Ivy Ridge Assisted Living

Allegation investigated: Staff does not ensure facility serves food of good quality. Facility does not maintain adequate food supply. Staff does not ensure facility has sufficient supply of blankets and bedding for residents in care. Staff do not ensure residents are spoken to in an appropriate manner. Licensee does not follow infection control plan. Licensee does not ensure facility has adequate staffing to meet the care needs of residents.

On August 06, 2026, at 9:30 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Lezel Bello during today’s visit and explained the purpose of this inspection visit. Throughout the course of this investigation, LPA Martinez conducted interviews, reviewed facility records, and resident records. LPA Martinez toured the facility kitchen with Lezel Bello on August 05, 2026, and inspected the food supply. LPA Martinez observed that there was an adequate food supply, and the food supply was of good quality. LPA Martinez observed that the facility had a sufficient supply of blankets and beddding for resident use. The facility has an infection control plan, and the facility has not had a recent infection outbreak at the facility. LPA Martinez observed that the facility had a supply of personal protective equipment (PPE). In addition, gloves and mask are made accessible to staff and residents. Continued... Unsubstantiated Five out five staff reported that the facility is not understaffed. Four out five residents reported the facility is not understaffed, and caregivers treat them with respect and provide good care to them. One out of five residents reported that facility has hired new caregivers. Due to the above noted information, 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, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 6, 2026 · control 27-AS-20260428081320

Type of visit: Required - 1 Year

On May 14, 2026, at 9:00 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Lezel Bello and explained the purpose of today's visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. The facility administrator holds current certificate . The facility is licensed for thirty-six non-ambulatory clients, which four may be bedridden. There are currently thirty-six residents who reside at this facility. The facility has an approved hospice waiver for two. The LPA Martinez toured the facility with Lezel Bello on May 14, 2026, at 1:00 PM. LPA Martinez reviewed five resident files and five staff files. The resident and staff files were maintained current. The last emergency drill was on March 02, 2026. The last fire alarm inspection was on June 17, 2026. The last fire inspection was on June 17, 2026. The facility has an emergency and disaster plan, and was last updated on February 09, 2026. The facility has an infection control plan. LPA Martinez will return at a later date to conduct a continuation annual inspection An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, May 14, 2026

Allegation investigated: Staff does not ensure facility is maintained in good repair, clean safe and/or sanitary. Staff does not ensure call signal system is in good repair.

On May 06, 2026, at 11:45 AM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit to initiate a complaint investigation and deliver complaint finding for the above allegations. LPA Martinez met with Lezel Bello and explained the purpose of today’s visit. During today's facility visit, LPA Martinez conducted a tour of the facility, conducted interviews, and tested call signal system. During today's facility tour, LPA Martinez observed the following items at the resident courtyard: Box spring; multiple plastic garbage cans that are not in use; shower chair, walker, rake, broke plastic storage box, Yellow mop bucket filled with dirty water and dirty mop, a gray and red mop bucket, chicken wire. Additionally, LPA Martinez observed an unattended yellow mop bucket located in a resident hall way. Continued... Substantiated LPA Martinez also observed an outdoor sink that was not cleaned and had rust spots. The sink basin was filled with miscellaneous unsanitary decor.(plastic owl, green frog statue, ceramic cat, ceramic pots, and a squirrel). LPA Martinez also observed a dead fly on resident R1's (R1) bedroom wall. During an interview, LPA Martinez was informed that the dead fly was on the wall for over a week. In addition, R1's bed was up against the wall that had the dead fly. LPA Martinez also tested call signal pull cords in resident bathroom three and resident bathroom four. LPA Martinez pulled the signal pull cord in bathroom three at 12:31 PM, and waited for ten minutes. Medication Technician 1 (MT1) walked by the bathroom and administered medication to resident 2 (R2). After MT1 administered the medication to R2, they walked away to administer medication to R1. LPA Martinez walked to bathroom 4 and pulled the signal cord around 12:45 PM. While LPA Martinez was waiting for staff to respond, they asked MT1 if they were aware that the bathroom call signal cord was pulled. MT1 reported they did not have a pager, so they were not aware that signal pull cord was pulled. MT1 used their walkie talkie to ask staff to locate the pager. Staff 2(S2) had the pager. However, the pager did not alert S2 that the bathroom signal pull cord was pulled. The facility maintenance employee was called to test bathroom 4 signal pull cord, and it was learned it was not working properly. The facility maintenance employee replaced the battery and cleaned the signal pull cord device. After installing a new battery and being cleaned the signal pull cord device began working properly. LPA Martinez learned that the signal pull cord device batteries are changed twice a year, and the signal pull cord devices are not inspected or tested throughout the year. Based on today's complaint investigation, it was learned that staff are not responding to call system alerts in a timely manner due to faulty signal pull cords. Based on observation and inspection of the facility, it was determined the facility is not maintained in good repair, clean safe and/or sanitary. As a result of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D page, per Title 22 Regulations. An exit interview was conducted, and a copy of this LIC 9099 report, LIC 9099-D page, and LIC appeal rights documents were provided to the facility.the state’s words, verbatim · CDSS document, May 6, 2026 · control 27-AS-20260428081320

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 20, 2026

87303(a) Maintenance and Operation: the facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidence by: Based on observation and interviews, the Licensee did not the facility was kept clean, safe, and sanitary. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 6, 2026

Plan of correction: Facility staff agrees to conduct a maintenance and operation in service training for staff by POC date 05/20/2026. Facility staff agrees to email in service training documents to LPA Martinez by 05/20/2025 by 5:00PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(B) · Plan of correction due date: May 20, 2026

87303(i)(1)(B) Maintenance and Operation: Facilities shall have signal systems which shall meet the following criteria: Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. this requirement was not met as evidence by:Based on inspection, observation, interviews, the Licensee did not ensure signal system was in good repair and that it was transmitting an auditory signal to care staff. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 6, 2026

Plan of correction: Facility staff agrees to conduct a maintenance and operation in service training for staff by POC date 05/20/2026. Facility staff agrees to email in service training documents to LPA Martinez by 05/20/2025 by 5:00PM.

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: Case Management - Deficiencies

Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on May 06, 2026, at 2:00 PM. LPA met with Lezel Bello and explained the purpose of the visit. The purpose of the visit today, is follow up on learned deficiencies. The facility did not ensure medications were made inaccessible to residents in care. LPA Martinez observed two unlocked first aid kits that stored medication. The facility has a first aid kit cabinet located next to the main entry door. This first aid cabinet was unlocked and had ANSI A Ointment, Tripple Antibiotic, First Aid Burn Cream. The facility also has a first aid kit located at the resident exterior patio. This first aid kit lock was not in good repair. The first aid kit had the following medications, medicated Medi Honey bandages, first aid burn cream, and antibiotic cream. Additionally, it was learned that resident 1 (R1) was not provided basic services. R1 was left in soiled briefs for an extended period of time and developed skin integrity problems. R1 also has red skin and skin tears on a private part area of their body. R1 has had the skin tears for approximately two days. It was also learned care staff did not inform the Administrator that R1 had skin tears and did not report this change in condition to R1's primary care physician. Based on the above learned information, the facility will cited the following 87464 (f)(1) Basic Services and 87465 (h)(2) Incidental Medical and Dental Care. An immediate health and safety civil penalty shall be assessed on May 06, 2026 in the amount of $500.00 for the violation of 87465 (h)(2) Incidental Medical and Dental Care. The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An Exit interview was conducted and 809 report and appeal rights and LIC 421 were given to the facility.the state’s words, verbatim · CDSS document, May 6, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 7, 2026

87465(h)(2) Incidental Medical and Dental Care: The following requirements shall apply to medications which are centrally stored:Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees. This requirement was not met as evidence by.Based on observation, inspection, and interviews, the Licensee did not ensure medication were kept in a safe locked place and made inaccessible to residents in care. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 6, 2026

Plan of correction: Facility staff agrees to email LPA Martinez Incidental and Medical and Dental in-service agenda by 05/07/2026 by 5:00 PM. Facility staff agrees to conduct in-service training by 05/20/2026. Facility Staff agrees to email in-service training document to LPA Martinez by POC date 05/20/2026 5:00 PM

From the deficiency page — Deficiency type: Type A · Section cited: CCR87464(f)(1) · Plan of correction due date: May 7, 2026

Basic Service 87464(f)(1):(f) Basic services shall at a minimum include:Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by: based on observation and interviews, the Licensee did not ensure to provide basic service to R1's and address R1's skin integrity/skin tears. This poses an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, May 6, 2026

Plan of correction: Facility staff agrees to report R1's change in condition to their primary physician by 05/07/2026. Facility staff agrees to conduct a reassessment and include incontinence care plan for R1 by 05/08/2026. Facility Staff agrees to email LPA Martinez Assessment and incontinence care documentation by poc date 05/08/2026 by 5:00 PM. Facility staff agrees to email LPA Martinez skin integrity/skin tear reporting information to LPA Martinez by 05/07/2026 by 5:00 PM

Allegation investigated: Staff are not meeting residents toileting needs. Staff yell at residents in care Staff are not meeting residents dietary needs. Staff are not seeking timely medical care for residents.

On 09/24/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Lezel Bello and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 36. A brief interview conducted with administrator Bello. It was alleged that that staff are not meeting residents’ toileting needs. This investigation included a review of records and interviews with facility staff, residents, and two outside agencies. According to Resident 1’s LIC 602 Physician’s report R1 is not able to care for R1’s own toileting needs; however, based on interview with R1 and facility staff R1 is being assisted with incontinent care. LPA Lee conducted interviews with 5 residents, and 5 out of five residents reported no concerns regarding staff not meeting their toileting needs. CONTINUED LIC 9099-C Unsubstantiated In an interview, R1 stated that R1 has no concerns with R1’s toileting needs and added that staff 1(S1) does a very good job assisting with toileting needs. Additionally, five out of five facility staff interviewed denied the allegation that residents’ toileting needs are not being met. Interviews were also conducted with two outside agencies responsible for residents under their care. Both agencies reported no concerns regarding the toileting care provided to the residents. Based on the records reviewed and interviews conducted, there is insufficient evidence to determine whether the alleged violations occurred. It was alleged that staff yelled at residents in care. This investigation involved interviews with facility staff, residents, and two outside agencies. LPA Lee interviewed 5 out of 5 residents, all of whom stated they had not experienced or witnessed facility staff yelling at them or other residents. In a separate interview, Resident 2 (R2) also denied that staff 2 (S2) yelled at them. R2 further expressed that R2 was not happy that a complaint had been filed which included R2 in the allegations. LPA Lee also interviewed 5 facility staff members, all of whom denied the allegation and stated they had not yelled at residents, nor witnessed any other staff yelling at residents. In addition, two outside agencies were interviewed. Both stated they had never witnessed staff yelling at residents and described the staff as kind and respectful. Based on the interviews conducted, there is insufficient evidence to determine whether the alleged violations occurred. It was alleged that staff are not meeting residents dietary needs. This investigation included observations and interviews with facility staff, residents, and two outside agencies. During two facility visits conducted on 07/07/2025 and 09/04/2025, LPA Lee toured the facility kitchen and observed that the facility had sufficient supply of food, including two days’ worth of perishable and seven days’ worth of non-perishable items. LPA Lee also observed residents being served adequate portions of food during both breakfast and lunch. Interviews were conducted with 5 out of 5 residents, all of whom stated they receive enough food and have no concerns regarding their dietary needs. Additionally, Resident 2 (R2) expressed that R2 was not happy that a complaint had been filed which included them in the allegations. LPA Lee also interviewed 5 out of 5 facility staff, all of whom denied the allegation that residents’ dietary needs are not met and that residents are allowed to ask for second during mealtime. Furthermore, two outside agencies confirmed that the residents under their care have not reported any concerns regarding the adequacy of food or dietary accommodation. CONTINUED LIC 9099-C During the course of the investigation, LPA Lee was provided with photographic documentation from the facility. It was learned that photos are taken of each meal, breakfast, lunch, and dinner by kitchen staff and shared in the facility's internal chat group for documentation purposes. These photos demonstrate that meals are provided in accordance with residents’ dietary needs and residents are given sufficient portion during mealtimes. Based on observations, record reviews, and interviews conducted, there is insufficient evidence to determine whether the alleged violations occurred. It was alleged that staff are not seeking timely medical care for residents. This investigation included a review of records and interviews with facility staff, residents, and two outside agencies. Based on the records reviewed, the facility currently has two residents on hospice care, and their wound care is being managed by hospice nurses. Additionally, documentation of two-hour rounding checks confirms that residents' wounds are being monitored regularly by facility staff and communicated to their hospice nurses. LPA Lee interviewed 5 out of 5 residents, all of whom expressed no concerns regarding staff failing to seek timely medical care. Interviews with 5 facility staff revealed that residents with wounds are under hospice care and that their conditions are monitored jointly by facility staff and hospice nurses. Staff also stated that all relevant care information is communicated directly to the hospice team. Two outside agencies were also interviewed. Both confirmed they had no concerns regarding the timeliness of medical care provided by the facility to the residents under their supervision. Based on the records reviewed and interviews conducted, there is insufficient evidence to determine whether the alleged violations occurred. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. An exit interview was conducted, and a copy of this report were provided to the facility at the end of this visitthe state’s words, verbatim · CDSS document, Sep 25, 2025 · control 27-AS-20250714162901

Allegation investigated: Due to staff neglect, resident sustained a pressure injury Staff retained a resident with a prohibited health condition

On 09/04/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with facility designated administrator (FDA) Lezel Bello and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 36. A brief interview was conducted with FDA Bello. It was alleged that due to staff neglect, resident sustained a pressure injury and that staff retained a resident with a prohibited health condition. This investigation consisted of records reviewed, interviews with staff, residents, and outside agencies. It was learned that on 9/25/2024, at approximately 2012 hours, resident 1 (R1) was admitted to Sutter Medical Center Sacramento Emergency Room (ER) for a chief complaint of a stage three pressure ulcer of the sacral region. Multiple staff reported R1 did not have any mobility issues and did not require assistance with transferring, repositioning, or toileting. CONTINUED LIC 9099-C Unsubstantiated Staff stated R1 requires stand-by assistance with the shower. Multiple staff confirmed interacting with R1 in the days leading up to the discovery of the pressure injury and denied R1 had any changes in condition or signs to indicate a skin breakdown. Staff denied R1 verbalized any pain until 9/25/2024, the day R1 was sent out to the hospital. Moreover resident 1 (R1) reported that the pressure injury occurred at the hospital, not at the facility. R1 stated they did not believe the injury was present before hospitalization, as they felt no pain prior but began experiencing pain while lying in the hospital bed. R1 also mentioned they independently handle their own showers. An outside agency (OA) representative, during an interview, expressed no concerns about R1 developing a pressure injury at the facility. OA observed R1 using the toilet independently and managing personal hygiene. On 09/10/2024, OA noted that R1 was walking around, had intact skin, and vital signs were within normal limits. OA also assisted R1 with perineal care that day and observed no redness or signs of pressure injury. OA had no concerns regarding the adequacy of R1’s care at the facility. OA confirmed R1 was not receiving home health services for a pressure injury. OA assessed R1 prior to discharge from home health and did not observe an injury. Staff 1 (S1) acknowledged being present when R1 took a shower on 9/23/2024 as a stand-by assist to prevent R1 from falling. S1 asked R1 if R1 wanted help, but R1 refused and showered him/herself. S1 and multiple staff denied seeing a pressure injury at any time during care. R1’s records corroborated the staff’s statements that R1 was independent with care and ambulatory. R1 was on home health from 7/24/2024 to 9/10/2024. Based on the interviews conducted during the investigation and records reviewed the department was unable to corroborate the allegations. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 27-AS-20240927142723

Allegation investigated: Staff do not allow residents access to phone.

On 07/30/2025 at 9:00 AM Licensing Program Analyst (LPA) Shakaricka Hughes conducted an unannounced facility visit to open a complaint investigation. LPA met with direct care staff Tanisha and administrator Lezel, and explained the purpose of today's visit. The census is 34 with 11 facility staff. Administrator was present during today’s visit. Allegation: Staff do not allow residents access to the phone. It was alleged that staff do not allow residents access to the phone. Staff are only allowing a few residents to use the phone and won’t assist anyone (residents) with making calls to family. The investigation consisted of interviews with staff and residents in care and facility observations. On 7/30/2025 LPA Hughes conducted an unannounced visit to the facility, and interviewed 3 out of 3 facility staff, S1 stated that the facility has two landlines, and residents can use the phone whenever they are available. Continuation 9099-C Unsubstantiated S1 stated that residents are given the phone whenever calls are received for the residents. S1 stated that there are only 2 residents in care who frequently use the phone, Residents R1 and R3. Additional interviews with facility staff indicated that staff assist residents with calls, including allowing residents to use their personal phones, and leaving messages for their family members. Interviews with 4 out of 4 residents in care reflected that 3 out of 4 residents have no issues with using the phone, stating they can use the phone whenever the phones are available. LPA Hughes observed residents in care using the phones with and without assistance from facility staff. LPA Hughes observed resident (R1) come into the administrator’s office to use the phone without any issue. The administrator assisted the resident with making the call. There is no evidence that supports the allegation; therefore, the allegation cannot be corroborated at this time. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Jul 30, 2025 · control 27-AS-20250725164241

Allegation investigated: Staff is not meeting residents’ medical needs Staff does not ensure facility is free of pests Facility does not provide variety food as required

On 06/18/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Lezel Bello and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 35. A brief interview with conducted with administrator Lazel. It was alleged that staff is not meeting residents’ medical needs. This investigation consisted of interviews with staff, residents, and an outside agency and records review. LPA Lee interviewed 3 out of 3 facility staff who denied the allegation. It was learned that the facility only monitors residents' blood sugar levels if there is a doctor's order in place. Administrator Lezel stated that currently, only three residents have such orders, and their blood sugar levels are being regularly monitored and managed by the facility. Continued LIC 9099-C Unsubstantiated Furthermore, the Administrator explained that for residents without a doctor's order, the facility does not perform blood sugar checks. This is handled on a case-by-case basis. Some residents are seen by their primary care providers (PCPs) on varying schedules such as annually, quarterly, every six months, or as needed. During these visits, lab work is typically conducted, and any necessary care is directed by the PCP based on those results. The Administrator also confirmed that for residents whose blood sugar is being monitored, the readings are documented in a log and shared with their PCPs when necessary. Furthermore, LPA Lee interviewed 11 out of 11 residents, and none expressed concerns about their medical needs not being met by facility staff. LPA Lee also interviewed an outside agency that regularly visits the facility, who also reported no concerns regarding residents’ medical needs are not being met by the facility. A review of records confirmed that three residents have a doctor’s order authorizing the facility to monitor and assist with their blood glucose levels. The facility’s blood glucose monitoring log shows that glucose levels are being regularly tracked for Resident 1 (R1), Resident 2 (R2), and Resident 3 (R3). Based on interviews and record reviews during the investigation, LPA Lee was unable to corroborate the allegations. It was alleged that staff does not ensure facility is free of pests. This investigation included interviews with staff, residents, and two outside agencies (OA), as well as observations and record reviews. LPA Lee interviewed 3 out of 3 facility staff who denied the allegation. 1 out of 11 residents, denied the allegation and stated they have not witness pest in their room nor in the facility and expressed no concern. In an interview with the two outside agencies, who both reported no concerns and had not observed any pests in the facility. Based on observations on 04/16/2025 and 06/05/2025, LPA toured multiple residents’ rooms in the main building, multiple residents’ rooms in the wall building, and multiple residents’ rooms in the Terrence Hall building and the TV room in Terrace Hall and found no evidence of roaches. A review of the facility’s records confirmed that the facility has maintained an active contract with All-in-One Pest Control Inc. since 10/10/22, with no gaps in service. The facility receives bi-monthly treatments for both the interior and exterior of the building, including resident bedrooms, as indicated in treatment logs from 04/08/25 through 06/10/25. Invoices provided show services were rendered from 04/08/24 to current, detailing the type and dates of service. Additionally, the facility’s maintenance staff, Carl, conducts its own pest control treatments on top of the services provided by the pest control company. Based on interviews, observations, and record reviews during the investigation, LPA Lee was unable to corroborate the allegations. Continued LIC It was alleged that facility does not provide variety food as required. This investigation included interviews with staff, residents, and two outside agencies, as well as observations and a review of facility records. LPA Lee interviewed all three facility staff members, who denied the allegation. Additionally, 8 out of 11 residents interviewed also denied the allegation, stating they have no concerns about the meals provided and that they like the food being served. LPA Lee also interviewed two outside agencies who reported no concerns and confirmed that a variety of meals are being offered to residents in care. During observations conducted on 04/16/25, 06/05/25 and during today’s visit 06/18/2025, LPA Lee observed both breakfast and lunch being served, noting a variety of food options available to residents. An inspection of the facility’s kitchen, refrigerator, and freezer also shows an adequate and varied food supplies. A review of facility records confirmed that the facility receives weekly food deliveries from Sysco and also does their own additional grocery orders from Walmart and Costco. Sysco delivery records also reflected a variety of food items being supplied to the facility. Based on the interviews, observations, and records reviewed, LPA Lee was unable to corroborate the allegation. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Interviews with two outside agency representatives also confirmed that they rarely see Hong Trinh at the facility, noting that they typically only see Lezel Bello during their visits. During facility visits conducted on 04/16/2025 and 06/05/2025, LPA Lee met with Lezel Bello, who informed Licensee Hong Trinh that CCLD was present at the facility. Hong Trinh later met with LPA Leet the facility on 04/16/2025. Hong Trinh previously served as the Administrator before appointing Lezel Bello as the new Administrator, effective 04/15/25. A review of the facility’s LIC 500 form, dated 04/16/2025, listed Hong Trinh as the Licensee/Administrator "on-call" with no set days or hours at the facility. Based on interviews, observations, and record reviews, LPA Lee was able to corroborate the allegation that the Administrator was not present at the facility for a sufficient number of hours. It was alleged that the facility is malodorous. This investigation included resident interviews and direct observations. During interviews, 6 out of 11 residents reported having noticed an incontinence odor in the facility and expressed concern. During two separate facility visits, LPA Lee made the following observations: on 04/16/2025, resident bedroom #10 had a noticeable incontinence odor; on 06/05/2025, resident room #24 was noted to have a mild incontinence related smell. Based on resident interviews and these observations, LPA Lee was able to corroborate the allegation. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Tasha and Melissa and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 27-AS-20250407102227

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Jun 25, 2025

87405(a) Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. This requirement is not met as evidenced by: Based on observations, interviews and record reviews, the licensee did not comply with the section cited above. The administrator Hong Trinh was not at the facility for a sufficient numbers of hours to permit adequate permit adequate attention to the management of the facility. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 18, 2025

Plan of correction: As of 04/15/25, the facility has appointed a new administrator Lazel Bello to the facility to ensure that the administrator is present at the facility for a sufficient numbers of hours to ensure adequate attention to manage the facility. Administrator will review the regulation cited and provided LPA Lee a statement of acknowledgement of reading and understanding the regulation cited.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Jun 25, 2025

87625(b)(3) Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry, and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on observations on 04/16/25 and 06/05/25, LPA Lee observed incontinence smell in the facility. This poses a potential health, safety or personal rights risk to persons in care. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 18, 2025

Plan of correction: Administrator stated the following plan will be put in place: staff will empty the resident trash and check resident room every two hours. Staff will check on resident bedding every 2 hours to see if it’s soil and if needed will change resident bedding. Administrator will generate a log regarding every two hours check and provide to LPA Lee from 06/19/2025 to 07/19/2025. Administrator will review the regulation cited and provided LPA Lee a statement of acknowledgement of reading and understanding the regulation cited.

Type of visit: Required - 1 Year

On 04/16/25, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with administrator Lezel Bello and explained the purpose of the visit. Administrator certificate # is 6051174740 and expired on 02/20/25, however, administrator renew her administrator certificate on 02/06/25, and it is currently pending. The current census is 34 with 8 facility staff. This facility is a two story building with two additional separate buildings licensed to serve thirty-six (36) non-ambulatory residents, of which (4) may be bedridden and approved for 2 hospice waivers. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room, staff office, medication room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. LPA Lee inspected residents bedroom in the main building, wall building and Terrence building and observed resident bedroom #10 to have an incontinence smell. During the visit, LPA Lee observed a facility staff cleaning and mopping resident room #10. There are no bodies of water present. LPA Lee toured the kitchen and observed sufficient seven day non-perishable and sufficient two day perishable food supplies. Hot water temperature was measured at 112.6 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and were observed to be stable and in good repair at this time. Non-slip mat was observed only in 2 bathrooms out of 4 resident’s bathrooms. Continued LIC 809-C Smoke and carbon monoxide detectors are in compliance with fire safety. Multiple fire extinguisher is located through the facility and in the separate buildings and was last serviced on 12/03/24. The last fire drill was conducted on 03/21/25. The facility has the required posters posted. Facility thermostat was observed at 74 degrees Fahrenheit. LPA Lee observed toxins kept locked and inaccessible to residents. LPA Lee observed sharp knives kept locked in the kitchen cabinet and inaccessible to residents. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA and the administrator also tested 8 residents call pendants, which appeared to be functioning properly and emit an auditory signal to produce an auditory signal loud enough to summon staff. LPA reviewed 2 out of 5 residents oh hand medications and medication administration record (MAR) and it was incomplete. Two of the resident’s medications are found in the resident’s medication box; however, they are not documented in the MAR logs. The first aid kit was checked and contained the required components. LPA Lee requested resident and staff files for review. LPA Lee reviewed 5 resident files, and they were complete. LPA Lee reviewed 3 staff files, and it was also complete. LPA Lee reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following documents was provided to LPA Lee during today’s visit. (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (4) LIC 610 Current Emergency Disaster Plan (5) Proof of Current Liability Insurance As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with administrator Lezel and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Apr 16, 2025

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Facility staff do not maintain facility free from malodors Facility staff do not maintain facility free from pests

On 03/24/25, Licensing Program Analysts (LPAs) Pang Lee and Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPAs met with Assistant Administrator Lezel Bello and Administrator Hong Trinh and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegations above. The current census is 33. It was alleged that facility staff do not maintain the facility free from malodors and facility staff do not maintained facility free from pests. This investigation included interviews with staff, residents, and an outside agency (OA), as well as observations and record reviews. LPA Lee interviewed 8 out of 8 residents, all of whom denied the allegations and expressed no concerns. Continued LIC 9099-C Unsubstantiated LPA Lee also interviewed 4 out of 4 facility staff, all of whom denied the allegations. In an interview with 1 out of 1 OA, they reported no concerns and had not observed any pests or incontinence odors in the facility. Based on observations on 02/12/25, LPA toured residents’ rooms in the main building (#1-6) and found no evidence of roaches and malodors. LPA continued the inspection in rooms #7-12 of the wall building, where no pests or malodors were observed. LPA then inspected rooms #13-27, again finding no roaches and malodors. The TV room in Terrace Hall was also inspected, and no pests or malodors were observed. A review of the facility’s records confirmed that the facility has maintained an active contract with All-in-One Pest Control Inc. since 10/10/22, with no gaps in service. The facility receives bi-monthly treatments for both the interior and exterior of the building, including resident bedrooms, as indicated in treatment logs from 11/28/22 through 02/11/25. Invoices provided show services were rendered from 01/04/24 to 02/01/25, detailing the type and dates of service. Additionally, the facility’s maintenance staff, Carl, conducts its own pest control treatments on top of the services provided by the pest control company. Moreover, based on the resident shower, laundry, and incontinence logs, residents are receiving showers, laundry services, and incontinence care at least 2 to 3 times per week. Based on interviews, observations, and record reviews during the investigation, LPA Lee was unable to corroborate the allegations. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Mar 24, 2025 · control 27-AS-20250206150202

Allegation investigated: Staff did not assist resident in a timely manner. Staff not preventing resident’s sleep from being disturbed by another resident. Staff is retaliating against resident. Staff not providing resident with meals in a timely manner.

On 02/12/25, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with assistant administrator Lezel Bello and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 33. It was reported that the facility staff did not assist a resident in a timely manner. The investigation involved interviews with staff, residents, and a review of records. LPA Lee interviewed 6 out of 7 residents who stated that they had no concerns about staff not assisting residents promptly. Additionally, these 6 residents reported they had not witnessed any falls where a resident was left unattended by staff. They also shared that they feel safe living in the facility. LPA Lee also interviewed 2 staff member and it was learned that Resident 1 (R1) experienced an unwitnessed fall in the bathroom. However, R1 was assisted promptly by care staff who heard the fall. The assistant administrator called EMTs, and R1 was transported to the hospital, returning the same day. A review of the records dated 11/22/24 confirmed the unwitnessed fall and the hospital transport. Furthermore, there were no records in the facility's electronic files indicating that (R2) having an unwitnessed fall. Continued LIC 9099-C Unsubstantiated The assistant administrator called EMTs, and R1 was transported to the hospital, returning the same day. A review of the records dated 11/22/24 confirmed the unwitnessed fall and the hospital transport. Furthermore, there were no records in the facility's electronic files indicating that (R2) having an unwitnessed fall. It was alleged that staff are not preventing resident from disturbing another resident's sleep. The investigation involved interviews with both staff and residents. LPA Lee interviewed 6 out of 7 residents, who reported no concerns regarding staff not preventing sleep disturbances caused by another resident. Additionally, these 6 residents stated that they enjoy (R3) guitar playing and have no issues with it. LPA Lee also interviewed 2 facility staff members, both of whom denied the allegations. They stated that R3 has the right to play the guitar, and that the assistant administrator has spoken with R3 about being considerate of other residents while playing. Through the interviews, it was discovered that R3 typically plays the guitar from noon to evening. It was also noted that (R4) usually goes to bed between 3:00 PM and 4:00 PM and wakes up around 12:00 AM to 1:00 AM. It was reported that staff are retaliating against resident. The investigation involved interviews with both staff and residents, as well as observations. LPA Lee interviewed 6 out of 7 residents, who stated that they had no concerns and had not witnessed any staff members retaliating against residents in care. Two staff members at the facility were also interviewed and denied the allegations. During both visits on 11/27/24 and 12/24/24, LPA Lee did not observe any mistreatment or retaliation by staff against residents in care. It was alleged that staff are not providing residents with meals in a timely manner. The investigation involved interviews with staff and residents, observations, and a review of records. LPA Lee interviewed 6 out of 7 residents, who reported no concerns about delays in receiving meals. Several residents mentioned that they either go to the dining room for their meals or have meals delivered to their rooms if they are unable to go to the dining room. Two facility staff members denied the allegations, explaining that if meals are delayed, it is usually by 10-15 minutes due to staffing or other factors affecting the schedule; however, that residents always receive their meals. During observations on 12/24/24, LPA Lee observed residents eating lunch around 12:15 PM. During today’s visit, LPA Lee observed at 12:55 residents were finishing their lunch. Records review revealed that breakfast is served from 8:00-9:00 AM, lunch from 12:00-1:00 PM, and dinner from 5:00-6:00 PM. Additionally, text messages confirmed that R4’s lunch was served within the designated mealtime frames. Continued LIC 9099-C Based on statements obtained, records review and observations during the investigation process, LPA was unable to corroborate the allegations. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Feb 12, 2025 · control 27-AS-20241217105430

Allegation investigated: Facility staff do not provide a safe environment for residents. Facility staff do not provide a comfortable environment for residents. Facility does not have sufficient number of bathrooms to meet residents need. Facility shower is in disrepair. Facility does not provide comfortable temperature for residents.

On 02/04/25 at 2:38 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with assistant administrator Lezel Bello and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 33. It was alleged that the facility staff did not provide a safe environment for residents. The investigation included interviews with staff, residents, and an outside agency, as well as observations. Of the residents interviewed, 6 out of 7 reported no concerns about the facility’s safety. These 6 residents expressed that they feel safe living in the facility. Additionally, 6 out of 7 of the residents interviewed reported not seeing other residents enter another resident’s room without permission. Four facility staff members denied the allegations, stating that they communicate daily about residents' needs. The outside agency also found no concerns regarding the safety of the facility. Continue LIC 9099-C Unsubstantiated Based on observations made on 11/27/24 and 12/24/24, LPA Lee did not find any evidence that the facility staff was providing an unsafe environment for residents in care. During the investigation, it was learned that the facility had accommodated resident 1 (R1) by installing a new doorknob at R1’s request. Furthermore, the facility made an effort to accommodate (R1) by offering a move to the front of the main building. However, R1 would need to share the room with (R2), as R2’s room was the only available space. R1 declined the offer, expressing a preference for a private room, similar to the one R1 is currently occupying in the Terrace Hall. It was alleged that the facility does not provide a comfortable environment and comfortable temperature for residents. The investigation included interviews with staff, residents, and outside agency as well as on site observations. Based on the interviews, 6 out of 7 residents expressed no concerns regarding the comfort of the environment or temperature in the facility. In fact, these residents stated they were content living in the facility. 4 facility staff members denied the allegations, stating that they communicate regularly regarding residents' needs. Staff also reported they frequently accommodate (R1) by providing room service such as ice, towels, meals, and a specific butter R1 requested. Additionally, staff stated that R1 is not charged for room delivery and that they make efforts to ensure R1 feels comfortable in the facility. Based on R1's admission agreement, there is no contract stating that the facility will provide room delivery, and R1 is not being charged for room delivery. Staff further denied allegation of uncomfortable temperatures, stating that the temperature is typically set between 70°F and 78°F. The outside agency also stated that the facility makes efforts to accommodate R1. During an observation on 11/27/24, LPA Lee observed residents appeared comfortable. A tour of the facility showed that the temperature in the main building downstairs was 72°F, while the temperature in the wall building measured 74°F. The temperature in the Terrace Hall downstairs was 78°F, and upstairs it was 72°F. The temperature in R1’s room was recorded at 69°F which is within the regulation of 68* F to 85* F. LPA Lee observed multiple residents room measured at 78* F. LPA Lee also confirmed there was no feces or potting soil in any of the resident bathroom toilets or sinks. During a follow-up visit on 12/24/24, LPA Lee observed 12 residents in the dining room and 4 in a smaller dining room, all having lunch and appearing comfortable. R1's room was measured at 73°F, and the bathrooms in the Terrace Hall were clean, sanitary, and free of feces or potting soil. It was alleged that the facility does not have sufficient number of bathrooms to meet residents' needs and that the facility’s shower is in disrepair. Continued LIC 9099-C The investigation included interviews with staff and residents. According to interviews, 6 out of 7 residents reported no concerns regarding the number of bathrooms and the shower not in good repair. 4 facility staff members denied the allegations, confirming that there are a total of 7 bathrooms in the facility. During a visit on 11/27/24, LPA Lee observed that the facility does indeed have 7 bathrooms. The main building has 2 bathrooms upstairs and 1 downstairs. The Terrace Hall has 2 bathrooms downstairs and 2 bathrooms upstairs. Both facility visits on 11/27/24 and 12/24/24, LPA Lee also observed that all showers in the facility were in good repair. Based on statements obtained, records review and observations during the investigation process, LPA was unable to corroborate the allegations. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Feb 4, 2025 · control 27-AS-20241125080927

Allegation investigated: Staff handle resident in rough manner while in care. Staff speak inappropriately to residents in care. Resident is sustaining unexplained injuries while in care. Facility freezer is in disrepair. Licensee is not addressing bed bug infestation at the facility. Staff stole from resident in care.

On 12/17/2024, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with assistant administrator Lezel Bello and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 34. A brief interview with conducted with administrator Lezel. An allegation was made that staff handle residents in a rough manner while in care and staff speak inappropriately to residents. The investigation included a review of records and interviews with staff and residents. LPA Lee interviewed 7 out of 7 residents, who each stated that they are not being handled in a rough manner and spoken to inappropriately by facility staff. Additionally, LPA Lee interviewed another individual from an outside agency, who reported not witnessing any instances of residents being handled roughly or spoken to inappropriately. Continued LIC 9099-C Unsubstantiated Treatment dates include September 10, 2024; September 24, 2024; October 8, 2024; October 22, 2024; November 12, 2024; November 26, 2024; and December 10, 2024. Based on interviews 7 out of 7 residents confirmed that they have not seen any bed bugs in their rooms or in the facility. Furthermore, five facility staff members denied the allegation. Additionally, LPA Lee interviewed another individual from an outside agency, who reported not witnessing any bedbugs in resident’s room. Based on the interviews, observations, and record review, there is no preponderance of evidence to support the claim of a bed bug infestation. Therefore, the allegation is unsubstantiated. An allegation was made that staff stole from resident in care. The investigation included interviews with both residents and facility staff. Based on these interviews, 7 out of 7 residents interviewed reported no concerns regarding staff stealing from residents. Additionally, five of the facility staff members interviewed denied the allegation. Through the investigation, it was learned that resident 2 (R2) had $200 and gave $100 to staff 1 (S1) to purchase groceries on R2’s behalf. S1 then reported and gave $100 to Assistant Administrator Lezel, who then returned the money to R2’s wallet and informed R2. When interviewed, R2 confirmed that $100 was given to a staff member and that the money was returned. However, R2 also stated uncertainty about what happened to the money; therefore, it is unclear what had happened to R2’s $100. After reviewing all interviews there is insufficient evidence to determine whether the alleged allegation did or did not occur. Therefore, the allegation is unsubstantiated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Five facility staff members interviewed also denied the allegations. Based on the information and interviews gathered, there is no preponderance of evidence to support the claim. Therefore, the allegation is unsubstantiated. An allegation was made that residents sustain unexplained injuries while in care. The investigation included observations, a review of records, and interviews with facility staff and residents. During visits to the facility on October 7, 2024, and November 7, 2024, LPA Lee did not observe bruises on Resident 1 (R1) or other residents. However, LPA Lee did observe old scabs on R1’s arm. Based on interviews staff stated that R1’s scabs are a result of R1’s use of blood thinner medication and bumping into objects. Records confirmed that R1 is on blood thinner medication. LPA Lee interviewed 7 out of 7 residents, all of whom denied any abuse by facility staff. R1 also stated that R1 tends to bump into things, which is how R1 sustained bruises and scabs. Furthermore, R1 indicated that R1 has no concerns regarding care. Additionally, LPA Lee interviewed another individual from an outside agency, who reported not observing any residents having bruises and injuries. Based on the interviews, observations, and information gathered, there is no preponderance of evidence to support the claim. Therefore, the allegation is unsubstantiated. An allegation was made that the facility freezer is in disrepair. The investigation included observations and interviews with facility staff. On October 7, 2024, and November 7, 2024, LPA Lee observed the freezer’s temperature to be -23°C and noted that it appeared to be in good repair. Additionally, the produce in the freezer was properly frozen with no signs of freezer burn or frostbite. Five facility staff members interviewed denied the allegation that the freezer is in disrepair. Based on the observations and interviews conducted, there is no preponderance of evidence to support the claim. Therefore, the allegation is unsubstantiated. An allegation was made that the licensee is not addressing a bed bug infestation at the facility. The investigation included observations, a review of records, and interviews with residents and facility staff. On October 7, 2024, and November 7, 2024, LPA Lee toured the facility, including resident bedrooms and mattresses, and did not observe any bed bugs. A review of the facility’s records confirmed that the facility has maintained an active contract with All-in-One Pest Control Inc. since October 10, 2022, with no gaps in service. Additionally, the facility is receiving treatment services twice a month. The All-in-One Pest Control treatment logs indicate that the facility has received services in both the interior and exterior of the building, including resident bedrooms. Continued LIC 9099-C On November 7, 2024, LPA Lee revisited the kitchen to inspect the freezer and refrigerator. During this inspection, 10 packages of pancakes, 2 packs of hot dog buns, 1 pack of waffles, and 1 pack of toast were observed in the freezer, with none displaying expiration dates, creating uncertainty about their freshness. Additionally, on October 7, 2024, LPA and Ombudsman observed two kitchen staff members preparing lunch for residents without wearing gloves and hair nets. One kitchen staff was observed cutting chicken without gloves and hair nets. When questioned by LPA Lee and Ombudsman Siraj why the staff was not wearing gloves staff explained that he/she had already washed their hands. Furthermore, it was noticed that a bag of frozen chicken breast was left in the kitchen sink, sitting in a bowl of water to thaw. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Tasha and Melissa and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Dec 17, 2024 · control 27-AS-20241003083728

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(8) · Plan of correction due date: Dec 30, 2024

87555 General Food Service Requirements (b) The following food service requirements shall apply: (8) All food shall be of good quality… This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above. Administrator didn’t ensure that multiple 2 days perishable food in the freezer had an expiration date. During interview when question the expiration date on the packages of 2 days perishable 3 facility staff stated, “I don’t know.” This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 17, 2024

Plan of correction: Administrator agrees to remove all expired food from facility and write a plan for storage and labeling of food in freezer. Administrator agrees to read the regulation cited and provide LPA Lee a statement of acknowledge of the regulation cited by POC date 12/30/24 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(15) · Plan of correction due date: Dec 30, 2024

87555 General Food Service Requirements (b) The following food service requirements shall apply: (15) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above. Administrator didn’t ensure that food services sanitation practices are conducted when LPA observed facility staff now wearing gloves and hair net. It was also observed chicken was left to thaw out in the kitchen sink inside a bowl with water. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 17, 2024

Plan of correction: Administrator will provide in-service to General Food Service Requirements and provided LPA Lee staff sign in sheet. Administrator agrees to read the regulation cited and provide LPA Lee a statement of acknowledge of the regulation cited by POC date 12/30/24 end of day 5:00 PM.

Allegation investigated: Licensee is encouraging staff to falsify documentation regarding residents in care. Licensee does not ensure that residents are provided with activities while in care.

On 11/07/2024 at 10:22 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Assistant Administrator Lezel Bello and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 35. A brief interview with Lezel was conducted. It was alleged that licensee is encouraging staff to falsify documentation regarding resident’s care. This investigation consisted of records review and interview with facility staff. To investigate, LPA Lee conducted a review of resident records and interviewed facility staff. LPA Lee reviewed the files of five residents and found no indication to show that the facility staff falsified resident documentation regarding their care. 5 out 5 residents were interviewed to compare resident services to what was written on documentation. LPA found no discrepancies between the care that was provided stated by residents to the resident care plan. Continued LIC 9099-C Unsubstantiated Additionally, LPA Lee interviewed 5 facility staff members, all of whom denied the allegations of document falsification. Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegations. It was alleged that licensee does not ensure that residents are provided with activities while in care. The investigation included observations, a review of records, and interviews with both facility staff and residents. On 10/07/2024, LPA Lee observed a facility staff member leading an exercise activity in the common area with the residents. A review of the facility’s records confirmed the presence of a monthly activity calendar, detailing daily events. Additionally, six out of seven residents interviewed denied the allegations, confirming that activities are provided regularly. They also stated that they are aware of the activity calendar’s location and were able to describe activities such as bingo, news discussions, movie nights, exercise sessions, and singing. LPA Lee also interviewed 5 facility staff members, all of whom denied the allegations and reported that there are three activities per day. Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegations. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Along with facility staff, LPA compared and reviewed medication count to medication administration record and found that resident 1 (R1)’s 14 pills of Atorvastatin were not accounted for however were signed off by facility staff as administered. The Med-Tech staff acknowledged the discrepancy at the time of audit and explained that the missing 14 pills may have not been accounted for when R1 was admitted to the facility 07/15/2024. Additionally, LPA Lee interviewed 3 out of 7 residents, who reported that they had not received their medications from the Med-Tech staff as prescribed. Based on the interviews and evidence gathered during the investigation it was found that the facility staff are mismanaging and not administering medication as prescribed to residents in care. An allegation was made that the facility is odiferous. The investigation included observations and interviews with residents and staff. On 08/19/2024, LPA Lee, Ombudsman Suhair, Administrator Hong Trinh, and Licensee Pak Wu toured the Terrance Hall. It was observed a strong urine odor in resident room #24. Additionally, a mild urine odor was noted in resident room # 27. Interviews with 4 out of 7 residents revealed that the upstairs area of the Terrace building does has a strong urine odor. Based on the observations and resident interviews, LPA Lee was able to corroborate the allegation. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Tasha and Melissa and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Nov 7, 2024 · control 27-AS-20240814165808

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Nov 14, 2024

87465(c)(2): Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN…. (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by: Based on observation, medication review and interview (R1)’s 14 pills of Atorvastatin were not accounted for however were signed off by facility staff as administered; therefore, resident’s medication were mismanaged. This posed an immediate potential health, safety, and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: Administrator will complete Incidental Medical and Dental Care in-service training. Administrator will provide training materials and sign in sheet of staff trained. POC will be emailed to LPA Lee by 11/14/2024 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(3) · Plan of correction due date: Nov 14, 2024

87465(c)(3) Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN…. (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidence by: Based on observation, medication review and interview (R1)’s 14 pills of Atorvastatin were not accounted for however were signed off by facility staff as administered therefore, resident’s medication is not being administered per physician’s order. This posed an immediate potential health, safety, and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: Administrator and Med-techs will review regulation 87465 Incidental Medical and Dental Care and provide LPA Lee a statement of acknowledgement and understanding of the regulation cite. POC due to LPA by 11/14/2024 end of day 5:00 PM

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Nov 14, 2024

5:00 PM 87625(b)(3) Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry, and that the facility remains free of odors from incontinence. This requirement is not met as evidence by: Based on observation and interviews It was observed a strong urine odor in resident room #24. Additionally, a mild urine odor was noted in resident room # 27. This posed a potential health, safety, and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: Administrator will conduct a Managed Incontinence In-service training. Administrator will provide LPA Lee training materials and sign in sheet to LPA Lee. Administrator will also provide a statement of acknowledgment of understanding of regulation. POC due by 5:00 PM 11/14/2024.

Allegation investigated: Unlawful eviction. Staff did not ensure the shower was not in disrepair.

On October 9, 2024, at 1:00 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced at the facility to conduct a complaint visit. LPA Lee met with Lezel Bello and explained the purpose of the visit: to deliver findings regarding the allegations mentioned above. The current resident census is 35. A brief interview was conducted with Administrator Assistant Lezel Bello. The department investigated the complaint alleging an unlawful eviction and alleging that staff did not ensure the shower was not in despair. The investigation revealed that Resident 1 (R1) received an eviction letter on August 1, 2024, due to frequent non-emergency calls made through the pull cord system and the main office phone line. R1 had moved into the facility on July 15, 2024. Records from the Emergency Call Log indicate that from July 15 to July 31, 2024, R1 activated the call system 26 times. The admission agreement and house rules do not specify a limit on call usage. Furthermore, R1 did not violate any conditions such as non-payment, failure to comply with state or local laws, or non-adherence to community policies. Consequently, the eviction was deemed unlawful, with deficiency documented on form LIC 9099-D. Continued LIC 9099-C Substantiated Additionally, observations made on August 5, 2024, and an interview with Administrator Hong Trinh revealed that two shower heads in the upstairs Terrace Hall building were intentionally removed. This decision was made because a resident frequently left the water running, causing overflow into the hallway. Based on the investigation, the Department finds the allegations to be substantiated, meaning the claims are valid and meet the preponderance of evidence standard. Deficiencies are cited on LIC 9099-D, in accordance with Title 22 Regulations. As a result, these allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with licensee and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. Allegations were made that staff failed to ensure the air conditioning (AC) was in proper working order. The investigation included observations and interviews with staff and residents. During visits on 08/05/2024 and 08/28/2024, temperatures in the common building, Terrence building, and Wall building were all recorded below 85 degrees Fahrenheit which is within the required regulation of 78 to 85 degrees Fahrenheit. LPA Lee also noted that the facility's AC was in good repair on both occasions. Interviews conducted during the investigation revealed that 7 out of 10 residents had no concerns about the facility’s temperature. Additionally, all 5 staff members interviewed denied the allegations. Allegations were made that staff were not providing adequate food service to residents. The investigation included observations and interviews with staff and residents. On 08/05/2024 and 08/28/2024, LPA Lee observed that the facility had a sufficient supply of perishable food for 2 days and nonperishable food for 7 days. During both visits, LPA Lee noted that appropriate portions of food were served to residents at breakfast and lunch. Interviews conducted during the investigation revealed that 7 out of 10 residents had no concerns about the adequacy of food service. Additionally, all 5 staff members interviewed denied the allegations. Allegations were made that staff did not ensure residents had access to Wi-Fi. The investigation included observations and interviews with staff and residents. On 08/05/2024 and 08/28/2024, LPA Lee observed that the facility's Wi-Fi was functioning properly. Administrator Hong Trinh informed the LPA that a Wi-Fi booster had been installed in the Terrence building. Interviews conducted during the investigation revealed that 7 out of 10 residents had no concerns about access to Wi-Fi. Additionally, all 5 staff members interviewed denied the allegations. Allegations were made that staff were not meeting residents' needs. The investigation involved interviews with staff and residents. Based on the statements obtained, LPA Lee was unable to corroborate the allegations. Out of 10 residents interviewed, 9 reported no concerns about staff not meeting their needs. Additionally, all 5 staff members interviewed denied the allegations. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to Administrator Assistant Lezel Ballo.the state’s words, verbatim · CDSS document, Oct 10, 2024 · control 27-AS-20240730114922

From the deficiency page — Deficiency type: Type B · Section cited: CCR 8722(a) · Plan of correction due date: Oct 18, 2024

87224(a) Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5) … This requirement was not met as evidence by: Based on record review and interviews, R1 was evicted due to due to frequent non-emergency calls made through the pull cord system and the main office phone line. This poses a potential health and safety to residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Administrator agrees to review eviction regulations by POC date 10/18/24. Administrator agrees to provide a written statement to LPA via email that states the review of eviction regulations has been completed by POC Date 10/18/24 by end of day 5:00 PM

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 18, 2024

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidence by: Based on observation and interviews the administrator did not ensure that resident’s shower was in good repair. This poses a potential health and safety to residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Administrator agrees to ensure that the facility is in good repair at all times. Administrator will also put the shower head back on to the shower in the Terrence building and send via email LPA a picture of the two shower heads in the Terrence building by end of day 10/17/2024 5:00 PM.

Allegation investigated: Staff did not properly store medications.

On 10/1/24, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to deliver the findings for complaint received on 6/19/2023. LPA met with Assistant Administrator Lezel Bello and explained the purpose of today’s visit. Throughout the course of the investigation, the Department conducted interviews and reviewed records. Based on records review, and staff and resident interviews, there is a preponderance of evidence that staff did not properly store medications. It was observed by the Department staff that medications were accessible to residents. It was learned that facility staff stored prescription medications to be administered throughout the day in a cart to save time from returning to the Medication Room on the second floor to obtain the medications. Although the cart was locked, facility staff and the administrator corroborated to the Department staff that a spare key was kept on top of the cart in a pen container and was easily assessable to anyone in the lobby, such as residents, and or visitors. Continued on 9099-C Substantiated According to R1’s death certificate, R1 passed away from respiratory failure and aspiration pneumonia, with drug overdose, and severe dementia listed as significant conditions that contributed to death. Final diagnosis was deemed to be poisoning by other opioids, accidental (unintentional). As a result of this investigation, the Department finds the allegation above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and a copy of the report was provided. As a result of this investigation, the Department finds the allegation above to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. Exit interview conducted. A copy of report, LIC 9099-D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 1, 2024 · control 27-AS-20230619115335

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Oct 2, 2024

87465(h)(2). Incidental Medical and Dental Care. (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on records reviewed, the licensee did not comply with the section cited above. The Department staff observed a spare key was kept on top of the medication cart in a pen container and was easily assessable to anyone in the lobby, such as residents, and or visitors. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: Facility will provide LPA a written statement that they have reviewed and understand requirements to make medications inaccessible to residents. Licensee will conduct medication training for all staff members who administer medications and will provide training materials to LPA for review by 10/2/2024 POC date.

Type of visit: Office

A in conference was conducted today on September 11, 2024, in the Sacramento South Regional Office. The purpose of this meeting is to discuss changes that the licensee wants to conduct at Ivy Ridge. Present in the meeting is Licensing Program Manager (LPM) Czarrina Camilon-Lee, Licensing Program Analysts (LPA) Pang Lee, Licensee Pak Wu and Administrator Hong Trinh. Issues discussed during the meeting were: · Expand the building census from 36 to 49. · How many residents are non-ambulatory/fire clearance. · Exhaust fan will be replaced in restroom in the Terrace building. · Install AC unit for Wall building. · Install solar panel in the Wall Building. · Licensee interested in connecting the Main Building with the Wall Building and the Terrace Building. · Install a lift and ramp to the Main Building and connect the ramp to the Terrace. CCLD advised to Licensee and Administrator: · Notify the planning department and with the fire department. · Building permit · Purposed in writing the changes and what to expand. · Provide CCLD a breakdown of the phrases of the changes. · What will the plan be for resident in care to ensure their safety during the expansion. · Notify building department to get permit. · Once obtain permit inform CCLD. An exit interview was conducted, and a copy of this LIC 809 report were provided to Licensee and Administrator.the state’s words, verbatim · CDSS document, Sep 11, 2024

Allegation investigated: Staff did not ensure facility is free of pest.

On 08/28/2024 at 11:09 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Assistant Administrator Lezel Bello and explained the purpose of the visit. The purpose of this visit is to opened and delivered the complaint. The current census is 36. A brief interview with conducted with Administrator Hong Trinh. Allegation: Staff did not ensure facility is free of pest. It was alleged that staff did not ensure facility is free of pest. This investigation consisted of observations, interviews with staff and residents and records reviewed. Based on facility visits on 08/05/2024, 08/19/2024 and today’s visit 08/28/2024, LPA Lee did not observe any pest in the facility. LPA Lee interviewed 5 facility staff who denied the allegation and stated they have not seen any pest in the facility since the facility start services with pest control. LPA Lee also interviewed 7 out of 10 residents who stated they have not observed any roaches or other pest in the facility and have no concern with the allegation. Continued LIC 9099-C Unsubstantiated Based on records review the facility has a contract with “All-in-One Pest Control Inc” since 10/10/2022 and that there has not been any break in service. Furthermore, the facility is receiving treatment services twice a month. Based on All-in-One Pest Control Log treatments, the facility is getting treatment done in the interior of the building including resident bedrooms and exterior of the building. Log treatment also revealed that the facility received an exterior services on 08/27/2024. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to Administrator Assistant Lezel Ballo.the state’s words, verbatim · CDSS document, Aug 28, 2024 · control 27-AS-20240821100429

Allegation investigated: Facility staff did not provide clean linens for resident in care. Facility staff did not provide adequate laundry service to resident in care.

On 08/28/2024 at 12:30 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Assistant Administrator Lezel Bello and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 36. A brief interview with conducted with Administrator Hong Trinh. Allegations: Facility staff did not provide clean linens for resident in care and facility staff did not provide adequate laundry service to resident in care. It was alleged that facility staff did not provide clean linens for resident in care and that facility staff did not provide adequate laundry service to resident in care. This investigation consisted of observations, interviews with staff and residents and records reviewed. Based on facility visits on 08/05/2024, 08/19/2024 and today’s visit 08/28/2024, LPA Lee observed facility staff doing laundry. Continued LIC 9099-C Unsubstantiated LPA Lee also observed multiple baskets in the laundry room waiting to be washed once the laundry in the washer has completed its cycle. LPA Lee also toured and observed resident bedrooms in the main building, wall building and Terrence Hall to have clean bedding and linens. LPA Lee also observed the linen closet, and it was observed that the facility has sufficient clean linens for residents in care. LPA Lee interviewed 5 facility staff who denied the allegations and stated that resident’s laundry and linens are being washed every day. LPA Lee also interviewed 9 out of 10 residents who stated that they no concern with the allegations and are getting their laundry done by facility staff. 9 out of 10 residents also stated they are provided with clean linens from facility staff. Based on Laundry Schedule it was learned that residents are scheduled to have two to three days of laundry a week and as needed. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to Administrator Assistant Lezel Ballo.the state’s words, verbatim · CDSS document, Aug 28, 2024 · control 27-AS-20240801135600

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Tung Truong and Licensing Program Manager (LPM) Czarrina Camilon-Lee arrived unannounced to conduct a case management visit on 4/25/2024. LPA met with Licensees Hong Trinh and Pak Wu and explained the purpose of today’s visit. The purpose of today's visit is in response to deficiencies observed due to the facility did not retain resident records for a minimum of 3 years following termination of service to the resident. On 3/29/24, LPA Truong requested the Needs and Service Plan, and MAR for month of October 2022 and November 2022 for resident R1. On 4/7/24, the facility administrator replied that they were unable to locate the requested records. Deficiencies were cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, a copy of this report, LIC 809-D and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Apr 25, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e) · Plan of correction due date: May 2, 2024

87506 Resident Records(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidence by: Based on observation, records review, and interviews, the Licensee did not retain resident R1's records as required which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: The Licensee agrees to submit a letter of understanding and develop a plan to maintain compliance with this regulation at all times to LPA by POC due date.

Type of visit: Required - 1 Year

On 04/03/2024 at 8:21 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with direct care staff, Tanisha Linzy, who then called administrator, Hong Trinh. Administrator and Licensee arrived approximately an hour later. LPA Lee explained the purpose of the visit. The Licensee and Administrator assisted with today’s visit. Administrator certificate # is 6042113740 and will expire on 12/4/2024. The current census is 30 residents with 7 facility staff which consist of 1 housekeeper, 1 Med-tech, 2 caregiver, 2 cook and the administrator and licensee. This facility is a two story building licensed to serve thirty-six (36) non-ambulatory residents, which 4 may be bedridden and approved for 2 hospice waivers. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, residents’ bedroom, residents’ bathroom, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be clean and in good repair. LPA Lee observed the back facility, Terrence Hall to have a strong urine odor as LPA Lee entered the building. The urine order was noticeable upstairs and downstairs of the building. In addition, when LPA Lee toured the Terrence building LPA Lee observed the following residents’ room to have a very strong urine odor: residents bedrooms number # 14, 20, 21, 27 and 24. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee toured the kitchen and observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 114.3 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. Continued LIC 809-C The fire extinguisher is located in the kitchen and common area and was last serviced on 12/22/2023. LPA Lee observed the facility has a has a public telephone in the kitchen and office. The facility has the required posters posted. The facility has an infection control plan and an emergency disaster plan. Facility thermostat observed at 72 degrees Fahrenheit. LPA Lee observed toxins located in laundry and kept locked and inaccessible to residents. LPA Lee observed sharp knives kept locked and inaccessible to residents. LPA Lee checked medication storage and found medication to be locked away and inaccessible to resident. LPA Lee along with Med-Tech Tanisha Linzy reviewed and compared 5 medication administration record (MAR) and it was not complete. MAR logs was missing staff initials. LPA Lee and Med-Tech Tanisha also audit 2 resident medications and it was learned that the medication is either not given to residents or are missing. The first aid kit was checked and contained all the required components. LPA Lee requested resident and staff files for review. LPA Lee reviewed 10 resident files and four resident's LIC 625 are missing resident's signature. LPA Lee reviewed 3 staff files, and they were complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following documents were given to LPA during today's visit. (1) LIC 308 Designation of Administrative Responsibility (2) LIC 610 Emergency Disaster Plan (3) Proof of Current Liability Insurance As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Apr 3, 2024

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: Facility does not have an administrator. Staff does not maintain a resident's room in an organized and clean fashion. Facility has pests.

On 02/21/2024 at 12:57 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Med-Tech Tanisha Linzy and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 28. A brief interview with conducted with designated staff Hong Trinh via telephone. Allegation: Facility does not have an administrator. It was alleged that the facility does not have an administrator. This investigation consisted of interviews with facility staff and residents. LPA Lee interviewed 10 out of 10 residents who confirm that they don’t know and have never seen administrator Sunnie Kitnikone. In addition, 10 out of 10 residents referred Zoe and Lezel as the administrator to the facility. On 01/26/2024 licensee Pak Wu admitted that Sunnie Kitnikone is a friend of his, who also owns her own residential facility. Licensee explained that Sunnie Kitnikone was added as the administrator to this facility since designated staff Hong Trinh’s administrator certificate had expired. Continued LIC 9099-C Substantiated Both licensee and designated staff Hong Trinh confirmed that Sunnie Kitnikone holds the administrator title for the facility only and that Sunny Kitnikone has no involved in the operations of the facility. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations Allegation: Staff does not maintain a resident's room in an organized and clean fashion. It was alleged that the staff does not maintain a resident's room in an organized and clean fashion. This investigation consisted of observations and interviews. LPA Lee interviewed 4 out of 10 residents who confirm that the facility staff does not help residents maintain the cleanliness of their rooms. During a complaint visit on 01/26/2024 LPA Lee toured the facility and observed 11 resident bedrooms. LPA Lee observed bedroom #9 to appear clean and organized; however, LPA Lee observed the toilet in bedroom #9 to be dirty and unsanitary. (R1) did confirmed that more cleaning assistant is needed in (R1)’s bathroom. Moreover, on 01/26/2024 LPA Lee observed resident’s bedrooms #23 and #24 had a very strong urine odor. On 01/26/2024, LPA Lee also observed resident’s bathroom #1 and #2 up stairs in the main building to be unsanitary and dirty. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations Allegation: Facility has pests. It was alleged that the facility has pests. This investigation consisted of observations and interviews. During the complaint visit on 01/26/2024 LPA Lee toured the facility with licensee Pak Wu and designated staff Hong Trinh and it was observed that resident bedroom #4 had two live bed bugs on the mattress and sheet cover. In addition, LPA Lee, licensee Pak Wu and designated staff Hong Trinh observed dead bed bugs in the upstairs bathroom #2. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Allegation is substantiated; however, there will be no deficiencies cited since this allegation was also substantiated and cited on 12/14/2023. An exit interview was conducted with Tanisha Linzy and a copy of this LIC 9099, LIC 9099-C, LIC 9099-D page and appeal rights was given to Tanisha Linzy.the state’s words, verbatim · CDSS document, Feb 22, 2024 · control 27-AS-20240123145354

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Mar 1, 2024

87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all the following personal rights: (2)To be accorded safe, healthful, and comfortable accommodations furnishings and equipment. This requirement was not met as evidence by: Based on observation and interviews the licensee did not ensure that resident’s rooms and bathrooms clean and sanitary for residents in care. This poses a potential health and safety to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Licensee agrees to ensure that all rooms are cleaned throughout the day. Licensee also hired an extra floater to help with the cleanliness of the facility. Resident bedroom #23 and 24 will be inspect and clean weekly. Licensee will email LPA Lee room cleaning schedule log for the month of February. POC will be email to LPA Lee by 03/01/2024 by 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Mar 1, 2024

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person... This requirement was not met as evidence by: Based on interviews, the Licensee did not ensure that the facility has an active administrator on the premises to provide adequate attention to manage the facility. This poses a potential health and safety to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Licensee agrees to ensure that an administrator that is associated to the facility is on the premises and provide adequate attention to manage the facility. Licensee will read regulation cited and write a statement of acknowledgement. POC will be email to LPA Lee by 03/01/2024 by 5:00 PM.

Allegation investigated: Staff does not maintain resident’s hygiene.

On 02/02/2024 at 1:37 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with care staff Ernie Inductivo and explained the purpose of the visit. Care staff called designated person in charge, Hong Trinh, who stated she won't be able to join the visit. LPA Lee explained the purpose of this visit is to deliver complaint findings for the allegations above to both Hong Trinh and Ernie Inductivo. The census is 29. Allegation: Staff did not maintain residents’ hygiene. It was alleged that staff did not maintain residents’ hygiene. This investigation consisted of records reviewed, observations, interviews with staff and residents. LPA Lee interviewed 9 out of 9 residents and 7 out of 9 residents have no concerns with staff not maintaining residents’ hygiene. On 12/14/2023 during a complaint investigation LPA Lee observed 10 residents in the common area and the 10 residents appeared to look clean. Continued LIC 9009-C Unsubstantiated LPA Lee also observed (S1) assisting residents with incontinence care. In addition, on 01/26/2024 during a complaint visit LPA Lee observe all the residents that LPA Lee interviewed appeared to be cleaned. LPA Lee also observed (S1) assisting residents with incontinence care. In addition, LPA Lee reviewed shower logs for the month of November 2023 to January 2024 and records review revealed that residents are getting incontinence care. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was conducted, and a copy of this report was provided. It was learned that on 01/26/2024 staff 1 (S1) had left the facility due to a family emergency. It was also learned that the (S1) did not inform the licensee and administrator before leaving the facility. As a result, the allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met Allegation: Staff did not provide residents with linens. It was alleged that staff did not provide residents with linens. This investigation consisted of records reviewed, observations, interviews with staff and residents. LPA Lee interviewed 9 out of 9 residents and 3 out of 9 residents stated that facility staff did not provide residents with linens. On 12/14/2023 during a complaint visit LPA Lee observed resident bedroom #27A missing a fitted sheet. In addition, on 01/26/2024 during a complaint visit, LPA Lee also observed resident bedroom #24 did not have a fitted sheet. As a result, the allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of this LIC 9099, LIC 9099-D page and appeal rights was given to the facility. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited. A copy of this report was provided, along with Appeal Rights and LIC 811, the Confidential Names List. Exit interview.the state’s words, verbatim · CDSS document, Feb 2, 2024 · control 27-AS-20231208105830

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 9, 2024

87464(f)(1) Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) (f) and Health and Safety Code section 1569.2(i). This requirement is not met as evidenced by: Based on interviews and observations the licensee did not ensure care and supervision needs were provided. LPA Lee observed 15 residents in the common area with no facility present. This poses/posed an immediate health and safety risks to resident in care.the state’s words, verbatim · CDSS document, Feb 2, 2024

Plan of correction: Licensee agrees to conduct care and supervision training for all staff and submit a written care plan on how the facility will provide adequate care and supervision to all residents. POC will be email to LPA Lee by POC date 02/09/2024 by the end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: Feb 16, 2024

87307(a)(3)(C) Personal Accommodations and Services a) Living accommodations and grounds shall be related to the facility's function… (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident… (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillowcases, mattress pads… This regulation was not met as evidence by: Based on observations and interview the licensee did not ensure that a provision of clean linens was available to each resident. Based on documentation two resident was observed with no sheets on their bed. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Feb 2, 2024

Plan of correction: Facility will provide training to staff regarding room checks to ensure that all residents have the adequate linens needed. POC will be provided to LPA Lee by POC date of 02/16/2024 by end of day 5:00 PM

Allegation investigated: Staff does not keep the facility free of pest. staff does not maintain the facility in clean and sanitary condition.

On 12/14/2023 at 8:15 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with House Manager Lezel Bello and explained the purpose of the visit. The purpose of this visit is to open and deliver complaint finding for the allegations above. The current census is 26 with 2 caregivers, 1 med-tech, 1 cook, 1 house manager and 1 maintenance staff present. At 2:45 PM, both Licensee Pak Wu and Licensee/administrator Hong Trinh arrived to the facility. Allegation: Staff does not keep the facility free of pest. It was alleged that staff does not keep the facility free of pest. This investigation consisted of observations, records reviewed, interviews with staffs, residents, and the resident family member. At 9:16 AM, LPA Lee toured resident 1 (R1) room. It was observed that (R1) mattress and bed sheets had numerous bed buds. LPA Lee also observed multiple bedbugs on the carpet in (R1) room. Furthermore, LPA Lee interviewed 12 residents and 7 out of 12 residents stated that they have seen bedbugs in their room. LPA Lee also spoke to administrator, Hong Trinh, who confirmed that residents in room #2, #4, #6 does have bedbugs. Continued LIC 9099-C Substantiated Administrator also stated that she has put an order for new mattress, bed sheets and comforter for all the bedroom upstairs in the main building. It was also learned that a care staff had also witness bedbugs in resident room # 10 and #27. Allegation: staff does not maintain the facility in clean and sanitary condition. It was alleged that staff does not maintain the facility in clean and sanitary condition. This investigation consisted of observations, records reviewed, interviews with staffs, residents, and the resident family member. It was learned that the facility had bedbugs in 5 resident room. Furthermore, at 9:20 AM, LPA Lee observed bedbugs in the resident bathroom shower upstairs. At 12:30 PM, LPA Lee and observed the kitchen was not clean and sanitary. LPA Lee observed the kitchen stove and the range hood to be dusty and having heavy grease. LPA Lee also observed left over foods and spills on the kitchen counters. As a result, these allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with licensee and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Dec 14, 2023 · control 27-AS-20231204130717

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 28, 2023

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on observation, interviews the licensee did not maintain the facility in a clean and sanitary condition. The facility currently has evidence of bedbugs. The kitchen is observed to be unclean and unsanitary. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 14, 2023

Plan of correction: The licensee shall have a certified pest control company conduct a facility-wide bedbug treatment. The licensee shall send proof/invoice of bedbug inspection/treatment to LPA. The licensee shall conduct routine pest control inspections to minimize the outbreak of future bedbugs. The licensee shall also conduct routine cleaning to ensure that the facility at all times is clean and sanitary. Licensee will send POC to LPA Lee via email by 12/28/2023.

Type of visit: Case Management - Other

A virtual Informal conference was conducted today on 12/13/2023 at 1:30 PM via Microsoft Teams. The purpose of the meeting is to discuss complaint findings and non-compliance concerns issued to facility # 347001903 while Ivy Ridge Care, Inc. was managing the facility which closed as of April 14, 2023, due to change of ownership. A new license has been issued to Ivy Ridge Care, Inc.#342701234. Present in the meeting are Licensing Program Manager Czarrina Camilon-Lee, and Licensing Program Analyst Pang Lee, Licensing Program Analyst Tung Truong, Licensee Pak Wu and administrator Hong Trinh. The informal conference process was explained during this meeting. During today’s meeting we discussed the administrator certification renewal. It was learned that administrator Hong Trinh renewal was not on the pending application list or the active certificate list. Licensee Pak Wu stated that he will follow-up with the Administrator Certification Section (ASC). LPA Lee will provide Licensee the Administrator Certification contact information. The following concerns were discussed: ·Three questionable death that was substantiated from previous change of ownership in November 2022, facility license number 347001903. ·The facility was issued 10 type A citations and 2 type B citations since 04/13/2023. ·Resident AWOL ·Insufficient staffing in the facility ·Monitoring residents for change of condition. ·Notifying the physician or calling 9-1-1 when medical attention is needed. The facility has stated they have and will do the following to achieve continued and substantial compliance: · Licensee stated they has terminated 90% of old staff and hired new staff for the facility. Continued LIC 809-C ·The facility has implemented employee meetings which are held once a month. The meeting consists of training staff on monitoring and supervising changes in residents’ condition, Title 22 regulations, observe and prevent open wound. · The facility has implemented a manager’s meeting held once a week. · The facility has implemented that during every staff shift staff are required to submit a written report to administrator Hong Trinh and then the report will be placed in residents’ file. · The facility has implemented that House Manager, Lezel Bello whovwill ensure to visually observe residents on a daily basis. · The facility will ensure that all staff are compliant with all required training. · The facility will ensure to conduct training for all staff on monitoring and identify for changes in residents’ conditions and seek medical attention. · The facility will ensure that all staff are clear on the requirements and responsibilities of their jobs. · The facility will conduct training for all staff on how to redirect residents to prevent AWOL. · The Facility Administrator will ensure the compliance plan is always followed. · The facility will submit LIC 500 Personnel Report and LIC 308 Designated Responsibility to LPA Lee Licensee Pak Wu and Licensee/Administrator Hong Trinh reported all facility plans to achieve compliance will be submitted to the Community Care Licensing Department by December 27, 2023, by 5:00 PM. The licensee was advised failure to follow the agreed plan could result in a Non-Compliance Conference. No deficiencies were cited during today's meeting. An exit interview was conducted with facility representatives Licensee Pak Wu and Licensee/Administrator Hong Trinh. A copy of this report was provided on 12/14/2023.the state’s words, verbatim · CDSS document, Dec 13, 2023

Allegation investigated: Facility staff are not assisting resident with bathing Facility staff are not assisting resident with personal care Staff are not providing adequate food service to resident(s)

Licensing Program Analyst (LPA) Tung Truong conducted an unannounced facility visit to complete and deliver findings for a complaint investigation received on 9/8/23. LPA met with Assistant Administrator Lezel Bello and explained the purpose of today’s visit. Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on record reviews, and staff and resident interviews, there is not a preponderance of evidence to substantiate the allegations mentioned above. LPA interviewed resident R1, R1 corroborated that facility staff do provide adequate food services but stated that food tasted “pretty bad”. R1 stated that staff do assist R1 with bathing once a week and personal hygiene needs. R1 stated that she can do her own grooming and doesn’t expect staff to do it for her. Based on staff interviews, staff stated that they do assist resident R1 with bathing and personal hygiene needs. Staff reported that R1 has no skin issues or bed sores. Continued on 9099-C Unsubstantiated As a result of the investigation, LPA finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and a copy of the report was provided upon exit.the state’s words, verbatim · CDSS document, Nov 30, 2023 · control 27-AS-20230908102235

Type of visit: Case Management - Other

On 11/20/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit. LPA met with Administrator Hong Trinh and explained the purpose of the visit. The purpose of this case management visit is to follow up on information obtained from a complaint investigation conducted by the Department. Complaint control number: 27-AS-20221223104058. The following was discussed with the Administrator: - Staff must report to the Administrator to seek approval before sending residents to the hospital. - Residents reported that they were not always receiving medication. - Someone was doing resident's tax and resident's refund check went missing. - Hoyer lift use/training. - Residents received Insulin administration not by nurse. Per the California Code of Regulations, Title 22, no deficiencies were cited during this visit. The administrator was advised that LPA would return at a later date to complete the investigation. An exit interview was held, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 20, 2023

Type of visit: Collateral

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a collateral visit. LPA met facility Administrator on issue that was not related to this facility. In the areas that were evaluated, no deficiencies were observed at the time of the visit. Exit Interview conducted.the state’s words, verbatim · CDSS document, Oct 12, 2023

Type of visit: Collateral

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a collateral visit. LPA interviewed facility staff on an issue that was not related to this facility. In the areas that were evaluated, no deficiencies were observed at the time of the visit. Exit Interview conducted.the state’s words, verbatim · CDSS document, Sep 28, 2023