted in Staff file that AD1 no longer works at facility and was separated as of 5/3/2022. Based on information gathered by records reviewed and interviews conducted, the allegation difficulty communicating with Administrator was deemed UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported. Regarding allegation smoke alarms are going off in a problematic manner, investigation consisted of interviews, record review, and observations. Per Staff interviews, five of five staff stated they have not experienced problematic alarms and staff stated sometimes alarms will beep if battery is running low. Interviews conducted with residents revealed that ten of ten residents have had no issues regarding problematic smoke detectors. Facility Annual inspections conducted by Department in 2021, 2022 and 2025 show that facility had operating smoke detectors and fire alarms which were inspected and passed by Cosco Fire Protection. During visits on 1/12/22, 10/22/25 and 11/18/25 LPA Tirre did not observe any issues with smoke detectors. Based on information gathered the allegation smoke alarms are going off in a problematic manner was deemed UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported. An exit interview was conducted with Business Office Manager Timarie Morrisey and copy of reports were provided to facility representative.the state’s words, verbatim · CDSS document, Nov 24, 2025 · control 22-AS-20220105143830

Allegation investigated: Lack of care and supervision Facility failed to assess resident for change in condition Facility failed to provide timely medical attention

On this day Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced subsequent visit to deliver complaint investigation findings. LPA was granted entry by staff. LPA Tirre discussed purpose of the visit and allegations with Business Office Manager Timarie Morrisey. The investigation consisted of interviews and review of Residents (R1) records such as Physician’s report, Appraisal, incident report and death report. The Investigation was completed by department and revealed the following: On July 30, 2021, the department received allegations that facility had lack of care and supervision, facility failed to assess resident for change in condition, and facility failed to provide timely medical attention. Regarding allegation facility had lack of care and supervision, Based on Facility roster provided at time of complaint facility had 111 Team members of which 25 caregivers were assigned to Assisted living and along with 12 Medication Technicians who provide similar services. CONTINUED ON 9099C Unsubstantiated Resident 1’s (R1) Initial assessment dated July 23, 2019 notes that R1 needs no additional status checks, needs minimal prompting/ cueing/ reminding, requires one person assist/ escorting for meals, is independent with transfers and was marked zero under fall concern. R1’s Physician’s Report dated July 25, 2019 notes R1 having diagnosis of Dementia and Gait imbalance listed under other conditions. R1’s recent appraisal dated August 10, 2019 noted R1 to be in good health, some confusion/ forgetfulness and Ambulatory. R1’s previous Appraisal dated July 30, 2019 noted R1 to be in fair health, forgetfulness, weak physical disabilities and Non-Ambulatory. Interviews with Staff members stated that two of five staff members interviewed recalled R1 being independent, lived with wife at facility and was in Assisted living for period of time. Three of Five staff members interviewed were not aware of R1 and their care needs. Based on conflicting information gathered by records reviewed and interviews conducted, the allegation facility had lack of care and supervision was deemed UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported. Regarding allegation facility failed to assess resident for change in condition, during record review Department observed initial Assessment dated July 23, 2019 prior to R1 moving into facility on August 16, 2019. Department did not review any additional assessments in residents file. Department reviewed a incident report dated May 10, 2020 in which R1 had a unwitnessed fall inside apartment. Report stated that facility contacted Emergency Personnel and R1 was transported to hospital. Incident report did not notate whether R1 has had 2 or more falls within past 30 days. Report noted that R1 had a change in condition and would be reassessed prior to returning to community and be placed on 48 hour alert charting. Incident report also notated that R1’s service plan would be updated upon return. Resident did not return back to facility and facility was notified of R1’s passing June 3, 2020. Department reviewed Facility Death Report dated June 3, 2020 which stated that R1 was sent out to hospital on May 10, 2020 after a fall in facility. Report noted that R1 was transferred to a Rehabilitation hospital on May 23, 2020 for diagnosis of MRSA and gangrene to bilateral feet. Report noted on June 3, 2020 family contacted facility of R1’s passing. Department did not observe any additional incident reports for R1. CONTINUED ON 9099C Interviews with staff members stated that two of five staff members recall R1 having a fall and being sent out to hospital. Interviewed staff members also mentioned that they were unaware of R1 having a change of condition. Based on information gathered, the preponderance of evidence has not been met meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegation is deemed UNSUBSTANTIATED Regarding allegation facility failed to provide timely medical attention. Department conducted investigation into allegation and revealed the following: Resident 1 (R1) had one incident report in profile dated May 10, 2020, stating R1 had a unwitnessed fall inside apartment. Report stated that facility found R1 at 10:35AM. Report noted that R1 was alert and verbally responsive. Report stated that facility contacted Emergency Personnel and R1 was transported to hospital by paramedics at 10:45AM. Report noted that facility contacted family who is Power of Attorney, Primary Physician and Nurse Practitioner of status. Facility unable to provide call logs due to logs being reset after period of time. Initial complaint was received in July 2021 and time duration of calls are no longer on record. Interviews with staff members revealed that Five of five staff members state that staff are expected to answer pages between seven to ten minutes. Staff members interviewed were not the first responder staff at time of R1’s incident. Interviews with residents revealed that Seven of Ten residents have had to use a pendant and staff have arrived on average between five to ten minutes. Based on Record review and interviews conducted although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegation is deemed UNSUBSTANTIATED An exit interview was conducted with Business Office Manager and Copy of report was provided R1’s Assessment dated July 23, 2019 notes under ambulation that R1 requires one person total assist or wheelchair escort to and from activities. R1’s Morse Fall Scale noted R1 has a history of falls. Incident Reported Dated May 10, 2020 notes R1 had a unwitnessed fall inside bedroom and R1 was found between bedside and bathroom floor. Incident report also noted that R1 had general weakness. Department did not observe any needs and service plan for R1 or other incident reports for R1. Information provided by Witness 1 states R1 had a fall in March of 2020 in which R1 suffered small abrasions from fall. Witness states Facility did not update care plan after fall. Witness stated that R1 had a fall in May of 2020 and as a result of fall suffered a T12 Fracture in the middle of the back. Witness stated that R1 required surgery as result of fall. Based on information gathered, the preponderance of evidence has been met deeming the allegation Facility failed to develop fall prevention plan SUBSTANTIATED. See LIC 9099 for cited deficiencies as per Title 22 Division 6 of California Code of Regulations. An exit interview was conducted with Business office manager and a copy of report, along with Appeals rights, and copy of LIC 811 confidential names was provided.the state’s words, verbatim · CDSS document, Nov 24, 2025 · control 22-AS-20210730142004

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Dec 5, 2025

The Licensee shall ensure that a separate, complete & current record is maintained for each resident in facility or in central administrative location available to facility staff and to licensing agency. Based on investigation this requirement was not met as evidenced by facility failed in providing a Needs and Service Care Plan for R1 along with fall prevention plan This poses a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 24, 2025

Plan of correction: plan of correction (POC) Licensee to provide updated in service to staff regarding resident records. Licensee to provide signatures of in service by POC due date 12/5/2025

Allegation investigated: Resdent requires a higher level of care Responsible party placed a camera in residents room Administrator is rude to residents and staff

On this day Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced subsequent visit to deliver complaint investigation findings. LPA was granted entry by staff. LPA Tirre discussed purpose of the visit and allegations with Executive Director Mike Marion. The investigation consisted of interviews and review of Residents (R1) records such as Physician’s report, incident reports, Assessments and Needs and service plan. The Investigation was completed by department and revealed the following: On January 15, 2021, the department received allegations that resident requires a higher level of care, responsible party placed a camera in residents room and Administrator is rude to residents and staff. Regarding allegation Resident requires a higher level of care, the following resident records were reviewed: Physician’s report dated 7/1/2019, Appraisal dated 4/1/2020 stated R1’s primary diagnosis as Parkinson’s Disease with a secondary diagnosis of Mild cognitive impairment and is able to follow directions. R1’s records list R1 as non ambulatory with required full assist in bathing, toileting, grooming and medication management. CONTINUED ON 9099C Unsubstantiated R1’s Needs and service plan dated 8/30/2020 states R1 needs full assist with bathing, dressing and transferring. Care plan states R1 is a potential fall risk and requires two person assist. Care plan states R1 needs to be reminded to use walker and wheelchair. Facility incident reports dated 7/10/20, 7/11/20 and 1/12/21 state that resident had witnessed falls while being assisted by staff and family during transferring. Resident had two assessments conducted, one on 9/28/20 and 11/1/20. Resident Assessment Level of care remained at level 5 for both assessments. Based on staff interviews, Five staff members were interviewed regarding complaint allegations. one of five staff members (Staff 2) recalled that R1 was bed bound, difficult to transfer and needed total assist. S2 stated R1 used a wheelchair for support. Four of five staff members interviewed do not recall R1 and their level of care needed. Two of five staff interviewed (S4 & S6) stated that if a resident required a higher level of care, an assessment would be done especially if Resident needed a two person assist. Interview with witness 1 (W1) states that R1 is paralyzed and needs full assist. Based on conflicting information gathered the preponderance evidence has not been met deeming allegation resident requires a higher level of care to be UNSUBSTANTIATED meaning although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported. Regarding allegation responsible party placed a camera in residents room, LPA Tirre reviewed resident 1’s (R1) file and did not observe any photo waivers or camera release in facility records. One of five staff members (S2) interviewed stated they were aware of R1 but not aware of R1 having a camera inside facility apartment. Staff interviews stated that facility policy if resident has a camera in room, resident is to have a sign posted on door indicating camera and sign a waiver/ camera release which is placed inside residents file. Staff 2 did not recall a posted sign on R1’s door. Resident 1 lived at facility between 4/1/2020 and moved out 1/16/2021. Resident is no longer residing at facility. Based on information provided, allegation responsible party placed a camera in residents room, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegation is deemed UNSUBSTANTIATED. CONTINUED ON 9099C Regarding the allegation Administrator is rude to residents and staff, Investigation revealed the following: Interview with Witness 1, stated that staff 1 (S1) was acting Administrator at time complaint was received and is very unprofessional and rude towards people. Per interviews with five staff members, five of five staff members do not recall S1. LPA Tirre reviewed S1’s employee records and did not observe any notes or write up’s for misconduct. According to Staff 4, S1 worked out of corporate office and assisted inside facility for temporary period of time till a new Administrator came on board. Based on information provided, allegation Administrator is rude to residents and staff, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegation is deemed UNSUBSTANTIATED An exit interview was conducted with Administrator Mike Marion and a copy of report was providedthe state’s words, verbatim · CDSS document, Nov 18, 2025 · control 22-AS-20210115083303

Allegation investigated: Resident sustained a fall while in care

Licensing Program Analyst (LPA) Jenifer Tirre made a unannounced visit and met with Administrator Mike Marion to discuss the findings for the above allegations. The investigation consisted of interviews and review of Residents (R1) records such as Physician’s report, incident report and Assessment The Investigation was completed by department and revealed the following: On September 28, 2021, the department received allegations that Resident sustained a fall while in care. Based off Interviews with staff, three of five staff members stated that they worked at facility during time R1 resided but does not recall R1 and their level of care needed. Two of Five staff interviews stated that they were not working at that time R1 resided at facility. Interviews with witnesses revealed that one of two witnesses (W1) states that per a medic report for UCI Health, R1 had a witnessed ground level fall (glf). W1 was not present at facility at time of fall. Per interview with W2 revealed that R1 had a fall at facility on September 24, 2021, W2 heard a thud while R1 was in bathroom, W2 found R1 on floor. CONTINUED ON 9099C Unsubstantiated Witness called staff for assistance and R1 was transported to hospital. W2 stated that R1 returned to facility on September 28, 2021. W2 stated that R1 uses a walker and is able to complete Activities of daily living on their own. W2 stated they had no issues with level of care being provided for R1. Per Record review Facility Internal incident report dated September 24, 2021 states that R1 had a witnessed fall caused by seizure. Facility called 911 Emergency personnel. R1’s Physician’s Report dated June 17, 2020 states R1 is Ambulatory, has a diagnosis of Muscle Atrophy, receives skilled nursing services & therapy. Physician’s Report also states R1 is able to communicate needs, able to independently feed themselves, moderately independent in bathing and dressing. Per R1’S Advantage Assessment dated 6/23/20, indicates R1 is a moderate fall risk and requires stand by assistance while toileting and grooming. This department has investigated the allegation Resident sustained a fall while in care. Based on interviews and Records reviewed, investigation revealed conflicting reports. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator Mike Marion and a copy of report was providedthe state’s words, verbatim · CDSS document, Oct 22, 2025 · control 22-AS-20210928135349

Allegation investigated: Unlawful eviction

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegation listed above. LPA met with Executive Director Mike Marion and explained the reason for the visit. The investigation into the allegation, unlawful eviction, revealed the following. The facility served Resident 1 (R1) an eviction notice on July 17, 2025, for violating section 20.c. of the Admission Agreement, which states that, “Residents must not be disruptive, must not create unsafe conditions, and must not be physically or verbally abusive to other residents or staff.” The eviction notice cites 2 incidents for the reason for the eviction which occurred on June 25, 2025, and July 1, 2025. During each incident the eviction notice states R1 violated the conditions of the Admission Agreement. 7 out of 8 staff interviewed and 5 out of 8 residents interviewed verified each incident took place. R1 and the Administrator verified both incidents took place as stated in the eviction notice. Unfounded A review of the eviction notice shows the eviction notice had all the information required by Title 22, which governs all facilities licensed by the Agency. The eviction notice is lawful. During the investigation on September 4, 2025, the facility rescinded the eviction notice and provided R1 with a letter informing them of their decision. R1 verified they received and read the rescission letter. R1 is no longer required to leave the facility. Based on the evidence gathered the allegation, unlawful eviction, is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with the Administrator and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 3, 2025 · control 22-AS-20250722122317

Allegation investigated: Facility is not in good repair. Staff were verbally harassing resident. Facility does not provide a safe environment for residents.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator Mike Marion and explained the reason for the visit. The investigation into the allegation, facility is not in good repair revealed the following. It was reported that the exit door next to the dining room would not close or open properly and that there was a leak in the second floor laundry room which caused water to leak on the floor. LPA interviewed the Administrator who reported that the washing machines were recently repaired but they were not leaking. The Maintenance Director reported that washing machines were fixed but there were no issues with leaking water. The Administrator reported that the facility has numerous washing machines and there was never a time when residents did not have access to washing machines. LPA toured the facility and observed that the laundry room on the second floor was clean and both washing machines were in use and there was no water leaking. Unsubstantiated 1 out of 7 residents interviewed reported that the washing machines didn't work right and leaked. 5 out of 5 staff interviewed reported that there have been no issues with the washing machines and no one reported any issues to staff. It was reported that the door next to the dining room would not open and close properly and would remain open. 1 out of 7 residents reported that the door would always stay open and would not close all the way and would remain partially opened. 5 out of 5 staff reported they were unaware with any issues regarding the door next to the dining room. The Administrator reported that the door can always be used to exit but closes by itself and then is locked and cannot be opened without a key from the outside. The Maintenance Director reported that the door is functioning properly and there have been no reports about it not working properly. LPA inspected and used the door. LPA observed the door functions properly, after someone exits, it closes by itself and is locked to the outside. It was reported that the carpet in the dining room was torn and a trip hazard. The Administrator reported that the carpet was replaced in the dining room. The Administrator reported that the carpet had normal wear and tear and had been scheduled to replaced but was unaware of any trip hazards. LPA interviewed 6 out of 7 residents who reported they never noticed any tears or rips in the carpet. 5 out of 5 staff interviewed reported the carpet was old but was not a trip hazard. The maintenance director reported that flooring is replaced as needed prior to it becoming a safety hazard. LPA observed that all of the flooring in the facility during the visit was in good repair. LPA observed no deficiencies regarding the physical plant during the visit. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, The investigation into the allegation, staff were verbally harassing resident, revealed the following. It was reported that 2 kitchen staff members and the Administrator verbally harassed Resident 1 (R1). R1 reported they were yelled at and spoken to in an inappropriate manner. Staff member 1 and Staff member 2 denied the allegations. The Administrator denied the allegations. No details as to the time and date of the incident were provided. 5 out of 5 staff members interviewed reported they have never witnessed any staff speaking inappropriately to any resident. 7 out of 7 residents interviewed reported they have never witnessed or been spoken to in an inappropriate manner by staff. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, The investigation into the allegation, facility does not provide a safe environment for residents, revealed the following. It was reported that the door by the kitchen, which leads to the parking lot is left open at night and people who do not live at the facility come into the facility and pose a threat to residents in care. 5 out of 5 staff interviewed reported the door is always closed and no one who isn't a resident has come into the facility though the door. 1 out of 7 residents interviewed reported that they saw someone who did not live at the facility come in through the door at night. No specific details were provided in this report. 6 out of 7 residents reported they have never seen anyone other than residents use the door. The Administrator reported that the door is working properly and a key is required to open the door from the outside. The Administrator reported that all night staff are aware and have been trained that all doors are required to closed and locked to the outside, except during normal business hours. LPA observed the door functions properly, after someone exits, it closes by itself and is locked to the outside .A review of incident reports from the facility for the months of August 2025 and September 2025 do not show any incidents that are related to the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with the Administrator and a copy of the report provided.the state’s words, verbatim · CDSS document, Oct 3, 2025 · control 22-AS-20250812094242

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced case management visit. LPA met with Executive Director Mike Marion and explained the reason for the visit. During the investigation of complaint # 22-AS-20250722122317 it was revealed that a Resident (R2) was coughing and hacking in the dining room during mealtimes. 8 out of 8 residents reported that R2’s coughing and hacking has been occurring since January 2025, except for March 2025 when R2 was not present at the facility. 5 out of 5 staff interviewed verified this report. During the LPA’s initial 10-day visit, LPA witnessed R2 coughing and hacking and heard it from outside the dining room while in the lobby of the facility. 6 out of 8 residents interviewed reported this issue to the resident council and the resident council reported this issue at least 3 times to the Executive Director since January 2025. The Executive Director verified this report. 6 out of 8 residents reported that no action has been taken by the facility to address this issue. The Executive Director stated no action has been taken because R2 has the right to be in the dining room. The Executive Director reported that according to R2’s physician R2 is not sick, and coughing and hacking is most likely a nervous tick. During the investigation of complaint # 22-AS-20250722122317 it was discovered that there were two incidents involving a resident yelling at another resident and at a staff member. The incident on June 25, 2025, and the incident on July 8, 2025 were verified to have taken place. 8 out of 8 residents interviewed, 5 out of 5 staff interviewed and the Executive Director verified these incidents took place. Neither incident was reported to the Agency. The facility is required to report, “Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.” As stated in California Code of Regulations (CCR) Title 22 Division 6, 87211(a)(1)(D). In addition, all residents have the right to, “To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.” As stated by CCR, Title 22 Division 6, 87468.1 (a)(2). The facility has failed to address the issue of R2 coughing and hacking in the dining room, which violates the personal rights of the other residents at the facility. 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 (LIC809 and LIC809D) along with a copy of the appeal rights was provided to the facility representative.the state’s words, verbatim · CDSS document, Aug 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Aug 29, 2025

To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement has not been met as evidenced by The resident council has brought up the issue of R2 coughing and hacking during mealtimes disturbing other residents since January 2025 and the facility has not taken any action on addressing the issue, which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Licensee agrees to address the issue of the Resident coughing and hacking by completing a written plan on making available the private dining room available to residents so they can have the option to eat in a dining room without any disturbances. Licensee to submit the plan by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Sep 8, 2025

(a) Each licensee shall furnish to the licensing agency…(1) A written report shall be submitted to the licensing agency (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below…This requirement has not been as evidenced by the facility did not report the incidents involving resident yelling that took place on June 25, 2025 and July 8, 2025 to the Agency. This poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Licensee agrees to train staff on reporting requirements and to sign a statement of understanding of CCR 87211. Proof of training and statement of understanding to be submitted to the LPA by the POC due date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Michael Tea made an unannounced visit for the purpose of conducting a health and safety check. LPA was greeted and granted entry by staff. LPA met with Executive Director (ED) Mike Marion and discussed the purpose of the visit. During today's visit LPA followed up on a death report for Resident 1 (R1) dated August 20, 2025, received by CCLD on August 22, 2025. LPA toured the facility and conducted a health and safety check on all residents in care. LPA observed no health and safety issues. LPA obtained pertinent documentation such as Resident Face sheet, Identification and Emergency Information, Medical Assessment, Preplacement Appraisal, Release of Medical Consent, POLST, Facility Resident Assessment, Needs and Service Plans, R1's Narrative Charting Notes and MAR. LPA filled out the questionable death report. An exit interview was conducted with ED Marion and a copy of this report along with a list of confidential names was left with the facility.the state’s words, verbatim · CDSS document, Aug 26, 2025

Type of visit: Required - 1 Year

On July 21, 2025, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced annual inspection of the facility. Upon arrival, LPA Haddadin was greeted by the Executive Director (ED), Mike Marion, who granted entry and was advised of the purpose of the visit. Together, they toured the interior and exterior of the three-story building. The facility is licensed for thirty (30) ambulatory residents and one hundred fifty-five (155) non-ambulatory residents, which includes fifteen (15) bedridden residents. The facility has an approved hospice waiver for thirty (30) residents. The total capacity is 185 residents, and the census at the time of inspection was 166. During the visit, residents were observed in the dining room enjoying breakfast, while others participated in scheduled physical activities or rested in their rooms. Eight resident rooms were chosen randomly for inspection and were found to be furnished with a bed, a chair, and clean linens. The rooms also provided adequate storage space and were free of tripping hazards. Exterior portions of the facility, including the courtyards, were well-maintained. Furnishings were in good repair, pathways were clear of hazards, and the grounds appeared safe and inviting with a shaded seating area. Eleven fire extinguishers were checked and observed to be fully charged, with the indicators in the green zone. The hot water temperature in the randomly selected rooms was measured between 113.8∘F and 115.5∘F, meeting regulatory requirements. The facility maintains sufficient food supplies, including at least a two-day supply of perishable items and a seven-day supply of nonperishables. The kitchen was observed to be in good repair, and all major appliances were operational. Cleaning supplies were stored securely and were inaccessible to residents. All medications are kept locked in the medication room on the third floor, inaccessible to residents in care. A review of residents' files showed no discrepancies. Staff files were complete, each containing the required documentation. Records further confirmed that the facility conducted its annual emergency drill on June 25, 2025. Based on today's visit and observations, no deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted with Mr. Marion, and a copy of this report was provided to him.the state’s words, verbatim · CDSS document, Jul 21, 2025

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Eboni Bentley and Jessica Cho arrived at the facility unannounced to deliver amended complaint investigation findings for Complaint Control No 22-AS-20250703124044 for visit date July 8, 2025 from 8am-1:50pm. LPAs were greeted and granted entry after stating the purpose of the visit to Executive Director (ED) Mike Marion. An exit interview was conducted with Executive Director Mike Marion, and a copy of this report including the amended complaint investigation report were provided at the end of the visit.the state’s words, verbatim · CDSS document, Jul 14, 2025

Allegation investigated: Staff are not providing adequate food service to residents.

Licensing Program Analysts (LPAs) Eboni Bentley and Jessica Cho arrived at the facility unannounced to initiate the complaint investigation into the above allegations. LPAs were greeted and granted entry after stating the purpose of the visit to Business Office Manager (BOM) Timarie Morrissey and obtained the following documentation: Resident Roster, Personnel Report Summary, Employee Contact Information, Menus, Face Sheets and Physician’s Reports for seventeen (17) residents. The following was determined based on observations, interviews, and record review: It is alleged that staff are not providing adequate food service to residents. Based on LPA’s observations of one meal service approximately 8:30-9:00am, all residents were observed eating the items listed on the main dining menu which was the breakfast quesadilla with toast, fresh fruits, hot or cold cereal with eggs made to order, choice of sausage, bacon, ham and breakfast potatoes. Unfounded LPAs were given a tour of the kitchen by Dining Supervisor Kathy Ofeguede and observed ample amount of perishables and non-perishable food items. LPAs observed a variety of proteins such as chicken, beef, pork, fish which include salmon, tilapia, shrimp, and etc. Based on the interviews, sixteen out of the sixteen residents and three out of the three staff indicated that residents are served three fresh and nutritious meals a day, alternative options are available upon request, the menu is typically followed, meals meet the food groups with a variety of proteins served, and snacks are available in the Bistro throughout the day. Based on the review of weekly and daily menus, residents are provided with a variety of adequate meals with alternative options available upon request. Per the menus for the weeks of June 22nd, June 29th, and July 6, 2025, salmon is typically served once a week on Fridays, however there is a second option available for lunch and dinner as well as the daily menu alternatives. Therefore, based on the observations made, interviews which were conducted, and the records that were reviewed, 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 following allegation: Staff are not providing adequate food service to residents, is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Mike Mario and Business Office Manager Timarie Morrissey, and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Jul 8, 2025 · control 22-AS-20250703124044

Type of visit: Required - 1 Year

On February 24, 2025 Licensing Program Analyst’s (LPAs) Jenifer Tirre and Edward Kim conducted an unannounced visit for the purpose of conducting a required annual visit using the CARE Inspection Tool. LPA’s were greeted by staff and granted entry after stating the purpose of the visit. Administrator (AD) Mike Marion was present to assist with the facility inspection on today's date. The facility is licensed for thirty (30) Ambulatory residents, One hundred fifty five (155) Non Ambulatory which 15 bedridden with approved hospice waiver for thirty (30) residents. Currently, there are twelve (12) Hospice residents present during today’s visit. Facility is a three story building with 155 units combined in both Assisted Living and Memory Care. At around 8:15 AM, LPA’s Tirre and Kim conducted a tour of the physical plant accompanied by Director of sales Susan Peterson, and the following was observed: Facility has an enclosed pool located in outside patio area. Rooms which were inspected observed to be furnished Beds and bedding supplies were in operational condition, lighting was provided, and storage for the Resident’s personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured between 108.5 to 115.5 degrees F. A comfortable temperature of 70 degrees F. was maintained in the facility. Residents were observed relaxing in common areas, eating on the dining room, and relaxing in bistro as well as relaxing in bedrooms. Memory care residents were observed engaged in group exercise activities. The kitchen was inspected, and facility has sufficient perishable and non-perishable foods as well as supply of emergency food and water. Storage areas for sharps objects and cleaning supplies were stored and not accessible to residents. Facility has multiple fire extinguishers. During today’s visit Ten (10) fire extinguishers were observed to be fully charged and mounted. A review of the Medication Records Administration (MAR) was conducted, and LPA’s observed the records are in compliance. CONTINUED ON 809C During the visit, LPA’s observed the facility's infection control practices. LPA’s observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted. LPA observed First Aid Kit was maintained. A working landline phone was operational. Facility has operating smoke detectors and audible alarms which LPA's observed Last fire inspection paperwork was completed by Fire Safety Service, The last fire drill was conducted on January 28, 2025. The facility has current liability insurance on file effective 7/1/2024 – 7/1/2025. LPA’s observed four evacuation chairs located on top of third story stairwells. During today’s visit a review of Seventeen (17) residents (R1-R17) service files and Ten staff (S1-S10) personnel files revealed to be complete. The facility has the current administrator's certification on file for Michael Marion Expiration 9/12/2025. No deficiencies during this inspection visit. An exit interview was conducted with Executive Director Mike Marion, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 24, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced case management visit to Huntington Terrace. LPA was greeted, granted entry, and explained the reason for the visit. LPA met with Business Office Manager Timarie Morrisey. The purpose of today's visit was to conduct a Case Management visit to discuss self reported incident that was sent to the Orange County Adult and Senior Care Regional Office on September 30, 2024 and to gather information and documents. On today's visit LPA Tirre discussed the incident regarding Resident 1 (R1) with Business Office Manager Timarie Morrisey. LPA Tirre obtained records related to incident such as bank statements, copy of deposit, facility staff roster, facility resident roster, and Resident physicians report. LPA conducted interviews with Business Office Manager and R1. No deficiencies observed during visit. A exit interview was conducted with staff representative and a copy of report was provided.the state’s words, verbatim · CDSS document, Oct 1, 2024

Allegation investigated: -Staff speaks inappropriately towards a resident. -Staff do not comply with an infection control practice. -Staff behavior is preventing a resident from sleeping.

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA arrive at facility was greeted by receptionist and granted entry. LPA spoke with Timarie Morrissey, Business Office Manager and explained the purpose of the visit. Morgan Ware, Executive Director Specialist arrived shortly after and met with LPA. Findings are based upon this investigation which included interview conducted, tour of physical plant of facility and review of records. It is alleged that staff speak inappropriately towards a resident. Interview with 8 of 8 residents that resided in the surrounding cottages to resident (R1) indicated that they have not heard or witnessed staff speaking inappropriately to R1. Furthermore, residents indicate that they have not been talk to Continued on LIC9099-C Unsubstantiated inappropriately from any staff at the facility. Interview with 3 of 3 staff indicated that staff 1 (S1) and staff (S2) went to R1’s cottage to retrieve medication and R1 was upset and not cooperating. S2 indicated that they were there to be a second pair of eyes and we observant to the interaction between R1 and staff. Staff indicated that R1 had been out of the community and upon return did not return his medication to staff. S2 stated that R1 was very upset and was not cooperating with staff and staff was simply trying to retrieve the medication. Record review revealed that R1 is on med management with the facility. It is alleged staff do not comply with an infection control practice. Interview with staff (S3) indicated that facility had 15 residents who tested with covid in early July and by July 29, 2024, all the 15 were cleared. S3 stated that they called The Public Health Department and informed them of the positive test and were informed to only test residents that are exhibiting symptoms as well as to close the dinning hall for precaution. Therefore, mass testing was not required. Per directive from public health dining to resume operations as usual on July 27, 2024. Facility was following protocol for Department of Social Services as well as the Department of Public Health. We were also told that it is considered an out break when there is 20% of the census positives. Which in this case it was not because 20% would be about 32-33 residents. It is alleged that staff behavior is preventing a resident from sleeping. Interview with R1 did not give any indications about being disturbed at night or not being able to sleep. Interview with 8 of 8 residents indicated that they don’t hear any noise or disruption that may prevent them from sleeping. Resident also indicated that it is rare that staff come to their bedroom late at night. Interview with S3 stated that R1 has always been a night owl since they move in the facility and has always had a hard time sleeping till late at night. Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with the facility representative and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Aug 26, 2024 · control 22-AS-20240722135716

Allegation investigated: Staff does not ensure reporting requirements are met for residents in care

On this day Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to follow up on complaint investigation. LPA discussed purpose of the visit and allegations with Executive Director Zehra Syed. The Investigation consisted of obtained records and interviews with Huntington Terrace Staff. On 10/06/2023 the department received allegations Staff does not ensure reporting requirements are met for residents in care. The Investigation was completed by the department and revealed the following: based on record review facility documents in several areas where they report changes based on resident’s care and needs. Facility uses a program called ICON Voice Friend where mass messages are sent out to residents, families and staff notifying of changes in the community such as reporting Covid or any other infectious diseases in the community. Record review also revealed that facility staff fill out end of day reports to update staff members of changes in condition of residents. CONTINUED ON 9099C Unsubstantiated The end of day reports are provided by Med Tech’s to communicate with care giving team of updates. Record review reveals that facility sends out fax confirmations of incident reports submitted to Licensing Agency and Primary Care Providers of incidents with residents. LPA reviewed recent reports and fax confirmations documented. Based on staff interviews investigation revealed that when an incident occurs with a resident, facility staff assess situation, if serious condition or at request of resident; resident may be sent out to hospital, family are contacted in conjunction with incident, Care Providers are notified as well as Licensing Agency. 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 above allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director and copy of this report along with appeal rights was left at facility.the state’s words, verbatim · CDSS document, Apr 26, 2024 · control 22-AS-20231006141818

Allegation investigated: Staff failed to meet resident's needs. Staff is not responding timely to resident calls Facility has insufficient staff Facility staff are not dispensing medication as prescribed Personal Rights

Licensing Program Analyst (LPA) Jenifer Tirre made a unannounced visit and met with Administrator Zehra Syed to discuss the findings for the above allegations. The investigation consisted of interviews and review of documentation such as Physician’s report, Medication Order, Physician Visit form and Resident Assessments. The Investigation was completed by department and revealed the following: On 12/16/2020 the department received allegations that facility staff failed to meet resident’s needs, staff is not responding timely to resident’s calls, facility has insufficient staff, facility staff are not dispensing medication as prescribed and personal rights violation. Based off interviews with residents, four of four residents have stated facility is meeting their needs and feel safe with staff at facility. Interviews with residents revealed that two of four residents state that staff answer their calls in timely manner averaging 10 minutes response time. Interviews with residents revealed that one of four residents feel that facility has had insufficient staffing previously at facility. Interviews with residents also revealed that three of four residents receive prescribed medications in timely manner. CONTINUED 9099C Unsubstantiated Based off interviews and statements conducted with staff, six of six staff state they try to meet the needs of their residents as best as they can, respond to calls within 10 to 15 minutes and has sufficient staff on site. Interviews revealed that during 2020 to 2021, facility used staffing agencies to help fill in shifts. Interviews with Four of Four staff responsible for medications stated resident 1 received medication as prescribed however mentioned that resident 1 medication times would vary depending on resident’s schedule. Interviews with staff revealed resolution in Resident 1’s medication schedule. Interview with Resident 1 revealed that Resident 1 stated they have no issues with staffing and stated staff assist with ADL’S such as showering, toileting, medication and transporting to facility dining area. Interview revealed that resident confirms if they have an issue with facility, they bring attention to issue. Resident confirms they like living at facility and feels safe in facilities care. During investigation, LPA reviewed documentation and investigation revealed the following: Facility Assessment records dated from 3/29/2020 to 11/28/2023 revealed that Resident 1 has daily status checks 4 times per shift, 12 times a day. Facility Assessments are updated every 6 months. Hospice Records revealed that Resident 1 received weekly showering and wound care from 9/16/2020 to 12/23/2020. Facility notification revealed discontinued Hospice care for Resident 1 on 1/29/2021. This department has investigated these allegations and based on LPA’s observations, and interviews which were conducted investigation revealed conflicting reports. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegations are all deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator and a copy of report along with LIC 811 Confidential Names List was provided.the state’s words, verbatim · CDSS document, Dec 13, 2023 · control 22-AS-20201216092545

Allegation investigated: Staff did not seek medical attention for resident in a timely manner. Staff did not ensure that resident's dietary needs were met.

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced inspection to deliver findings on a complaint investigation. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Administrator Zehra Syed. During course of the investigation, the Department interviewed staff, residents and witnesses as well as review and obtained pertinent documentation. The investigation conducted revealed the following: It was alleged staff did not seek medical attention for resident in a timely manner and staff did not ensure the resident’s dietary needs were met due to Resident 1 (R1) being hospitalized with a stroke and dehydration. R1 was admitted to the facility on May 14, 2020. Shortly after being admitted staff reported R1 became verbally aggressive and threatening to leave the facility. The following day staff referred R1 for a psych evaluation and transferred R1 to Anaheim Global Hospital for a Geri Psych evaluation. Records reviewed show that Huntington Terrace staff were receiving detail updates from Anaheim Global staff regarding R1’s progress. CONTINUED ON 9099C Unsubstantiated On May 24, 2020 R1 was transported back to Huntington Terrace from Anaheim Global. Upon arrival, R1 was noted to be lethargic and weak which was consistent with progress report updates received in the days prior. The staff and R1’s responsible party believed at the time R1 to be over medicated. Huntington Terrace staff reported R1’s condition to an approved Doctor and on May 25, 2020 received orders to cut R1’s medication dose in half. On May 26, 2020 staff noticed a change in R1’s condition and informed R1’s responsible party and approved Doctor. R1’s approved Doctor recommended R1 be sent out to the hospital. Staff reported they offered to call 9-1-1 but R1’s responsible party declined, instead stating they would take R1 to the hospital. Interviews conducted with R1’s responsible party disputed staff’s reports, stating that facility staff offered to have R1 assessed by the facility doctor a few days later on May 28, 2020 instead of taking R1 to the hospital. R1’s responsible party declined and took R1 to the hospital after consulting with a family member in the medical field. R1’s preplacement appraisal completed on May 24, 2020 notes R1 was able to bear weight using a front wheel walker with assistance. R1 was admitted to the hospital on May 26, 23 at 5:13PM and was diagnosed with dysphagia, Lacunar Stroke and Right Hemiparesis. The medical records reviewed notes that R1’s responsible party told hospital staff R1 was lethargic and weak upon being picked up from Geriatric Psych. Hospital records reviewed further notes that R1’s responsible party informed hospital staff R1 called them on May 23, 2020 and reported having right sided weakness, a day prior to R1 being transported back to Huntington Terrace. R1 was further diagnosed with an Acute kidney injury due to dehydration which was noted to be resolved as of May 28, 2020 with IV hydration. Due to the dysphagia R1 was ordered to have a feeding tube and required pureed diet and thickened liquids. Findings from R1’s chest X-Ray notes chronic lung changes compatible with previous granulomatous. Per facility records, R1 was listed as participating in the facility’s meal club due to requiring assistance with feeding and having a special diet upon return on May 24, 2020. Facility meal attendance tracking records note that R1 refused to eat dinner the night of May 24, 2020. The following day R1 was noted to eat Lunch but did not eat dinner. A day later, records show R1 ate all three meals in their room. Although facility staff did not immediately call 9-1-1, interviews and records obtained confirmed staff were communicating with R1’s approved Doctor regarding R1’s condition and were following physician orders. It remains unclear at this time if the actions taken by the facility were sufficient to determine if timely services were sought. CONTINUED ON 9099C Furthermore, although R1 was refusing meals, documentation observed and interviews conducted could not corroborate if R1’s dietary needs were not being met due to R1’s choice to refuse services or facility staff neglect. Therefore, based on a records reviewed and interviews conducted, the allegations that Staff did not seek medical attention for resident in a timely manner and Staff did not ensure that resident's dietary needs were met was determined to be Unsubstantiated. Although the allegations may have happened or may be valid; there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator and a copy of this report was provided at the time of exit.the state’s words, verbatim · CDSS document, Oct 27, 2023 · control 22-AS-20200602120131