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Type of visit: Case Management - Health Checks

On 09/16/26 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Health and Safety check due to the Department receiving a priority 1 complaint. During the health and safety check, LPA observed a total of 2 staff and 3 residents at the facility. LPA toured facility with staff, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report providedthe state’s words, verbatim · CDSS document, Sep 16, 2026

Allegation investigated: Facility staff neglect/lack of care and supervision of resident

On 07/29/26 at 10:45 AM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit, met with staff (S1) and spoke to administrator (ADM) on the phone who authorized S1 to act on her behalf and sign the repots. LPA gathered information and delivered investigation findings to staff (S1,ADM). LPA explained the purpose of the visit with staff. On 06/02/26 and 06/08/26, LPA D Panlilio conducted interviews with reporting party (RP), responsible party (POA), staff (ADM, S1) and obtained the following documents: Personnel record (LIC500), Residents roster, R1's admission agreement, pre-placement appraisal, needs & services plan, physician's report, ID/Emergency information, staff notes, centrally stored medication logs, medication administration records and incident reports. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Facility staff neglect/lack of care and supervision of resident Investigation Finding: Unsubstantiated During investigation, LPA D Panlilio conducted interviews with reporting party (RP), responsible party (POA), facility staff (ADM, S1) and reviewed resident (R1) documents. R1 was first admitted at the facility on 10/13/23. Review of R1’s functional assessment dated 10/28/24 showed him as ambulatory - able to move in and out of bed or chair, feeds himself completely, sits without support, has no vision problem or hearing loss, uses a walker to ambulate, able to use the restroom and empty his Foley bag independently. Review of R1’s physician’s report dated 09/27/23 showed there was no history of R1 being a high fall risk. On 05/29/26, staff noticed a change in condition in R1 (limping and complaining of left flank pain) and sent him to the hospital for treatment and evaluation. ER doctor diagnosed him with a left fractured hip due to a possible fall. LPA interviewed staff (ADM, S1) who stated they did not witness R1 fall while in care at the facility. LPA interviewed POA who stated that R1 may have had an unwitnessed fall during the night at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation of facility staff neglect, lack of care and supervision of resident is unsubstantiated. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 29, 2026 · control 15-AS-20260601101218

Type of visit: Case Management - Deficiencies

While at the facility conducting investigation of a complaint (Complaint Control # 15-AS-20260618105114), LPA conducted inspection with staff, Kumba Quemollu and upon review of residents' records, Licensing Program Analyst (LPA) Delmundo observed the following: at 11:36 am, mattress, broken glass closet door, detached fenced wood plank in the side yard. Side fence gate pad locked. at 11:37 am, broken folded chair blocking the fence gate and plywood in the backyard. Fence gate pad locked. at 11:40 am, closet door missing in one of the resident's rooms of which the staff stated the glass closet door was broken by the resident sometime in December 2025. at 11:50 am, dowel on the sliding exit door in the resident room preventing the door to be opened. at 11:52 am, razor in the ensuite bathroom. at diaper rash ointment in one of the resident's room where dowel was observed. at 11:56 pm, transitions strips on the flooring all throughout the facility were missing of which tape were used. three (3) out of 4 residents' LIC601 Identification and Emergency Contact Information were not filed-up properly - either left blank or indicated N/A on the following: resident's name; responsible person; name of nearest relative date admitted to the facility; date left; reason(s) for leaving. The other 1 residents does not have LIC601 on file. all 3 entrance and exit doors' auditory signals not working. . ...continued on 809C CONTINUATION FROM PAGE 1: Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500.00 civil penalty is assessed for deficiency section 87203. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in additional civil penalties. Deficiencies, plan and proof of corrections and civil penalty were with the administrator (ADM) over the phone. ADM gave authorization for Kombu Quermollu to sign and receive this report. Exit interview conducted. Appeal Rights, LIC421IM, LIC9098 Proof of Correction form, and copy of this report provided.the state’s words, verbatim · CDSS document, Jun 25, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jun 26, 2026

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above in locked fence gates, chair blocking the fence gate and dowel in the sliding door which pose an immediate safety risks to the persons in care.the state’s words, verbatim · CDSS document, Jun 25, 2026

Plan of correction: Staff removed the padlocks and dowel while LPA was at the facilty. Adminsitrator to do the folllowing and submit proof by 6/26/26: 1. Read the Regulation and submit self-certification of understanding. 2. In-service the staff and submit copy of training topic with attendees signatures. A $500.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Jun 26, 2026

87309 Storage Space and Access (a)...... the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended....... -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above in unlocked razor and ointment in the resident's room which pose an immediate safety risks to persons in care.the state’s words, verbatim · CDSS document, Jun 25, 2026

Plan of correction: Staff locked the items. In addition, administrator to In-service the staff and submit copy of training topic(s) with attendees signatures by 6/26/26.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 9, 2026

87303 Maintenance and Operation (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 is not met as evidenced by: -Based on observation, the licensee did not comply with the section above in the following which pose a potential safety, and/or personal rights risks to persons in care: mattress, broken glass closet door, detached fenced wood plank in the side yard; missing closet door; transition strips missingthe state’s words, verbatim · CDSS document, Jun 25, 2026

Plan of correction: Administrator to do the following and submit pictures by 7/09/26: 1. Have the yard cleaned. 2. Have the fence repaired. 3. Have the tape removed from the flooring and replace with transition strips. 4. Closet door installed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Jul 9, 2026

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. -This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with the section above in 3 of residents' LIC601 not properly filed-up and 1 resident has no LIC601 on file which pose a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 25, 2026

Plan of correction: Licensee to complete the LIC601s and submit copies by 7/09/26.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: Jun 26, 2026

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above in having auditory signals on 3 doors not working which pose an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 25, 2026

Plan of correction: Administrator to have the auditory signals checked and install new batteries, otherwise replace with new ones. Proof to be submitted by 6/26/26.

Type of visit: Required - 1 Year

On 10/29/25 at 1:15PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with staff (S1) and spoke to administrator (ADM) on the phone who authorized S1 to act on her behalf and sign the reports. LPA explained the purpose of the visit with S1 and ADM. LPA observed ADM has current administrator certificate # 7018880740 which expires 03/25/2027. At 1:30PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 73 deg F. Hot water temperature was measured at 114 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguisher was observed fully charged. LPA reviewed 2 staff and 4 resident files. Updated copies of the following documents were collected for facility file:  LIC500- Personnel Report  Resident Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 29, 2025

Type of visit: Required - 1 Year

On 09/22/23 at 10AM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with staff (S1) and spoke to administrator (ADM) on the phone who authorized S1 to act on her behalf and sign the reports. LPA explained the purpose of the visit with S1 and ADM. LPA observed ADM has current administrator certificate # 7018880740 which expires 03/25/2025 LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 78 deg F. Hot water temperature was measured at 115 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguisher was observed fully charged. LPA reviewed 3 staff and 5 resident files. LPA observed the following deficiency during visit: Incomplete staff records (missing staff training records, missing CPR certifications, employee rights LIC 9052, criminal record statement LIC 508, training records, TB test results) Continued on next page, LIC 809-C Updated copies of the following documents were collected for facility file:  LIC500- Personnel Report  Resident Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 10, 2024