Ivy Park at Otay Ranch

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Jose De La Cruz made an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Diana Weinstein (ED). The facility's license shows a maximum capacity of one hundred thirty seven (137) non-ambulatory residents . LPA reviewed staff, residents and facility files. LPA toured the interior and exterior of the facility and inspected eight rooms in the memory care area, two on the first floor and five on the second floor. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows screens, toilets, and showers were in working order. Two maintenance issues were found during the visit, which were fixed promptly by staff. Emergency chair was found on the facility stairs. Extra linens and hygiene supplies were present in each residents room and with the laundry, as well as Personal Protective Equipment in different areas around the facility, including kitchen, medications room, and in some residents rooms. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. LPA checked medications cabinet. Medications were labeled, as required, and stored in a locked mobile station. No pools, bodies of water exist on the premises. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC809] Per ED, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lights, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. A calendar with daily activities was displayed on different areas of the facility. Menus were displayed on the dining room, elevators, and memory care area Water temperatures were measured around the facility with readings in Fahrenheit degrees between 105 and 119 degrees. LPA interviewed staff and clients. The interviews mentioned that the facility required more staff due to some wait times and staff missing work (see TV's) , however, the residents felt appreciative of the facility and their staff, and mentioned feeling cared for. LPA reviewed facility, staff and resident records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited per California Code of Regulations. An exit interview was conducted with Executive Director Diana Weinstein, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.the state’s words, verbatim · CDSS document, Aug 25, 2026

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Jose De La Cruz made an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Diana Weinstein. The facility's license shows a maximum capacity of one hundred and thirty seven non-ambulatory residents (137) ages 60 and over, and a hospice waiver for 20. LPA arrived at 2:00 PM. LPA toured the facility, interviewed staff and clients, and reviewed facility records. Due to time restrictions, the visit could not be completed today and will be resumed at a different date. No deficiencies were cited per California Code of Regulations during today's visit. An exit interview was conducted with Executive Director Diana Weinstein, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.the state’s words, verbatim · CDSS document, Aug 21, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Jose De La Cruz conducted an unannounced visit regarding an incident report received on 08/14/2026. LPA disclosed the purpose of the visit with Executive Director Diana Weinstein No deficiencies were cited in accordance with the California Code of Regulations. An exit interview was conducted with Executive Director Diana Weinstein, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Aug 21, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jose De La Cruz made an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Diana Weinstein. The facility's license shows a maximum capacity of one hundred and thirty seven non-ambulatory residents (137) ages 60 and over, and a hospice waiver for 20. LPA arrived at 8:40 AM. LPA toured the facility, interviewed staff and clients, and reviewed facility records. Due to time restrictions, the visit could not be completed today and will be resumed at a different date. No deficiencies were cited per California Code of Regulations during today's visit. An exit interview was conducted with Executive Director Diana Weinstein, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.the state’s words, verbatim · CDSS document, Aug 5, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jose De La Cruz conducted an unannounced visit to deliver an amended LIC9099(D) report originally delivered on 06/16/2026. LPA disclosed the purpose of the visit with Business Director Celgine Tabingo. No deficiencies were cited in accordance with the California Code of Regulations. An exit interview was conducted with Business Director Celgine Tabingo, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Jul 20, 2026

Allegation investigated: Licensee did not arrange timely medical care for resident

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegation. LPA was welcomed by, identified themself to, and discussed the purpose of the visit with Executive Director Diana Weinstein, who granted entry for the visit. The Complainant alleged that the Licensee did not provide timely medical care for Resident 1 (R1) [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] It was explained that on 03/22/2025, R1 fell and hit their head on the ground, after which they had a subsequent decline in cognition. R1 was not evaluated until they were hospitalized on 03/29/2025 where they remained until their death on 04/25/2025. The Department’s investigation involved multiple unannounced facility tours/welfare checks, interviews of pertinent staff and outside sources, and review of relevant medical, hospital, and facility care records. Substantiated A review of the investigation and evidence was also performed by the Department’s Program Clinical Consultants (licensed medical professionals). Records and interviews showed: On 03/22/2025 around 7:50 PM, R1 was carrying food/groceries when they tripped and fell, landing on the welcome mat just outside the facility’s main entrance door. The fall was partially witnessed by Person #1 (P1). Receptionist Staff #2 (S2) observed R1 on the ground, right after the fall, and radioed caregiver Staff #3 (S3) for help. S2 and S3 went outside to assist R1. R1 quickly got back up on their feet, with S3’s help. R1 insisted to these staff that they were fine/uninjured and declined to be evaluated by the medication technician on duty, Staff #3 (S3). Neither P1, S1, nor S2 observed any skin tear, mark, or bruise on R1’s head or body. S2 then escorted R1 back to their apartment/room. According to P1, they phoned R1 around 8:30 PM, at which time R1 told P1 they had a headache for which they would take a Tylenol. Neither P1 nor R1 mentioned R1’s headache to facility staff. Interviews of multiple facility staff and P1 aligned to show that R1 seemed normal over the next several days; R1 ate their meals in the dining room and act/spoke as usual. Per interview of P1: They spoke to R1 via phone on 03/27/2025, telling CCLD that R1 sounded “fine” that day. Then on 03/28/2025, P1 transported/escorted R1 to run errands outside the facility, and for the first time P1 noticed a change/decline in R1; specifically, P1 witnessed R1 struggle with separating their personal checks from the carbon copies, which was unlike R1. P1’s observation was communicated to facility staff the next day on 03/29/2025. Upon receiving this information, facility medication technician Staff #4 (S4) and nurse manager Staff #5 (S5) went to observe R1, finding that R1 was alert and speaking, but also confused compared to their baseline. Facility mediation technician Staff #6 (S6) measured R1’s blood pressure at this time, finding it abnormally high at 251/102. Staff arranged for R1 to be transported to a local hospital emergency room (ER) via ambulance. Hospital ER records showed: The first computed tomography (CT) scan conducted of R1’s head on 03/29/2025 showed “no acute findings” and “no traumatic findings.” The following day, R1 experienced a stroke around 8:00 PM on 03/30/2025; this was the first time during this hospitalization that R1 was diagnosed with “Acute Stroke,” after which point R1 was transferred to the hospital’s intensive care unit and put on ventilator support. According to their official death certificate, R1’s immediate cause of death was “Acute Respiratory Failure,” secondary to “Nontraumatic Cerebral Intraventricular Hemorrhage” and “Hypertensive Emergency.” There was no involvement from the San Diego County Medical Examiner’s office in this case. According to their LIC603 Preplacement Appraisal, R1 was already diagnosed with hypertension and hyperlipidemia when they moved into the facility. R1’s LIC602 Physician’s Report showed that both such diagnoses were chronic and preexisting for years before the above fall. R1’s medical records corroborated these same diagnoses and showed R1 had prior history of cerebrovascular accident (aka “stroke”). R1 last met with their primary care physician on 01/06/2025 (over 3.5 months before the above fall); on that date R1’s elevated blood pressure (which was 190/51), along with “complex conditions case management,” was the treatment focus of said doctor's appointment. Together, records and interviews showed that during the complaint timeframe: R1 was and remained independent in all their activities of daily living (ADLs), including mobility, transferring, and medication management. R1’s doctor wrote that R1 was not confused/disoriented, was able to follow instructions, and was able to communicate their own needs. While some of R1’s prescribed medications at the time treated/related to high blood pressure, R1 was not on any blood-thinner type medications during the complaint timeframe. According to the National Institutes of Health, an intracerebral hemorrhage is “a severe type of stroke occurring when a ruptured blood vessel causes bleeding inside the brain, creating pressure, destroying brain tissue, and blocking oxygen,” and “it is often caused by chronic hypertension.” The NIH also reports, “Hypertension is the most common cause of spontaneous, primary intraventricular hemorrhage (PIVH) in adults, with high blood pressure causing small vessels to rupture. It typically presents with sudden headache, nausea, and altered consciousness.” With the available evidence, the Department concluded that R1’s fall on 03/22/2025 was not a proximate cause of R1’s elevated blood pressure; hypertension was a preexisting chronic condition for R1. While R1 arrived at the ER in a state of hypertensive crisis on 03/29/2025, R1’s stroke/cerebral hemorrhage occurred the following day while R1 was under hospital care, and not at the facility. Hospital staff determined R1’s stroke/cerebral hemorrhage was “nontraumatic,” meaning R1’s earlier fall on 03/22/2025 was not a proximate cause for the stroke/hemorrhage’s occurrence (8) days later, on 03/30/2025. The “nontraumatic” nature of the stroke/cerebral hemorrhage was reiterated on R1’s official death certificate. Based on records and interviews, a preponderance of evidence does not exist to support the allegation that the Licensee was culpable for R1’s death. Therefore, the allegation is unsubstantiated and no deficiencies are cited. An exit interview was conducted with Diana Weinstein, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. The report was amended for signatures. A review of the investigation and evidence was also performed by the Department’s Program Clinical Consultants (licensed medical professionals). According to their LIC603 Preplacement Appraisal, R1 was diagnosed with hypertension and hyperlipidemia when they moved into the facility. R1’s LIC602 Physician’s Report showed that both diagnoses were chronic and preexisting for years. Together, records and interviews showed that during the complaint timeframe: R1 was and remained independent in all their activities of daily living (ADLs), including mobility, transferring, and medication management. R1’s doctor wrote that R1 was not confused/disoriented, was able to follow instructions, and was able to communicate their own needs. Records and interviews showed: On 03/22/2025 around 7:50 PM, R1 was carrying food/groceries when they tripped and fell, landing on the welcome mat just outside the facility’s main entrance door. The fall was partially witnessed by Person #1 (P1). Receptionist Staff #2 (S2) observed R1 on the ground, right after the fall, and radioed caregiver Staff #3 (S3) for help. S2 and S3 went outside to assist R1. R1 got back up on their feet, with S3’s help. R1 insisted to these staff that they were fine/uninjured and declined to be evaluated by the medication technician on duty, Staff #3 (S3). Neither P1, S1, nor S2 observed any skin tear, mark, or bruise on R1’s head or body. The responding facility staff (S1 and S2) did not inform any medication tech, nurse, or manager about this fall. Instead, S2 escorted R1 back to their apartment/room. According to P1, they phoned R1 around 8:30 PM, at which time R1 told P1 they had a headache for which they would take a Tylenol. Neither P1 nor R1 mentioned R1’s headache to facility staff. Interviews of multiple facility staff and P1 aligned to show that R1 seemed normal over the next several days; R1 ate their meals in the dining room and act/spoke as usual. Then on 03/28/2025, P1 transported/escorted R1 to run errands outside the facility, and for the first time P1 noticed a change/decline in R1; specifically, P1 witnessed R1 struggle with separating their personal checks from the carbon copies, which was unlike R1. P1’s observation was communicated to facility staff the next day on 03/29/2025. Upon receiving this information, facility medication technician Staff #4 (S4) and nurse manager Staff #5 (S5) went to observe R1, finding that R1 was alert but confused compared to their baseline. Facility medication technician Staff #6 (S6) measured R1’s blood pressure at this time, finding it abnormally high at 251/102. Staff arranged for R1 to be transported to a local hospital emergency room (ER) via ambulance, where they remained hospitalized until their death. According to their official death certificate, R1’s immediate cause of death was “Acute Respiratory Failure,” secondary to “Nontraumatic Cerebral Intraventricular Hemorrhage” and “Hypertensive Emergency.” There was no involvement from the San Diego County Medical Examiner’s office in this case. Per Licensee’s “Fall Management Protocol” written policy, all falls, witnessed or unwitnessed, require several response steps to include that “any resident sustaining a fall will also be placed on Alert charting status” and that “the [resident's] healthcare practitioner will be notified using Form 213a, Physician Fax Report of Fall.” As confirmed in administrator interview, Licensee defined “Alert charting” as the facility’s licensed nurse meeting with the resident face-to-face daily, for at least three (3) consecutive days after the fall, to assess the resident’s health and ask about their experienced symptoms, and to document these findings in electronic progress notes. During their 06/02/2025 site visit, LPA Nguyen requested from Licensee copies of the facility staff’s charting and/or progress notes, which would evidence that “Alert charting” was performed on R1 post-fall. However, facility managers replied that no such notes existed which could prove that R1 was placed on “Alert charting status,” as was required by Licensee’s own written policy. While the available evidence cannot prove that R1’s blood pressure was elevated during or shortly after their fall on 03/22/2025, or that staff had constructive knowledge of R1’s rising blood pressure, the facility plan of operation, and interviews with facility staff corroborate that the proper protocol was to have R1 medically assessed and continuously observed by competent medical authority after their fall. While there was not enough evidence to show that that the facility was ultimately responsible for R1’s death, [See related LIC 9099 for complaint control number 08-AS-20250530085015], there is a preponderance of evidence to show that R1 experienced a serious medical emergency for which they did not receive timely medical care. Therefore, the complaint is substantiated and deficiencies cited [see attached LIC 9099(d)]. The licensee is hereby notified that additional civil penalties are under review by the Department’s legal division per Health and Safety Code § 1569.49(f). An exit interview was conducted with Executive Director Diana Weinstein, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 08-AS-20250530085015

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Jun 17, 2026

87468.2 Additional Personal Rights… (a)… residents… shall have… the following… rights: (8) To be free from neglect… This requirement was not met as evidenced by: Based on interview and record review, the licensee did not provide medical attention for one resident (R1) after a fall as required by facility policy, which resulted in delayed medical care for their serious illness/injury. This posed an immediate health, safety and personal rights risk to 1 of 122 residents in care.the state’s words, verbatim · CDSS document, Jun 16, 2026

Plan of correction: Licensee agreed to conduct an in-service retraining for all current staff on Licensee’s operative “Fall Management Protocol” (aka “Policy: 213”) and “Change of Condition Reporting” (aka “Policy: 301”) documents. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date. This is an amended version of an LIC 9099(d) originally delivered on 6/16/2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director Diana Weinstein to discuss the purpose of the visit. Today's visit is to deliver two amended reports from complaint visits originally conducted on September 11, 2025 and April 3, 2026. One complaint allegation was substantiated on the April 3, 2026 amended report and deficiencies were cited. The licensee is hereby notified that additional civil penalties are under review by the Department’s legal division per Health and Safety Code § 1569.49(f). An exit interview was conducted with Executive Director Diana Weinstein , who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jun 16, 2026

Allegation investigated: -Licensee culpability in resident’s death. -Licensee did not arrange timely medical care for resident.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Diana Weinstein. The Complainant alleged that Licensee did not timely arrange timely medical care for Resident #1 (R1), and that Licensee had culpability in R1’s death. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] CCLD’s investigation involved multiple unannounced facility tours/welfare checks, interviews of pertinent staff and outside sources, and review of relevant medical, hospital, and facility care records. [CONTINUED ON LIC 9099-C, 1 of 3] Unsubstantiated [CONTINUED FROM LIC 9099] The Complainant stated on 03/22/2025, R1 fell and their head contacted the ground. They said R1 had a subsequent decline in cognition, but Licensee’s staff did not arrange for R1 to go to the hospital until 03/29/2025. They said R1 remained in the hospital’s Intensive Care Unit (ICU) until R1 died on 04/25/2025. According to their LIC603 Preplacement Appraisal, R1 was already diagnosed with hypertension and hyperlipidemia when they moved into the facility. R1’s LIC602 Physician’s Report showed that both such diagnoses were chronic and preexisting for years before the above fall. R1’s medical records corroborated these same diagnoses and showed R1 had prior history of cerebrovascular accident (aka “stroke”). R1 last met with their primary care physician on 01/06/2025 (over 3.5 months before the above fall); on that date R1’s elevated blood pressure (which was 190/51), along with “complex conditions case management,” was the treatment focus of said doctor's appointment. Together, records and interviews showed that during the complaint timeframe: R1 was and remained independent in all their activities of daily living (ADLs), including mobility, transferring, and medication management. R1’s doctor wrote that R1 was not confused/disoriented, was able to follow instructions, and was able to communicate their own needs. While some of R1’s prescribed medications at the time treated/related to high blood pressure, R1 was not on any blood-thinner type medications during the complaint timeframe. Records and interviews showed: On 03/22/2025 around 7:50 PM, R1 was carrying food/groceries when tripped and fell, landing on the welcome mat just outside the facility’s main entrance door. The fall was partially witnessed by Person #1 (P1). Receptionist Staff #2 (S2) observed R1 on the ground, right after the fall, and radioed caregiver Staff #3 (S3) for help. S2 and S3 went outside to assist R1. R1 quickly got back up on their feet, with S3’s help. R1 insisted to these staff that they were fine/uninjured and declined to be evaluated by the medication technician on duty, Staff #3 (S3). Neither P1, S1, nor S2 observed any skin tear, mark, or bruise on R1’s head or body. Neither R1 nor P1 claimed to these facility staff, at that time, that R1 had head contact during the fall. S2 then escorted R1 back to their apartment/room. According to P1, they phoned R1 around 8:30 PM, at which time R1 told P1 they had a headache for which they would take a Tylenol. Neither P1 nor R1 mentioned R1’s headache to facility staff. [CONTINUED ON LIC 9099-C, 2 of 3] [CONTINUED FROM LIC 9099-C, 1 of 3] Interviews of multiple facility staff and P1 aligned to show that R1 seemed normal over the next several days; R1 ate their meals in the dining room and act/spoke as usual. Per interview of P1: They spoke to R1 via phone on 03/27/2025, telling CCLD that R1 sounded “fine” that day. Then on 03/28/2025, P1 transported/escorted R1 to run errands outside the facility, and for the first time P1 noticed a change/decline in R1; specifically, P1 witnessed R1 struggle with separating their personal checks from the carbon copies, which was unlike R1. P1’s observation was communicated to facility staff the next day on 03/29/2025. Upon receiving this information, facility medication technician Staff #4 (S4) and nurse manager Staff #5 (S5) went to observe R1, finding that R1 was alert and speaking, but also confused (compared to their baseline). Facility mediation technician Staff #6 (S6) measured R1’s blood pressure at this time, finding it abnormally high at 251/102. Staff timely arranged for R1 to be transported to a local hospital emergency room (ER) via ambulance. Hospital ER records showed: The first computed tomography (CT) scan of R1’s head on 03/29/2025 (soon after R1’s arrival to the ER) showed “no acute findings” and “no traumatic findings.” Hospital staff wrote that R1 was overall alert and oriented at that time. R1’s new diagnoses on 03/29/2025 were “Hypertensive Emergency” and “Elevated Troponin I,” the latter of which was the likely explanation for R1 shortness of breath. [According to the National Institutes of Health, elevated Troponin I “in the context of hypertension signals significant myocardial strain, stress, or damage” and “represents a marker of severe, acute stress on the heart muscle” and increased risk of mortality.] A subsequent CT scan of R1’s head performed on 03/30/2025 showed “extensive new intraparenchymal, subarachnoid, and intraventricular hemorrhage.” ER records showed R1 experienced a stroke around 8:00 PM on 03/30/2025; this was the first time during this hospitalization that R1 was diagnosed with “Acute Stroke,” after which point R1 was transferred to the hospital’s intensive care unit and put on ventilator support. R1 was diagnosed with “Nontraumatic Cerebral Intracerebral Hemorrhage, Multiple Localized” starting 03/31/2025. R1’s was diagnosed with “Nontraumatic Cerebral Intraventricular Hemorrhage” starting 04/01/2025. R1 was diagnosed with “Acute Respiratory Failure” and “Altered Mental Status” starting 04/01/2025. R1 remained minimally alert/responsive, ventilated, and on nasal-gastric feeding tube in the ICU, until their death on 04/25/2025. According to their official death certificate, R1’s immediate cause of death was “Acute Respiratory Failure,” secondary to “Nontraumatic Cerebral Intraventricular Hemorrhage” and “Hypertensive Emergency.” There was no involvement from the San Diego County Medical Examiner’s office in this case. [CONTINUED ON LIC 9099-C, 3 of 3] [CONTINUED FROM LIC 9099-C, 2 of 3] Academic research for this case showed: A headache, in and of itself, does not reliably indicate external trauma. A headache can have another internal physiological basis, such as hypertension. Confusion, in and of itself, does not reliably indicate external trauma. Confusion can have another internal physiological basis, such as hypertension. According to the Cleveland Clinic, “Hypertensive encephalopathy is brain dysfunction caused by extremely high blood pressure,” of which headache and confusion are both hallmark symptoms, and “most adults who experience hypertensive encephalopathy enter the emergency room with a dangerously high reading greater than 220/130 mmHg, but it could sometimes occur with blood pressure readings as low as 160/100 mmHg.” According to the National Institutes of Health, an intracerebral hemorrhage is “a severe type of stroke occurring when a ruptured blood vessel causes bleeding inside the brain, creating pressure, destroying brain tissue, and blocking oxygen,” and “it is often caused by chronic hypertension.” The NIH also reports, “Hypertension is the most common cause of spontaneous, primary intraventricular hemorrhage (PIVH) in adults, with high blood pressure causing small vessels to rupture. It typically presents with sudden headache, nausea, and altered consciousness.” With the available evidence, the Department concluded: R1’s fall on 03/22/2025 was not a proximate cause of R1’s elevated blood pressure; hypertension was a preexisting chronic condition for R1. While R1 arrived at the ER in a state of hypertensive crisis on 03/29/2025, R1’s stroke/cerebral hemorrhage occurred the following day while R1 was under hospital care (and not at the facility). Hospital staff determined R1’s stroke/cerebral hemorrhage was “nontraumatic,” meaning R1’s earlier fall on 03/22/2025 was not a proximate cause for the stroke/hemorrhage’s occurrence (8) days later, on 03/30/2025. The “nontraumatic” nature of the stroke/cerebral hemorrhage was reiterated on R1’s official death certificate. The available evidence does not support that the 03/22/2025 fall itself caused R1 pain or injuries warranting immediate hospital care on that date, or on successive days. The available evidence cannot prove that R1’s blood pressure was elevated during their fall on 03/22/2025, or on the successive days between the fall and 03/28/2025, or that Licensee’s staff had constructive knowledge of R1’s elevated blood pressure for which they also failed to timely respond to. Based on records and interviews, a preponderance of evidence does not exist to prove Licensee culpability in R1’s death, or that Licensee did not arrange timely medical care for R1. Both allegations are therefore Unsubstantiated, and no deficiencies were cited for them. An exit interview was conducted with Executive Director Diana Weinstein, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 3, 2026 · control 08-AS-20250530085015

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite a deficiency identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Diana Weinstein. CCR 87466 states, “The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning…” Per Licensee’s “Fall Management Protocol” written policy, all falls, witnessed or unwitnessed, “will require completion of an Unusual Occurrence Report and an investigation of the circumstances leading to the fall,” and “any resident sustaining a fall will also be placed on Alert charting status.” The policy further states that an “internal Incident Report (Form 406a) is completed every time a resident falls,” and the “the [resident's] healthcare practitioner will be notified using Form 213a, Physician Fax Report of Fall.” Review of records and interviews of staff and outside sources showed: Resident #1 (R1) fell just outside the facility’s main entrance door on 03/22/2025. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] The responding facility staff, Staff #1 (S1) and Staff #2 (S2), did not timely inform any medication tech, nurse, or manager about this fall. No internal Incident Report (Form 406a) was completed for this fall around when it occurred. Also, Licensee did not timely submit an LIC624 Unusual Incident/Injury Report to CCLD for this fall (this latter element was already addressed/cited in a separate complaint report). R1’s primary care physician (i.e., the pertinent healthcare provider) was also not timely notified of R1’s fall via a Form 213a, or by any other means. [CONTINUED ON LIC 809-C, 1 of 2] [CONTINUED FROM LIC 809] During his own 06/02/2025 site visit, LPA requested from Licensee copies of the facility staff’s charting and/or progress notes, which would evidence that “Alert charting” was performed on R1 post-fall. However, facility managers replied that no such notes existed which could prove that R1 was placed on “Alert charting status,” as was required by Licensee’s own written policy. As confirmed in administrator interview, Licensee defined “Alert charting” as the facility’s licensed nurse meeting with the resident face-to-face daily, for at least three (3) consecutive days after the fall, to assess the resident’s health and ask about their experienced symptoms, and to document these findings in electronic progress notes. “Alert charting” is therefore more than a cursory observation of the resident in passing, by lay staff.] Staff interviews showed: By 03/29/2025, Staff #4 (S4), the facility medication technician who called/arranged an ambulance for R1’s confusion and elevated blood pressure, was still unaware that R1 had fallen a week earlier. Likewise, the nurse manager then overseeing the facility’s clinical operations, Staff #5 (S5), and their deputy supervisor, Staff #7 (S7), both did not become aware that R1 had fallen a week earlier, until after R1 was already at the hospital. While there is no regulation specifically addressing internal communication, the failure of staff to internally communicate in this instance evidenced Licensee falling short of its own policy/procedural requirements regarding post-fall observation of R1. (In the final analysis, CCLD’s investigation showed that R1’s fall was not a proximate cause of R1’s confusion or elevated blood pressure. However, S4, S5, and S6 each affirmed to LPA that knowing about a prior fall provides useful context needed to inform subsequent observation checks and incidental medical care decisions, and that S1 and S2 should have reported the fall per protocol, when it occurred.) Additionally, during an earlier 06/23/2025 site visit, a California Department of Social Services (CDSS) Investigator (a peace officer acting in an official capacity on behalf of CCLD) formally requested from facility manager S5 a copy of the surveillance camera video footage segment depicting R1’s aforementioned fall on 03/22/2025. As of the date of this 06/23/2025 request, the pertinent footage was still intact and viewable, as witnessed by the Investigator. The Investigator made multiple follow-up phone calls to S5 for a copy of this footage for CCLD’s case file, but it was not provided to the Department. The Investigator subsequently spoke to the new facility administrator on 10/03/2025, who reported that as of that date, the pertinent footage no longer existed. [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809-C, 1 of 2] Two (2) deficiencies were cited according to California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Executive Director Diana Weinstein, to whom a copy of this report, the LIC 809-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 3, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: May 3, 2026

87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning…” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 1 of 113 residents (R1) was regularly observed for changes in physical, mental, emotional and social functioning following their fall. This posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: Licensee agreed to conduct an in-service retraining for all current staff on Licensee’s operative “Fall Management Protocol” (aka “Policy: 213”) and “Change of Condition Reporting” (aka “Policy: 301”) documents. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87755(c) · Plan of correction due date: Apr 3, 2026

87755 Inspection Authority of the Licensing Agency: “(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not cooperate with the licensing agency’s authority to receive a copy of a facility recording pertaining to an investigation involving 1 of 113 residents (R1). This posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: As of the date of deficiency issuance, CCLD completed its investigation of R1’s fall without a preserved recording of the pertinent footage. LPA advised the facility administrator to consult with whomever is needed to learn / better understand the technical features of their video surveillance system, such that preserving future recording excerpts is done easily. Licensee was advised that repeat violations may incur a civil penalty and/or trigger a Non-Compliance Conference (NCC).

Allegation investigated: Staff did not administer medications as prescribed

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver complaint findings. LPA introduced himself and disclosed the purpose of the visit with Executive Director Diana Weinstein. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA observations, records review, interviews with staff, residents and outside sources. LPA Serrano investigated allegations that facility staff failed to administer medications to Resident 1 (R1) and Resident 2 (R2) as prescribed. LPA reviewed both residents’ records, including physician reports, hospice documentation, Medication Administration Records (MARs), charting notes, and incident reports. The Department also interviewed staff regarding medication administration procedures, PRN protocols, and coordination with hospice nurses.For R1, the physician report dated 4/3/25 indicated that R1 had COPD, anxiety, and ongoing pain from pelvic and rib fractures requiring full care and hospice-level management. Unsubstantiated Hospice notes described R1 as medically fragile with ongoing pain, shortness of breath, increased anxiety, and agitation. Charting notes from January through April 2025 showed R1 regularly received morphine and Ativan as ordered, while staff documented that R1 often expressed severe pain shortly after receiving their PRN medication. R1 frequently stated that they believed staff were withholding their medication, even when charting showed the medication had just been administered. Staff consistently documented attempts to redirect R1, explain hospice medication orders, and reassure them about their care. Review of R1’s MARs showed that R1 was out of the facility for extended periods: from January 31, 2025 through March 22, 2025; again from March 23, 2025 through April 3, 2025; and again from April 6, 2025 through April 30, 2025. MARs and charting showed that on the limited days R1 was present in the facility, they received their medications as ordered. Facility records described several incidents where R1 became distressed, attempted to use their wheelchair as a walker, refused redirection, grabbed staff clothing, and verbally escalated to the point that 911 was contacted. R1 also called 911 independently, attempting to reach hospice and request changes to their medication orders. Incident reports and hospice notes both indicated that R1 frequently reported feeling unheard or unsupported, though documentation showed medications were given as prescribed. For R2, LPA reviewed MARs dated August through September 2025, physician orders, and charting notes from January through September 2025. R2 had COPD and acute kidney failure and was prescribed one medication daily at noon. MARs showed that the noon medication was withheld from August 1 through September 10, 2025 following orders from a physician or registered nurse. Staff had initialed and documented each date accordingly. Charting notes indicated that R2 sometimes became upset, thinking their medication was late when it was not, and also showed confusion about how many times per day they should receive medication. Staff documented multiple instances where R2 forgot that they had already taken their medication. No evidence was found indicating staff failed to administer medication as ordered. Record review, interviews, MARs, and hospice documentation did not support the allegation that staff failed to administer medications to R1 or R2. The documentation consistently showed that both residents received medication in accordance with physician and hospice directives. R1’s concerns appeared related to ongoing pain, anxiety, and behavioral symptoms, while R2’s concerns were related to confusion about medication schedules. The allegation that staff did not administer medications as prescribed is unsubstantiated. This means there is not enough evidence to prove the allegation occurred. An exit interview was conducted with Diana Weinstein A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Diana Weinstein whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Feb 24, 2026 · control 08-AS-20250410161651

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director Diana Weinstein to discuss the purpose of the visit. Today's visit is in response to the self reported death report involving Resident 1 (R1- see LIC811 Confidential Names List) who passed away on 2/18/26. LPA interacted with staff and obtained facility records. No deficiencies were cited or observed on this date. An exit interview was conducted with Executive Director Diana Weinstein. who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Feb 24, 2026

Allegation investigated: Neglect resulting in serious bodily injury

On 11/14/2025 at 02:30 PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger meet virtually via Teams to deliver findings for the above allegations. LPA explained the purpose of the visit with Health Service Director, Stacey Dickmann. The Department conducted a tour of the facility, interviewed residents and staff members who may have witnessed or had relevant information regarding the incidents, and reviewed relevant documentation, including resident care plans, incident reports, and other relevant records. On the allegation: Neglect resulting in serious bodily injury On 9/11/2024 R1 fell in the activity room and attempted to leave the facility on their own without waiting for assistance. Staff was nearby to assist R1 and R1 was immediately taken to the hospital to be evaluated. Continued on LIC 9099C... Unsubstantiated ...Continued from LIC9099 Based on the statements provided by staff present during R1’s fall on 9/11/2024, there would have been little they could do to prevent R1 from falling. R1 had been on fall precautions since April of 2024, and R1 is assisted to and from bed by staff and taken into the community during the day for more supervision. R1 receives frequent checks while in her room during the evening hours. R1 was also provided a fall mat alongside their bed, and their bed was lowered to its lowest position. Based on the above information. The allegation of Neglect/Lack of Care and Supervision of R1 suffering a fall and sustaining serious bodily injury will be Unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 14, 2025 · control 08-AS-20240912160901

Allegation investigated: Neglect to resident resulting in serious bodily injury. Staff did not ensure resident's needs were met

On 11/7/2025, LPA Grace Donato conducted a telephone interview with the facility to deliver findings. LPA spoke with Executive Director, Diana Weinstein and explained the purpose of the call. Regarding the allegation of neglect to resident resulting in serious bodily injury, resident (R1) was sent to the hospital and had undergone surgery. According to records, on 7/15/2024, during medication pass, R1 reported experiencing pain. R1 was asked if he/she had a fall but kept denying. PRN medication was given but was ineffective. Staff asked family to send R1 to hospital for further evaluation. On the same day, R1 was sent to hospital and was evaluated. For the allegation of staff did not ensure resident's needs were met, based on the records reviewed, there is constant alert charting for R1. There are also notes from facility staff about R1s behaviors and daily activities. Based on records review, the department has determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Report is reviewed and a copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 7, 2025 · control 08-AS-20240805130104

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA was greeted by and met with Resident Care Coordinator Luz Rivera, to discuss the purpose of the visit. LPA delivered an amended complaint report. The original complaint report findings were delivered on September 11, 2025. No deficiencies were cited or observed on this date. An exit interview was conducted with Luz Rivera who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Sep 17, 2025

Allegation investigated: Staff did not prevent resident from eloping from facility

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit and also delivered findings regarding the above complaint allegation. LPA introduced himself and disclosed the purpose of the visit with Memory Care Director Trobell Orana. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA observations, records review, interviews with staff and resident. It was alleged that facility staff did not prevent Resident 1 (R1) from eloping from the facility. It was reported that R1 eloped from the facility and was not located for several hours. R1's Physician's Report dated August 13, 2025 revealed R1 has a diagnosis of Major neurocognitive disorder. R1 is not able to leave the facility unsupervised and R1 becomes disoriented at times. Substantiated R1's Individualized Service Plan dated August 15, 2025 states that R1 is ambulatory and is unable to leave the facility unsupervised. Service plan further states that R1 is required to wear their safety bracelet if they are in the assisted living section of the community. LPA interviewed R1 who stated that less then a week ago they exited the facility without any supervision. R1 stated that they wanted to take a walk so they walked down the stairwell and exited the facility onto the sidewalk. R1 stated that they did not injure themselves during their walk but they did feel dehydrated. R1 stated that they now have a private caregiver who takes them for walks outside of the facility LPA interviewed Staff 1 (S1) who stated that on the date of the incident a woman called the facility advising staff that a person was found walking down the sidewalk who appeared lost and confused. The woman was able to confirm with R1 their identity. S1 then drove to pick up R1 who was with law enforcement. S1 asked R1 "what happened." R1 replied that they went for a walk and got lost. S1 stated that R1 was located approximately three blocks from the facility. S1 was unable to confirm how long R1 was outside of the facility unsupervised. LPA interviewed Staff 2 (S2) who stated that R1 eloped from the facility on the second day that R1 was admitted. S2 stated that R1 resides on the second floor in the assisted living section of the facility. S2 stated that R1 exited the facility from a stairwell on the second floor that exits onto the sidewalk. S2 stated that R1 was out of the community for approximately two hours. S2 stated that R1 was picked up by S1 and brought back to the facility. S2 stated that R1 now has a private caregiver that was provided by R1's responsible party. On September 3, 2025 CCL received an incident report (IR) regarding R1. IR stated that on September 2, 2025 the facility received a telephone call from a neighbor advising them that R1 was seen walking by the nearby homes. R1 was immediately picked up by facility staff. R1 returned to the facility without any visible injuries. After R1 showed facility staff the exit they took, staff concluded that they "cleared the alarm" without realizing that a resident had exited the facility. The Department has investigated the complaint alleging staff did not prevent R1 from eloping from facility. Based on evidence obtained R1 eloped from the facility on September 2, 2025. Accordingly, the above allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. The deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D. An exit interview was conducted, a plan of correction was developed by Trobell Orana and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to Trobell Orana whose signature on this form confirms receipt of the documents.the state’s words, verbatim · CDSS document, Sep 11, 2025 · control 08-AS-20250904161054

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Oct 6, 2025

87464 Basic Services (f)(1).... “Care and Supervision” means the facility assumes responsibility for…on going assistance with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents. This requirement was not met as evidenced by: Based on LPA interviews and records review the licensee did not provide R1 supervision. 1 in 1 of 126 persons in care [R1] which posed a potential health and safety risk to persons in care. ·the state’s words, verbatim · CDSS document, Sep 11, 2025

Plan of correction: Licensee agreed to conduct a full scale elopement driil and a training on elopements/absent without leave (AWOL), supervision for residents in care. This drill and training will be completed by POC date of 10/6/25. Licensee will provide LPA with a signed drill and training roster and training agenda. As of 9/2/25Tha R1 has a private caregiver that is with R1 24/7. This is an amended lic9099D that was orginally delivered on 9/11/25

Allegation investigated: Neglect resulted in rib fractures

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Executive Director Diana Weinstein and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of Department observation, records review, interviews with staff, residents and outside sources. It was alleged that Resident 1 (R1) sustained rib fractures due to staff neglect. It was specifically reported that on March 23, 2025 R1 was admitted to the hospital with two rib fractures, and R1 advised reported that they were mistreated by facility staff. The Department reviewed medical records which indicated that on January 31, 2025, R1 left the facility due to being hospitalized for an unrelated incident. Unfounded R1 remained in the hospital for treatment until February 10, 2025 when they were discharged to a Skilled Nursing Facility (SNF). On March 22,2025, R1 returned to the facility, but due to pain, they were taken back to the hospital the next day. Upon arrival, R1 was diagnosed with subacute fractures to their 10th and 11th rib. On June 19, 2025 the Department interviewed R1 who confirmed that they lived at the facility. R1 said they were in independent living and clarified, “it wasn’t for me.” R1 stated “One kid got rough with me.” R1 explained the kid was a male staff member. R1 could not recall the date this occurred and stated it occurred before R1 came to the hospital. R1 stated the incident occurred in the evening time when R1 was receiving their “pills.” R1 stated the male staff member threw R1 against a chair. On May 1, 2025 the Department interviewed Outside Source #1 (OS1), a close family member of R1 who was very familiar with their care. OS1 explained that R1 had the tendency to exaggerate.” OS1 further clarified that on January 31, 2025 R1 fell in their room and fractured their pelvis, not their ribs. OS1 clarified they believed that the new fractures happened sometime after the fall, when R1 was out of the facility and under the care of the SNF. R1 specifically told OS1 that one of the staff members there had “roughed them up.” The Department interviewed several facility staff (S1, S2, S3) that were assigned to care for R1 when they were present on March 22, 2025, and March 23, 2025. No interviews corroborated that staff forcefully repositioned R1 at the facility, and all staff interviewed denied physically abusing R1 at the facility. The Department reviewed hospital records dated 1/31/2025 which indicated that R1’s diagnosis and scans were unrelated to any rib fractures. Records from March 23, 2025 indicate that the main complaint was “pain control,” and that R1 reported they were repositioned roughly at the facility. On 7/23/2025, the Department interviewed the hospital Doctor (OS2) who provided care to R1. OS2 corroborated that R1’s fractures were not present during their January Hospital Stay. They also corroborated that R1 reported that, one day prior to their March Emergency Department (ED) visit, someone at their facility moved them “forcefully.” However, OS2 further explained to the Department that R1’s X-rays showed the rib fractures to be “subacute,” and “chronic,” which meant that they were not new fractures. OS2 further clarified that R1’s report that they were injured one day prior is medically inconsistent with their X-rays, which indicated that R1 had the fractures for some time. It should be noted that Local Law Enforcement (LEO) also investigated the facility abuse allegation. LEO report documented that medical staff believed the injuries most likely occurred when R1 was a patient at the SNF, not at the facility. Due to the inability of the doctor and hospital staff to determine if the injuries were caused due to foul play or negligence, the incident was recorded as a “Miscellaneous Incident.” During the course of the investigation, no corroborating evidence was obtained to support the allegation that neglect/lack of care and supervision resulted in R1 sustaining multiple rib fractures at the facility. Therefore the above allegation is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Executive Director Diana Weinstein A copy of this report along with licensee rights (LIC 9058, 3/22) was provided Executive Director Diana Weinstein whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Aug 25, 2025 · control 08-AS-20250410161651

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was allowed entry and discussed the purpose of the visit with Executive Director Diana Weinstein . According to the facility’s license, the facility has a maximum capacity of one hundred thirty seven (137) residents. All of whom may be non-ambulatory. Hospice waiver approved for twenty (20) residents. Forty four (44) residents may be bedridden. LPA, accompanied by Executive Director toured the interior and exterior of the facility, and inspected five rooms in both the assisted living and the memory care unit. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. Hot water temperature was measured in the facility at 116 degrees F. The ambient temperature inside the facility was measured at 75 degrees F. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas. Their are no bodies of water on the premises. Per Executive Director, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C] LPA reviewed multiple staff and resident records/files. LPA file review did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Executive Director Diana Weinstein whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 25, 2025

Allegation investigated: Licensee did not issue refund as required.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Health Services Director Eva Zuluaga and Senior Regional Business Office Director Specialist Aaron Phillips. The Complainant alleged that Licensee did not issue refund as required to Resident #1 (R1). [See LIC 811 Confidential Names List for a description of R1.] CCLD’s investigation involved unannounced facility tours/welfare check and interview of pertinent staff and outside sources. The Department also reviewed R1’s facility admissions agreement contract, R1’s facility billing records, R1’s official death certificate from the county, incident reports from Licensee, additional financial statements, and U-Haul billing records. [CONTINUED ON LIC 9099-C, 1 of 2] Substantiated [CONTINUED FROM LIC 9099] Interviews and records showed: R1 was independent in care and medications, paying Licensee only for room and board. On 03/29/2025, R1 was transported to the emergency room, where they were admitted and hospitalized. On 04/09/2025, R1’s responsible person (RP) vacated R1's apartment of belongings, relinquishing control of the room to Licensee. Licensee continued to bill R1 for room and board through 05/09/2025, which was initially consistent with the 30-day move-out notice provision in R1’s residency agreement, so long as R1 was alive. However, R1 died at the hospital on 04/25/2025, as confirmed by their official death certificate from the county. On 04/30/2025, R1’s RP notified Licensee that R1 had since died, and Licensee replied to confirmed receipt. R1’s admissions agreement states, “Death of Resident: This Agreement shall terminate automatically upon your death.” Furthermore, California Health and Safety Code Section 1569.652 specifies in part, “(a) A residential care facility for the elderly shall not require advance notice for terminating an admission agreement upon the death of a resident. No fees shall accrue once all personal property belonging to the deceased resident is removed from the living unit.” R1’s admissions agreement also states that in cases where a resident has died, “Within fifteen (15) days after your personal property is removed from your apartment, your estate, or other person or entity responsible for payment of fees under this Agreement, will receive a refund of any fees paid in advance covering the period after your personal property has been removed.” This 15-day refund deadline is also consistent with California Health and Safety Code. As of the commencement of CCLD’s investigation on 06/02/2025, Licensee still had not credited/refunded C1’s account/estate for room and board fees from 04/26/2025 through 05/09/2025, as were owed. Additionally, records and interviews showed: Earlier on 11/10/2024, R1 spent $114.88 on pest control products for their facility apartment, in response to seeing mice in their room. Upon discovering this expenditure, R1’s RP spoke with a facility manager, who agreed to speak with the facility administrator regarding a credit/refund of this money. This manager claimed they did speak to the administrator about this. However, the RP told CCLD they did not receive a follow-up response from Licensee, one way or the other. [CCLD’s subsequent investigation substantiated the earlier presence of mice in R1’s facility apartment, based on witness testimony and photographic evidence.] During today’s visit, Licensee agreed to additionally credit/refund this incidental amount to R1’s account/estate. [CONTINUED FROM LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] Based on records and interviews, a preponderance of evidence exists to show Licensee earlier did not issue refund as required to R1. The allegation was therefore Substantiated, and one (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction were jointly developed with the Licensee. An exit interview was conducted with Zuluaga, to whom a copy of this report, the LIC 9099-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 13, 2025 · control 08-AS-20250530085015

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652 · Plan of correction due date: Jun 13, 2025

1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds: “(a) A residential care facility for the elderly shall not require advance notice for terminating an admission agreement upon the death of a resident. No fees shall accrue once all personal property belonging to the deceased resident is removed from the living unit.” This requirement was not met, as evidenced by: Upon the death of 1 of 113 residents (R1), Licensee continued to allow fees to accrue after the deceased resident’s personal property was removed from the living unit. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 13, 2025

Plan of correction: During today’s visit, Licensee, in front of LPA: a) Issued a credit of (-$2,112.39) to the account of R1 to wipe out the room and board charges from 04/26/2025 through 05/09/2025, essentially treating 04/25/2025 (the day R1 died) as the last billable day; b) Issued a credit of (-$114.88) to reimburse R1 for their one-time pest control product/incidental expense. The total credit was therefore (-$2,227.27), and given R1 had a balance owed of $1,341.99, this resulted in an excess refund payment of (-$885.28) to R1’s estate. These actions resolve the deficiency.

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

Allegation investigated: Licensee did not issue refund as required.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Health Services Director Eva Zuluaga and Senior Regional Business Office Director Specialist Aaron Phillips. The Complainant alleged that Licensee did not issue refund as required to Resident #1 (R1). [See LIC 811 Confidential Names List for a description of R1.] CCLD’s investigation involved unannounced facility tours/welfare check and interview of pertinent staff and outside sources. The Department also reviewed R1’s facility admissions agreement contract, R1’s facility billing records, R1’s official death certificate from the county, incident reports from Licensee, additional financial statements, and U-Haul billing records. [CONTINUED ON LIC 9099-C, 1 of 2] Substantiated [CONTINUED FROM LIC 9099] Interviews and records showed: R1 was independent in care and medications, paying Licensee only for room and board. On 03/29/2025, R1 was transported to the emergency room, where they were admitted and hospitalized. On 04/09/2025, R1’s responsible person (RP) vacated R1's apartment of belongings, relinquishing control of the room to Licensee. Licensee continued to bill R1 for room and board through 05/09/2025, which was initially consistent with the 30-day move-out notice provision in R1’s residency agreement, so long as R1 was alive. However, R1 died at the hospital on 04/25/2025, as confirmed by their official death certificate from the county. On 04/30/2025, R1’s RP notified Licensee that R1 had since died, and Licensee replied to confirmed receipt. R1’s admissions agreement states, “Death of Resident: This Agreement shall terminate automatically upon your death.” Furthermore, California Health and Safety Code Section 1569.652 specifies in part, “(a) A residential care facility for the elderly shall not require advance notice for terminating an admission agreement upon the death of a resident. No fees shall accrue once all personal property belonging to the deceased resident is removed from the living unit.” R1’s admissions agreement also states that in cases where a resident has died, “Within fifteen (15) days after your personal property is removed from your apartment, your estate, or other person or entity responsible for payment of fees under this Agreement, will receive a refund of any fees paid in advance covering the period after your personal property has been removed.” This 15-day refund deadline is also consistent with California Health and Safety Code. As of the commencement of CCLD’s investigation on 06/02/2025, Licensee still had not credited/refunded C1’s account/estate for room and board fees from 04/26/2025 through 05/09/2025, as were owed. Additionally, records and interviews showed: Earlier on 11/10/2024, R1 spent $114.88 on pest control products for their facility apartment, in response to seeing mice in their room. Upon discovering this expenditure, R1’s RP spoke with a facility manager, who agreed to speak with the facility administrator regarding a credit/refund of this money. This manager claimed they did speak to the administrator about this. However, the RP told CCLD they did not receive a follow-up response from Licensee, one way or the other. [CCLD’s subsequent investigation substantiated the earlier presence of mice in R1’s facility apartment, based on witness testimony and photographic evidence.] During today’s visit, Licensee agreed to additionally credit/refund this incidental amount to R1’s account/estate. [CONTINUED FROM LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] Based on records and interviews, a preponderance of evidence exists to show Licensee earlier did not issue refund as required to R1. The allegation was therefore Substantiated, and one (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction were jointly developed with the Licensee. An exit interview was conducted with Zuluaga, to whom a copy of this report, the LIC 9099-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 13, 2025 · control 08-AS-20250530085015

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652 · Plan of correction due date: Jun 13, 2025

1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds: “(a) A residential care facility for the elderly shall not require advance notice for terminating an admission agreement upon the death of a resident. No fees shall accrue once all personal property belonging to the deceased resident is removed from the living unit.” This requirement was not met, as evidenced by: Upon the death of 1 of 113 residents (R1), Licensee continued to allow fees to accrue after the deceased resident’s personal property was removed from the living unit. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 13, 2025

Plan of correction: During today’s visit, Licensee, in front of LPA: a) Issued a credit of (-$2,112.39) to the account of R1 to wipe out the room and board charges from 04/26/2025 through 05/09/2025, essentially treating 04/25/2025 (the day R1 died) as the last billable day; b) Issued a credit of (-$114.88) to reimburse R1 for their one-time pest control product/incidental expense. The total credit was therefore (-$2,227.27), and given R1 had a balance owed of $1,341.99, this resulted in an excess refund payment of (-$885.28) to R1’s estate. These actions resolve the deficiency.

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

Allegation investigated: -Licensee did not meet reporting requirements. -Licensee did not keep resident’s room free of rodent(s). -Licensee did not provide copy of admissions agreement to resident’s representative.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to commence a Complaint Investigation regarding the above allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Calais Anguiano. The Complainant alleged that Licensee did not keep meet reporting requirements regarding an incident involving Resident #1 (R1), that Licensee did not keep R1’s room free of rodents, and that Licensee did not provide a copy of R1’s admissions agreement contract to R1’s representative. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] The Department’s investigation involved an unannounced facility tour/welfare check, review of pertinent CCLD and facility records, and interviews of relevant staff and outside sources. [CONTINUED ON LIC 9099-C] Substantiated [CONTINUED FROM LIC 9099] Interviews aligned to show: On 03/22/2025, R1 fell on the facility premises, right outside the lobby front door, to which facility staff responded timely. On 03/29/2025, facility staff arranged for R1 to be transported to the hospital for a change in condition, where R1 was admitted. R1 remained at the hospital, where they subsequently died in late April 2025. Licensee did not submit written incident reports to CCLD or R1’s responsible person describing R1’s fall, hospitalization, or death; these were required to be submitted to both parties within seven (7) days of occurrence. Interviews of a corroborating outside source showed this person found two (2) mice hiding inside a cardboard box inside R1’s bedroom, which they removed and brought outside. CCLD also obtained photographic evidence of rat multiple droppings on R1’s personal effects. Available records and interviews showed: R1’s and their representative/responsible person (RP) both previously signed an Admissions Agreement which Licensee prepared for R1. However, a facility representative did not co-sign on behalf of Licensee. [Licensee’s missing signature will be addressed in a separate Case Management visit report.] R1’s RP then requested a copy of the contract from Licensee, but Licensee did not follow through on this request. Based on records and interviews, a preponderance of evidence exists to show Licensee did not meet reporting requirements, that Licensee did not keep resident’s room free of rodents, and that Licensee did not provide copy of admissions agreement to resident’s representative. These allegations were Substantiated, and three (3) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Anguiano, to whom a copy of this report, the LIC 9099-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 2, 2025 · control 08-AS-20250530085015

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jun 9, 2025

87211 Reporting Requirements: “(a) (1) A written report shall be submitted to the licensing agency 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…(D) Any incident which threatens the welfare, safety or health of any resident…” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not submit a written report to the licensing agency and to the person responsible for 1 of 113 residents (R1) who had an incident which threatened their welfare, safety, or health. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 2, 2025

Plan of correction: Licensee agreed to submit write and submit one (1) LIC624 Incident Report (to cover both R1’s fall and hospitalization) and one (1) LIC624A Death Report (to cover the extent of what Licensee knows about R1’s death, as reported by their RP). Licensee agreed to E-mail copies of the LIC624 and LIC624A to the Department (CCLASCPSanDiegoRO@dss.ca.gov, Cc’ing LPA Nguyen) and to R1’s RP, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 2, 2025

87303 Maintenance and Operation: “(a) The facility shall be clean, safe, sanitary…at all times.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure the facility was clean and sanitary at all times. This posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 2, 2025

Plan of correction: As of the date of deficiency issuance, the mice observed in R1’s room have been removed and the room has been thoroughly cleaned. On 05/09/2025, the facility’s Executive Director and Regional Maintenance Director walked the room, finding no evidence of vermin. Licensee agreed to bring in a professional pest control company to inspect the facility for vermin, to ensure no future problems, and to E-mail a copy of the visit report to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(e) · Plan of correction due date: Jun 9, 2025

87507 Admission Agreements: “(e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. The licensee shall provide additional copies to the resident or resident’s representative upon request.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not provide copy of the signed and dated current admission agreement to the representative of 1 of 113 residents (R1) immediately upon singing the admission agreement and upon request. This posed a potential personal rights violation to persons in care.the state’s words, verbatim · CDSS document, Jun 2, 2025

Plan of correction: Licensee agreed to E-mail a copy of R1’s latest unaltered admissions agreement document to their responsible person (Cc’ing LPA Nguyen), by the POC due date.

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

Allegation investigated: -Licensee did not meet reporting requirements. -Licensee did not keep resident’s room free of rodent(s). -Licensee did not provide copy of admissions agreement to resident’s representative.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to commence a Complaint Investigation regarding the above allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Calais Anguiano. The Complainant alleged that Licensee did not keep meet reporting requirements regarding an incident involving Resident #1 (R1), that Licensee did not keep R1’s room free of rodents, and that Licensee did not provide a copy of R1’s admissions agreement contract to R1’s representative. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] The Department’s investigation involved an unannounced facility tour/welfare check, review of pertinent CCLD and facility records, and interviews of relevant staff and outside sources. [CONTINUED ON LIC 9099-C] Substantiated [CONTINUED FROM LIC 9099] Interviews aligned to show: On 03/22/2025, R1 fell on the facility premises, right outside the lobby front door, to which facility staff responded timely. On 03/29/2025, facility staff arranged for R1 to be transported to the hospital for a change in condition, where R1 was admitted. R1 remained at the hospital, where they subsequently died in late April 2025. Licensee did not submit written incident reports to CCLD or R1’s responsible person describing R1’s fall, hospitalization, or death; these were required to be submitted to both parties within seven (7) days of occurrence. Interviews of a corroborating outside source showed this person found two (2) mice hiding inside a cardboard box inside R1’s bedroom, which they removed and brought outside. CCLD also obtained photographic evidence of rat multiple droppings on R1’s personal effects. Available records and interviews showed: R1’s and their representative/responsible person (RP) both previously signed an Admissions Agreement which Licensee prepared for R1. However, a facility representative did not co-sign on behalf of Licensee. [Licensee’s missing signature will be addressed in a separate Case Management visit report.] R1’s RP then requested a copy of the contract from Licensee, but Licensee did not follow through on this request. Based on records and interviews, a preponderance of evidence exists to show Licensee did not meet reporting requirements, that Licensee did not keep resident’s room free of rodents, and that Licensee did not provide copy of admissions agreement to resident’s representative. These allegations were Substantiated, and three (3) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Anguiano, to whom a copy of this report, the LIC 9099-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 2, 2025 · control 08-AS-20250530085015

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jun 9, 2025

87211 Reporting Requirements: “(a) (1) A written report shall be submitted to the licensing agency 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…(D) Any incident which threatens the welfare, safety or health of any resident…” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not submit a written report to the licensing agency and to the person responsible for 1 of 113 residents (R1) who had an incident which threatened their welfare, safety, or health. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 2, 2025

Plan of correction: Licensee agreed to submit write and submit one (1) LIC624 Incident Report (to cover both R1’s fall and hospitalization) and one (1) LIC624A Death Report (to cover the extent of what Licensee knows about R1’s death, as reported by their RP). Licensee agreed to E-mail copies of the LIC624 and LIC624A to the Department (CCLASCPSanDiegoRO@dss.ca.gov, Cc’ing LPA Nguyen) and to R1’s RP, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 2, 2025

87303 Maintenance and Operation: “(a) The facility shall be clean, safe, sanitary…at all times.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure the facility was clean and sanitary at all times. This posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 2, 2025

Plan of correction: As of the date of deficiency issuance, the mice observed in R1’s room have been removed and the room has been thoroughly cleaned. On 05/09/2025, the facility’s Executive Director and Regional Maintenance Director walked the room, finding no evidence of vermin. Licensee agreed to bring in a professional pest control company to inspect the facility for vermin, to ensure no future problems, and to E-mail a copy of the visit report to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(e) · Plan of correction due date: Jun 9, 2025

87507 Admission Agreements: “(e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. The licensee shall provide additional copies to the resident or resident’s representative upon request.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not provide copy of the signed and dated current admission agreement to the representative of 1 of 113 residents (R1) immediately upon singing the admission agreement and upon request. This posed a potential personal rights violation to persons in care.the state’s words, verbatim · CDSS document, Jun 2, 2025

Plan of correction: Licensee agreed to E-mail a copy of R1’s latest unaltered admissions agreement document to their responsible person (Cc’ing LPA Nguyen), by the POC due date.

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

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite a deficiency identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Calais Anguiano. Former Resident #1 (R1) and their representative/responsible person (RP) signed the Admissions Agreement contract which Licensee prepared and presented to them. [See LIC811 Confidential Names List for a description of R1.] However, a facility representative did not co-sign this contract on behalf of Licensee, even after seven (7) days after move-in. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Anguiano, to whom a copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 2, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(c) · Plan of correction due date: Jun 9, 2025

87507 Admission Agreements: “(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee or their designated representative did not sign the admissions agreement for 1 of 113 residents (R1) within seven (7) days after the resident’s admission. This posed a potential personal rights violation to persons in care.the state’s words, verbatim · CDSS document, Jun 2, 2025

Plan of correction: Licensee agreed to E-mail a copy of R1’s latest unaltered admissions agreement document to their responsible person (Cc’ing LPA Nguyen), by the POC due date.

Allegation investigated: Staff did not prevent residents from eloping from facility Staff did not report incidents to appropriate parties

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Executive Director Calais Anguiano and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of LPA observation, records review, interviews with staff, residents and outside sources. It was alleged that facility staff did not prevent Resident 1 (R1) and Resident 2 (R2) from eloping from the facility. It was also alleged that staff did not report these incidents to appropriate parties. It was reported that R1 eloped from the memory care unit, walked a long distance and was gone from the facility for more than one hour. R1 was said to have been found by Staff 1 (S1). It was also reported that R2 eloped from the memory care unit, walked down a main road near the facility and was located by Staff 2 (S2) while they were driving to work. Substantiated LPA attempted to interview R1 on May 14, 2025. R1 was unable to answer qualifying questions. R1 was unable to state the date or time. LPA then asked R1 basic questions regarding leaving the facility unattended. R1 stated that they have left the facility in the past but not recently. LPA interviewed R2 who stated that they have lived at the facility too long. R2 stated that they were recently thinking about walking across the street and catching a bus. R2 stated that in the past when they tried to leave the facility unsupervised a staff member yelled at them to get their walker. R2 stated that last month they left the facility and walked to the intersection by themselves. LPA interviewed S1 who stated that the memory care unit was conducting an "elopement drill" right before the incident occurred with R1. S1 stated that the caregiver assigned to R1's section claimed that they "cleared their section." S1 stated that the egress door alarm sounded a short time after and the staff conducted a head count of residents. S1 stated that as they were driving away from the facility they saw R1 outside on the sidewalk area. S1 stated that they placed R1 in their car and drove them back to the facility. S1 stated R1 had no injuries and they estimate that R1 was out of the facility for approximately 10 minutes before R1 was located. LPA interviewed S2 who stated that while driving to work on April 26, 2025 they saw R2 walking towards the street intersection of Olympic Parkway and East Palomar Street. S2 stated that they were worried and immediately called their supervisor to advise them where R2 was located. S2 stated that they do not believe R2 had any injuries as a result of the elopement. S2 stated that R2 lived in the assisted living section of the facility and has eloped from the facility more then three times. LPA interviewed Outside Source 1(OS1) who stated that the facility staff called them immediately after the incident and advised OS1 that R1 "got out of the facility through the back." OS1 stated that the Director contacted OS1 the following day and was apologetic for what occurred. OS1 stated that they do not believe it was a major incident since their were no injuries and R1 simply slipped out. OS1 stated that R1 has never eloped before and they have full confidence in the facility staff. LPA interviewed Executive Director (ED) who stated that on the date of the incident memory care staff were conducting an "elopement drill" and R1 exited the unit. ED stated that the alarm sounded and a head count and room checks were conducted. ED stated that care staff did not accurately count the residents and failed to alert that R1 was missing. ED stated when staff checked the memory care exit door area R1 had walked to far along to be seen. ED stated that the care staff that did not accurately count the residents was place on suspension and was later terminated. ED stated that R2 goes out for walks since their physician's report states they can leave the facility unassisted. ED stated that R2 did walk to the intersection by the facility and R2's family just requests that they do not get lost. Records review revealed an incident report for R1 was submitted to CCL on March 13, 2025. Incident report stated that on March 6, 2025 the memory care egress door alarm sounded off at 410pm. Facility staff did not locate a resident in the surrounding area and conducted a head count. Facility staff located R1 at 417pm outside of the community, walking on the sidewalk. No injuries were noted. Records review revealed R1 had a diagnosis of Alzheimer's. R1 was unable to leave the facility unassisted and R1 was a high elopement risk due to resident expressing they wanted to leave the facility. Records review revealed R2 had a diagnosis of Encephalopathy and a traumatic brain injury with loss of consciousness. R2's physician's report indicated that R2 was non-ambulatory and R2 was able to leave the facility unassisted at their families discretion. R2's care plan stated that R2 had a cognitive impairment, was unable to leave the community unsupervised and they are required to wear a safety bracelet if in assisted living. The Department has investigated the complaint alleging staff did not prevent residents from eloping from facility and staff did not report incidents to appropriate parties. Based on evidence obtained R1 and R2 eloped from the facility and R2's elopement was not reported to the licensing agency. Accordingly, the above allegations are substantiated. This finding means that the preponderance of the evidence standard has been met and the allegations are valid. The deficiencies are cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D. An exit interview was conducted, plans of correction were jointly developed, and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to Calais Anguiano, Executive Director. Signature on this form confirms receipt of the documents.the state’s words, verbatim · CDSS document, May 14, 2025 · control 08-AS-20250310095341

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 9, 2025

87464 Basic Services (f)(1).... “Care and Supervision” means the facility assumes responsibility for…on going assistance with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents. This requirement was not met as evidenced by: Based on interview and record review, two residents (R1 and R2) wandered from the facility without required supervision. This posed an immediate health, safety, and personal rights risk to 2 of 109 residents in care.the state’s words, verbatim · CDSS document, May 14, 2025

Plan of correction: Licensee agreed to conduct training by an outside source on elopements/absent without leave (AWOL), supervision for residents in care. This training will be completed by POC date of 6/9/25. Licensee will provide LPA with a signed training roster and training agenda.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 9, 2025

REPORTING REQUIREMENTS 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. This requirement was not met as evidenced by: Based on interviews and record review, the licensee failed to report R2's elopement to law enforcement and the licensing agency. 1 in 1 of 109 persons in care [R2] This posed a potential health and safety risk to R2.the state’s words, verbatim · CDSS document, May 14, 2025

Plan of correction: Licensee stated the incident report would be completed and submitted to the licensing agency by POC date and a facility training will be conducted on "reporting requirements" This is an amended version of a report originally delivered on 5/14/25.

Allegation investigated: Resident sustained an injury due to lack of supervision

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced visit at the facility to open a complaint investigation regarding the above mentioned allegation. LPA identified themselves, stated the purpose of the visit and was greeted by Executive Director (ED) Calais Anguiano. It was alleged that Resident 1 (R1) sustained an injury due to lack of supervision. It was reported that R1 fell down on two consecutive days, October 21st and October 22nd. On the second incident, R1 sustained a head injury and was sent to the hospital. It was further reported that Staff 1 (S1) was the responsible caregiver during both incidents. LPA reviewed facility resident rosters dated September 2024 through February 2025. LPA also reviewed facility staff rosters dated September 2024 through February 2025. Review of records revealed R1 did not reside at the facility and S1 did not work at the above mentioned facility. LPA interviewed Outside Source (OS) who stated that R1 and S1 were located at a different facility and this complaint was generated in error. Unfounded LPA interviewed ED who stated that R1 has never resided at the facility and S1 has never been employed at the facility. LPA review of initial complaint correspondence revealed the facility name and address attached to the complaint allegation did not correspond with the above mentioned senior care facility. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained from interviews and records review, we have found that the complaint was unfounded. An unfounded determination means that the allegation was false, could not have happened and/or is without a reasonable basis. The allegation was not pertinent to this licensed facility. The report was discussed, and an exit interview was conducted with Calais Anguiano. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) was provided to Calais Anguiano at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Feb 20, 2025 · control 08-AS-20250212120748

Allegation investigated: Facility financially abused resident Staff moved a resident who doesn’t have dementia to the memory care unit Staff instructed residents not to use their pendants, or they will be charged extra for using them

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Maintenance Director Justin Brown and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of LPA observation, records review and interviews with facility staff, residents and outside sources. It was alleged that facility staff financially abused Resident 1 (R1) (an LIC 811 Confidential Names List was provided to the facility representative to identify the resident) It was reported that R1 was paying for three apartments without R1's knowledge. LPA reviewed the standard fee schedule dated January 2024 as well as billing invoices dated June 2024 through August 2024. The billing invoices did not show that R1 was charged for three apartments. A slight price increase occurred on the July invoice when R1 moved to the memory care unit. LPA interviewed an outside source (OS) who stated that in regards to the facility billing for R1's room. Unsubstantiated R1 was recently upgraded to a private suite which means R1 has two rooms, that the facility bills separately. OS stated that R1 gets billed for two rooms but it's not being done fraudulently. It was reported that R1 does not have a dementia diagnosis and was moved to the memory care unit in error. Records review of R1's Physician's report revealed R1 has a dementia diagnosis. Physician's report also indicated that R1 gets confused and disoriented. R1 wanders and requires assistance with medication management. LPA interviewed outside source (OS) who stated that R1 "absolutely" should be in the memory care unit. OS stated that R1 has a dementia diagnosis and R1's doctor recently conducted R1's yearly check-up which found R1 to have more memory loss. OS stated that R1 has memory discrepancies 50-60 seconds after something is told to R1. It was alleged that staff instructed residents not to use their pendants, or they will be charged extra for using them. LPA interviewed Memory Care Director (MCD) who stated that although their are call buttons in the bathrooms in memory care, their are no call pendants in the bedrooms. MCD stated that they keep "eyes' on the memory care residents throughout the day by keeping them out of their rooms. MCD stated that for the few residents that remain in their rooms staff members check up on them often. LPA interviewed outside source (OS) who stated that R1 did utilize their call pendant in the assisted living (AL) side of the facility, but OS found that call pendants are not a tool used in the memory care section of the facility. LPA interviewed outside source 2 (OS2) who stated that her father has lived at the facility for 4.5 years. OS2 stated that she is very pleased with the facility and the memory care unit. OS2 stated that the memory care staff are highly attentive to her father's needs. OS2 stated that she highly recommends the facility since they have great communication between the facility and the resident's family. LPA observation found that the call pendant device is not used in the bedrooms of the memory care unit. No evidence was found to substantiate the claim that residents were instructed not to use call pendants which are non-existent in the memory care unit. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. An exit interview was conducted with John Brown. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to John Brown whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Sep 25, 2024 · control 08-AS-20240729110908

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was allowed entry and discussed the purpose of the visit with Executive Director Calais Anguiano. According to the facility’s license, the facility has a maximum capacity of one hundred thirty seven (137) residents. All of whom may be non-ambulatory. Hospice waiver approved for twenty (20) residents. Forty four (44) residents may be bedridden. LPA, accompanied by Executive Director toured the interior and exterior of the facility, and inspected five rooms in both the assisted living and the memory care unit. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. Hot water temperature was measured in the facility at 117 degrees F. The ambient temperature inside the facility was measured at 76 degrees F. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas. Their are no bodies of water on the premises. Per Executive Director, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C] LPA reviewed multiple staff and resident records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Calais Anguaino whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 26, 2024

Allegation investigated: Staff neglected resident resulting in hospitalization.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Executive Director Calais Anguiano and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA direct observation, records review and interviews with facility staff. It was alleged that staff neglected Resident 1 (R1) resulting in hospitalization.[an LIC 811 Confidential Names List was provided to the facility representative to identify the resident.]It was reported that R1 fell in their room and called for staff assistance multiple times. An outside party called emergency services for R1 and R1 was transported to the hospital. Interviews were conducted with seven staff members, during this time period. Of the seven staff members, all reported that staffing was an issue and five of the seven reported that either residents did not get care and/or the residents had to wait a while to receive the care. Substantiated Agency care notes indicated that R2 was awake, alert and verbally responsive. No reports of pain or cough noted. Recommendations included; keep nails trimmed and apply sarna lotion prn. Outside agency did not observe or document R2 being left in feces or unbathed. Facility internal care notes dated May 2021 through April 2022 indicate R2 was regularly monitored and assessed by facility staff. Care notes indicate R2 was monitored for both R2's mental and physical well being. R2's responsible party was also advised of any change of condition. R2's service plan dated Jan 1, 2022 indicated that R2 needed assistance with incontinence supplies, hygiene, and changing linens. R2 would be toileted day and night. Service plan further indicated that R2 would receive assistance with toileting according to R2's schedule, need, and requests. Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid. An exit interview was conducted with Calais Anguiano. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Calais Anguiano whose signature below verifies receipt of these rights. The other two staff members acknowledged that staffing was a problem and they are often required to work very hard but that resident's needs were being met. Review of internal logs was conducted. The call alert logs from the facility reflected an ongoing concern with long wait times for care. In one week analyzed over 13% of resident calls were answered after 20 minutes or more. Some resident calls took over an hour to answer. LPA interviewed Executive Director (ED) who stated that she began working at the facility on July 2023. ED stated that as of today the facility is sufficiently staffed and the resident pendant calls are answered on a timely basis. ED further stated that the response call time has also improved from the previous year. Based upon the foregoing, the above listed allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and is noted on the attached LIC 9099-D. An exit interview was conducted with Calais Anguiano and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Calais Anguiano whose signature below confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 29, 2024 · control 08-AS-20211115095357

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Aug 5, 2024

87464 Basic Services (f) (4) Basic services shall at a minimum include, personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living. This requirement was not met as evidence by: Based on interviews and records review, the licensee did not ensure that residents received personal assistance and care as needed on a timely basis to meet the residents’ needs. This posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Jul 29, 2024

Plan of correction: Facility managment will conduct in-service trainings with all staff to ensure call buttons are attended within the standard response time.

Allegation investigated: Neglect/lack of supervision resulted in resident sustaining head injury. Licensee did not address resident's change in condition.

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced a follow up complaint investigation visit, and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Business Office Director Silvia Garcia. Throughout the investigation, the Department secured records and conducted interviews with external and internal sources. It was alleged neglect/lack of supervision resulted in a resident sustaining a head injury. On 05/18/2023, the Department received an SOC 341, a report of Suspected Dependent Adult/ Elder Abuse. It was reported Resident # 1 (R1) had sustained an unwitnessed fall on 5/3/23 and was transported to the hospital for further evaluation. On 5/4/23, 911 was again called to the facility as R1 had sustained another fall resulting in head trauma. (See LIC 9099C form for continuation of report.) Unsubstantiated R1 was an 88 year resident considered non- ambulatory due physical and mental state, required supervision when ambulating with a walker, required assistance with escorts, and was diagnosed with Dementia, hypertension, and general weakness among other comorbidities. Interviews with internal sources revealed R1 resided at the facility from 4/27/23 to 5/5/23. The facility staff had conducted visual checks on R1 every two hours, or less. After the initial fall was reported, interviews consistently revealed R1 was placed on alert charting, which increased the frequency of each check to every hour and staff spent more time with R1 during each check. It was believed R1’s bed was high off the ground, not appropriate and a possibly contributed to the falls. Interviews consistently disclosed staff had notified R1’s family R1’s bed may not be appropriate, but family declined to provide a lower bed. During the second fall on 5/4/23, staff reported family and staff had interacted with R1 prior to the fall. Staff had checked on R1 approximately twenty minutes prior to the fall, and staff had witnessed R1’s family exiting the room after. Interviews with external sources revealed R1’s family believed the facility was understaffed, because R1’s spouse, who resided with R1, was once found with a soiled undergarment. It was confirmed R1 no longer resided at the facility, and R1’s had a lower hospital bed which made it easier for R1 to ger in and out. Although a review of records revealed R1 was considered non-ambulatory, was a fall risk, and required assistance with being supervised when ambulating with a walker, there was not enough evidence to support staff negligence resulted in R1 sustaining injuries. Both incidents were unwitnessed, staff responded and summoned medical attention, therefore, the allegation was Unsubstantiated. It was alleged the licensee did not address resident's change in condition. Review of incident reports along with interviews confirmed R1 had two unwitnessed falls. The first fall occurred on 5/3/23, R1 was found by staff, was transported for medical attention, and returned with not injuries noted. The second fall occurred on 5/4/23, R1 was found with a facial laceration and was transported for medical attention. Interviews consistently revealed staff had conducted wellness checks on average every two hours. After the initial fall, management relayed R1 would be placed on alert requiring hourly wellness checks. Staff confirmed alert charting, hourly wellness checks, and observation was increased for R1. Although a higher bed was identified as a possible contributor to R1’s falls, and a care conference may have been scheduled to discuss appropriate level of care, there was not enough evidence to prove staff did not address R1’s change of condition. An exit interview was conducted with Business Office Director , to whom a copy of this report, LIC 811 Confidential names list and Licensee/Appeals Rights (LIC 9058,) were providedthe state’s words, verbatim · CDSS document, May 21, 2024 · control 08-AS-20230518133003

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced case-management visit. LPA met with Business Office Manager Silvia Garcia, and discussed the purpose of the visit. This visit was initiated due to a self-reported incident involving possible abuse of Resident #1 (R1). During today's visit, LPA toured the facility with Maintenance Director Justin Brown, observed residents in care, and obtained copies from Silvia Garcia of staff and R1's records . No immediate health and/or safety concerns were observed during the visit. No deficiencies were cited during today's visit. An exit interview was conducted with Silvia Garcia, and a copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to them at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 15, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA was greeted by and met with Business Office Director Silvia Garcia, to discuss the purpose of the visit. Today's visit is in response to the self reported incident of Resident 1 (R1 - see LIC811 Confidential Names List) who suffered a fall and hit their head. LPA interviewed staff and obtained facility records. R1 remained hospitalized at the time of the visit. No deficiencies were cited or observed on this date. An exit interview was conducted with Silvia Garcia, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Apr 18, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Health Services Director Brittany Blaul. Today's visit was in response to two (2) SOC341 Reports of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 12/07/2023 and 02/01/2024, respectively). Per the first SOC341: it was alleged that Resident #1 (R1) had around $300 in cash stolen from their wallet sometime between 11/21/2023 and 12/06/2023. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] Per the second SOC341: R1 had another $250 in cash stolen from their wallet sometime between 01/29/2024 and 01/31/2024. During today’s visit, LPA performed a brief facility tour and collected copies of and reviewed pertinent care and personnel records, visitor logs, theft logs, and investigative notes. LPA also interviewed relevant staff. R1, who was a hospice care patient, passed away on 02/09/2024 and was unable to be directly interviewed by CCLD. Regarding the first theft incident (i.e., $300) against R1, records and staff interviews showed: Licensee learned of the cash loss from R1’s responsible person (RP). Licensee timely reported the loss to CCLD, the Long-Term Care Ombudsman Program (LTCOP), and local police (CVPD). Per manager interview, Licensee’s internal investigation involved interviewing R1, who at that time, was of sound mind and a reliable historian. R1 told Licensee that they clearly saw Staff #1 (S1) take $300 in cash from their wallet. A review of personnel records showed that Licensee ended S1’s employment on 12/15/2023 for an unrelated reason, per the written termination notice. However, manager interview revealed that R1’s testimony about the first theft incident was a contributing factor towards R1’s termination of employment. The facility’s LIC9060 Theft and Loss Record corroborated that one of the “Action[s] Taken / Follow Up” for the first theft incident against R1 included “term of employee.” [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Regarding the second theft incident (i.e., $250) against R1, records and staff interviews showed: Licensee learned of the cash loss from R1’s RP. Licensee timely reported the loss to CCLD, LTCOP, and CVPD. Per manager interview: Licensee’s internal investigation involved interviewing R1, outside sources, and facility frontline staff who were assigned to R1 during the date range of the loss (which was after S1 was no longer working at the facility). Interviews of frontline staff did not reveal any breakthrough in the second case. R1 by the date of the second investigation was less alert, as they were nearing end of life. Manager interview, corroborated by hospice visit notes and the facility’s visitor log, showed: During the date range of the second loss, R1 was visited inside their bedroom by multiple outside personnel, to include hospice agency staff and durable medical equipment (DME) company staff. Hospice notes showed R1 was asleep during at least two of these visits. A preponderance of evidence exists to show that on at one occasion, Licensee’s staff (S1) did not ensure that a resident in care (R1) was protected from theft or loss. One (1) deficiency was cited per California Code of Regulations, Title 22 (see attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. LPA also issued one (1) Technical Violations (TV) per California Health and Safety Code, regarding delayed-egress door signs (see LIC 9102-TV page). An exit interview was conducted with Blaul, to whom a copy of this report, the LIC809-D page, the LIC9102-TV page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Feb 14, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(25) · Plan of correction due date: Feb 14, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents…shall have all of the following personal rights: “(25) To protection of their property from theft or loss…” This requirement was not met, as evidenced by: Based on records and interviews, licensee’s staff (S1) did not ensure that 1 of 114 residents (R1) was protected from theft of loss, which posed an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 14, 2024

Plan of correction: Per manager interview and personnel and training records: S1’s employment ended on 12/15/2023, resolving the immediate risk. Licensee also retrained remaining frontline staff on its Theft and Loss Policy on 12/28/2023. Licensee agreed to retrain remaining frontline staff on Resident’s Personal Rights (see from LIC613-C), and to submit the training sign-in sheet to LPA by 03/14/2024.

Allegation investigated: Resident sustained injuries due to lack of care from staff

Licensing Program Analyst (LPA) Ramon Serrano, conducted an unannounced Complaint Visit. LPA introduced himself and discussed the purpose of the visit with Executive Director Calais Anguiano. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of records review and interviews with facility staff and outside source. It was reported to CCL that Resident 1 (R1)(an LIC 811 Confidential Names List was provided to the facility representative to identify the resident) had an unwitnessed fall and sustained bruising. It was alleged that R1 sustained those injuries due to lack of care from staff. Records review revealed R1 had an unwitnessed fall on February 4, 2024. Hospital discharge records revealed no new findings or new medications. Facility staff notated on February 5, 2024 at approximately 2pm; R1 was confused and crying and a "PRN" was given to R1. R1 refused to eat dinner that same day and was "very confused." Facility staff notified R1's POA and Physician. Unsubstantiated Records review indicate R1 was monitored by facility staff daily and on February 6, 2024 facility staff notated that R1 ate well and took all of R1's medications with no issues to report. On the same day, R1 was found on R1's bathroom floor and was transported to the hospital. Interview with Memory Care Director(MCD) revealed they are in close contact with R1's responsible party due to the recent changes R1's Primary Care Physician had made. MCD stated that most of R1's medication's were changed, as a result, R1 has been much more confused and agitated. MCD stated that R1 has also been falling more. MCD stated that R1 returned from the hospital both times with no new orders. R1 was given a walker due to R1 being "more unstable." MCD stated that R1's responsible party is working directly with R1's physician to the "fix" R1's medications. LPA interviewed R1's responsible party (RP) RP stated that the hospital staff advised RP of bruising that was found on R1's body. RP stated that R1 was transferred to a different hospital after the initial hospital R1 was sent to. RP stated that R1 was given a suction catheter and a full catheter at both hospitals. RP stated that R1 was seen pulling at the catheter tubes. RP advised hospital doctor of the various catheters that R1 was given for over three days and questioned if that could have been the cause of the bruising. RP stated that the hospital doctor stated that "it made sense" and agreed that the catheters could have been the cause of the bruising that was found on R1. Interview with Executive Director (ED) revealed R1 often gets confused and needs to be redirected and as a result constant staff attention is paid to R1. ED stated that facility staff follow R1's care plan which states that R1 needs constant observation. ED stated that although the staff to resident ratio is not 1:1, the facility staff are still able to monitor R1 closely. ED further stated that often times R1's behaviors or refusals are the cause of R1's incidents and facility staff are constantly trying to figure out ways to better assist R1. Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid. An exit interview was conducted with Calais Anguiano. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Calais Anguiano whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Feb 12, 2024 · control 08-AS-20240207120418

Allegation investigated: Staffing is not sufficient to meet resident's needs.

Licensing Program Analyst Becky Kennedy concluded the investigatioSilvia Garcia, Business office Manager. LPA advised her of the reason for today's visit and delivered the investigation findings on the above allegation. The investigation into the above allegations consisted of interviews with internal sources, a review of internal and external documents, and a tour of the facility. It was alleged that the facility’s staffing is not sufficient to meet resident's needs. The investigation revealed that when a resident pushed their call alert button often a staff member responded in less than five minutes, however it was not uncommon for call alerts to be answered in more than 20 minutes, 30 minutes, to over an hour. Substantiated A review of documents revealed that in a single 7-day period it took 20 minutes or longer to answer 136 of the 1024 call alerts throughout the facility. For the week analyzed, 13.3% of the alerts took 20 minutes or longer to answer. Interviews revealed that facility staffing had declined specifically the number of care staff working at any given time. As a result, residents wait longer to receive care. This situation was ongoing and potentially affected all resident that required care. On one identified occasion Resident 1 (R1) (A list of confidential names was provided to the facility) pushed their call alert button. When no staff arrived to assist R1, an outside source became aware and attempted to contact staff members on behalf of R1. When no staff member could be reached by telephone, the outside source dialed 911. Documents revealed that facility staff did not respond to call alert for 45 minutes. The local emergency agency responded and found R1 required basic care that facility care staff then provided. The care was only provided after the emergency staff responded to the facility. Based on the evidence obtained during the complaint investigation, the allegation that the facility is not adequately staffed to meet resident’s needs is SUBSTANTIATED, meaning that there is a preponderance of the evidence proving that the alleged violation occurred. An exit interview was conducted with Silvia Garcia, Business Office Manager; a copy of this report and Licensee's Rights (LIC9058) were provided.the state’s words, verbatim · CDSS document, Feb 2, 2024 · control 08-AS-20211011082146

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Feb 9, 2024

Personnel Requirements Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… Based on interviews and review of records the licensee did not have personnel sufficient in numbers…to provide the services necessary to meet the needs 104 of the 104 persons in care which posed a potential risk to the health and safety of persons in care.the state’s words, verbatim · CDSS document, Feb 2, 2024

Plan of correction: Facility hired more full time staff and part time staff to cover as any vacancies. Policy of call report review daily was initiated.

Allegation investigated: Facility staff were not adequately trained. Facility staff mismanaged the residents' medications.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Executive Director Calais Anguiano and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of LPA direct observation, records review and interviews with facility staff. It was alleged that facility staff mismanaged resident medications and were not adequately trained. It was reported to CCL that med-techs lack proper medication administration training. It was also reported that facility staff are not properly documenting when the residents medications are unavailable. LPA reviewed the training file of three random facility staff members. Staff 1's (S1) training file was reviewed. S1 shadowed another facility staff and completed the following tasks from 11/5/23-11/9/23; 3 hours of "QMAR" videos, using a bubble pack card, reading the labels, measuring liquid medicines, administering and documenting PRN meds, Unsubstantiated ordering meds and ordering replacement doses for dropped or damaged pills. S1 was also observed conducting med pass and administering meds on 11/7/23-11/13/2023 and the training records were signed and dated. Staff 2 (S2) training file was reviewed. S2 completed the following medication training; 8 hours of initial medication training, live 4 hour med-tech on boarding training and 16 hours of hands on shadow training, signed and dated on 9/25/2023. The following tasks were completed and observed by a supervisor on 9/25/2023; hand washing, pouring per the 6 rights, crushing medications, eye drops, ear drops, inhalers, nebulizer etc. Staff 3 (S3) training file was reviewed. S3 completed the following; 12 hours of Relias medication courses dated 8/2/2022-8/17/2022, 10 hours of medication training on 8/22/2022 and completion of the California RCFE medication training on 11/16/2022. LPA reviewed the medication records of three random residents. Resident 1 (R1) records revealed R1 receives their medications through a non-contracted medical group. Facility records included over seven faxed medication requests to R1's pharmacy dated 11/29/2023 through 12/5/2023. R1 was also included on the "medication refill log" indicating R1's medication name, pharmacy, staff that ordered the medication and date. Resident 2 (R2) medication records revealed R2 receives their medication through the contracted pharmacy. Medication orders dated 1/15/24 reveal R2's medications are refilled on monthly cycle. Resident 3 (R3) medication records revealed R3 receives their medication through the contracted pharmacy. Medication orders dated 1/15/24 reveal R3's medications are refilled on monthly cycle. Interview with S1 revealed they have worked at the facility since October 2023 as a Med-Tech. Prior to working at the facility S1 worked as a Pharmacy technician for seven years. S1 feels properly trained in the area of medication, including; med-pass, emergency services, wound care, hospice, reporting incidents, etc. S1 stated that S1 assists other staff members with refills of medication since S1 is knowledgeable in that area. Interview with S2 revealed S2 has worked at the facility since September 2023 as a Lead Med-Tech. S2 stated that S2 feels properly trained. S2 has a Bachelors degree in Biology and Public Health. S2 stated that S2 has alot of experience and knowledge in the area of medication and regularly assists other staff members with refills of medication. S2 stated that the hire of the Health Services Director has made a dramatic improvement. Interview with Health Services Director (HSD) revealed they have worked at the facility for four months. HSD stated that the biggest issue in the facility was the Resident Care Coordinator (RCC) who was terminated 3 weeks ago. HSD stated that in the past four months HSD has made improvements in oversight in the med room, implementing policy, making sure policies are being followed and overall "culture change" in the facility. HSD further stated that the Regional Specialist conducted an audit in both med rooms and the entire clinical department on November 2023 and the facility scored 96% which is the highest the facility has ever scored. Interview with Executive Director (ED) revealed they have worked at the facility since June 2023. ED stated that she encountered many problematic issues due to the poor performance of the RCC. ED stated that it was brought to her attention that medication refills were not being processed in a timely manner as well as other facility issues. ED stated that after hiring the HSD she has seen alot of improvement. The HSD has created new audit tools and new communication logs for refills. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. An exit interview was conducted with Calais Anguiano. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Calais Anguiano whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Jan 23, 2024 · control 08-AS-20240122104916

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Calais Anguiano. Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 10/26/2023), involving Resident #1 (R1) and Staff #1 (S1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPA performed a brief facility tour and welfare check, verifying R1 was safe. LPA reviewed pertinent facility and law enforcement records. LPA also interview R1 and relevant staff. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Anguiano, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Nov 21, 2023