Jasmin Terrace at El Molino

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit on 03/19/2026 and was greeted by Wellness Director-Rocio Gonzalez. Administrator Virigina Garcia arrived shortly after. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a two-story dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected eight (8) resident rooms. All resident bedrooms contained the required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside shower. LPA Ramirez observed no-slip mat in showers. LPA observed shower chairs in resident bathrooms. Video surveillance was observed in common areas. Food Service: LPA Ramirez observed sufficient supply of nonperishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). LPA observed a whiteboard in the kitchen area with resident names and dietary restrictions. LPA observed kitchen staff wearing hair nets and gloves while handling food. Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. LPA observed several residents in the activities See 809-C Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 02/2026 and 12/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in pantry. Residents with Special Needs: No large bodies of water were observed. LPA observed a water fountain which was gated. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. This facility is approved for delayed egress. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication closet and in bubble packs and/or original containers. LPA Ramirez observed Centrally Stored Medication and Destruction Record. The facility provides incidental medical services. Staffing: Administrator Certificate for Virgina Garcia 10/14/2026. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for four (4) out of the four (4) personnel record reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4) out of the four (4) personnel record reviewed. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. LPA observed disinfecting logs posted near hallway rails and in elevators. Facility has an Infection Control Plan in place. Operational Requirements: The facility is licensed to serve 206 residents over the age of 60 years old of which 171 may be non-ambulatory, 35 bedridden, and a hospice waiver for 20 hospice residents. Resident Records/Incident Reports: LPA reviewed resident records for nine (9) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. No deficiencies were observed during this visit. Exit interview conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 19, 2026

Allegation investigated: Staff does not provide adequate supervision resulting in resident falling. Staff did not seek medical attention to resident.

On today’s visit, Licensing Program Analyst (LPA) Luis De Leon conducted a subsequent complaint visit and met with Assistant Administrator Lori Lackey. LPA explained the reason for today’s visit was to deliver findings on the above allegations. LPA toured the physical plant and observed residents’ common areas engaging in various activities and observed no health and safety risks to residents in care. LPA obtained staff and resident rosters, incidents reports, and interviewed two residents. During the initial visit on 10/02/2025, LPAs toured the facility and obtained copies of the following documents: Staff roster, Resident roster, R1’s physicians reports, R1’s resident assessments, R1’s admission agreement, R1’s face sheet, nurses notes, incidents reports. LPA interviewed eleven (10) residents and seven (7) staff. Report continues on page LIC-9099c Unsubstantiated Regarding allegation: Staff does not provide adequate supervision resulting in resident falling It is alleged that Staff does not provide adequate supervision resulting in resident falling. It is alleged that R1 has experienced falls while living at the facility due to lack of care and supervision. On 8/30/2025, R1 fell forward from edge of bed. Resident evaluation was performed, and resident was able to move all extremities without pain. On 8/31/2025, R1’s doctor’s nurse practitioner examined R1 on a video call and determined that there was no need for hospital visit. On 9/22/2025, R1 experienced another fall while transferring from recliner with staff assistance. R1 was transported to hospital. Investigation consisted of interviews with staff, residents, and review of R1 facility file. LPA was unable to interview R1 since R1 was in hospital during initial visit, and on today’s visit, R1 is no longer residing at facility. During interview with the residents, three (3) out of fifteen (15) residents experienced a fall at the facility. R7 stated that R7 did not need assistance after fall, R15 did not recall details of fall, and R14 stated that R14 lost balance. Twelve (12) out of fifteen (15) residents stated that residents don’t need supervision or were not able to respond whether residents needed supervision. R1, R7, R9, and R14 stated that staff take good care and supervise residents. During record’s review, R1’s physician’s report and R1’s appraisal reports, it revealed that R1 is non-ambulatory and has no history of fall. During interview with staff, eight (8) out of eight (8) staff denied the above allegations. S1 stated that the facility has twelve (12) caregivers, two (2) med-techs, and two (2) supervisors in the morning and afternoon shifts. The facility has a policy of a wellness check every 2 hours. S4 and S5 stated that there is enough staff to provide supervision for residents. Staff stated that facility protocol is to always evaluate residents after sustaining a fall and transport residents to hospital for evaluation if necessary. Based upon the investigation, client and staff interviews, document review, and LPA observations, the facility provides adequate supervision to residents in care. Report continues on page LIC-9099c... Regarding allegation: Staff did not seek medical attention to resident. It is alleged that facility staff did not seek medical attention in a timely manner for R1. On 8/30/2025 and 9/22/2025, R1 suffered falls where it is alleged that no medical attention was provided. Investigation consisted of interviews with staff, residents, and review of R1 facility file including incident reports, doctor’s communication, and nurse notes for R1’s incidents. The investigation reveals the following: The facility staff sought medical assistance for R1’s falls. On R1’s fall on 8/30/2025, facility staff performed R1’s evaluation after the fall and facility staff determined that R1 was able to move all extremities without pain or discomfort. On 8/31/2025, the facility sought medical support to R1’s doctor office and nurse practitioner determined to apply antibiotic cream to red nose. The nurse practitioner determined that no other medical assistance was needed. R1’s responsible party was notified, and responsible party refused emergency room transport. On 9/22/2025, R1 experienced another fall while transferring from recliner with staff assistance. R1 sustained a bump on left side of head. R1 was transported to hospital for further evaluation. During interviews with the residents, nine (9) out of fifteen (15) residents stated that staff is supportive of residents’ medical needs including setting up appointments, going to doctor, or hospital. Residents stated that residents were confident that staff would assist with their medical needs if requested. Interview with staff revealed that eight (8) out of eight (8) staff denied knowledge of the above allegation. Staff stated that staff follow protocol for resident’s falls to seek medical attention after a resident fall. Staff denied ever refusing to seek medical attention for any resident in care. Staff stated that, per protocol, staff follows contact information with residents’ physicians and residents’ responsible party. Based upon the investigation, client and staff interviews, document review, and LPA observations, the facility staff provided first aid and sought medical attention to R1's physician after both fall incidents. R1’s physician and responsible party were notified after each fall. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held with Executive Director Virginia Garcia. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 9, 2026 · control 28-AS-20250924204158

Allegation investigated: Staff do not prevent resident from wandering into other residents room resulting in verbal altercations

Licensing Program Analyst (LPA) Nune Margaryan conducted an initial 10-day complaint visit to investigate the above allegation. The purpose of the visit was discussed with Assistant Executive Director Lori Lackey. Executive Director Virginia Garcia arrived shortly after. The investigation consisted of the following: LPA Margaryan obtained a copy of the staff roster, residents roster, reviewed and obtain documentation relevant to this investigation and interviewed Executive Director, Staff 1 to Staff 6 (S1 to S6) and Resident 1(R1), Resident 3 to Resident 14 ( R3 to R14). LPA was not able to interview Resident 2 (R2). R2 was at the hospital for evaluation at the time of visit. Continue 9099C Unsubstantiated Regarding allegation: Staff do not prevent resident from wandering into other residents room resulting in verbal altercations. It was alleged that R2 entered R1's room without being invited and will refuse to leave, and then R1 threatened R2 to leave while holding a fork in her hand. Based on interviews conducted it was revealed that there are some residents that wander at the facility and R2 is one of them. R2 walks around the whole facility and goes to residents rooms sometimes if residents doors unlocked. Facility staff always encouraged residents to keep their doors closed to prevent other residents entering their rooms. Interviewed staff stated that since R2 was admitted to the facility, R2 thinks that the facility is their home and trying to enter every room and wants everyone to leave her/his house. Interviewed staff stated that they aware of R2's behavior and R2 always supervised by staff as well as others. Staff always redirect R2 when R2 is confused. On 08/13/25 R2 entered R1's room and refused to leave. Interviewed S6 stated that they heard loud voices from R1's room and rushed to R1's room. S6 saw that R1 screaming and telling R2 to leave the room. S6 stated that R1 was confused and taught that he/she was in his/her room telling R1 to leave the room. S6 redirected R2 out of R1's room. S6 stated that they didn't see that R1 holding fork in their hand. Interviewed S4 stated that was another episode of R2's behavior that R2 tried to go to room #238 and was redirected by S4. The Executive Director and staff interviewed stated that there are always enough staff to always supervise R2 and other residents and that room / residents checks are every 2 hours. Executive Director also mentioned that Police Officer from Pasadena Police Department came to the facility to do a wellness check. The Police Officer gave a case number with no report. Copy of Police case number was provided to LPA. Interviewed R1 stated that R2 entered their room uninvited and they told R2 to leave the room. R1 stated that staff is nice and helpful. Interviewed R3 stated once R2 entered his/her room and when they told R2 to leave, R2 left the room. Interviewed R12 stated that R2 sometimes enter their room when the door is not closed, but it's not bothering them. Interviewed R4, R7, R1 and R14 were unable to answer due to cognitive skills. Interviewed R5, R6, R8, R9, R10, R13, stated that they don't know R2 and no one entered their room uninvited. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 28-AS-20250813111621

Allegation investigated: Staff are not ensuring resident exercises.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the above allegation. The purpose of the visit was discussed with Assistant Executive Director Lori Lackey. Executive Director Virginia Garcia arrived later. The investigation consisted of: LPA conducted a physical plant tour of common areas, activity areas, and dining room breakfast and lunch meal times. Residents (R1- R12), staff (S1-S9), and Home Health Director were interviewed. Record review was completed. Copies of relevant documents were obtained. *See LIC9099C for report summary. Substantiated Allegation: Staff are not ensuring resident exercises. It is alleged that resident (R1's) was ordered by a physician to participate in daily exercise after recent medical issue, but on Friday, July 25, 2025 the resident was not observed in the 10:30 AM exercise class. An interview with R1 was attempted, but due to cognitive impairment they were not able to give feedback pertaining to the allegation. A total of 12 residents were interviewed. They confirmed exercise class is offered daily in the morning. A total of nine (9) staff were interviewed. Staff interviews revealed that resident (R1) is supposed to attend daily exercise classes at 10:30 AM, but sometimes the resident does not attend because staff are not escorting the resident to the exercise activity room. Staff stated that the resident is usually a late riser and eats breakfast close to 9:30 AM. During today's visit, LPA observed the exercise class begin at 10:30 AM. At 10:43 AM, resident (R1) was observed sitting by themselves in the dining room table. There was no food in front of the resident. Dining staff stated the resident was done with their meal at 10:15 AM. Resident (R1's) home health agency was contacted. The agency director said that the resident was discharged from physical therapy services on July 10, 2025. Home health representative stated that 2 facility staff were notified that R1 should join daily activities and group exercises, and should be encouraged to walk daily with supervision and use of walker. There is sufficient evidence to support the allegation. Based on interviews, observation, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Executive Director Virginia Garcia. A copy of the report and appeal rights were provided. Allegation: Staff are not meeting residents showering needs. The complaint alleges resident (R1) is supposed to get three showers per week but it in recent weeks it was observed that the resident's hair was dirty, not combed, and their body wash had not been used. A total of nine (9) staff were interviewed. All staff said that residents are showered three times a week. Review of shower assignment indicates R1 is showered Monday, Wednesday, and Fridays. According to staff, R1's responsible party recently requested the resident be showered four times per week, and in recent weeks the resident has been showered on Sundays as well. A total of 12 residents were interviewed. The majority of residents have cognitive impairment. One (1) resident stated they are not showered. Resident (R1) was not oriented to time and place. The resident was well groomed and was last showered yesterday. Observation of residents, record review, and interviews conducted did not support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was discussed and provided to Virginia Garcia.the state’s words, verbatim · CDSS document, Jul 31, 2025 · control 28-AS-20250729153617

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Aug 14, 2025

Basic Services. A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. Based on interviews, observation, and record review resident (R1) was not escorted to exercise class on 7/25/25 and today (7/31/25). Per home health orders R1 requires daily exercise participation. The Appraisal/Needs and Services Plan states R1 is to be escorted to activities. This poses a potentila health, safety, and personal rights risk.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: Executive Director agreed to develop a plan of action on how facility will meet all resident's basic needs. Plan shall include staffing, staffing responsibilities, and facility procedures. Submit plan and proof of staff training.

Allegation investigated: Staff did not prevent resident from being harmed by another resident. Staff did not respond to resident's request for assistance in a timely manner.

Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Virginia Garcia and explained the reason for the visit. The investigation consisted of the following: LPA conducted interviews with Staff 1-3 (S1-3) and Residents 1-6 (R1-R6). Attempts were made to interview Resident R7 who was unable to respond to questioning. Interview was conducted with the Administrator. LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1 and R7's facility file. LPA collected copies of Appraisal Needs and Services, Physician's Report, and Identification and Emergency Information. Facility submitted Staff Log of Resident Room checks. In regards to the allegation Staff did not prevent resident from being harmed by another resident, based on Unsubstantiated interviews conducted and information gathered it was revealed by Resident R1 that staff were not told that Resident R7 had hit her and spit on her. Said that she yelled out help, but stated that staff were down the hall and helping other residents and might not have heard her. Resident's R2- R6 all stated that staff are very good and they respond quickly when resident's need assistance. Said staff are very helpful. Administrator stated that room checks are every 2 hours and staff has to always report it to the front desk that everyone is accounted for. Staff Logs for 7/9/25 and 7/10/25 reveal the following: 7/9/25- Staff S1 checked Resident R1's room at 11:30, 1:35, 3:24, 6:16 and 7:00. 7/10/25- Staff S1 checked Resident R1's room at 11:39, 1:33, 3:35, 6:15 and 7:30. Interview with Staff S1 who stated that Resident R1 and R7's room was checked all nite and always 1 staff in each corner of the facility and was close by and never heard a yell for help and pull cord was not pulled. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff did not respond to resident's request for assistance in a timely manner. based on interviews conducted and information gathered Resident R1 stated that staff was not told about the incident with R7 afterwards and only told Social Worker. Resident's R2- R6 all stated that staff are very good and they respond quickly when resident's need assistance. Said staff are very helpful. 1 resident witnessed a resident as was described as having a meltdown and right away a staff was there and walked with the resident and was very patient. Administrator stated that room checks are every 2 hours and staff has to always report it to the front desk that everyone is accounted for. Staff Logs for 7/9/25 and 7/10/25 reveal the following: 7/9/25- Staff S1 checked Resident R1's room at 11:30, 1:35, 3:24, 6:16 and 7:00. 7/10/25- Staff S1 checked Resident R1's room at 11:39, 1:33, 3:35, 6:15 and 7:30. Interview with Staff S1 who stated that Resident R1 and R7's room was checked all nite and always 1 staff in each corner of the facility and was close by and never heard a yell for help and pull cord was not pulled. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 28-AS-20250711143825

Allegation investigated: Staff do not safeguard resident's personal belongings Staff do not provide resident with a comfortable environment Staff do not answer resident's call button in a timely manner

*This report supersedes report dated 2/24/25 to change report from confidential to public.* Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Rocio Gonzalez and explained the reason for the visit. The investigation consisted of the following: LPA requested a copy of staff/resident rosters. Conducted a tour of the facility and observed 10 random resident bedrooms. LPA interviewed 10 residents and 8 staff and requested a copy of resident #1(R1)’s resident personal property and valuables, admission agreement, emergency information sheet, and physician’s report, receipt and letter signed by R1. The investigation revealed the following: Regarding allegation: Staff do not safeguard resident’s personal belongings. It is alleged resident’s personal belongings were stolen. Interviews conducted with residents revealed 4 out of 10 residents stated to not have lost or have had anything stolen from their rooms. 4 out of 10 residents were unable to answer due to cognitive skills and 2 out of 10 residents stated to have lost personal items at the facility. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews with staff revealed residents have not complaint of loosing any personal items recently. During the facility’s tour LPA observed one of the three items allegedly stolen in the resident’s bedroom. Per documents the stolen and not observed items were not listed on the resident's personal and property and valuables. Per physician's report R1 is responsible for own cash resources. Assistant administrator last updated personal item list on 8/20/24. Per admission agreement facility is not responsible for items lost unless the personal inventory form was updated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff do not provide resident with a comfortable environment. It is alleged resident screams and plays the television loud which bothers other residents. Interviews conducted with residents revealed 4 out of 10 residents stated that there are no loud noises heard at the facility, 4 out of 10 residents were unable to provide information due to cognitive skills and 2 out of 10 residents stated that have heard loud noises that do not allow them to sleep or disturb them. Interviews conducted with staff revealed 9 out of 10 staff stated residents have not complaint about hearing loud noises at the facility and have not observed residents screaming or been loud. One (1) out of ten (10) staff stated to have heard a resident yelling at the facility which can be disturbing to others. Administrator stated that once the concern of the noise was brought up, the staff looked into it. However, the resident being accused of creating the noise cannot increase the volume in the TV on their own due to their physical/cognitive skills and does not have a behavior of scream. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff do not answer resident’s call button in a timely manner. It is alleged staff assist resident an hour after call light has been pressed. Interviews conducted with residents revealed 5 out of 10 residents stated staff are prompt and available to assist in a short amount of time, 4 out of 10 residents were unable to provide answers due to their cognitive skills and 1 out of 10 residents stated that staff take over an hour to provide assistance with personal care. Interviews with staff revealed staff respond promptly to residents call light button. If staff are busy with other residents providing showers or bathroom assistance, staff notify the front desk via radio and another staff steps in at that time. (CONTINUED ON LIC 9099C) Per administrator the wait time is no more than 5 minutes to respond to a call light. During the facility’s tour LPA tested three call buttons and each was responded within less than 5 minutes. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Virginia Garcia and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 11, 2025 · control 28-AS-20250220121232

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced continuous annual visit using the CARE inspection tool. LPA met with Virginia Garcia Administrator and explained the reason for the visit. On 2/24/25 LPA Flores conducted an annual visit and completed the following domains: Physical Plant/Environmental Safety: see report dated 2/24/25 for details. Food Service: sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Special diets are posted in the kitchen. Incidental Medical and Dental: medication was reviewed for 10 residents. During today visit LPA Flores complete the following domains: reviewed 10 resident and 10 staff files. Infection Control: Facility meets infection control procedures and the plan was reviewed. Staff have a TB test on file. Operational Requirements: LPA reviewed liability insurance which is current and meets all requirements. Staffing: Per LIC 500 there is sufficient staffing, there are 5 staff during the night shift and a front desk person. Staff have CPR/First Aid on file. Personnel Records/Staff Training: Ten staff files were reviewed with the required documentation. Initial and yearly 20 hours of training were observed for each staff. Administrator certificate was observed for Virginia Garcia #7006263740 exp. date: 10/14/26. Resident Rights/Information: Resident rights, PUB 475, Ombudsman poster were posted in common areas of the facility. Planned Activities: Activities calendar is posted in the activity area. An activity director is on duty and activities for persons with dementia were observed. (CONTINUED ON LIC 809C) Resident Records/Incident Reports: Ten resident files were reviewed. Appraisals and physician's reports were observed conducted within the last 12 months. Bed rails request were reviewed for each half/full bed rail observed. However, there were (3) residents observed with full bed rails and physician's request were observed but residents are not on hospice care. Disaster Preparedness: Emergency Disaster plan was reviewed and last reviewed on 3/1/24. Last emergency drill was conducted on 3/5/25. LPA observed an evacuation chair on top of each stairwell. Residents with Special Health Needs: Hospice plans were reviewed for pertaining residents. Staff have received training on Hospice care, Restricted Health conditions, Postural support and Dementia. A deficiency was noted today per Title 22 Regulations. Exit interview was conducted with Virginia Garcia and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 11, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Flores conducted an annual inspection visit at the facility using the CARE inspection tool. LPA met with Rocio Gonzalez and explained the reason for the visit. The facility is licensed to serve 206 residents over the age of 60 years old of which 171 may be non-ambulatory, 35 bedridden, and a hospice waiver for 20 hospice residents. There are currently 15 residents on hospice. Facility is a two story building in a residential area which consist of shared bedrooms, several common areas, a commercial kitchen, and a courtyard. Facility cares for residents with dementia and has delayed egress on exit doors. There is a water feature in the courtyard. The water feature has a fence around the entire perimeter. Facility has a fire sprinkler system throughout the building. Today's visit consisted of a tour of the facility (Physical Plant Domain) with Lori Lackey and medication review. LPA observed the following: First floor common areas: Lobby, visitation room, dining rooms, activity room all have sufficient space with furniture in good repair, and fireplaces are covered. Commercial kitchen was observed clean, in good repair, and food supplies were observed sufficient for at least 2 days of perishables and 7 days of non-perishables. Fiver (5) random bedrooms were observed in the first floor; each room is furnished with the required furniture, with sufficient lighting, and bedding supplies. Bathrooms were observed in good repair. Water temperature was tested between 111.0 -116.4 degrees F., which is within the required 105-120 degrees F. Second floor: Seven (7) random bedrooms were observed each room is furnished with the required furniture, with sufficient lighting, and bedding supplies. Bathrooms were observed in working condition. Water temperature was tested between 106.5 - 114.4 degrees F., which is within the required 105-120 degrees F. (CONTINUED LIC809C) Second floor: dining room has sufficient furniture and in good repair. Medication room was observed inaccessible to the residents. Medication was reviewed for 10 residents. LPA will return at a different time to continue the annual visit and complete the other domains. No deficiencies were noted during this visit. Exit interview was conducted with Virginia Garcia and a copy of this report.the state’s words, verbatim · CDSS document, Feb 24, 2025

Allegation investigated: Staff did not prevent resident from being physically abused by another resident while in care.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with Virginia Garcia and explained the reason for the visit. The investigation consisted of the following: On 6/5/24 LPA Flores conducted a health and safety check at the facility and requested pertaining documents to resident #1-#2(R1-R2). On 6/4/24 complaint was referred to the Investigation Bureau department and it was assigned to Sonia Sandoval for investigation. On 11/13/24 LPA Flores delivered findings for above allegation. The investigation revealed the following: Regarding allegation: Staff did not prevent resident from being physically abused by another resident while in care. It is alleged two residents had been involved in an altercation at the facility, and R1 sustained an abrasion to upper lip as a result. (CONTINUED ON LIC 9099C) Substantiated On 5/30/24, R1 was found in his bed with a cut to the lip after staff heard R1 calling out for help, roommate R2 was found in the room seating in own bed. Interviews conducted with staff revealed staff #2(S2) heard R1 yelling from the room and S2 responded. Upon S2 entering the room R1 stated “R2 hit me, for no reason.” Assistant administrator stated to have had knowledge of R2’s aggressive behaviors and the roommate arrangement was done on 5/29/24. Assistant administrator stated to been made aware by a staff that during R2’s stayed at a different licensed facility, R2 had assaulted a roommate. Staff stated R2 had demonstrated a few aggressive incidents with other residents. Interviews were attempted with R1 and R2. However, due to cognitive skills both residents were unable to provide information about the incident. On 6/5/24 LPA Flores conducted a health and safety and observed R1 had bruising in the left side of the face from the cheekbone to the chin. Documents reviewed revealed: On 6/3/24 Police officers responded to the facility on a report for a battery investigation, due to R1 have bruising to the mouth and jawline, an abrasion to the upper lip and a broken prosthetic eye. On 6/4/24 facility submitted an incident report to the department to report R1 was found in the room with a cut to the lip. Assisted Living Waiver (ALW) individual plan - dated: 12/5/23 notes R2 could be verbally aggressive and is frequently agitated with poor judgement. R2’s appraisal - dated: 5/23/24 notes R2 has poor judgment. On 5/14/24 R2’s physician’s order was created for an evaluation of altered mental state. Clinical flex notes revealed, on 4/19/24 R2 had punch another resident in the arm. Clinical flex notes dated 5/24 and 5/25/24, note R2 had 2 episodes of aggressive behavior. Due to interviews conducted and documents reviewed facility staff failed to properly assess R2 and prevent R1’s injury after observing and gaining knowledge of R2’s history of behaviors. Therefore, this allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to Resident #1 obtaining an injury by Resident #2 while in care. Refer to LIC 421IM*** The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49 (f); if the department determines the injury of the resident is due to neglect.the state’s words, verbatim · CDSS document, Nov 13, 2024 · control 28-AS-20240604123448

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 14, 2024

87468.2...Personal Rights...: (a)...shall have all...: (4) To care, supervision, and services that meet their individual needs ... that are sufficient..., qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on observations, interviews, and documents reviewed licensee failed to ensure R1 was injured by R2 while in care which poses an immediate health, safety, or personal rights risk to the persons in care. *Immediate $500 civil penalty is being assess*the state’s words, verbatim · CDSS document, Nov 13, 2024

Plan of correction: Administrator will update needs and care plan to reflect supervision, care, needs, behaviors, and room status for R2 and will submit a copy to the department by POC due date 11/14/24. **An additional $500 civil penalty was assessed due to repeated violation noted on 4/23/24.** *Civil penalties were assess for a total of $1000.*

Allegation investigated: Facility failed to provide resident's records.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Virginia Garcia and explained the reason for the visit. The investigation consisted of the following: LPA requested copies of resident and staff rosters, interviewed administrator. During the review of resident roster it was found that resident in question does not reside or resided at the facility. LPA proceeded to review documents and communication with requesting party. Based on the information gathered during this visit, the allegation is deemed UNFOUNDED. A finding of UNFOUNDED means that the allegation is either false, could not have happened, and/or is without a reasonable basis. Exit interview conducted with administrator and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Nov 13, 2024 · control 28-AS-20241106154510

Allegation investigated: Staff did not meet resident's toileting needs Staff did not seek medical attention for resident in a timely manner Facility is in disrepair

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Rocio Gonzalez and explained the reason for the visit. The investigation consisted of the following: On 6/17/24 LPA conducted an initial visit and requested the following documents: staff/resident roster, physician's report, appraisal, functional capability assessment, medication sheet June 2024, emergency information sheet, incident reports from February- June 2024, facility's clinical notes for resident #1(R1). LPA interviewed administrator and assistant administrator. On 7/29/24 LPA interviewed 8 residents and 6 staff, requested copies of individual service plan, and physician's orders. LPA Flores toured 8 randomly chosen residents’ rooms. The investigation revealed the following: Regarding allegations: Staff did not meet resident's toileting needs, Staff did not seek medical attention for resident in a timely manner, and Facility is in disrepair. (CONTINUED ON LIC 9099C) Unsubstantiated It is alleged R1 has been covered “in poop” and “had pants down with a soiled diaper” due to having uncontrollable diarrhea for which staff did not provide anti diarrheal medication, and the toilet and shower were clogged due to R1 placing toilet paper or paper towels. Interviews conducted with staff revealed R1 returned from skill nursing facility to the facility on 6/3/24. Upon R1’s returned a declined in cognitive development was observed which prevented R1 from communicating own needs. Per staff upon R1’s return, R1 showed unusual behaviors. Such as, needing to use the bathroom outside of the bathroom, seating without cleaning self after using the bathroom in the bed, combative behaviors when staff attempted to assist with hygiene care. Staff noticed R1 had loose stool on the evening of 6/7/24. Care giving supervisor notified Med-techs, who notified the kitchen staff for a diet adjustment, and monitor for diarrhea. Staff stated that when they notice any resident with diarrhea symptoms the following takes place; If the symptoms continue after 24 hours, the physician is either notified for as needed(PRN) medication to be prescribed or if the PRN medication is already prescribed it is provided to the residents. Per staff in R1’s case the diarrhea did not last longer than 24 hours. Staff stated that the toilet was in fact clogged once due to R1 throwing toilet paper or paper towels inside and flushing it. As well as paper towels found in the shower. However, staff responded to cleaning, removing items that could clog the toilet, and fixing the toilet right away. Per staff R1 was redirected, change as needed after each incident, and provided care. Interviews with residents revealed, residents are assisted as needed with medical care, have not observed fault odors around the facility, and their toilets/showers are in good repair. Document review revealed, R1’s physician’s report dated: 1/7/24 notes resident needs assistance with incontinence care. On 6/3/24 Skill nursing facility notes R1 may be discharge back to assisted living facility. On 6/4/24 R1 had a physician’s house call due to staff concerns of R1’s behaviors. On 6/6/24 a physician order was place for anti-diarrhea medication. On 6/7/24 and 6/8/24 facility’s clinical notes, noted R1 was refusing assistance with changing and behaviors. On 6/10/24, incident report notes R1 was send to the hospital due to aggressive behaviors. June 2024 medication sheet notes R1 was provided one dose of anti-diarrhea medication on 6/7/24 and a dose on 6/8/24. Although R1 may have had diarrhea and behaviors, per interviews conducted and documents reviewed R1 was provided assistance as needed and facility staff communicated with physician regarding R1’s change in condition and medical needs. During the facility’s tour LPA did not observed any toilets or showers clogged or in disrepair. (CONTINUED ON LIC 9099C) Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Virginia Garcia - Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 29, 2024 · control 28-AS-20240610091426

Allegation investigated: Staff did not accept resident back into care following hospitalization.

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation visit for the allegation above. LPA met with administrator Virginia Garcia and the purpose of the visit was discussed. LPA conducted the following: LPA toured the physical plant of the facility, interviewed staff #1-#4 (S1-S4) and Residents #2-#5(R2-R5), LPA collected copies of the staff and resident roster as well as reviewed and collected documents from Resident #1's (R1) file. R1 was unavailable for interview. LPA interviewed R1's responsible party (W1). The investigation revealed the following: In regards to the allegation "Staff did not accept resident back into care following hospitalization" it is alleged that facility staff refused to accept R1 back to after being discharged from the hospital.... Continued on LIC 9099-C Unsubstantiated (3) of (3) Staff interviewed denied the allegation. (4) of (4) Residents could not corroborate the allegation. Interviews state that R1 was hospitalized on 5/31/24 after an incident involving an altercation with a roommate causing behavioral outbursts. While R1 was in the hospital, staff communicated to want to reassess R1's current health and mental status when the hospital then discharged R1 to a skilled nursing facility on 6/20/24. Staff interviewed denied ever refusing to take R1 back into the facility. Staff interviewed stated they are currently awaiting discharge from the skilled nursing facility and will be able to take R1 back. There is no set date on discharge from the skilled nursing facility. W1 stated they had not been informed by the facility either verbally or written that R1 would not be able to return to the facility. File review did not show any documentation of R1 being evicted not allowed back to the facility. LPA observed facility to still be holding R1's personal belongings. Based on interviews, files reviewed and observations conducted; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 25, 2024 · control 28-AS-20240620150052

Allegation investigated: Staff did not prevent resident from harming another resident in care

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Assistant Administrator Lori Lackey and explained the reason for the visit. The investigation consisted of the following: LPA conducted interviews with Assistant Administrator Lori Lackey, Staff 1-4 (S1-4) and Residents 3-10 (R3-10). R1-2 were not interviewed as they were not in the facility at the time of the visit. LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1-2's facility file. LPA collected copies of documents pertinent to the complaint investigation and conducted a facility tour. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Staff did not prevent resident from harming another resident in care, it is alleged that on 06/21/2024 staff at the facility saw R2 twisting R1's arm which resulted in R1 sustaining a fracture and dislocation to their left elbow. Interview with Assistant Administrator revealed that R1 did sustain a fracture and dislocation to their left elbow which was caused by R2. She stated that R2 wanders and constantly touches things but has never hurt anyone. She stated that staff redirect R2 and any other resident when they are wandering. She stated that R1 and R2 are both non verbal and staff (S2) was assisting another resident when the incident happened. Interview conducted with S2 revealed that they were finishing assisting another resident when the incident occurred but they saw when R2 came close to R1, lifted their blanket, grabbed their arm and immediately called out for assistance in redirecting R2. S1 immediately came to redirect R2 but R2 had already walked away and S1 then proceeded to request assistance from S3 to examine R1's arm. S1-3 stated that the incident happened in a matter of seconds and R2 was immediately redirected but that R2 was also unaware of the harm they caused to R1 due to resident being diagnosed with Major Neurocognitive Disorder. 5 out of 5 staff interviewed denied the allegation and stated that there are enough staff on schedule to properly supervise and care for the residents. 8 out of 8 residents interviewed were unable to corroborate the allegation. They stated that they are satisfied with the services, staff protect them from harm and do not have any concerns. LPA reviewed R1-2's Physician's Report for Residential Care Facilities for the Elderly (RCFE) which revealed that R1-2 are diagnosed with Major Neurocognitive Disorder and have conditions and behaviors in relation to that diagnosis. R2 has wandering behavior and R1 is not able to feed self and is nonambulatory. During the time of the visit, LPA did not observe any altercations between residents and observed that there were enough staff on schedule. LPA additionally observed staff tending to residents and redirecting residents which were exhibiting wandering behavior. LPA reviewed documents and observed that the proper reporting was done by facility staff as well as proper follow up calls made to both involved resident's responsible parties. LPA additionally reviewed Facility Personnel Report (LIC500) which revealed that the facility is properly staffed to oversee and care for the residents in placement. Based on statements gathered from interviews conducted with staff, residents, LPA record review and observations there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held. A copy of the report was provided to Assistant Administrator Lori Lackey.the state’s words, verbatim · CDSS document, Jun 24, 2024 · control 28-AS-20240621152618

Allegation investigated: Facility staff sexually abused resident while in care.

Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation visit regarding the above allegation. LPA met with Lori Lackey and explained the reason for the visit. The investigation consisted of the following: On 1/16/24 LPA Flores conducted a health and safety check visit. LPA Flores obtained a copy of admission agreement for resident #1(R1) as other documents were collected on 1/11/24 during a case management visit. On 1/12/24 The Investigation Bureau Department (IB) assigned IB investigator Heidy Bendana to the investigation and conducted interviews with 5 staff, 2 residents, R1’s conservator, reviewed video footage, obtained medical records, and police report. On 4/23/24 LPA Flores conducted a visit at the facility and delivered findings. The investigation revealed the following: Regarding allegation: Facility staff sexually abused resident while in care. It is alleged R1 claimed that staff member entered R1’s bedroom and sexually assaulted R1. (CONTINUED ON LIC 9099C) Unsubstantiated On 1/8/24 R1 was found sleeping in the dining room and refused to sleep in own bedroom. On 1/9/24 Assistant administrator asked R1 why R1 refused to sleep in own room. R1 stated that staff #1(S1) kept entering R1’s room to sleep with R1. Assistant Administrator continue to ask more questions and R1 stated, “S1 raped me.” On 1/9/24 Facility’s administration team cross reported R1’s allegation of sexual assault by staff to community care licensing and local ombudsman. On 1/10/24 facility contacted local police department. Police officers responded to the report. R1 was send to the hospital to be evaluated. Interviews conducted revealed facility staff and R1’s conservator do not believe S1 raped R1. Facility staff stated that S1 does not go into residents’ room as S1 job does not require them to enter the rooms. S1 was observed leaving the facility the night of 1/8/24. S1 stated to not have been alone with R1 at any time and does not know why R1 would state that as S1 does not go to rooms alone. Documents reviewed revealed R1’s physician report dated 1/17/24 notes R1 as confused and in need of redirection due to mild cognitive skills. Police report dated 1/10/24 notes police officers responded to a call at the facility due to suspicious circumstances. Officers conducted interviews with administrator team, R1, and reviewed video footage at the facility, attempted to interview S1, no further investigation was reported by Pasadena Police Department. IB investigator reviewed facility’s video footage and observed R1 sleeping in the dining room on 1/8/24, R1 seem to be speaking to someone. However, there was no one there. S1 was observed leaving the facility at the end of the shift and no where near R1. Due to R1's cognitive skills and other interviews the allegation cannot be corroborate. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Lori Lackey and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 23, 2024 · control 28-AS-20240111160546

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Mary FLores conducted an unannounced case management visit regarding incident report submitted to the facility on LPA met with Lori Lackey and Rocio Gonzalez and explained the reason for the visit. On 4/16/24 the department received incident report which reports on 4/13/24 Resident #1(R1) jumped over the fence and left the facility. Staff went out to search for R1 and police was contacted. R1 was found by someone who lives in the neighborhood on Oak Knoll St., the individual called 911 after witnessing R1 fall down. R1 was then transported to the hospital. On 4/19/24 LPA contacted Lori Lackey and requested physician's report, needs and care plan, hospital discharge documents for R1. During this visit LPA reviewed the documents and tour the facility. Per the incident report R1 jumped over the fence in the courtyard that faces El Molino St. Fence at 1:59pm. The fence is over 6ft in high. Staff noted R1 missing at 2:10pm. Per physician's report dated: 9/8/23 R1 cannot leave the facility unattended due to cognitive skills. Per Individual Service Plan dated 12/5/23 R1 has a history of wandering and leaving unassisted. Needs and Service Plan dated 4/22/24 notes R1's wandering behavior and staff will provide monitoring due to wandering. Medication sheet shows medication was adjusted on 4/23/24. Admission agreement shows R1 was admitted on 4/9/24. Per Assistant administrator R1 is still assimilating to the facility, a psychological evaluation was conducted on 4/22/24 and adjustment in medication has been done by the physician. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Lori Lackey and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 23, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 24, 2024

87468.2 Additional Personal Rights... (a) ...residents...shall...: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on documents review and interviews conducted facility did not ensure R1 left the facility unattended which poses an immediate risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Apr 23, 2024

Plan of correction: Administrator will update needs and care plan to note the frequency of supervision provided and accomodations to assist R1 with assimilating to the environment by POC due date 4/24/24.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit for an annual continuation by using the CARE inspection tool. LPA met with Denise Miller Office Coordinator an explained the reason of the visit. On 3/26/24 LPA Flores completed The CARE tool domains of Physical Plant/Environmental Safety and Food Service. During today's visit LPA reviewed 10 resident files and 10 staff files. LPA observed Appraisal Needs and Service Plan for resident #6 (R6) was last updated on 9/1/22 and #9 (R9) was last updated 1/6/23 which was not updated within the last 12 months. LPA reviewed Infection Control Plan last reviewed on 3/1/24, Emergency Disaster Plan last reviewed on 2/6/24 , Fire drill log (last fire drill conducted on 3/8/24), In-Service training file. LPA observed 20 hours of training. However, in service training did not include 4 hours of hospice care, postural support, and restricted health conditions/health services. LPA conducted interviews with 5 residents and 5 staff. The following CARE tool domains were completed during this visit: Infection Control, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Planned Activities, Incidental Medical and Dental, Resident Records/Incident Reports, Disaster Preparedness, Residents with Special Health Needs. Deficiencies were noted in LIC 809D per Title 22 Regulations. Exit interview was conducted with Lori Lackey and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 28, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the inspection CARE tool. LPA Flores met with Lori Lackey and explained the reason for the visit. The facility is licensed to serve 206 residents over the age of 60 years old of which 171 may be non-ambulatory, 35 bedridden, and a hospice waiver for 20 hospice residents. There are currently 17 residents on hospice. Facility is a two story building in a residential area which consist of shared bedrooms, several common areas, a commercial kitchen, and a courtyard. Facility cares for dementia residents and has delayed egress on exit doors. There is a water feature in the courtyard. The water feature has a fence around the entire perimeter. Facility has a fire sprinkler system throughout the facility. Today's visit consisted of a tour of the facility (Physical Plant Domain) with Lori Lackey and medication review. LPA observed the following: First floor common areas: Lobby, visitation room, dining rooms, activity room all have sufficient space with furniture in good repair, and fireplaces are covered. Commercial kitchen was observed clean, in good repair, and food supplies were observed sufficient for at least 2 days of perishables and 7 days of non-perishables. Seven (7) random bedrooms were observed in the first floor; each room is furnished with the required furniture, with sufficient lighting, and bedding supplies. Bathrooms were observed in working condition and in room #107 a bottle of disinfectant spray was observed under the bathroom cabinet accessible to the resident. Water temperature was tested between 89.7 - 110.3 degrees F., which is not within the required 105-120 degrees F. (room#114 at 103.8 F., room #119 at 89.7 F., room #134 at 100.5 F.) Second floor: Seven (7) random bedrooms were observed each room is furnished with the required furniture, with sufficient lighting, and bedding supplies. Bathrooms were observed in working condition. Water temperature was tested between 100.4 - 114.4 degrees F., which is not within the required 105-120 degrees F. (room #259 at 100.4 F., room #240 at 104.1 F., room #204 at 90.3 F.)(CONTINUED LIC809C) Second floor: dining room has sufficient furniture and in good repair. Medication room was observed inaccessible to the residents. Each egress system exit door was tested in working condition except for the egress system in the exit gate to the left of the building which exits to El Molino. The gate was observed tied with a rope to hold closed. Medication was reviewed for 14 residents. LPA will return at a different time to continue the annual visit and complete the other domains. Deficiencies were noted during this visit per Title 22 Regulations. Exit interview was conducted with Lori Lackey and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 26, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit due to an incident reported to the department on 1/9/24 via SOC 341. LPA met with Annalyssa Camacho Front desk and explained the reason for the visit and requested a copy of staff roster and resident roster. On 1/9/24 Administrator submitted to the department a copy of SOC 341 (report of suspected dependent adult/ elder abuse) reporting Resident #1(R1) reported that staff #1(S1) came into R1's room and raped R1. During today's visit the following documents were reviewed: Physician's report dated 2/2/23, Identification and Emergency Information dated 3/10/21, Individual Service Plan - Assisted Living Waiver dated 8/1/23 and 2/10/21, medication sheets for the last three months, R4's notes, S1's personnel record, fingerprint clearance, criminal record clearance, and copy of S1's identification card. LPA interviewed Lori Lackey Assistant Administrator, who stated the following on 1/9/24 R1 stated to assistant administrator not to want to go to R1's room as R1 was afraid S1 wants to sleep with R1, R1 further said "S1 wants to have sex with R1 and rape R1." On 1/9/24 facility's administrator reviewed video footage for the night of 1/8/24 -1/9/24 and R1 was observed in the dining couch throughout the night. Staff attempted to redirect R1 to the bedroom and was not able to. In the morning of 1/9/24 Lori Lackey held a conversation with R1 that let the above statement. S1 worked on 1/8/24 from 12:00pm - 8:30pm. S1 was observed by facility's administration on video surveillance clocked out at 8:30pm and leave the facility. 1/9/24 facility submitted SOC 341 to Community Care Licensing (CCLD) and Local Ombudsman. On 1/10/24 facility contacted the Pasadena Police Department and report the allegation, Officer Cabuto visited the facility and requested the video footage to be send to Pasadena Police Department. R1 was taken to USC Verdugo Emergency Hospital for evaluation. Facility placed S1 on a verbal suspension on 1/9/24, and will follow up with a written suspension until the investigation is concluded. Further investigation is required at this time and LPA will wait for Pasadena Police Department report and hospital evaluation to determined if the allegation took place. Exit interview was conducted with Lori Lackey and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 11, 2024

Allegation investigated: Resident wandered from the facility due to lack of staff supervision. Resident sustained a fall resulting from lack of staff supervision.

Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation visit regarding the above allegations. LPA met with Virginia Garcia and explained the reason for the visit. The investigation consisted of the following: On 3/14/23 LPAs Flores and Zaragoza conducted an initial complaint investigation visit and requested a copy of the staff and resident roster, interviewed assistant administrator, reviewed Resident #1(R1)'s file and requested the following copies: incident report dated 3/7/23, identification and emergency information sheet, physician's report dated 3/7/23 and 4/28/21, individual service plan, admission agreement, hospital discharge documents dated 3/5/23. In addition, copy of warning report for staff #2(S2). LPA Flores interviewed R1. On 10/31/23 LPA Flores interviewed administrator and staff #3(S3) and S2 over the phone. (CONTINUED ON LIC 9099C) Substantiated The investigation revealed the following: Regarding allegations: Resident wandered from the facility due to lack of staff supervision and Resident sustained a fall resulting from lack of staff supervision. It is alleged R1 exited the residential care facility unsupervised and subsequently fell 3 blocks north of the location and was later transported to the hospital. Documents reviewed revealed; On 3/5/23 Pasadena Police Department officers responded to a report of an individual who had fallen on the sidewalk, upon responding the individual was identify as R1 and per protocol transported to the emergency room at Huntington Hospital for an evaluation. Incident report dated 3/7/23 notes R1 left the facility on 3/5/23 at 5:16pm and was taken to the hospital due to a fall. Physician’s report dated 2/2/23 notes R1 has dementia and cannot leave the facility unassisted. Hospital discharge dated 3/5/23 notes R1 was evaluated for brain and cervical trauma and was discharge back to the facility on 3/6/23. On 3/6/23, S2 was given a warning with a (3) three-day suspension for “danger of resident going out the front desk door”. LPA attempted to interview R1 however due to cognitive skills was not able to obtain information. Interviews with staff determined the incident did happen and corroborated that R1 fell down upon leaving the facility unassisted. Per S2, forgot to turn switch to lock the front door and did not notice when R1 left the facility. Upon caregivers inquiring S2 reviewed video footage and saw R1 leave the facility, notify other staff and went out looking for R1. S2 noticed people and police officers assisting R1, who was on the floor, and was transported to the hospital. Based on LPAs interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Virginia Garcia and a copy of this report, LIC 9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 31, 2023 · control 28-AS-20230306144748

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 1, 2023

87468.2 Additional Personal Rights of Residents...: a)...residential care facilities ...shall ...: 4)..., supervision,... that meet... and are delivered by staff that are sufficient in..., qualifications, and competency to meet their needs.This requirement is not met as evidence by: Based on interviews and documents reviewed licensee did not ensure R1 left the faciltiy unassisted and R1 obtained a fall while unsupervised which poses an immediate risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2023

Plan of correction: Adminsitrator will ensure that all staff are qualify, sufficient in numbers, and competent to perform their duties and will schedule in-service training on prevention of wandering by POC due date 11/1/23. Will provide a copy of in-service with date, duration, and subject by 11/7/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(k)(8) · Plan of correction due date: Nov 1, 2023

87705 Care of Persons with Dementia (k) The following...must be met...: (8) Delayed egress devices shall not substitute for trained staff... to meet... supervision needs of all residents and to escort residents who leave the facility. This requirement is not met as evidence by: Based on interviews and documents reviewed licensee did not ensure R1 left the facility unassisted through the front door while a staff was at the front desk which poses an immediate risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2023

Plan of correction: Adminsitrator will ensure that all staff are qualify, sufficient in numbers, and competent to perform their duties and will schedule in-service training on ensuring egress system is working and escorting residents outside the facility by POC due date 11/1/23. Will provide a copy of in-service with date,

Allegation investigated: Staff attempted to financially abuse resident while in care.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Malou Bernardo and explained the reason for the visit. The investigation consisted of the following: LPA requested a copy of staff/resident rosters. Interviewed administrator, staff #2-#5(S2-S5), and resident #1-7(R1-R7). Reviewed R1’s file and requested copies of physician’s report, face sheet, admission agreement, assisted living waiver(ALW) individual service plan agreement, resident’s facility invoices. LPA attempted to interview ALW’s social worker and R1’s family members. The investigation revealed the following: Regarding allegation: Staff attempted to financially abuse resident while in care. It is alleged resident was brought inside the branch in a wheelchair by two facility’s employees and stated were “here to help assist resident with getting a debit card and a cashier's check”. (CONTINUED ON LIC 9099C) Unsubstantiated Interview with Administrator and Assistant administrator revealed R1 was recently admitted to the facility and have attempted to obtain the family’s assistance but have not been able to. Facility is assisting R1 with arranging finances as currently R1 is self-responsible for own finances and recently obtained financial information from social security. Assistant administrator, driver, and R1 visited R1’s banks to assist R1 with access to accounts. Although assistant administrator spoke with bank staff, R1 provided the information for the account. Per documents reviewed R1 was admitted to the facility on 5/9/23. Physician’s Report dated 5/3/23 notes R1 has dementia and cannot handle own cash resources. However, ALW’s individual service plan notes R1 is legally self responsible. Interviews conducted with additional residents revealed the facility’s staff does not become involved in their financial decisions. Residents are taken to make purchases which they pay for on their own. Interviews conducted with staff revealed facility’s driver assist residents with going to appointments, stores to shop, bank, etc. Driver uses facility’s fund trust credit card to make purchases for residents when the residents request something and they cannot go. Although the facility did take R1 to the bank and communicated R1’s needs, the staff was not attempting to financially abuse R1. However, staff attempted to assist R1 with access to R1’s accounts in order for R1 to be able to finance R1’s current needs. The facility is currently assisting R1 with the process of guardianship or having a responsible party due to R1’s change in condition. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Virginia Garcia and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 31, 2023 · control 28-AS-20231024124234

Allegation investigated: Staff do not safeguard resident's personal belongings.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Elizabeth Kirk and explained the reason for the visit. The investigation consisted of the following: LPA requested staff/resident rosters. Interviewed administrator, staff #1-#3(S1-S3) and residents 1-7(1-7). LPA requested a copy of physician's report, identification and emergency information sheet, admission agreement, and personal property and valuables sheet for R1. The investigation revealed the following: Regarding allegation: Staff do not safeguard resident's personal belongings. It is alleged many of resident’s personal belongings have gone missing since they were transported to the facility. Interviews conducted with residents revealed, 5 out 8 residents stated that personal belongings have not disappeared from their rooms and when they moved in all their items were provided to them. (CONTINUED ON LIC 9099C) Unsubstantiated 2 out of 8 residents stated that items have disappeared and did not know what happened to them. 1 out of 8 residents was unable to answer questions due to cognitive skills. Interviews with staff revealed, 4 out of 5 staff interviewed stated that recently they have been assisting a resident who moved-in on 8/9/23 to bring personal items from the resident’s previous residence to the facility. Per staff resident has stated that personal items have gone missing. However, the items have been found in the room or are still slowly being cleaned and provided to the resident. Assistant administrator explained that the resident requested assistance with brining items from the previous residence to the resident’s room. Upon going to the previous residence and picking up the items staff observed an infestation of bugs in the apartment. Therefore, the staff decided to continue to assist the resident but in order to prevent bringing any bugs into the facility they will clean the items first. Prior bringing the items into the resident’s room, the staff are cleaning, ensuring there are no bugs in the items, washing the clothes first. The resident was made aware about this process and explained the reason why it was being done that way. Although the items may have not been provided to the resident right away. The facility is ensuring to avoid an infestation of bugs inside the resident’s room and the items are being provided to the resident clean. Document reviewed revealed resident had 3 items listed on the personal property and valuables upon arriving at the facility. An update of the personal property and valuables is to be done upon resident has all her items in the room as the transition is still on going since the resident moved in. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Lori Lackey Assistant Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 28-AS-20231016153749