Jade Guest Home

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced Case Management visit to the facility on August 28, 2026. Upon arrival, LPA met with Administrator Jean Veracruz, who granted entry into the facility. LPA explained the purpose of the visit. The purpose of today’s visit was to amend Complaint control # 22-AS-20260811151254 An exit interview was conducted. A copy of this report, the amended LIC 9099-D, and appeal rights were provided to Administrator Jean Veracruz.the state’s words, verbatim · CDSS document, Aug 28, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Sam Haddadin conducted a Case Management visit to the facility for the purpose of completing a health and safety check. Upon arrival, LPA was greeted by Administrator (AD) Jean Veracruz, who granted entry into the facility and was informed of the purpose of the visit. During the visit, LPA observed five residents in care. Three residents were asleep and two were eating t. LPA, accompanied by facility staff, toured the interior of the facility and reviewed resident medications and records. No discrepancies were identified. Both resident bathrooms were observed to be clean and operational. Hot water temperatures were measured between 115.1 and 116.7 degrees Fahrenheit. LPA observed First Aid Kit was maintained. The facility had operational smoke and carbon monoxide in bedrooms and common areas. Cleaning supplies were secured in a locked cabinet under the kitchen sink, and knives and other sharp objects were secured in the caregiver’s room. The facility maintained an adequate food supply consisting of at least a two-day supply of perishable food and a seven-day supply of nonperishable food. The facility had operating electricity, gas, and water services. Kitchen appliances were checked and observed to be operational and in good working condition. The required “See Something, Say Something” poster (PUB 475) was posted in the hallway. The fireplace in the living room was equipped with a protective screen. Based on the observations made during today’s visit, no deficiencies are being cited. An exit interview was conducted with AD Jean Veracruz, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 31, 2026

Allegation investigated: Staff yell at resident

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Administrator (AD) Jean Veracruz, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that staff yell at resident revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, staff, and residents, and obtained and reviewed copies of the resident roster and staff roster. CONTINUED Substantiated It was alleged that staff yell at Resident #1 (R1), harass R1, and speak badly about R1. LPA interviewed AD and one staff who denied the allegation. LPA interviewed the three other residents present, and the two residents who could communicate did not provide any information corroborating the allegation. During the inspection, LPA observed a verbal confrontation between R1 and AD, but while R1 yelled loudly at AD and other staff and slammed the table, the staff did not yell back at R1. However, during a previous phone call with R1, LPA overheard a staff say something loudly towards R1 in an argumentative manner, but was unable to identify the staff. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. Regarding the allegation that staff handled resident in an aggressive manner: it was alleged that staff push and hit Resident #1 (R1). LPA interviewed R1 who stated AD pushed them last year resulting in their hospitalization with a pelvis injury. LPA interviewed AD and one staff who denied the allegation, stating R1 fell outside the facility while intoxicated last year as they are free to leave the facility, but they are unsure of the injury. LPA interviewed the three other residents present, and the two residents who could communicate did not provide any information corroborating the allegation. The information obtained is conflicting. Regarding the allegation that staff do not safeguard resident’s personal belongings: it was alleged that staff stole R1’s food stamp card and food. When interviewed, R1 stated they had given AD the food stamp card for AD to buy items for R1 and also allowed AD to use it for themselves, AD had overspent, R1 demanded the card back and AD had returned it, and other staff had stolen some of R1’s eggs. LPA interviewed AD and one staff who denied the allegation. Per one staff, R1’s allegation regarding the eggs is a misunderstanding, no eggs were actually missing or stolen from R1, and staff gave R1 the allegedly missing eggs from their own supplies when the issue was raised. Per AD, R1 gave AD their food stamp card to buy groceries for R1, AD followed R1’s shopping list, although R1 offered to allow AD to purchase things for themselves using the card AD never did, and R1 did not have enough money to purchase everything they needed at one point so AD used their own money to purchase R1’s groceries for them. LPA interviewed the three other residents present, and the two residents who could communicate did not provide any information corroborating the allegation. Regarding the allegation that staff mishandle resident's P&I funds: it was alleged that AD uses R1’s P&I money to purchase personal items for themselves. When interviewed, R1 stated AD used their food stamp money for their own use. LPA interviewed AD who denied the allegation, stating R1 gave AD their food stamp card to buy groceries for R1, AD followed R1’s shopping list, although R1 offered to allow AD to purchase things for themselves using the card AD never did, and R1 did not have enough money to purchase everything they needed at one point so AD used their own money to purchase R1’s groceries for them. LPA interviewed the three other residents present, and the two residents who could communicate did not provide any information corroborating the allegation. Regarding the allegation that facility staff are not providing telephone access to residents: it was alleged that staff are not allowing R1 to use the facility telephone. LPA interviewed R1 who stated their phone was not working so they used the facility phone for internet access, staff needed to use it so they demanded it back and accused R1 of stealing the phone, and R1 has since avoided using the facility phone due to this pushback. LPA interviewed AD and one staff who denied the allegation, stating that the facility has a cell phone that also has internet access, that R1 used it for an entire day despite having their own phone, but that staff also need to use it to coordinate resident care. Per AD and one staff, R1 is able to use the phone and its internet access reasonably and they have not prevented R1 from using the phone. LPA interviewed the three other residents present, and the two residents who could communicate did not provide any information corroborating the allegation. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 22-AS-20260702082618

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jul 16, 2026

87468.1 Personal Rights of Residents in All Facilities (a) … (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on observation, the licensee did not ensure R1 was treated with dignity when staff spoke loudly towards R1 in an argumentative manner, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Licensee stated that they will retrain staff on deescalating tense situations and speaking to residents with dignity.

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20260702082618. LPA met with Administrator (AD) Jean Veracruz and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, interviewed AD, staff, and residents, and obtained and reviewed copies of the resident roster and staff roster. Per AD, the facility has only one cell phone which is the house cell phone and is also the only device residents can use for internet access, staff also need to use it to coordinate resident care through phone calls, which limits residents’ access to an internet device, and this has led to conflicts with residents regarding ability to use the phone and access the internet. Per AD, the facility has internet service and wifi. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 2, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.319(a) · Plan of correction due date: Jul 16, 2026

§1569.319(a) A licensee of a facility that has internet service shall provide at least one internet access device… dedicated for resident use. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure residents have dedicated internet device access when the only device is also used as the facility phone needed by staff, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Licensee stated they will obtain an internet capable device dedicated for resident use and submit proof to LPA by POC due date.

Allegation investigated: Staff did not safeguard residents personal documents Staff did not reorder residents medications timely resulting in resident missing medications

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit. The Department received the complaint on November 20, 2024 and the initial visit was conducted on November 25, 2024, during that visit the Department interviewed resident and staff. LPA Mendivil obtained copies of Resident 1’s (R1) documentation including: physician’s report, assessment, admission agreement, medication administration records and hospice documentation. Regarding the allegations Staff did not safeguard residents personal documents and Staff did not reorder resident’s medications timely resulting in resident missing medications, the investigation revealed the following: It was alleged that staff did not safeguard resident’s personal documents. Per interview with Licensee Brevet Dao, Brevet stated all resident’s facility documents are stored in the locked medication cabinet in the hallway. Unsubstantiated Licensee stated residents have access to their documents to review. Interviews with 1 out of 6 current residents, residents stated their items are safeguarded and have access to their documents/personal belongings. The remaining 5 residents were not oriented to time and space or did not wish to engage with LPA Mendivil. It was alleged that staff did not reorder resident’s medications timely resulting in resident missing medications. Per interview with Licensee Brevet, Brevet stated that R1’s hospice nurse oversaw ordering medications and providing the medications to the facility. Brevet stated that they would contact hospice if a resident was going to run out of medication. No documentation or records of the dates the medications were missing were provided to LPA Mendivil. Brevet stated that staff started a pain medication management log for R1 and had R1 sign when medications were given. An interview with 1 out of 6 residents stated that they receive all of their medications and has not had an issue with the medications being ordered. Therefore based on the preponderance of evidence through records reviewed and interviews the allegations Staff did not safeguard resident’s personal documents, Staff did not reorder residents medications timely resulting in resident missing medication are determined to be UNSUBSTANTIATED meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiencies cited. An exit interview was conducted and a copy of this report this report was left at the facility.the state’s words, verbatim · CDSS document, May 26, 2026 · control 22-AS-20241120112843

Type of visit: POC

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a Plan of Correction (POC) visit for deficiencies cited on May 21, 2026. LPA was greeted and granted entry into the facility and explained the reason for the visit. Deficiency cited under Title 22 Regulation 87303 (a) pertaining to facility maintenance and operation has been cleared. LPA observed kitchen to be cleaned and free of roaches. Licensee has complied with the POC Deficiency cited under Title 22 Regulation 87309 (a) pertaining to storage and access to toxins and sharps has been cleared. Licensee corrected during visit on May 20, 2026. Licensee has complied with the POC. Deficiency cited under Title 22 Regulation 87645(h) (2) pertaining to secured medications has been cleared. Licensee corrected during visit on May 20, 2026. Licensee has complied with the POC. Deficiency cited under Title 22 Regulation 87555 (b) (8) pertaining to general food service requirements has been cleared. LPA observed a cleaned out refrigerator and LPA received a copy of grocery receipt dated May 22, 2026. Licensee has complied with the POC. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, May 26, 2026

Type of visit: Case Management - Deficiencies

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit in conjunction with complaint control #22-AS-20241120112843. LPA was greeted and granted by staff and explained the reason for the visit. During the course of the visit LPA Mendivil observed both dead and alive roaches in kitchen drawers, on the floor throughout the kitchen, and in the refrigerator. LPA Mendivil observed dead roaches in the living room near the fire door which leads to resident bed rooms. LPA Mendivil observed expired pork dated May 16th 2026. LPA Mendivil observed rotting vegetables in the refrigerator. LPA Mendivil observed laundry cabinet to be unsecured with toxins present. LPA Mendivil observed unsecured sharps under kitchen sink. LPA observed unsecured medications in refrigerator which were in the same area as dead roaches. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted with Administrator and a copy of this report, LIC 809-D, and appeal rights was provided at the time of exit.the state’s words, verbatim · CDSS document, May 20, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: May 21, 2026

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by LPA observed dead and alive roaches throughout facility kitchen including the refridgerator (photos taken). This poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, May 20, 2026

Plan of correction: Administrator stated will clean out the refridgerator and kitchen and will contact exterminator and provide proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: May 21, 2026

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives...otther similar items which could pose a danger to residents are in locked storage... This requirement was not met as evidence by LPA observed unsecured laundry area with.. toxins and unsecured sharps under kitchen sink. This poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, May 20, 2026

Plan of correction: Administrator corrected during visit .

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 21, 2026

(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 was not met as evidence by unsecured medications were in refridgerator. (photos taken)the state’s words, verbatim · CDSS document, May 20, 2026

Plan of correction: Administrator corrected during visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87555(b)(8) · Plan of correction due date: May 21, 2026

(b) The following food service requirements shall apply:(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement was not met as evidence by expired pork and rotting vegetables were present in the refrigerator. (photos taken)the state’s words, verbatim · CDSS document, May 20, 2026

Plan of correction: Administrator will clear refridgerator and replinish food supply by POC due date and provide proof to LPA.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to conduct in conjunction with complaint investigation 22-AS-20260409160730. During visit, LPA requested fpr copies of pertinent records for residents (R1-R6) and Personnel Records for Staff (S1-S3). Based on record review, the following deficiencies are being cited on D-page as per the Title 22 Division 6 Chapter 8 of the California Code of Regulations. An exit interview was conducted with Licensee Bervet Dao and a copy of this report along with Confidential names list LIC 811 and appeal rights was provided to facility representative.the state’s words, verbatim · CDSS document, Apr 10, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Apr 15, 2026

87506 (a) resident records. The licensee shall ensure that a separate, complete, & current record is maintained for each resident in the facility or in a central location available to staff and to licensing staff. This requirement is not being met as evidence by: Records for residents were not complete for R1 and R2. Records were missing required documents for Admission. This poses a potential risk, personal rights to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Apr 10, 2026

Plan of correction: Licensee to provide Dept. a signed statement acknowledging regulation as well as a signed statement from Licensee stating they will not admit residents without proper records & understanding they will be subject to citations if not met. Licensee to provide copy by POC date 4/15/26

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(f)(g) · Plan of correction due date: Apr 15, 2026

87412(f) All personnel records shall be available to the licensing to inspect, audit, and copy upon demand during business hours.(g) All personnel records shall be maintained at facility & be available to the licensing for review. This requirement is not met as evidence by: Personnel Records are not available at facility for review or copy. This poses a potential risk, personal rights to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Apr 10, 2026

Plan of correction: Licensee to provide a signed statement understanding reg as well as securring copies of staff files in facility. Licensee stating in POC understanding they will be subject to citations if not met. Licensee to provide copy by POC date 4/15/26.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to follow up on a complaint investigation #22-AS-20250121083618. LPA delivered updated findings for complaint investigation as well as getting signatures from facility representative Administrator Lady Jean Veracruz for amended report. Administrator contacted Licensee Bervet Dao for LPA to discuss purpose of visit. Based on record review, a deficiency is being cited on D-page as per the Title 22 Division 6 Chapter 8 of the California Code of Regulations. An exit interview was conducted with Administrator Lady Jean Veracruz and a copy of this report along with appeal rights was provided to facility representative.the state’s words, verbatim · CDSS document, Feb 5, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(a)(1)(A) · Plan of correction due date: Feb 12, 2026

The licensee shall complete an individual written Admission Agreement as defined in section 87101(a), with ea resident or rep, if any: text of the Admin agreement, including any attachments & modifications, shall be printed in black type of not less then 12 point on plain paper. This requirement is not being met as evidence by: Facility had two of four resident agreements modified with handwritten changes. This poses a potential risk, personal rights to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Feb 5, 2026

Plan of correction: Licensee to provide to Dept an updated Admission Agreement all typed & signed for Resident 3 who remains in facility. Licensee to provide in service for staff who handle Admission Agreements acknowledging regulations of facility admission agreement by POC due date 2/12/26

Allegation investigated: Licensee modified the admission agreement without department approval.

Licensing Program Analyst (LPA) Jenifer Tirre made a subsequential visit to deliver findings on complaint investigation. LPA Tirre was greeted and granted entry into the facility by caregiver and explained reason for visit. Administrator Lady Jean Veracruz was present during visit. During the course of investigation, the Department conducted interviews and reviewed documents. The investigation conducted revealed the following: Department conducted a record review of residents Admission’s agreements. LPA reviewed Four Resident agreements and LPA observed on two Residents Agreements (residents 3 and 4) have handwritten on pages 10 and 11, “No refund when on hospice care". On R4’s agreement a Responsible party signature is provided on bottom. On R3’s Agreement no responsible parties signature is provided due to R3 being own responsible party. LPA did not observe handwritten “no refund” on Residents 1 and 2’s agreement. Record review revealed that all four residents were under Hospice Care. CONTINUED ON 9099C ***THIS IS AN AMENDED REPORT*** Substantiated Interviews conducted revealed one of four residents who is under Hospice care, stated they signed their Admission agreement and Licensee reviewed agreement with them. Resident stated they can not recall refund policy. Three of four residents were unable to provide information regarding Agreements. As a result of information gathered in complaint investigation, the allegation Licensee modified the admission agreement without department approval is deemed as SUBSTANTIATED, meaning that the preponderance of evidence has been met. Based on record review, a deficiency is being cited as per the Title 22 Division 6 Chapter 8 of the California Code of Regulations. An exit interview was conducted with Administrator Lady Jean Veracruz and a copy of this report along with appeal rights was provided to facility representative.. ***THIS IS AN AMENDED REPORT***the state’s words, verbatim · CDSS document, Dec 30, 2025 · control 22-AS-20250121083618

Type of visit: Case Management - Other

On this day Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to follow up on deficiencies that were issued from complaint visit #22-AS-20250914154018 on September 16, 2025. LPA Tirre discussed the purpose of the visit with Administrator Lady Jean Vera Cruz. LPA Tirre explained D-page with Amended citation and had Administrator sign. LPA Tirre provided copy of Amended D-Page and exit interview conducted with Administrator Vera Cruz.the state’s words, verbatim · CDSS document, Oct 29, 2025

Type of visit: Required - 1 Year

On October 29, 2025, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. Administrator Lady Jean Vera Cruz was available to assist with the facility inspection. The facility is licensed for six (6) non-ambulatory residents of which two (2) may be bedridden with approved hospice waiver for five (5) residents. Currently, there are two (2) Hospice residents present during today’s visit. This is a single story with a detached garage facility. The facility has four bedrooms (three shared resident rooms and one staff room) and two bathrooms. At around 8:45AM, LPA conducted a tour of the physical plant accompanied by caregiver Veronica Lirios and Administrator Lady Jean Veracruz, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 106.5 degrees F. A comfortable temperature of 73 degrees F. was maintained in the facility. LPA observed the facility to be furnished at the time of the visit. Storage areas for toxins, cleaning supplies and sharps objects were stored and not accessible to residents. CONTINUED ON 809C The kitchen was inspected, and sufficient two day perishable and seven day non-perishable food was maintained. Facility has one fire extinguisher which was mounted and fully charged. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common area entry way. LPA observed the facility has a supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA observed First Aid Kit was maintained. A working land line phone was operational. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 3/18/25 – 3/18/26. A review of four residents (R1-R4) service files and two staff (S1-S2) personnel files revealed to be complete. The facility has the current administrator's certification on file for Lady Jean Veracruz # 6070564740 - Expiration June 1, 2026. No deficiencies during this inspection visit. An exit interview was conducted with Administrator Lady Jean Veracruz, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 29, 2025

Allegation investigated: Staff did not properly transfer resident's personal belongings.

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced inspection visit to deliver findings for complaint investigation into the above allegations. LPA explained the reason for the visit with Administrator Lady Jean Vera Cruz. During the course of the investigation LPA toured facility, reviewed records, conducted staff interviews, made visual observations, documented photos of belongings and requested pertinent documentation such as Admission agreement, resident personal property and valuables and emergency identification form. During investigation LPA reviewed facility records such as resident admission agreement dated March 17, 2024, which noted under “Belongings Removal” section, “In the event of resident vacating premises, facility will make reasonable efforts to assist resident or responsible person with belongings removal. Facility requires all resident personal belongings to be removed as quickly as responsible party can”. LPA also reviewed Resident’s Personal property and Valuables form noting Resident 1 to have four long sleeve shirts and four jogging pants. CONTINUED ON 9099C Substantiated During investigation LPA observed, facility had a box secured inside garage with Resident 1’s personal belongings. LPA Tirre observed the box to have 10 clothing shirts/ Jacket, a bag of slippers and a bag of socks & underwear. After conducting interview with staff, LPA inquired if there were any additional belongings of R1 to which LPA observed facility to have R1’s mail, ATM card and checkbook. Per Investigation interviews three of three staff confirmed R1 left facility via ambulance on June 30, 2025. Per interviews with staff, two of three staff members stated that R1 left facility due to being a fall risk due to a recent change in condition. Per staff interviews R1 required a higher level of care and was transported to a hospital and then transported to a Skilled Nursing Facility. Per staff interviews, two of three staff stated that A Coordinator from Skilled Nursing Facility was to pick up R1’s belongings but as of today’s date September 16, 2025 had not picked up items. Based on records reviewed, observations and interviews conducted the preponderance of evidence has been met. The following deficiencies are being cited per Title 22. An exit interview was conducted with Administrator Lady Jean Vera Cruz and a copy of this report, along with confidential names list and appeal rights was reviewed and provided.the state’s words, verbatim · CDSS document, Sep 16, 2025 · control 22-AS-20250914154018

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(i) · Plan of correction due date: Sep 23, 2025

**AMENDED REPORT** Safeguards for resident cash, personal property & valuables. Upon discharge of a resident ,all cash resources, personal property & valuables, of that resident...shall be surrendered to resident or responsible person. A signed receiprt shall be retained. Based on investigation this requirement was not met as evidenced by facility failed to transfer personal belongings in a timely manner. R1 has been out of facility since 6/30/25. This poses a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: As plan of correction (POC) , Facility is to coordinate and transfer R1’s belongings with new facility. Facility to provide proof of transfer by having a signed document from facility representative by POC due date 9/23/25.

Allegation investigated: Staff yelled at resident in care. Staff did not ensure the facility was free of pests.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the two allegations listed above as well as to deliver findings to the licensee. LPA was greeted and granted entry by facility caregivers after introducing himself and stating the purpose of the visit. Administrator Jean Veracruz was notified of the visit and assisted. An initial investigation visit was conducted by licensing staff on January 6, 2025. LPAs accompanied by facility staff toured the facility's physical plant. There were four residents in care, all of which are receiving hospice care. LPAs requested and reviewed resident records for all four residents as well as for a recently deceased resident. Two staff interviews and one resident interview conducted during the visit. During the present visit, LPA conducted an additional tour of the premises and two staff interviews. Additional witness interviews conducted via telephone during the investigation. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff yelled at resident in care, the following has been concluded: Based on observation conducted during the facility visits as well as on the interviews conducted with staff, residents and witnesses, there was no stated occurrence of yelling or inappropriate verbal interactions confirmed. One interviewee stated that they believed staff efforts to communicate with a specific resident with hearing impairment may have been interpreted to be yelling but denied any perceived inappropriate or abusive intent. Regarding the allegation that Staff did not ensure the facility was free of pests, the following has been concluded: Both observations conducted failed to evidence any signs of an infestation being present. A wide majority of statements gathered denied any direct observation or suspicion of the presence of rodents and/or insects on the premises. As a result and based on the evidence gathered, both allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Mar 21, 2025 · control 22-AS-20241230110812

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Brandon Lopez conducted an unannounced visit for the Required 1 Year Inspection. LPAs explained the purpose of today’s visit, and were greeted and granted entry by Caregiver Juanita Marvin. Administrator (AD) Brevet Dao was notified via telephone by staff. AD arrived at approximately 3:45 pm. For today’s visit, LPAs observed a total of three residents in care and one staff member on duty. LPAs observed the Administrator Certificate for Administrator Assistant Ladyjean Veracruz which expires on June 01, 2026. LPAs toured the interior and exterior portions of the facility with caregiver Marvin. The facility is a single level structure and is licensed for six non-ambulatory residents of which five may be on hospice and two bedridden. There are a total of four bedrooms, of which three are resident bedrooms, and one private bedroom for staff. During the tour LPAs observe the 20"x26" complaint poster (PUB 475) located by the entryway. LPAs toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of two restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars were provided. LPAs observed that two of two restrooms do not have non-skid floor mats; a Deficiency was issued. Water temperature tested between 106.3-110.6 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were observed to be unlocked in a kitchen drawer; a Deficiency was issued. Fire extinguisher was charged and located by the kitchen. Fire extinguisher was last service on June 18, 2024. CONTINUED ON LIC809-C... LPAs observed the emergency disaster and evacuation plan which is located by the entryway. Facility had back-up emergency food and water. LPAs observed that the First Aid Kit had all the required components. LPAs observed that medications were locked and inaccessible to residents in care. During the tour LPAs observed a Comex bleach powder cleaner and a liquid bleach cleaner on the first restroom, next to the living room; a Deficiency was issued. Chemicals were observed to be unlocked. For the exterior portion, LPAs observed a shaded area, patio furniture, and the grounds were free of any hazards. There is one gate in the backyard, which both is self-closing and self-latching. No bodies of water were observed. LPAs reviewed three resident files and two staff files. LPAs reviewed the Medication Administrator Record (MAR) for Resident 1 (R1). Per preplacement appraisal dated 10/21/23 under Services Needed it states that Resident 1 (R1) needs help with medication. LPAs observed that PM Buspirone 5mg and PRN Hydrocodone-Acetamin were out of pills; a For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Ladyjean Veracruz. A copy of this report and Appeal Rights were provided at the time of exit.the state’s words, verbatim · CDSS document, Nov 21, 2024

Type of visit: Case Management - Other

LPA served amended report.the state’s words, verbatim · CDSS document, Oct 11, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(2) · Plan of correction due date: Oct 18, 2024

Resident Records. 87506(b)Each resident’s record shall contain at least the following information: (2) Social Security number. Based on record review, Licensee did not comply with the section cited above due to one resident's file not having a social security number documented.the state’s words, verbatim · CDSS document, Oct 11, 2024

Plan of correction: Facility staff stated they will ensure all resident files contain all of the information required by Title 22 867506(b) by the assigned POC due date. Facility staff stated all resident files will be accessible for review upon request.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(9) · Plan of correction due date: Oct 18, 2024

Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9) To have communications to the licensee from their representatives answered promptly and appropriately. Based on interviews conducted, the Licensee did not comply with the section cited above due to the Ombudsman's request for records not being fulfilled and no further communication regarding the request being made.the state’s words, verbatim · CDSS document, Oct 11, 2024

Plan of correction: Administrator stated they will conduct an in-service training with staff on record requests and fulfilling them. AD stated they will document the topics covered, staff attending, date/time of the training. AD stated they will send the above documentation to LPA via email by the assigned POC due date.

Allegation investigated: Licensee is not ensuring that a separate, complete, and current record is maintained for resident in care. Staff do not respond to requests for communication regarding resident in care in a timely manner.

(This is an amended report.) This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by Leonor Gamolo, Caregiver. LPA met with Administrator Brevet Dao via phone call and explained the nature of the inspection to her and staff. The department received a complaint on 8/14/2024 alleging Licensee is not ensuring that a separate, complete, and current record is maintained for resident in care and Staff do not respond to requests for communication regarding resident in care in a timely manner. During the investigation, the department interviewed facility Administrator (AD) and staff. On 8/23/2024 LPA conducted a visit to the facility to initiate investigation into the above allegations. LPA obtained copies of the personnel report and resident census. LPA also obtained electronic copies of all records the facility has on file for R1. (continued on LIC9099-C) Substantiated This is an amended report. (continued from LIC9099) LPA conducted interviews with AD and Staff (S1). AD and S1 stated R1 passed away and that R1’s file is being maintained at the Administrative Office. LPA reviewed R1’s records electronically. LPA observed a Death Report for R1 dated 8/17/2024. LPA determined they would not be able to conduct interview with R1. Based on record review, LPA determined, R1's social security number was not listed on any of the documentation in R1's provided files. On 10/9/2024, LPA conducted interview with facility's Ombudsman (OM). OM stated that, while at the facility on 8/12/24 they requested to see R1's hospice records. OM stated that the records were not produced during their visit and they did not receive a follow-up contact. LPA conducted interview with AD. AD stated that they spoke to OM over the phone on 8/12/24 and stated the file should be at the facility. AD stated they did not follow up with staff or OM. On 10/11/2024, LPA Mason returned to the facility. LPA conducted interviews with AD, staff (S1, S2) and Hospice Provider (HP). AD stated the resident was unable to communicate the social security number to facility. Staff stated they don't oversee the completion of documentation like that. HP stated they have record of R1's social security number. Regarding the allegation of: Licensee is not ensuring that a separate, complete, and current record is maintained for resident in care, based on interviews conducted and records reviewed, LPA determined R1’s file does not include a social security number. Title 22 Regulations state: "87506(b) Each resident’s record shall contain at least the following information: (2) Social Security number." Regarding the allegation of: Staff do not respond to requests for communication regarding resident in care in a timely manner, based on interviews conducted, OM stated that while at the facility, they requested R1's hospice file and did not receive the file or any follow-up communication. AD stated they were able to recall OM's request. AD also stated they did not follow-up with staff or OM to ensure OM received the records requested. Title 22 Regulations state: "87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9) To have communications to the licensee from their representatives answered promptly and appropriately." The preponderance of evidence standard has been met. The allegation of Licensee is not ensuring that a separate, complete, and current record is maintained for resident in care is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Sep 10, 2024 · control 22-AS-20240814101419

Allegation investigated: Facility staff failed to provide adequate care and supervision, resulting in injury

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Administrator/Licensee Brevet Dao and explained the reason for the visit. The Department received the complaint on 08/07/2023 and LPA Quiroz conducted the initial 10-day visit on 08/15/2023 and LPA Mendivil conducted a follow up visit on 03/27/2024. LPA Mendivil interviewed staff and was unable to interview residents as all were asleep at the time of the visit. LPA Mendivil obtained copies of documents such as admission agreement and physician’s report. Regarding the allegation Facility staff failed to provide adequate care and supervision, resulting in injury, the investigation revealed the following: Per review of Resident’s 1 (R1) documentation R1 arrived at the facility on 07/26/2023. Based on R1’s physician report dated 07/2023 it was noted that R1 is diagnosed with hypertensive heart disease with heart failure, it is also noted that R1 needs assistance with all activities of daily living. Per physician’s report R1 did not have a history of skin breakdown. Unsubstantiated Based on interviews with staff R1 was withdrawn and wanted to remain in bed. It was reported by Administrator/Licensee Brevet Dao that R1 left the facility 08/02/2023. Interviews with 2 out of 2 staff indicate they did not see any pressure injuries in the 7 days that R1 was at the facility. LPA Mendivil was unable to reach hospice for further records. Therefore, based on the preponderance of evidence through records reviews and interviews the allegation facility staff failed to provide adequate care and supervision, resulting in injury the allegation is UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report was provided to facility Administrator.the state’s words, verbatim · CDSS document, Apr 15, 2024 · control 22-AS-20230807135753

Allegation investigated: Staff did not seek medical attention for resident's change in condition Staff did not reposition bedridden resident Staff did not treat resident with dignity Staff did not administer resident's medications as prescribed Staff are unable to meet residents needs due to language barrier Staff left resident in bed all day

On this day Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Melanie Geller, Caregiver and explained the reason for the visit. Administrator Brevet Dao arrived at the facility shortly after. The Department received the complaint on 01/16/2024 and LPA Mendivil conducted the initial 10 day visit on 01/22/2024. LPA Mendivil interviewed staff and obtained copies of pertinent documents including: physician's reports, admission agreement and medication administration record. LPA Mendivil was unable to interivew residents as they were asleep during visits. Regarding the allegations staff did not seek medical attention for resident's change in condition, staff did not reposition bedridden resident, staff did not treat resident with dignity, staff did not administer resident's medication as prescribed, staff are unable to meet residents needs due to language barrier and staff left resident in bed all day, the investigation revealed the following: Unsubstantiated Per interviews with Administrator Brevet Dao Resident 1 (R1) arrived at the facility on 12/05/2023 with the diagnosis of Non-ST-Elevation Myocardial Infarction and cerebrovascular accident. Per R1's physician report listed the R1 as non-ambulatory but also notes R1 is bed bound and has motor impairment/paralysis. It was alleged that facility staff did not seek medical attention when there was a change of condition, per review of LIC 624 Unusual Incident/Injury Report for the dates 12/08/2023 and 12/10/2023 when there was a change in condition with Resident 1 (R1) 911 was called. In both cases R1 was taken to the hospital and returned to the facility after discharge. It was alleged that staff did not reposition bedridden resident. Per review of R1’s LIC 602 physicians’ report dated 11/15/2023 list R1 as bed bound, but not bedridden. Based on interviews with 2 out of 2 staff resident would request to stay in bed or be moved to their wheelchair. Per interview with Administrator R1 was able to reposition themselves but due to diagnosis had weakness on left side of the body. Interviews with 2 out of 2 staff denied that they did not treat residents with dignity. Per LPA Mendivil's observations residents have access to a call button which plays an auditory sound in the living room/kitchen. Per LPA Mendivil's observations staff responded within 2 minutes. Based on review of R1's medication administration records (MAR) for December 2023, per review medications were given as prescribed and on the days/times noted. Based on interviews with 2 out of 2 staff deny medications are not given as prescribed. It was alleged that staff are unable to meet residents needs due to language barrier, per LPA Mendivil's observations LPA Mendivil has observed the staff to all communicate with resident's in previous visits in English and to be able to communicate effectively. It was alleged staff left resident in bed all day, based on interviews with 2 out of 2 staff the resident would request to either stay in bed or would request to be placed in wheelchair and view outside. Therefore, based on the preponderance of evidence through records reviewed, interviews and observations the allegations staff did not seek medical attention for resident's change in condition, staff did not reposition bedridden resident, staff did not treat resident with dignity, staff did not administer resident's medication as prescribed, staff are unable to meet residents needs due to language barrier and staff left resident in bed all day are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report this report was left at the facility. Per interviews with staff 1 out of 2 staff indicated they were unaware that R1 had a special diet. Based on interview with Administrator Brevet Dao there is no record of what was fed to R1 during December 2023 to prove that a renal diet was followed. Therefore based on preponderance of evidence through interviews the allegation Staff did not provide adequate food service to resident is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.the state’s words, verbatim · CDSS document, Mar 5, 2024 · control 22-AS-20240116131630

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(5) · Plan of correction due date: Mar 11, 2024

(b) The following food service requirements shall apply:(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidence by 1 out of 2 staff was not aware of Residents 1 special diet. This poses a possible health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 5, 2024

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