Iris Guest Home

Type of visit: POC

Licensing Program Analyst (LPA) Sam Haddadin conducted an unannounced Plan of Correction (POC) visit to Iris Guest Home on 08/07/2026 to follow up on deficiencies cited on 08/04/2026. LPA was greeted by Administrator (AD) Jean Veracruz, granted entry into the facility, and explained the reason for the visit. LPA toured the interior and exterior of the facility and conducted a health and safety check, including all residents’ bedrooms. LPA also conducted a medication audit for all four current residents in care. LPA verified that the deficiency cited under Title 22 Regulation section 87309(a), Storage Space, which states, “Disinfectants, cleaning solutions, poisons, firearms, and other items that could pose a danger if readily available to residents shall be stored where inaccessible to residents,” has been cleared. LPA observed that the cabinet containing chemicals, sharps, and cleaning supplies was secured and inaccessible to residents in care. LPA verified that the deficiency cited under Title 22 Regulation section 87555(b)(26), General Food Service Requirements, which states, “Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises,” has been cleared. LPA observed that the facility maintained a sufficient two-day supply of perishable food to meet the needs of the residents in care. Based on observations made during today’s visit, all deficiencies cited on 08/04/2026 have been cleared, and no deficiencies are being cited. An exit interview was conducted with Administrator Jean Veracruz, and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Aug 7, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Sam Haddadin conducted a Case Management visit to the facility for the purpose of conducting a health and safety check. Upon arrival, LPA was greeted by Administrator (AD) Jean Veracruz, who granted entry into the facility. During the health and safety check, LPA observed a cabinet containing chemicals, sharps, and cleaning supplies that was unlocked and accessible to residents in care. AD acknowledged the cabinet was not secured. This observation does not comply with California Code of Regulations, Title 22, Section 87309(a), Storage Space, which requires disinfectants, cleaning solutions, poisons, and other items that could pose a danger if readily available to residents to be stored where they are inaccessible. LPA also inspected the facility’s food supply and observed that the facility did not maintain a minimum two-day supply of perishable food for the residents in care. AD acknowledged that the available perishable food supply was insufficient. This observation does not comply with California Code of Regulations, Title 22, Section 87555(b)(26), General Food Service Requirements, which requires facilities to maintain a minimum one-week supply of nonperishable food and a minimum two-day supply of perishable food on the premises. Both resident bathrooms were observed to be clean and operational. Hot water temperatures were measured between 111.5 and 113.1 degrees Fahrenheit. Deficiencies are being cited during today’s visit pursuant to Title 22 of the California Code of Regulations. An exit interview was conducted, and a copy of this report, along with appeal rights, was provided.the state’s words, verbatim · CDSS document, Aug 4, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Aug 7, 2026

87309(a)Disinfectants, cleaning solutions, poisons, firearms, and other items that could pose a danger if readily available to residents shall be stored where inaccessible to residents. This requirement was not met as evidenced by: Based on observation, the Licensee failed to ensure that chemicals, sharps, and cleaning supplies were inaccessible to residents. During the visit, LPA observed an unlocked cabinet containing chemicals, sharps, and cleaning supplies. The cabinet was accessible to residents in care. This poses an immediate health and safety risk to residents.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: The Administrator secured the cabinet containing the chemicals, sharps, and cleaning supplies during the visit. The Licensee agreed to conduct staff training regarding the proper storage of hazardous items and submit proof of training to the Licensing office by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87555(b)(26) · Plan of correction due date: Aug 7, 2026

87555(b)(26) General Food Service Requirements Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by: Based on observation the Licensee failed to maintain a minimum two-day supply of perishable food on the premises. During the visit, LPA inspected the facility’s food supply and observed that there was not enough perishable food to meet the needs of the residents in care for a minimum of two days. The Administrator acknowledged that the facility’s perishable food supply was insufficient. This poses a potential health, safety, and personal-rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: The Licensee agreed to purchase sufficient perishable food to maintain a minimum two-day supply and submit photographs and purchase receipts to the LPA by the POC due date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Sam Haddadin conducted a Case Management visit to the facility for the purpose of completing a health and safety check. Upon arrival, LPA was greeted by Administrator (AD) Jean Veracruz, who granted entry into the facility and was informed of the purpose of the visit. During the visit, LPA observed four residents in care. All residents were asleep at the time of the visit. LPA, accompanied by facility staff, toured the interior of the facility and reviewed resident medications and records. No discrepancies were identified. Both resident bathrooms were observed to be clean and operational. Hot water temperatures were measured between 111.5 and 113.1 degrees Fahrenheit. Cleaning supplies were secured in a locked cabinet under the kitchen sink, and knives and other sharp objects were secured in the caregiver’s room. The facility maintained an adequate food supply consisting of at least a two-day supply of perishable food and a seven-day supply of nonperishable food. The facility had operating electricity, gas, and water services. Kitchen appliances were checked and observed to be operational and in good working condition. The required “See Something, Say Something” poster (PUB 475) was posted in the hallway. The fireplace in the living room was equipped with a protective screen. Based on the observations made during today’s visit, no deficiencies are being cited.An exit interview was conducted with AD Jean Veracruz, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 31, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sam Haddadin conducted an unannounced visit to the facility for the purpose of conducting the required annual inspection. Upon arrival, LPA was greeted by Administrator (AD) Jean Veracruz, who granted entry into the facility. The facility is licensed for six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility has an approved hospice waiver for five (5) residents. At the time of today’s visit, there were three (3) residents receiving hospice services. The facility is a single-story residence with a detached garage. The facility consists of four bedrooms, including three shared resident bedrooms and one staff bedroom, and two full bathrooms. During the inspection, LPA toured the interior and exterior areas of the facility. All bathrooms were observed to be clean, sanitary, and operational. Hot water was tested and measured between 109.9 degrees Fahrenheit and 112.2 degrees Fahrenheit. The kitchen was observed to be clean and organized, and the facility had an adequate food supply, including at least a two-day supply of perishable food and a seven-day supply of non-perishable food. Knives and cleaning supplies were secured in a locked cabinet located in the hallway and were inaccessible to residents in care. All kitchen appliances were observed to be operational and in working condition. The fire extinguishers were observed to be fully charged. Smoke detectors and carbon monoxide detectors were tested and found to be operational. The first aid kit contained the required supplies. Medication was observed to be locked and secured in a cabinet located in the hallway. LPA inspected the detached garage and observed that it was being used for storage. Residents’ bedrooms were inspected and contained the required furnishings. The backyard included a covered patio with a seating area for residents. No bodies of water were observed on the premises. The exit gate was operational, and no hazards or obstructions were observed in the backyard. A review of resident files revealed no discrepancies. Staff files were also reviewed and found to be complete, with the required documentation maintained in each file. Based on observations made during today’s inspection, no deficiencies are being cited pursuant to Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to AD Jean Veracruz at the conclusion of the inspection.the state’s words, verbatim · CDSS document, Jul 7, 2026

Allegation investigated: Staff handled resident in an aggressive manner Staff yell at resident Staff do not safeguard resident’s personal belongings Staff mishandle resident's P&I funds

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegations. LPA met with Administrator (AD) Jean Veracruz, discussed the purpose of the inspection, and explained the allegations. The investigation into the allegations that staff handled resident in an aggressive manner, staff yell at resident, staff do not safeguard resident’s personal belongings, and staff mishandle resident's P&I funds revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, and obtained and reviewed copies of the resident roster and staff roster. CONTINUED Unfounded Regarding the allegation that staff handled resident in an aggressive manner: it was alleged that staff hit residents. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. Based on observations, documents, and an interview with AD, the events alleged did not occur at this facility. These events will be investigated under the correct facility. Regarding the allegation that staff yell at resident: it was alleged that staff yell at, harass, and speak badly about residents. Based on the information obtained, the events alleged did not occur at this facility. These events will be investigated under the correct facility. Regarding the allegation that staff do not safeguard resident’s personal belongings: it was alleged that staff steal residents’ property and food. Based on the information obtained, the events alleged did not occur at this facility. These events will be investigated under the correct facility. Regarding the allegation that staff mishandle resident's P&I funds: it was alleged that staff use residents’ money for their own use. Based on the information obtained, the events alleged did not occur at this facility. These events will be investigated under the correct facility. The Department has investigated the above allegations and found them to be Unfounded, meaning the allegations were false, could not have happened, or are without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 22-AS-20260624103416

Type of visit: POC

Licensing Program Analyst (LPA) Sam Haddadin conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on 06/26/2026. LPA was greeted by Administrator (AD) Jean Veracruz, granted entry into the facility, and explained the reason for the visit. LPA toured the interior and exterior of the facility and conducted a health and safety check, including all residents’ bedrooms. LPA also conducted a medication audit for all four current residents in care. LPA verified that the deficiency cited under Title 22 Regulation section 87303(a), Maintenance and Operation, which states, “The facility shall be clean, safe, sanitary and in good repair at all times,” has been cleared. The broken closet door located directly behind the resident’s head was repaired. LPA verified that the deficiency cited under Title 22 Regulation section 87303(e)(6), Maintenance and Operation, which states, “Toilet, handwashing and bathing facilities shall be maintained in operating condition,” has been cleared. Bathroom 1 now has a working sink and running hot water. LPA verified that the deficiency cited under Title 22 Regulation section 87309(a), Storage Space and Access, which states, “The licensee shall ensure that disinfectants, cleaning solutions, knives, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage,” has been cleared. LPA observed that all knives, sharps, and cleaning supplies are now secured and locked in the laundry room. Based on today’s visit, all deficiencies cited on 06/26/2026 have been cleared. An exit interview was conducted with Administrator Jean Veracruz, and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Jun 30, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Sam Haddadin conducted a Case Management visit to the facility for the purpose of conducting a health and safety check. Upon arrival, LPA was greeted by Administrator (AD) Jean Veracruz, who granted entry into the facility. During the visit, LPA observed four residents in care. LPA toured the residents’ bedrooms and observed that the bedrooms contained the required furnishings and accommodations. However, Bedroom 1 had a broken closet door located directly behind the resident’s head area, which posed an immediate health and safety risk to the resident in care. LPA also observed that Bathroom 1 had a nonworking sink and no running hot water, which posed an immediate health and safety risk to residents in care. LPA checked the hot water temperature in Bathroom 2, which measured 116.9 degrees Fahrenheit. During the inspection of the kitchen, LPA observed knives and sharps unsecured under the kitchen sink, along with cleaning supplies, which posed an immediate health and safety risk to residents in care. Deficiencies are being cited during today’s visit per Title 22 of the California Code of Regulations. An exit interview was conducted, and a copy of this report, along with appeal rights, was provided.the state’s words, verbatim · CDSS document, Jun 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jun 29, 2026

87303(a), Maintenance and Operation, states: “The facility shall be clean, safe, sanitary and in good repair at all times.” This requirement was not met as evidenced by: Based on observation, LPA observed Bedroom 1 had a broken closet door located directly behind the resident’s head area. This posed an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Jun 26, 2026

Plan of correction: Plan of Correction: The Licensee/Administrator shall repair or remove the broken closet door to ensure the resident’s bedroom is maintained in safe and good repair. Proof of correction, including photos and/or repair invoice, shall be submitted to LPA by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: HSC87303(e)(6) · Plan of correction due date: Jun 29, 2026

87303(e)(6), Maintenance and Operation, states: “Toilet, handwashing and bathing facilities shall be maintained in operating condition.” This requirement was not met as evidenced by: Based on observation, LPA observed Bathroom 1 had a nonworking sink and no running hot water. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 26, 2026

Plan of correction: The Licensee/Administrator shall ensure Bathroom 1 sink is repaired and maintained in operating condition, and that hot water is available to residents. The Licensee/Administrator shall submit proof of correction, including photos, repair invoice, and a hot water temperature log, to LPA by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87309(a) · Plan of correction due date: Jun 22, 2026

87309(a), Storage Space and Access,"the licensee shall ensure that disinfectants, cleaning solutions knives,tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage" This requirement was not met as evidenced by: Based on observation, LPA observed knives and sharps unsecured under the kitchen sink, along with cleaning supplies. The items were accessible to residents in care and posed an immediate health and safety risk.the state’s words, verbatim · CDSS document, Jun 26, 2026

Plan of correction: The Licensee/Administrator shall immediately remove and secure all knives, sharps, cleaning supplies, disinfectants, and other hazardous items in locked storage. The Licensee/Administrator shall conduct staff training regarding proper storage of hazardous items and submit proof of correction, including photos and staff training documentation, to LPA by the POC due date.

Allegation investigated: Staff sexually abused resident while in care Staff handled resident in a rough manner Staff hit resident with objects Facility is malodorous Facility floors are dirty

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of delivering findings. LPA met with Administrator (AD) Lady Jean Vera Cruz and explained the purpose of the inspection. On April 14, 2026, LPA toured the facility and conducted interviews with residents and staff. LPA was unable to review records of former residents and staff as those were no longer available. Regarding allegations, Staff sexually abused resident while in care and Staff handled resident in a rough manner, the following was revealed: Complaint alleges Staff 1 (S1) sexually abused and handled Resident 1 (R1) in a rough manner. During the course of the investigation, LPA attempted to interview R1, however, R1 had not resided at the facility since July 2022, and their contact information was no longer available. LPA also attempted to interview S1, however, S1 retired in 2022 and their contact information was no longer available. (Cont. LIC9099-C) Unsubstantiated Interviews were conducted with three current facility residents (R2-R4), who were admitted after both R1 and S1 left the facility. All denied being sexually abused or handled in rough manner and denied having any knowledge of any other resident being sexually abused or handled in a rough manner. During interview, Staff 2 (S2) stated they were employed at the facility after R1 and S1 had left the facility and were not personally acquainted with them. S2 denied having any knowledge of S1 sexually abusing or handling R1 in a rough manner. S2 denied personally sexually abusing or handling a current or former resident in a rough manner or having any knowledge of any current or former staff sexually abusing or handling a current or former resident in a rough manner. During interview, Staff 3 (S3) stated they were acquainted with S1 and had previously worked with them. S3, however, stated they were not acquainted with R1, as they were not working at the facility at the time that R1 was a resident. S3 denied having any knowledge of S1 sexually abusing or handling R1 in a rough manner. S3 denied personally sexually abusing or handling a current or former resident in a rough manner or having any knowledge of any current or former staff sexually abusing a current or former resident. Regarding allegation, Staff hit resident with objects, the following was revealed: Complaint alleges S1 hit R1 on the head twice with a soiled diaper and once with a bag of popcorn. LPA was unable to interview R1 as they have not resided at the facility since July 2022, and contact information for them was no longer available. LPA was also unable to interview S1, as they retired in 2022 and their contact information was no longer available. All current facility residents were admitted after both R1 and S1 left the facility. Three of three residents interviewed denied being hit with objects or having any knowledge of any other residents being hit with objects. During interview, S2 stated they were employed at the facility after R1 and S1 had left the facility and were not personally acquainted with them. S2 denied having any knowledge of S1 hitting R1 with objects and denied personally hitting a current or former resident with objects or having any knowledge of any current or former staff hitting a current or former resident with objects. During interview, Staff 3 (S3) stated they were acquainted with S1 and had previously worked with them. S3, however, stated they were not acquainted with R1, as they were not working at the facility at the time that R1 was a resident. S3 denied having any knowledge of S1 hitting R1 with objects and denied personally hitting a current or former resident with objects or having any knowledge of any current or former staff hitting a current or former resident with objects. Regarding allegations, Facility is malodorous and Facility floors are dirty, the following was revealed: Complaint alleges facility smelled of urine and the floors were sticky. (Cont. LIC9099-C) Three of three residents interviewed denied the facility being malodorous or the floors being sticky. During interview, Staff 2 (S2) stated they heard that prior to their employment, the facility had smelled of urine, and the floors had been dirty, however, stated they never observed the floors were dirty or the facility to smell of urine and stated they maintain the facility floor clean and odor free. During interview, S3 denied the facility smelling of urine or the facility floors being dirty. Per S3, the facility used to smell of “chlorine” and floor cleanliness has been and continues to be maintained. During the course of the investigation, LPA noted the facility was odorless and the tile flooring was free of any stickiness, smearing, smudging, or discoloration. Based on information gathered, the department did not find sufficient evidence to support the allegations, “Staff sexually abused a resident while in care, Staff handled a resident in a rough manner, Staff hit a resident with objects, Facility is malodorous, and Facility floors are dirty”. 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 allegations are Unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 22-AS-20220602115903

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced Case Management inspection in conjunction with investigation into complaint number 22-AS-20220602115903. LPA met with Administrator Jean Vera Cruz and Staff Norby Banggalat and explained the purpose of the inspection. During the course of the investigation, LPA conducted record review for five of five resident files and observed three of five files did not include a physician report, and five of five files were observed to have double sided admission agreements. Based on observations made during this inspection, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Apr 14, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87458(a) · Plan of correction due date: Apr 15, 2026

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional... This requirement is not met as evidenced by: Based on record review, the Licensee did not comply with the section cited above in three of five resident files, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 14, 2026

Plan of correction: AD stated a medical assessment for the three residents will be obtained a copy provided to LPA via email by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(a)(1)(A) · Plan of correction due date: Apr 28, 2026

(a) The licensee shall complete an individual written admission agreement... (1) The text of the admission agreement... shall be: (A) Printed... on plain white paper. The print shall appear on one side of the paper only. This requirement is not met as evidenced by: Based on record review, the Licensee did not comply with the section cited above in five of five admission agreements, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 14, 2026

Plan of correction: AD stated admission agreements will be re-printed to appear on one side of the paper only and a copy will be provided to LPA via email. AD stated original agreements will be retained in residents' files.

Allegation investigated: Facility staff did not ensure resident's records were complete

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced subsequent visit to follow up on complaint investigation. LPA Tirre was greeted and granted entry into the facility by staff and explained reason for visit. LPA Tirre met with Administrator Lady Jean Veracruz. During the course of investigation, LPA toured facility, reviewed documents, conducted interviews and requested pertinent documentation such as Resident 1’s records including Admission Agreement, Physician’s Report, Appraisal, Needs and Service plan. The investigation conducted revealed the following: On January 27, 2026 the department received a complaint alleging Facility staff did not ensure resident's records were complete. Record review revealed that R1 had the following documents: Emergency ID Information, Preplacement Appraisal, and Resident Appraisal were all incomplete and not signed. Per record review CONTINUED ON 9099C Substantiated LPA did not observe Resident 1 to have an Admission Agreement completed or signed in facility file. Record review revealed that resident 1 was admitted to facility on December 10, 2025 and left on January 6, 2026. Interviews conducted with staff revealed that Resident 1 was at facility for a month and left to go back home to be with family. Interview with witness also revealed that R1 was at facility for a month. Interview with witness stated that R1 believes they signed documents but were not explained of what they signed. An interview with R1 was not conducted due to R1 no longer at facility and no contact info available. Therefore based on preponderance of evidence information gathered is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted with Administrator Lady Jean Vera Cruz and a copy of this report, along with confidential names list and appeal rights was reviewed and provided.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 22-AS-20260127120316

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Feb 25, 2026

Resident Records (a) Licensee shall ensure that a separate, complete, and current record is maintained for ea resident in facility or in central administrative location readily available to facility staff and licensing agency staff. Based on record review this requirement was not met as evidenced by facility failed to ensure resident records were complete. R1 is missing signatures on appraisals and missing Admission agreement.R1 is no longer at facility as of 1/6/26.This poses a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 18, 2026

Plan of correction: As POC, Licensee to review and update Resident files with missing signatures. Licensee to do an inservice training including themselves and staff acknowledging understanding of Regulation 87506 Resident Records & provide signed copy to Department by COB due date 2/25/26

Type of visit: Required - 1 Year

On July 15, 2025, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA Tirre was greeted by staff and granted entry after stating the purpose of the visit. Administrator (Ad) Lady Jean Veracruz was present to assist with the facility inspection on today's date. The facility is licensed for six (6) non-ambulatory residents of which one (1) may be bedridden with approved hospice waiver for five residents. Currently, there are three (3) Hospice residents present during today’s visit. This is a single story with detached garage facility. The facility has four bedrooms, ( three shared resident rooms and one staff room) and two full bathrooms. At around 11:30AM, LPA conducted a tour of the physical plant accompanied by Administrator Lady Jean Veracruz, and the following was observed: There are no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 113.1 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for cleaning supplies and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained. Facility has one fire extinguisher which was charged. A review of the Medication Records Administration (MAR) was conducted for three residents and LPA observed the records are in compliance. CONT ON 809C During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed the facility has a supply of Personal Protective Equipment (PPE). LPA observed First Aid Kit was maintained. A working phone was operational. The last fire drill was conducted on June 6, 2025. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 6/20/2025 -6/20/2026. A review of five residents (R1-R5) service files revealed to be complete. The facility has the current administrator's certification on file for Lady Jean Veracruz # 6070564740 - Expiration 06/01/2026. Staff present during visit had proper background clearance. Based on the observations made during today's visit, a deficiency is being cited as per the Title 22 Division 6 Chapter 2 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator VeraCruz.the state’s words, verbatim · CDSS document, Jul 15, 2025

Type of visit: POC

Licensing Program Analysts (LPAs) Kimberly Lyman and William Vanegas conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on 09/26/2024. LPA's were greeted and granted entry into the facility and explained the reason for the visit. At 2:10PM LPA's toured the facility and observed the following: Deficiency cited under Title 22 Regulation 87608(a)(3) pertaining to postural supports has been cleared. LPA's observed physicians order for bed rails for all resident's noted in 809. Licensee has complied with the POC. Deficiency cited under Title 22 Regulation 87303(a) pertaining to maintenance and operation has been cleared. LPA's observed all noted items in 809 to be repaired. Licensee has complied with the POC. Deficiency cited under Title 22 Regulation 87303(e)(2) pertaining to water temperature has been cleared. LPA's tested water temperature to be 109.2 F degrees. Licensee has complied with the POC. Licensee addressed all items on advisory note issued on 09/26/2024. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 17, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Iris Guest Home. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents of which 1 may be bedridden. Facility has an approved hospice waiver for 5 residents and the home currently has 4 residents on hospice. Administrator/ Licensee Brevet Dao arrived during the visit. Administrator Jean Veracruz has an administrator certificate valid until 06/01/2026. LPA Lyman along with Caregiver Norbi Banggalat toured the facility at 8:25 AM. LPA toured the physical plant, checked food service, first aid kit and reviewed records. The home consists of three resident bedrooms, 2 common restrooms, one staff room, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed a closet threshold in disrepair in room #3. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured 103.1 degrees F in one common restroom. At 8:40 AM, LPA is unable to measure water temperature in second common restroom as the sink is overflowing with water. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. Auditory exit alarms are turned off during today's visit. First aid kit had all the elements including thermometer, tweezers and scissors as well as a first aid manual. LPA observed toxins are secured during today's visit. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA tested smoke detectors during today's visit. Smoke detectors in room #1 and the hallway are non-operational. Fire extinguisher is fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating for residents. At 8:45, LPA observed back exit gate does not easily open. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan and plan is thorough and complete. CONT ON LIC809-C DATED 09/26/2024. Facility provided documentation of last fire drill conducted on 07/06/2024. Facility provides activities in the form of exercise, and karaoke. At 9:30 AM, LPA reviewed six resident files and four staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Resident 1 (R1) does not have a physician order on file for half bed rails. Staff files reviewed contained required documentation of medical clearance/ TB, CPR training and criminal record clearance as well as required training. At 10:15 AM, LPA reviewed medication storage and administration. Medications are stored in a locked closet. Medications are being administered per physician order. Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.the state’s words, verbatim · CDSS document, Sep 26, 2024

Allegation investigated: -Resident's hygiene needs are not being met. -Resident left in soiled diaper/linens for an extended period of time. -Staff does not meet resident's needs.

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit to deliver complaint findings regarding the allegations listed above. LPA was greeted and granted entry into the facility by Caregiver 1 (CG1) LPA Quiroz called and spoke to Licensee/Administrator (L/AD) Brevet Dao and discussed purpose of the visit. The department received a complaint on 12/29/2020. LPA Shobhana Frank conducted the initial 10 day visit on 01/06/2021 and follow up visit on 9/9/2021. During the course of the investigation LPA Quiroz conducted a complaint follow up visit and interviewed staff and residents. LPA Quiroz obtained copies of resident records but not limited to physician reports, needs and services and identification forms. Regarding the allegations that "Resident's hygiene needs are not being met," "Resident left in soiled diaper/linens for an extended period of time" and "Staff does not meet resident's needs," the investigation revealed the following: During the course of the investigation, six of eight interviewees corroborated with three of three allegations listed above. CONTINUED ON NEXT LIC 9099-C PAGE... Substantiated CONTINUED...LPA Quiroz was not able to interview Resident 1 (R1), due to R1 passing away. During inspection visit conducted on 1/22/2024, on or about 11:40am LPA Quiroz observed Resident 3 (R3) to be unkept with maladorous scent noted and unkept, long toe nails and finger nails. This was verified with Caregiver 1. Witness indicated "The Administrator never comes and they never listen about the resident's needs. They ignore our needs." On or about 11:58am, LPA Quiroz observed Resident 5 (R5) to have soiled diaper. Witness indicated alerting staff of soiled diaper and request to change diaper and that request was ignored. Witness stated, "Last changed long time ago, and staff never returned after request was made." Therefore, based on evidence through records reviewed and interviews conducted the allegations that "Resident's hygiene needs are not being met," "Resident left in soiled diaper/linens for an extended period of time," and "Staff does not meet resident's needs" are determined to be SUBSTANTIATED, meaning the complaint allegations are valid and that a violation has occurred. (SEE LIC 9099-D) The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. Civil penalties area assessed due to repeated violations within 12 months. (SEE CIVIL PENALTY-LIC 421IM) An exit interview was conducted with (L/AD) Brevet Dao via telephone and with CG1 at the facility, and a copy of this report, Appeal rights, LIC 9099-D page, LIC 421 IM and LIC 811- Confidential names were provided at exit.the state’s words, verbatim · CDSS document, May 15, 2024 · control 22-AS-20201229142426

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(a) · Plan of correction due date: May 22, 2024

Basic Services-87464(d): (a)The services provided by the facility shall be conducted so as to continue and promote, to the extent possible, independence and self-direction for all persons accepted for care. ..This requirement was not CONT met as evidenced by: On 1/22/2024, on or about 11:40am LPA Quiroz observed Resident 3 (R3) to be unkept with maladorous scent noted and unkept, long toe nails and finger nails. This was verified with Caregiver 1. Witness indicated "The Administrator never CONTINUED...the state’s words, verbatim · CDSS document, May 15, 2024

Plan of correction: L/AD Dao will read and understand CCR 87464, provide inservice training to staff identified on LIC 500 and update needs and services plans for all residents residing at the facility by POC due date of 5/22/2024.(CIVIL PENALTY ASSESSED) comes and they never listen about the resident's needs. They ignore our needs." This poses a potential risk to residents in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: May 22, 2024

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.CONT This requirement was not met as evidenced by:On 1/22/24 or about 11:58am, LPA Quiroz observed Resident 5 (R5) to have soiled diaper. Witness indicated alerting staff of soiled diaper and request to change diaper and that request was ignored. CONTINUED...the state’s words, verbatim · CDSS document, May 15, 2024

Plan of correction: L/AD Dao will read and understand CCR 87625, provide inservice training to staff identified on LIC 500 and develop log for routinely incontinence care by POC due date of 5/22/2024.(CIVIL PENALTY ASSESSED) Witness stated, "Last changed long time ago, and staff never returned after request was made." This poses a potential risk to residents in care (CIVIL PENALTY ASSESSED)

Type of visit: Case Management - Deficiencies

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced case management visit in conjunction with complaint control #22-AS-20201229142426. LPA Quiroz was greeted and granted entry into the facility by Caregiver 1 (CG1). LPA Quiroz called and spoke to Licensee/Administrator (L/AD) Brevet Dao via telephone and explained the reason for the visit. During today's visit while conducting inspection tour of the facility, on or about 2:50pm, LPA Quiroz observed recording monitor in Resident's 1 bedroom. On or about 3:07pm, LPA Quiroz observed monitor in bedroom area displaying picture and recording of Resident 1. This was verified with CG1 who indicated "Yeah, the AD put it there so we can see what R1 is doing when we're busy out here in the living-room and at night we put it in the bedroom so we can see the resident at all times." LPA Quiroz did not observe sign of recording in progress taking place in R1s bedroom. On or about 3:10pm, LPA Quiroz observed Resident's 2 family in living room area where R1's recording was being displayed. The facility is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted with CG1 and L/AD Brevet Dao via telephone and a copy of this report, appeal rights and LIC 811- Confidential names were provided at exit.the state’s words, verbatim · CDSS document, May 15, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: May 15, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...CONTINUED This requirement is not met as evidenced by:During today's visit while conducting inspection tour of the facility, on or about 2:50pm, LPA Quiroz observed recording monitor in Resident's 1 bedroom. On or about 3:07pm, LPA Quiroz observed monitor in bedroom area displaying CONTINUEDthe state’s words, verbatim · CDSS document, May 15, 2024

Plan of correction: Recording camera removed during today's visit. L/AD Dao and Caregivers agreed to not use recording devices in residnent's bedroom areas. L/AD agreed to read and submit proog of understanding for CCR 87468.1 by POC due date of 5/22/024. picture and recording of Resident 1. This was verified with CG1 who indicated "Yeah, the AD put it there so we can see what R1 is doing when we're busy out here in the living-room and at night we put it in the bedroom so we can see the resident at all times." This poses a potential risk to residents in care.

Allegation investigated: facility tried to prevent resident from being taken to the hospital by family facility staff decided resident should be on hospice facility did not keep accurate resident records

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by XX and explained the reason for the visit. The Department received a complaint on 06/12/2023 and LPA Mendivil conducted the initial 10 day visit on 06/15/2023. LPA Mendivil interviewed staff and residents and obtained copies of pertinent documents such as physician report, admission agreement and hospice documentation. Regarding the allegation facility tried to prevent resident from being taken to the hospital by family, facility staff decided resident should be on hospice and facility did not keep accurate resident records, the investigation revealed the following: Resident 1 (R1) arrived at the facility on 03/09/2023 and their admission agreement was signed on 03/16/2023 by a responsible party. Substantiated Per R1’s physician report dated 01/12/2023 R1 was diagnosed with Cerebral vascular accident and a secondary diagnosis of chronic kidney disease. R1 was not noted to have any mild cognitive impairment or dementia and is noted to be able to communicate needs and follow directions. It was reported on 05/08/2023 R1 was taken to the hospital due to chronic pain and returned home on 05/06/2023 with diagnosis of abnormal suputum. On 06/05/2023 it was reported on an Unusual Incident/Injury report dated 06/07/2023 that on 06/05/2023 R1’s son took them to the hospital due to complaints of R1 being lethargic and R1 was admitted to the hospital for further evaluation. Based on witness interviews R1 was diagnosed with pneumonia. It was reported by 2 witnesses that facility staff told family to not take R1 to the hospital as R1 was on hospice, R1’s family decided to take him to the hospital anyway. Based on interviews with 2 out of 2 staff indicate they did notify family that R1 was on hospice and by taking the resident to the hospital it would discontinue their hospice. Per review of hospice agreement R1 signed the documentation to enroll in Helius Hospice on 03/26/2023, based on the evaluation listed on the hospice documentation it stated that R1 had less than 6 months, which was not reflected in the physician’s report dated 01/12/2023. It was reported by witnesses that R1 was signed up for hospice by facility representative and not by the resident or resident’s responsible party. Licensee/Administrator Brevet Dao denies this allegation. Based on review of documentation from hospice Helius Hospice, LPA observed the documents to be incomplete and did not contain a plan of care. Therefore, based on the preponderance of evidence through records reviewed and observation the allegations facility tried to prevent resident from being taken to the hospital by family, facility staff decided resident should be on hospice and facility did not keep accurate resident records the allegations are determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. Based on interviews with 2 out of 5 residents, they indicated R1 was moved to his wheelchair to go outside and smoke cigarettes and was moved into the living to watch TV. Per review of R1’s physician report R1 has a history of skin breakdown, but 2 out of 2 staff deny seeing pressure injuries. Therefore, based on the preponderance of evidence through records reviewed and interviews the allegations staff did not notify resident’s family of change in resident’s condition and facility staff did not prevent resident from sustaining pressure injuries are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report was provided to facility Administrator.the state’s words, verbatim · CDSS document, Apr 15, 2024 · control 22-AS-20230613154512

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Apr 16, 2024

(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidence facility told R1's family that he was on hospice and would be discontinued. This poses an immediate health and safety risks to person in care.the state’s words, verbatim · CDSS document, Apr 15, 2024

Plan of correction: Licensee/Administrator Brevet agreed to conduct an inservice training for 911 procedures and to provide proof by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87633(a)(3) · Plan of correction due date: Apr 16, 2024

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician..., to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met: (3) Hospice agency services are contracted for by each terminally ill resident.. not by the licensee on behalf of a resident or prospective resident...This requirement was not met as evidence by Licensee signed up resident for hospice. This poses an immediate risk to persons in carethe state’s words, verbatim · CDSS document, Apr 15, 2024

Plan of correction: Licensee/Administrator agreed to review hospice regulations and provide proof that it was understood by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87633(a)(4) · Plan of correction due date: Apr 16, 2024

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician..., to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident.. This requirement was not met as documents were not complete.the state’s words, verbatim · CDSS document, Apr 15, 2024

Plan of correction: Licensee to review hospice regulations and provide proof to LPA by POC due date.

Allegation investigated: Licensee does not ensure that a comfortable temperature is maintained in rooms that residents occupy. Facility does not meet resident's dietary needs

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Adminstrator/Licensee Brevet Dao and explained the reason for the visit. The Department received a complaint on 09/02/2022 and the Department conducted the initial 10 day visit on 09/08/2022. Regarding the allegations licensee does not ensure that a comfortable temperature is maintained in rooms that residents occupy, and facility does not meet resident’s dietary needs, the investigation revealed the following: During the visit on 10/31/2022 LPA Mendivil interviewed residents present at that time indicated the facility will provide fans if the weather outside is warm. LPA Mendivil visited the facility on 05/19/2023, 5/25/2023,06/15/2023 , 07/11/2023 and 8/15/2023 and the facility was within regulatory temperatures and LPA Mendivil observed the air conditioning to be operational and on, on multiple occasions. Unsubstantiated During the visit on 10/31/2022 LPA Mendivil interviewed residents present at that time indicated the facility will provide fans if the weather outside is warm. LPA Mendivil visited the facility on 05/19/2023, 5/25/2023,06/15/2023 , 07/11/2023 and 8/15/2023 and the facility was within regulatory temperatures and LPA Mendivil observed the air conditioning to be operational and on, on multiple occasions. Based on observations by LPA Mendivil observed the refrigerator was stocked with eggs, bread, ham, and chicken. LPA Mendivil observed a sample menu on the refrigerator. Based on interviews with Administrator Brevet Dao the menu is not always followed, and it is modified. Administrator stated they try to accommodate all resident's dietary restrictions with are mostly low sodium and low carbohydrate meals. Interviews with staff indicate that groceries are purchased every 5 days. Therefore, based on the preponderance of evidence through interviews and observations the allegations that licensee does not ensure that a comfortable temperature is maintained in rooms that residents occupy and facility does not meet resident’s dietary needs are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report was provided. Therefore based on interviews the allegation that staff yells are residents is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. Civil Penalty assessed based on repeat violation. An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.the state’s words, verbatim · CDSS document, Apr 15, 2024 · control 22-AS-20220902153422

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 16, 2024

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by: 2 out of 6 residents stated that S1 yells. This poses a potential risk to persons safety in care.the state’s words, verbatim · CDSS document, Apr 15, 2024

Plan of correction: Licensee to provide proof of all staff training for personal rights to LPA by due date. S1 is no longer working at the facility.

Allegation investigated: Staff did not follow doctor's dietary orders for resident in care

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced to deliver findings. LPA was greeted and granted entry into facility by Gemma Wanawan, Caregiver and explained the reason for the visit. Administrator Brevet Dao was available by phone. The Department received a complaint on 07/07/2023 and LPA Mendivil conducted the initial 10 day visit on 07/11/2023. During the visit LPA obtained copies of sample menus and interviewed residents and staff. Regarding the allegation Staff did not follow doctor's dietary orders for resident in care, the investigation revealed the following: Based on interviews with 1 out of 2 staff indicated they were unaware that any of the residents had a prescribed modified diet. Interviews with 2 out of 4 residents indicated they do not have a specific diet, the 2 other residents would not answer LPA Mendivil's questions. Substantiated Per review of resident’s files Resident 1 (R1) does have a prescribed diet which was provided to the facility in June/July of 2023. Based on interviews with 2 witnesses the meals provided to R1 did not contain the food groups in the prescribed diet. Therefore based on the preponderance of evidence through records reviewed and interviews the allegations that staff did not follow doctor’s dietary orders for resident in care is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.the state’s words, verbatim · CDSS document, Mar 27, 2024 · control 22-AS-20230707154552

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: Apr 8, 2024

(b) The following food service requirements shall apply:(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidence by 1 out of 2 staff was not aware of Resident 1's prescribed diet. This poses a potential health risks to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2024

Plan of correction: Licensee agreed to provide in service to staff on renal diets and other possible diets that residents may have. Licensee agreed to keep a log of groceries purchased to prepare meals and provide proof to LPA by POC due date.

Allegation investigated: Facility failed to provide afternoon snacks to residents

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Caregiver Jean Vera Cruz and explained the reason for the visit. Administrator Brevet Dao arrived shortly after. The Department received a complaint on 06/11/2023 and the initial 10 day visit was conducted by LPA Cho on 06/20/2023. During the visit LPA Cho interviewed residents and staff. LPA Mendivil conducted a follow up visit on 08/15/2023 during another complaint visit for 22-AS-20230808134542. LPA Mendivil observed kitchen pantry and refrigerator. Regarding the allegation facility failed to provide afternoon snacks to residents, the investigation revealed the following: Based on interviews with staff 2 out of 2 staff stated they have snacks available for residents. Based on interviews with 2 out of 4 residents indicate there is food and snacks available in the home. CONT on LIC 9099-C dated 12/14/2023. Unsubstantiated The remaining 2 residents could not confirm or deny if there are snacks available in the home. LPA Mendivil observed snack and fruit in the refrigerator. Based on Department regulation, 87555 General Food Service Requirements, regarding snacks states " (b)The following food service requirements shall apply: (3) Between-meal nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician." Therefore based on the preponderance of evidence through interviews and observation the allegation Facility failed to provide afternoon snacks to residents is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report was provided to facility Administrator.the state’s words, verbatim · CDSS document, Dec 14, 2023 · control 22-AS-20230612075559

Type of visit: POC

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the plan of correction for complaint referenced #22-AS-20230317113524. LPA was greeted and granted entry by caregiving staff after stating the purpose of the visit. An interview was conducted with facility staff S1. Per the updated LIC500 provided by facility administrator on December 12, 2023 along with facility observation and staff interview, the type A deficiency cited on December 5, 2023 was noted as cleared. A clearance letter for the citation, an amended LIC9099-D for the deficiency cited on December 5, 2023 and a copy of the present report were provided to a facility representative.the state’s words, verbatim · CDSS document, Dec 13, 2023

Allegation investigated: Facility did not seek timely medical assistance Facility lacked care and supervision resulting in a resident's malnourishment

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the allegation listed above. LPA was greeted and granted entry by facility staff after introducing himself and stating the purpose of the visit. Administrator Brevet Dao was notified of the visit and arrived later to assist. The allegations investigated were presented to the administrator. An initial complaint investigation visit was conducted by LPA Saborit-Guasch on March 20, 2023. The complaint was investigated by the Department and consisted of a review of staff and resident’s records, a physical plant inspection and interviews of staff, witnesses and residents. Emergency Medical Transport records were obtained in addition to hospital records from Orange County Global and Kaiser Hospital. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 Resident R1 was admitted to the facility on August 29, 2022. Physician record dated August 28, 2022, documents resident’s weight to be 208 pounds. R1’s medical history upon admission is noted to be “atrial fibrillation, history of recurrent Deep Vein Thrombosis and Pulmonary Embolism, hypothyroidism, a history of diastolic congestive heart failure and adrenal insufficiency”. R1’s Preplacement Appraisal Information also includes “Celiac disease [Defined by the Mayo Clinic as “an illness caused by an immune reaction to eating gluten. Gluten is a protein found in foods containing wheat, barley or rye. If you have celiac disease, eating gluten triggers an immune response to the gluten protein in your small intestine. Over time, this reaction damages your small intestine's lining and prevents it from absorbing nutrients, a condition called malabsorption”], Diarrhea, Fall risk, hypertension, orthostatic hypotension (…) and long term warfarin usage”. Hospital notes from Kaiser dated November 19, 2022, state a weight of 186 pounds. On November 18, 2022, R1 was transferred to Orange Global Hospital for chest pain, constant, sub-sternal, pressure-like, non-radiating with pain at 8/10 after a facility caregiver measured R1’s blood pressure at 188/109 with an elevated heart rate. Administrator and responsible party were notified. During the initial assessment at the hospital, R1’s Body Mass Index was calculated to be 25.9, placing the resident in a normal range. R1 was then transferred to Kaiser Hospital on November 19, 2022. An interview with R1’s Kaiser Primary Care Physician was conducted to review the medical diagnoses based on nutritional assessment conducted by a Kaiser RN stated that R1 “qualifies for severe malnutrition in the context of chronic illness, as of 11/20/2022. Weight loss: -12 kg weight loss over 3 months = 12.5%. Loss of subcutaneous fat: mild-moderate loss at upper arm region (triceps). Muscle loss: moderate loss at clavicle bone region, moderate loss at acromion bone region (shoulders), moderate loss at scapular bone region, mild-moderate loss in quadriceps and/or calf region (legs)”. According to the physician if R1’s body mass index was less than 18.5 that would qualify him as being underweight, the fact he did have loss of subcutaneous fat and loss of muscle mass could have been contributed by his Celiac Disease. R1’s Body Mass Index was 25.9, which health experts would say was a healthy number for someone of his height. CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C Regarding the allegation that Facility did not seek timely medical assistance, the following has been concluded: Based on interviews conducted with facility staff, witnesses as well as a review of records resulting from a call to paramedics made on November 17, 2022, and subsequent hospital admissions at Orange County Global Hospital and Kaiser Hospital, facility staff measured R1’s blood pressure to be elevated. Following this, both the facility administrator and R1’s authorized representative were notified. R1’s authorized representative appears to have placed the call to the paramedics upon her arrival at the facility, however no lapse of time in contacting the paramedics was evidenced due to potential facility staff neglect. As a result, the allegation is found to be 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. Regarding the allegation that Facility lacked care and supervision resulting in a resident's malnourishment, the following has been concluded: Based on interviews conducted with facility staff, witnesses as well as a review of records resulting from a call to paramedics made on November 17, 2022 and subsequent hospital admissions at Orange County Global Hospital and Kaiser Hospital, both a sufficient Body Mass Index of 25.9 and a potential history of weight loss evaluated at approximately “12.5%, [with] loss of subcutaneous fat: mild-moderate loss at upper arm region, muscle loss: moderate loss at clavicle bone region, moderate loss at acromion bone region, moderate loss at scapular bone region, mild-moderate loss in quadriceps and calf region”. An interview conducted by telephone with R1’s primary care provider at Kaiser Hospital evidenced that “[R1]’s body mass index is fine for his body mass” and further hypothesized that the documented celiac disease could have been a contributing factor in the loss of subcutaneous fat and loss of muscle mass described by the hospital staff. Therefore the evidence is not sufficient to establish both the actual state of malnutrition and whether it can be attributed in part or in full to the facility’s lack of care and supervision. The allegation is found to be 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 this report was provided to a facility representative. CONTINUED FROM FORM LIC9099 During the initial investigation, LPA was provided with a copy of Facility Roster form LIC500 dated January 18, 2020. The licensee did not provide any other updated staff’s schedule. During the investigation, four individual staff members were identified as providing care and supervision at the facility, with shifts covering both day time and night time hours. However, on multiple instances of Department’s inspection to the facility, response delays were noted due to the fact that staff members were actually covering both the present facility and the adjacent facility (Jade Guest House, license number 306006062). One single staff member cannot be deemed sufficient to take care of two separate facilities without a centralized call system, both with a capacity of six residents including some bedbound residents. Without actual schedules, it could not be established whether this was a regular occurrence, however two separate facility visits resulted in the same deficiency being observed and a civil penalty for a repeat violation was issued to the licensee. As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A Type A citation is issued on the attached form LIC9099-D. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.the state’s words, verbatim · CDSS document, Dec 5, 2023 · control 22-AS-20230317113524

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 6, 2023

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on observation conducted at the facility, on at least (...) two separate occasions staff members were observed to be absent from the premises. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Dec 5, 2023

Plan of correction: Licensee offers to provide documentation of the elapsed week from the present visit until the plan of correction due date to demonstrate staffing and adequate coverage. This 9099-D was amended to modify the plan of corrections due date per Department policy.

Allegation investigated: Staff is not meeting resident's needs. Facility is malodorous.

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Jean Vera Cruz, caregiver and explained the reason for the visit. Licensee/Administrator Brevet Dao arrived at 10:40 am. The department received a complaint on 07/21/2023 and LPA Cho conducted the initial 10 day visit on 07/28/2023. During the course of the investigation LPA Cho interviewed staff and residents. LPA Mendivil obtained copies of apprasials/needs and services plans. Regarding the allegations that Staff is not meeting resident's needs and facility is malodorous, the investigation revealed the following: LPA Mendivil reviewed 4 out of 4 residents files. Per review 4 out of 4 Appraisal/Needs and Services Plan did not provide actionable objectives/plans. Review of Resident 1 (R1) Appraisal/Needs and Services Plan dated 12/01/2022 indicating R1’s diagnosed with Parkinson’s Disease, atrial fibrillation, hypertension, bipolar, mild cognitive impairment, depression, and unsteady gait. CONT on LIC 9099-C Substantiated For the category of Physical/Health it is noted that “because of Parkinson’s affecting him, his physical mobility has been affected” it was noted that Physical Therapist (PT) and Occupational Therapist (OT) would be responsible for this need. Based on interviews with Administrator as of the date 12/02/2022 no PT/OT has seen R1. Review of Resident 2 (R2) Appraisal/Needs and Services Plan dated 01/14/2023 indicating R2 is diagnosed with depression, psychosis, and dementia. In the category of Emotional Needs, it is noted “he is able to adjust emotionally and no issues”. For the objective/plan for the emotional need the objective is “to continue to monitor”, per review there is no actionable item to monitor. Based on LPA’s observations of R2, R2 remains in his room and does not socialize with house mates. Review of Resident 3 (R3) Appraisal/Need and Services Plan dated 04/14/2023 indicating R3 is diagnosed with dementia, hypertension, and glaucoma. It is also noted that R3 needs assistance with all activities of daily living. In the category for Functioning Skills, it is noted "due to generalized weakness overall body function is affected", for the objective/plan "encourage to mobilize extremities, perform exercises on both hands and feet" the care team is responsible for this action. Based on interviews with witnesses, PT has been utilized but care giving staff has not. Review of Resident 4 (R4) Appraisal/Need and Services Plan dated 06/02/2023 indicating R4 is diagnosed with wernickie's encephalopathy and dementia. Per review of all five category's did not list any services for a diagnosis of dementia. Regarding the facility being malodorous LPA Mendivil experienced a strong smell of body odor and urine when entering the room of R1 and R3 on multiple occasions, no explanation provided from staff. Therefore, based on evidence through records reviewed and interviews the allegations that Staff is not meeting resident's needs and facility is malodorous are determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. Civil penalty is assessed due to repeat violation within 12 months. An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 22-AS-20230721153400

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(a) · Plan of correction due date: Oct 23, 2023

(a) The services provided by the facility shall be conducted so as to continue and promote, to the extent possible, independence and self-direction for all persons accepted for care... This requirement was not met as evidence by in 4 out of 4 residents needs and services did not provide actionable items to assist residents in any given category. This poses a potential risk to persons in care.the state’s words, verbatim · CDSS document, Oct 17, 2023

Plan of correction: Licensee to update resident needs and services. Licensee stated will keep records of actions taken and outcomes daily.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Oct 23, 2023

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidence by LPA Mendivil experienced a strong body odor and urine smell from R1 & R3's room. This poses a potential health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Oct 17, 2023

Plan of correction: Licensee has a cleaning schedule and as of 10/17/2023, the facility no longer is malodorous.

Allegation investigated: facility does not maintain a healthful and comfortable accommodations for residents Facility water temperature is not within regulatory temperature range

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into facility by caregiver Jean Vera Cruz and explained the reason for the visit. Administrator Brevet Dao was notified of LPA’s arrival and joined approximately at 10:40am. The Department received a complaint on 05/11/2023 and conducted the initial visit on 05/19/2023. LPA Mendivil obtained copies of pertinent documents including but not limited to: physician orders. In regards to the allegations Facility does not maintain a healthful and comfortable accommodations for residents and Facility water temperature is not within regulatory temperature range the investigation revealed the following: Regarding the allegation facility does not maintain a healthful and comfortable accommodations for residents, it was alleged Resident 1 (R1) was left in soiled clothing. Per physician report dated 12/14/2021 R1 is able to dress and groom self and is able to communicate needs. R1 is noted to have a diagnosis of Depression, Bipolar disorder and Parkinson’s disease. Unsubstantiated During LPAs visit on 5/19/23 LPA Mendivil observed R1 to have stained clothing and noted a strong body odor coming from R1. Per records reviewed, R1 needs and service plan dated 12/1/22 does not address and/or note any issues with R1’s refusal and/or inability to self care for grooming needs. Per interviews conducted with facility staff, R1 will refuse to provide staff with their laundry at times. Staff reported doing laundry at minimum twice a week for residents in care and sometimes more, depending on how much laundry there is to wash. Interviews conducted with 4 of 4 residents could not corroborate the allegation. R1 reported their laundry is clean after staff wash their clothes and reported they have enough clean clothing. Although R1 at times will refuse to participate in meeting own hygiene needs, it does not appear that the facility did not maintain a healthful and comfortable accommodations for residents. Therefore, based on preponderance of evidence, the allegation has been determined to be Unsubstantiated meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. It was alleged the facility water temperature is not within regulatory temperature range. During LPA’s visit dated 09/26/2023 LPA tested hot water temperature in bathroom 1 and observed the hot water to be 110 degrees F. Facility does not maintain a hot water temperature log. Per interviews with residents, residents reported the water to be ice cold. Staff denied knowledge of issues regarding hot water. Therefore, based on preponderance of evidence, the allegations has been determined to be Unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. An exit interview was conducted with Administrator and a copy of this report was provided at the time of exit. During LPA’s initial visit, no residents were observed to have full bedrails. Therefore, based on the preponderance of evidence gathered, We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit was conducted and a copy of this report was provided to facility representative. It was alleged the Facility is using half bed rails without physician orders. During the investigation, LPA observed Resident 2 (R2) to have half bed rails. Upon review of R2’s physician orders, no order could be found for half bedrails. LPA further observed Resident 3 (R3) to have half bedrails. Upon review of R3’s file, R3 was observed to have physician orders on file for half rails. During LPA’s initial visit, no residents were observed to have full bedrails. Therefore, based on the preponderance of evidence gathered, the allegations that Facility is using half bed rails without physicians orders and Facility's shower drain is in disrepair are determined to be Substantiated. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted with Administrator and a copy of this report, LIC9099-D, and appeal rights was provided at the time of exit.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 22-AS-20230511091058

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(3) · Plan of correction due date: Oct 18, 2023

87608(a)(3) (a) Postural Supports. Based on the individual's preadmission appraisal, and subsequent changes to that appraisal,...(3) A written order from the physician indicating the need for the postural support shall be maintained in the resident's record. This requirement was not as evidence by R2 did not have physician's orders for half bed rails. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 17, 2023

Plan of correction: Licensee previously removed R2's bedrails and currenlty R2 is no longer at the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 23, 2023

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by LPA observed drain in bathroom 1 to have pooling when water was ran. This poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 17, 2023

Plan of correction: Licensee corrected issue after visit on 05/19/2023.