Karlton Residential Care Center

Allegation investigated: Resident sustained multiple skin lesions and rib fractures due to neglect and lack of supervision.

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by Matthew Weiner and met with Elena Weiner, Administrator and explained the purpose of the visit. During the course of the investigation, the Department interviewed staff and witnesses; and subpoenaed and reviewed hospital medical records. The Department also reviewed documents for Resident #1 (R1) and obtained a resident and staff roster. The investigation revealed the following: Resident #1 (R1) is ninety years old and was admitted to the facility on December 21, 2023. Per Physician report dated March 10, 2025, R1 had a diagnosis of Major Neurocognitive Disorder due to unspecified disease; unspecified Dementia. Physician report further assessed R1 was non-ambulatory and required supervision for self-care needs and activities of daily living. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) On February 26, 2026, R1 went to Urgent Care due to scattered rashes on various parts of the body. Per Unusual Incident Report, R1 was assessed by the physician, a treatment was prescribed and staff continued to monitor R1’s skin integrity. On May 2, 2026, R1 was transported to Kaiser Hospital via ambulance, due to lethargy, and was admitted to the hospital. Upon admission, R1 had a small scratch on the left cheek and on the left forearm. Hospital records from May 2, 2026, evaluated R1 with diagnoses of Pleural Effusion Hypoxemia, Shortness of breath and Major Neurocognitive Disorder due to Alzheimer’s Disease. Chest x-rays on this date revealed there was an acute mildly displaced right lateral third rib fracture. R1 remained in the hospital due to aspiration pneumonia and was discharged on May 7, 2026. On May 26, 2026, the Department interviewed Resident #1 (R1) at their new Residential Care Facility for the Elderly (RCFE). R1 could not recall when they moved from Karlton Residential Care Center (KRCC) to their current location, or when they were in the hospital. R1 did not remember having any falls but recalled having a rash at KRCC. R1 denied any neglect or lack of supervision by the KRCC facility caregivers. Two of two additional residents interviewed stated that staff were attentive to their needs and that care was being provided. Three of three residents denied the allegation of neglect and lack of supervision. The Department interviewed Witness #1 (W1) who is familiar with R1. The witness stated that the facility notified them of R1’s rash issues and that they were monitoring the rash. W1 stated that R1 has dementia and did not have any complaints or problems with the care R1 received. W1 stated that they, as well as the facility, were not aware of any falls and that the rib fracture was discovered from the last hospital visit when R1 had shortness of breath. W1 denied the allegation that R1 sustained multiple skin lesions and rib fractures due to neglect and lack of supervision. Additionally, four of four staff were interviewed regarding R1’s skin lesions and rib fractures. Four of four staff were unaware of R1 having a fall and sustaining a rib fracture. Staff were informed by the hospital on May 2, 2026, regarding the rib fracture. Four of four staff denied the allegation that the skin lesions and rib fractures were sustained due to staff neglect and lack of supervision. (Continued on LIC 9099-C1) (Continued from LIC 9099-C) Based on the Department’s records review, interviews and observations the allegation that Resident sustained multiple skin lesions and rib fractures due to neglect and lack of supervision is Unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator Elena Weiner, and a copy of this report and LIC 811 was left at the facility.the state’s words, verbatim · CDSS document, Sep 22, 2026 · control 22-AS-20260504161046

Allegation investigated: Facility failed to ensure resident room is clean and sanitary Facility did not provide incontinence care to resident Facility did not reposition resident per physician order Staff member assisted resident with incontinence care without consent Facility allowed unauthorized personnel to draw blood from resident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and witness as well as reviewed and obtained pertinent documentation such as facility notes. Regarding the allegations that facility failed to ensure resident room is clean and sanitary, facility did not provide incontinence care to resident, facility did not reposition resident per physician order, facility allowed unauthorized personnel to draw blood from resident and staff member assisted resident with incontinence care without consent, the investigation revealed the following: Five out of five staff state there was no smells in the resident's room and the room was being cleaned daily. Staff indicate there was a taco in a hospital gown presented by family allegedly found in the closet. Staff deny the facility uses hospital gowns and is unsure where the item came from. LPA toured the facility and facility appeared clean and sanitary. Facility provides incontinence care every 2 hours or as needed along with repositioning. CONTINUED ON LIC 9099C DATED 07/07/2026 Unsubstantiated Two out of two caregivers as well as Administrator interviewed confirm incontinence care and repositioning was being provided to Resident 1 (R1). Facility uses resident monitoring checklists and review of checklists show caregivers were documenting incontinence care. R1's responsible party requested female caregivers only and staff state honoring the wishes. However, male staff would assist with transfers and repositioning due to resident requiring a two person assist. While transitioning from care in Los Angeles, a phlebotomist arrived to the facility in October 2025 to draw blood from the resident. The Administrator indicates the draw did not happen and both Administrator and family were advising the medical group to discontinue care for the resident. LPA reviewed emails to that affect. Seven out of seven staff denied all allegations through written statements obtained by LPA. Based on the interviews conducted and record review, the Department is unable to corroborate the allegations. Therefore, the 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 that the alleged violations did or did not occur. An exit interview was conducted, and this report was reviewed with Facility Representative. A copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jul 7, 2026 · control 22-AS-20260223134858

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry and met with Administrator (AD) Elena Weiner at 8am. The facility is a single story building with a fire clearance of seventy six non-ambulatory and seventy six bedridden. A hospice waiver is approved for fifteen residents. Currently there are forty-seven residents in care and eight residents receive hospice services. The facility was a comfortable 74 degrees. LPA toured the facility with AD and tested the hot water temperature in four of four resident bathrooms. The hot water temperatures ranged between 112.4 and 115.9 degrees Fahrenheit. The fire alarms, carbon monoxide detectors and sprinkler system were inspected by an outside vendor on October 22, 2025 and passed inspection. The fire extinguishers were charged and inspected on May 6, 2025. The fire extinguishers will be inspected in two weeks for 2026 and the next fire alarm inspection for the facility will be scheduled in July 2026. The last fire drill was conducted on January 13, 2026. During the visit LPA observed residents listening to music in the television area and participating in activities such as ball toss and Bingo. Hazardous chemicals were stored and locked in three different locations: the kitchen, a locked storage room and in the laundry area; which is a separate area outside of the building which residents do not have access to. Washer and dryers were operational. All secured chemical areas had binders with Material Safety Data Sheets (MSDS) and pictures of the chemicals. Upon touring the kitchen, the facility had more than two-days of perishable items and seven-days of non-perishable food on hand. (Continued on LIC 809-C) (Continued from LIC 809) A grocery delivery was to be delivered in the afternoon. The oil extinguisher, in the kitchen, was charged and inspected on May 6, 2025. Sharps and knives are secured in the kitchen and special diet instructions for residents were observed and separated on different carts with a color coding system. The dining room area was clean and LPA was told all dining room chairs are being updated and replaced. LPA toured the shaded central courtyard and the facility is also getting brand new patio furniture. There are no hazards or obstructions in the patio area; only sandbags which were used during the rainy season. LPA reviewed three of three staff training and fingerprint records and reviewed five of five resident records. Staff in-services coincide on pay days and cover a variety of topics. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA audited five of five Medication Administration Records and medications were being given as prescribed. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Elena Weiner, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Mar 26, 2026

Allegation investigated: Lack of supervision resulting in resident sustaining multiple falls

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility to deliver findings regarding the above-mentioned allegation. Upon arrival, LPA was greeted and granted entry by AD Weiner Elena . The investigation revealed that Resident (R1) was admitted to the facility on May 18, 2023. The Physician’s Report dated May 17, 2023, documented diagnoses of seizures, epilepsy, and dementia, and indicated R1 was non-ambulatory, required full assistance with all Activities of Daily Living (ADLs), and had generalized weakness. R1 was admitted under hospice care through Vitas Hospice of Orange County with terminal diagnoses of cerebrovascular disease and hypothyroidism. Hospice records indicated that R1 was completely dependent for all ADLs, incontinent of bowel and bladder, and identified as a high fall risk due to agitation and confusion. {***CONTINUE***9099C1} Substantiated The facility’s Appraisal and Needs and Services Plan dated May 18, 2023, contained only general instructions for redirection with ADLs and noted R1 “walks very fast at times.” It did not include individualized plan, instructions, directives or a defined supervision plan to ensure adequate supervision or preventative fall strategies. Between October 2023 and April 2025, R1 sustained at least nine documented falls. The earliest known incident occurred on October 29, 2023, when R1 fell while attempting to transfer from their bed to wheelchair per Vitas Hospice records. R1 was assessed by Vitas Hospice on November 2, 2023, and documented to have a skin tear to the left elbow. The facility had no records documenting the fall, assessing the R1 and discovering and treating the tear. Ten days later R1 sustained a second fall on November 8, 2023, and complained of left hip pain. R1 was transferred to Kaiser Hospital and diagnosed with left intertrochanteric femur fracture and underwent surgical repair the following day. R1 was later transferred to South Coast Post Acute Care for Rehabilitation. The facility’s internal self-report reflects the fall entry was not documented until November 29, 2023. Despite the seriousness of the incident, no significant changes were made to R1’s supervision schedule or care plan. On February 19, 2024, hospice documented that R1 was a high fall risk and uncooperative with transfers. On June 27, 2024, Hospice again documented that R1 was a high fall risk. On July 08, 2024, R1 sustained another fall as documented by Vitas Hospice. No injuries were noted on the report. Hospice records documented R1 sustained a follow up fall on August 11, 2024, and did not sustain any serious injuries. On December 17, 2024, R1 complained of knee pain and swelling which was reported by the facility Med Tech to Vitas Hospice nurse. The visiting nurse prescribed Tylenol for R1’s pain and instructions to staff to monitor the swelling and contract hospice if needed. On December 26, 2024, R1 was observed to still have left knee swelling by the hospice doctor, however, facility staff denied R1 sustaining any fall. A subsequent X-ray completed on December 27, 2024, by Pacific Coast Mobile Radiology confirmed a complete transverse fracture of the distal left femur. Facility documentation stated that R1 kicked the bed railing. Despite the seriousness of the incident, no significant changes were made to R1’s supervision schedule or care plan. The facility did not re-appraise R1. R1’s Physician’s Report was updated on March 13, 2024, and March 6, 2025, and reaffirmed that R1 remained non-ambulatory and dependent for all transfers. {***CONTINUE 9099C2} On March 10, 2025, R1’s appraisal was updated and notated that they were a fall risk and was sent to the hospital for behavioral management. The Needs and Services Plan documented that R1 constantly attempted to get up and walk unassisted due to confusion yet still lacked specific plan, instructions or directives regarding supervision frequency or staffing interventions. On March 20, 2025, R1 sustained an unwitnessed fall and was found by facility staff on the floor with no visible injuries noted. On April 16, 2025, R1 was observed to have a bruise to their left forehead. Two days later, hospice held a meeting with the facility staff and documented that a six-bed facility may be more appropriate to meet R1’s increased needs. Later that night, R1 sustained an unwitnessed fall around 8 PM. Hospice records note that the facility refused a visit upon the fall and requested hospice to visit the following day. Interviews conducted revealed that the Administrator (AD) stated staff were expected to conduct resident checks every fifteen to thirty minutes during the day and every fifteen minutes at night. However, interviews with two of two caregivers indicated that checks were typically conducted approximately every two hours. Hospice records documented repeated recommendations for increased supervision, and when they attempted to discuss the matter with the Administrator (AD), AD replied that she was “too busy.” Facility documentation reflected that bed rails, bed alarms, and floor mats were in place. However, multiple hospice notes indicated delayed or inconsistent staff response, demonstrating that these measures were insufficient to prevent repeated falls and injuries. Based on review of hospice medical records, hospital discharge summaries, facility incident reports, and interviews with staff and hospice personnel, the facility failed to modify its supervision plan or implement effective interventions despite repeated falls and serious injuries to R1 over an 18-month period. The preponderance of evidence has been met and the allegation Lack of supervision resulting in resident sustaining multiple falls is deemed to be SUBSTANTIATED. The following is being cited per Title 22, Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f). An exit interview was conducted, and copies of this report, LIC 9099-D, Appeal Rights, Immediate Civil Penalty Assessment, and LIC 811 (Confidential Names) were provided to AD, Weiner Elena, at the conclusion of the visit.the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 22-AS-20250417112836

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 29, 2025

87464(f)(1) “Basic services shall at a minimum include: Care and Supervision” This requirement was not met as evidenced by: Based on record review, interviews, and observations, the facility failed to provide adequate Care and supervision and follow-up interventions for R1, who sustained multiple falls, including a hip fracture and femur fracture, without corresponding changes in their supervision plan or care strategy. This lack of supervision posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 16, 2025

Plan of correction: Licensee will conduct a review of title 22 section 87464(f)(1) and provide a documented training for all working staff in the facility. Training record will be kept in staff file and send proof to LPA by POC due date

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Samer Haddadin conducted an announced case management visit to the facility. LPA Haddadin was greeted and granted entry by Administrator (AD) Weiner Elena. The purpose of the visit was to address deficiencies identified during the investigation of complaint #22-AS-20250417112836. The following deficiencies were observed: Per hospice records, between October 2023 and April 2025, R1 sustained at least nine documented falls. The earliest occurred on October 29, 2023, when R1 fell while attempting to transfer from bed to wheelchair. On November 2, 2023, Hospice record also showed that R1 had a skin tear to the left elbow. Facility had no records documenting regarding the falls or the skin tear. R1 sustained a second fall on November 8, 2023, and complained of left hip pain. R1 was transferred to Kaiser Hospital and diagnosed with left intertrochanteric femur fracture and underwent surgical repair the following day. R1 was later transferred to Post Acute Care for Rehabilitation. The facility’s internal self-report reflects the fall entry was not documented until November 29, 2023. Despite the seriousness of the incident, no significant changes were made to R1’s supervision schedule or care plan. On December 17, 2024, R1 complained of knee pain and swelling which was reported by the facility Med Tech to Vitas Hospice nurse. The visiting nurse prescribed Tylenol for R1’s pain and instructions to staff to monitor the swelling and contract hospice if needed. {***CONTINUE***809C} On December 26, 2024, R1 was observed to still have left knee swelling by the hospice doctor, however, facility staff denied R1 sustaining any fall. A subsequent X-ray completed on December 27, 2024, by Pacific Coast Mobile Radiology confirmed a complete transverse fracture of the distal left femur, resulting in a ten day delay of diagnosis and treatment of R1’s injuries. On February 19, 2024, hospice documented that R1 was a high fall risk and uncooperative with transfers. On June 27, 2024, Hospice again documented that R1 was a high fall risk. Despite this, updates to the facility’s Needs and Services Plans dated May 18, 2023, May 18, 2024, and March 10, 2025, did not address R1’s increased needs of supervision. The facility did not revise the plans as required to reflect R1’s high fall risk and need for closer supervision and assistance. Furthermore, between October 2023 and April 2025, the facility reported only one fall incident to Community Care Licensing, which was received on April 25, 2025. A search of the SIR portal system confirmed that no other fall incidents were reported during this period. Based on record review, the following are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report, confidential names list and appeal rights were provided at the time of exit.the state’s words, verbatim · CDSS document, Dec 16, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(b)(1)(E · Plan of correction due date: Dec 16, 2025

87463(b)(1)(E) ".Appraisal, shall be updated in writing as frequently as necessary" Based on record review, the facility did not update R1’s Needs and Services Plan following significant changes in condition, including nine falls resulting in two fractures between November 2023 and December 2024. The Needs and Services Plans dated May 18, 2023, May 18, 2024, and March 10, 2025, did not include individualized supervision requirements or interventions necessary to address R1’s fall risk needs. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 16, 2025

Plan of correction: Administrator will conduct training and update all current residents’ Needs and Services Plan and sent proof to LPA by POC due date

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(1) · Plan of correction due date: Dec 16, 2025

87465(a)(1)"licensee shall arrange, or assist in arranging, for medical care appropriate to the conditions and needs of residents"Based on record review, the facility did not ensure that R1 received timely medical attention following a change in condition. On December 17, 2024, R1 sustained a fracture of the distal left femur; however, R1 did not receive an x-ray diagnosing the fracture until approximately 10 days after initial swelling. This posed an immediate health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Dec 16, 2025

Plan of correction: Licensee along with Administrator will conduct training to all staff and in the facility and signed and date training conducted; training must be filed, and send proof to LPA by POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Dec 16, 2025

87211(a)(1)(D)"licensee shall furnish to the licensing agency such reports as the Department may require, including Any incident which threatens the welfare, safety or health of any resident" Based on record search of CCL SIR portal system the facility did not report incidents involving R1 that threatened the resident’s health and safety: nine repeated fall resulting in at least two fractures between November 2023 and December 2024. The facility’s failure to submit the required incident reports posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 16, 2025

Plan of correction: Licensee along with Administrator will conduct training to all staff as to when and how to report incidents to CCL, and send proof to LPA by POC due date

Allegation investigated: Lack of supervision resulting in resident sustaining multiple falls.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegation. LPA arrived at the facility and was greeted at the door and granted entry. LPA spoke with Elena Weiner, Administrator, and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, resident file review, and interviews conducted. It is alleged that lack of supervision resulting in resident sustaining multiple falls. Records review revealed that resident (R1) was admitted to the facility on January 26, 2024, with a diagnosis of Congestive Heart Failure and no history of falls. Appraisal needs and services plan was completed on January 26, 2024, Continued on LIC9099-C Unsubstantiated and on May 6, 2024, when the change of condition was noted. R1 had an incident on May 2, 2024, which was due to R1 having a UTI. May 6, 2024, incident was for an unwitnessed fall. Both incidents R1 was sent to two different hospitals for evaluation. Interview with staff stated that despite the first incident being ruled as a UTI, bed alarm and also half side rail was implemented with prescription. Upon noted change of condition they reassessed R1 on May 6, 2024, and made the necessary changes. Interview with 4 of 4 residents stated that staff check on them often, help them when they need help and are good to them. Residents stated they had no complaints to make. Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with the Administrator and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 22-AS-20240506110111

Allegation investigated: Resident sustained pressure injuries while in care. Staff leaves resident in wheel chair for extended periods of time. Staff does not ensure resident's podiatry needs are being met. Staff does not ensure resident's hygiene needs are being met.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegation. LPA arrived at the facility and was greeted at the door and granted entry. LPA spoke with Elena Weiner, Administrator and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, resident file review, and interviews conducted. It is alleged that resident sustained pressure injury while in care. Interview with staff stated that resident (R1) was sent out to the hospital on August 31, 2024, and returned the same day with home health referral. Record review revealed that R1 was sent to hospital on August 31, 2024, for left foot pain and Continued on LIC9099-C Unsubstantiated swelling. Discharge paperwork indicates R1 with cellulitis. The appraisal needs and services plan indicated that R1 had skin break down and a home health was ordered for her care. Continuous care was provided by home health as well as a physical therapy evaluation. It is alleged that staff leaves resident in wheelchair for extended periods of time. Interview with staff stated that R1 gets transferred out to their bed after lunch per R1’s request and was moved often. Staff stated that R1 gets physical therapy at the facility by an outside vendor. Records review revealed that progress notes from September and October 2024 reflect that R1 received physical therapy treatments. Resident monitoring logs for R1 reflect that R1 is moved out of the wheelchair often throughout the day. It is alleged that staff does not ensure resident's podiatry needs are being met. Interview with staff stated that R1 and residents from the facility received podiatry services at the facility by an outside vendor that would come and provide services. Interview with 5 of 5 residents indicated that a person comes and does their nails and looks at their feet at the facility. It is alleged that staff does not ensure resident's hygiene needs are being met, specifically to not being showered. Records review revealed that facility maintained a shower list for R1 and reflects that R1 received showers various times throughout the week. Interview with 5 of 5 residents stated that the staff make sure they shower at all times. Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is 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 with the Administrator and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 22-AS-20241007132932

Allegation investigated: Facility did not ensure that resident was kept clean and dry Facility did not ensure that resident was accorded dignity.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegation. LPA arrived at the facility and was greeted at the door and granted entry. LPA spoke with Elena Weiner, Administrator and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, resident file review, and interviews conducted. It is alleged that facility did not ensure that resident was kept clean and dry. Interview with staff stated that resident (R1) was never left in soiled diapers and when R1 calls for a diaper change they change them even if it’s every five minutes. Interview with R1 stated that staff change their diaper as needed. Continued on LIC9099-C Unsubstantiated R1 stated that they have never had a problem by being left in a soiled diaper. R1 stated that they wake up in a dry bed and they don’t recall being in soiled pants for over 4 hours. Record review monitoring logs from October 1, 2024, to November 20, 2024, reflected that R1 was changed every 2 hours or as needed for soiled diaper. It is alleged that facility did not ensure that resident was accorded dignity, specifically to hitting R1. Interview with resident stated that facility staff treat them good and treat them with respect and dignity. Record review shift notes revealed that on November 11, 2024, R1 was sent out to the hospital due to R1 being aggressive and agitated, R1 pushing care staff and refusing to get help, unable to control. Monitoring logs from October 1, 2024, to November 20, 2024, reflect that R1 when agitated they hit and push staff and refused to get help. Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is 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 with the Administrator and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 22-AS-20241113114841

Allegation investigated: Resident sustained severe injuries while care

On 05/23/2025, Licensing Program Analyst (LPA) Cassandra Mikkelson contacted the licensee via phone and email to deliver final findings regarding a complaint that was received on 08/05/2024. **Report continued on 9099- C page** Unsubstantiated Resident sustained severe injuries while care Interviews conducted with Administrator indicated that Resident R1 was considered a fall risk so staff monitored closely and escort R1 when they walk around the facility. Interviews with care staff indicated that R1 had fallen on 7/30/2024 while in the dining room. R1 attempted to stand on their own but was unable and they fell to a sitting position on the floor. Staff were quick to help R1 and check for injuries. Records reviewed indicated that R1 was a fall risk and needed assistance with moving about the facility and needed overnight observation due to wandering risk. Incident reports reviewed indicated that R1 had bruising/discoloration on forehead and right eye when R1 was admitted to facility on 07/28/2024. R1 also had a fall on 07/30/2024 which both physician and responsible party were notified about. Facility staff quickly and appropriately assisted R1. Based on interviews conducted and records reviewed, the allegation resident sustain sever injuries while in care is unsubstantiated. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, May 23, 2025 · control 22-AS-20240805115109

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry and met with Elena Weiner, Administrator (AD). The facility is a single story building with an approved fire clearance of seventy-six non-ambulatory and bedridden residents of which fifteen may be on hospice. The facility currently has a census of forty-eight residents in care with eight receiving hospice services. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing hot water temperature in five of five resident bathrooms. The hot water temperature measured between 114.9 and 117.5 degrees Fahrenheit. Fire extinguishers were charged and serviced on July 2, 2024. The facility’s last fire drill was conducted on January 4, 2025. Building sprinklers, smoke and carbon monoxide alarms were tested with an outside vendor on April 10, 2024. LPA and AD inspected the facility kitchen food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. Food expiration dates were clearly written on food items. LPA observed medication storage and reviewed the centrally stored medications with AD and MedTech. LPA discussed with AD and MedTech writing start dates on bubble packs for easier inventory and audit. Per review medications are being given as prescribed. The facility has an enclosed indoor courtyard and shaded seating areas were observed. There were no hazards or obstructed passageways outdoors. LPA toured the laundry area which is separate from the main building which is inaccessible to residents. (Continued on LIC 809-C) (Continued from LIC 809) LPA reviewed five of five staff training and fingerprint records and reviewed five of five resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA observed residents participating in a music sing-a-long and in Bingo. LPA confirmed that administrator has a current administrator certificate which expires on July 20, 2025. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Elena Weiner, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Mar 12, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced case management visit to follow-up on an Unusual/ Special Incident Report (SIR) received in our Regional Office on February 18, 2025. LPA was greeted and granted entry at 1pm by Staff #1. LPA met with Administrator (AD) Elena Weiner and explained the purpose of the visit. LPA obtained the following for review: Current resident and staff rosters, Resident Identification and Emergency Information, Physician's Report and Preplacement Appraisal Information. LPA requested the staffing schedule for February 12, 2025; the date when the incident occurred. LPA also obtained hospital discharge paperwork. LPA interviewed two of three staff members who witnessed the incident. Staff members stated that the incident was brief. Staff #1 had been in the resident's room and went to answer the door. Two other staff members were nearby when the resident began to slip from the bed. Resident does not have a history of falls. The resident tried to get up as the two staff members attempted to help resident and Staff #2 immediately called 911 and notified the family. Resident was sent out to the hospital for evaluation. The resident has returned to the community. LPA interviewed the resident who stated she did not feel pain. She did not remember the events that transpired on February 12, 2025 but stated she is not completely fine; just okay. LPA reviewed the staffing schedule and noted there were two med techs and eight caregivers on-site at the time of the incident. Based on the observations, record review and interviews made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Elena Weiner, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Feb 28, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 8:00 AM, LPA Tea was greeted and granted entry into the facility by caregiver Rosa Ramirez and explained the reason for the visit. The Administrator (AD) Elena Weiner and Assistant Administrators (AA) Matthew Weiner and Sylvia Garcia arrived shortly after to assist during the visit. The facility is a residential care facility for elders, focused on memory care. The facility is licensed for 76 non-ambulatory residents, in which 76 may be bedridden, and have a hospice waiver for 15. Currently there are 52 residents in care and 8 of the residents are on hospice. At 8:15 AM, LPA Tea reviewed six resident files and six staff files. Resident files and staff files contained all required documentation. Upon review of records, the facility is up to date with required quarterly fire drill, which was last conducted on June 15, 2024. AD Weiner’s current certificate expires on July 20, 2025, but due to the department’s back log in processing administrator certificates she has yet to physically receive her administrator certificate. LPA Tea along with AD Weiner and AA Matthew Weiner toured the physical plant at 10:58 AM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a single-story unit building that consists of 38 resident rooms with shared bathrooms. There are common areas, dining rooms, resident shower rooms, and kitchen for meal preparation. In the middle of the facility is the courtyard where there is a shaded patio seating area for residents to enjoy. The kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Emergency food supplies were in the pantry of the kitchen and emergency water supply was stored in a secured closet in the front part of the facility. Annual continuation on LIC809C LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. The fire and smoke detectors are serviced and maintained through a third-party company. They were last serviced on May 28, 2024. Fire extinguishers are fully charged throughout the facility. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly. Grab bars were secure, and showers were free of mold/mildew in resident shower rooms. Water temperature measured between 117.1 F degrees and 128 F degrees being the highest. AA Weiner adjusted the water temperature of the water tanks to meet regulation standards while on site. It would take half day for the tank to adjust to the temperature changes due to the size of the water tanks. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. LPA Tea observed residents in the morning and throughout the day doing exercises in the common area. Residents were also singing songs and playing bingo later in the afternoon. Activities are posted in the front and back of the facility with different activities for residents to participate. At 11:45 AM LPA reviewed medication storage and administration. Medications are stored in a med room that is locked and secured. Medications are being administered per physician order. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided. Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Assistant Administrators Matthew Weiner and Sylvia Garcia a copy of this report LIC809, 809-C, LIC858, LIC859, and LIC9102TV was read and provided to the facility.the state’s words, verbatim · CDSS document, Jul 30, 2024

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff are not following infection control practices Staff failed to provide adequate incontinence care to a resident

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. LPA was greeted and granted entry by facility staff after explaining the purpose of the visit. Administrator Elena Weiner was present on the premises and assisted with the visit. An initial complaint investigation visit was held on February 13, 2024. LPA accompanied by administrator conducted a tour of the facility's physical plant including a dedicated unit currently in place after a total of 18 residents tested positive for COVID starting on or around February 5th, 2024. LPA reviewed resident clipboards maintained for residents flagged with risks of skin breakdown due to the use of incontinence supplies and was provided a list of residents being provided with incontinence supplies. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM LIC9099 During the follow-up visit, LPA conducted or attempted interviews with five residents out of the 49 currently admitted individuals, multiple of which were among the residents who tested positive during the COVID outbreak reported in February 2024. Regarding the allegation that Staff are not following infection control practices, the following has been concluded: During the walk-through of the facility conducted on February 13, 2024, LPA observed that all residents who had tested positive had been put in isolation in a clearly identified wing of the facility. The use of Personal Protection Equipment was confirmed and disposal bins for donning and doffing were observed at both exits of the isolation section of the facility. It was also confirmed that facility had reported the cases as required and solicited guidance from the local public health authority and used that guidance to manage the outbreak. The presence of COVID-positive residents was confirmed to be notified to potential visitors and marked throughout the facility. Regarding the allegation Staff failed to provide adequate incontinence care to a resident, the following has been concluded: during the walk-through of the facility's physical plant as well as during interviews conducted during the present visit, LPA observed residents were clean, well-kept and that the facility was free of odors associated with the failure to manage incontinence. Interviews conducted failed to corroborate a failure to provide adequate incontinence care to the residents. Furthermore, records reviewed during the visit demonstrated the presence of a surveillance system designed to ensure the adequate monitoring of residents with incontinence issues. As a result, 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 that the alleged violations did or did not occur. An exit interview was conducted, and this report was reviewed with Executive Director. A copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, May 6, 2024 · control 22-AS-20240209141147