Kendall Guest Home 2

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Administrator Ana Gallegos and explained the reason for the visit. The purpose of the visit is to complete the required inspection. LPA Trueman toured the facility along with Administrator Ana Gallegos today 04/23/2026 at 1:10 PM and the following was observed: Facility contains 6 Client Bedrooms and 4 Client Bathrooms, dining room, living room, TV room, and activity room. Annual Inspection includes the following Domains: Infection Control, Physical Plant and Environment Safety, Operational Requirements, Staffing, Personnel Records- Staff Training, Resident Records- Incident Reports, Resident Rights/Information. Food Service, Planned activities, Incidental Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. 3 client files and 3 staff files were reviewed All staff were cleared and associated. Medication was administered per physician's directions. Signage for hand washing and proper sanitizing were posted. Staff have been trained in hand washing. Staff responsible for providing care and supervision received training in First Aid. Licensee maintained an individual admission agreement for each client. Fire Clearance has been maintained. Facility had sufficient supply of 2 day perishable and 7 day non-perishables meeting regulations. Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature. Program site was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors. No deficiencies Exit interview conducted and copy provided.the state’s words, verbatim · CDSS document, Apr 23, 2026

Allegation investigated: Staff did not prevent a resident from sexually assaulting another resident in care. Staff are bribing residents in care. Staff left residents in soiled clothing for a long period of time.

The purpose of this report today 3/12/2026 is to obtain additional information in regards to the allegation, Staff are bribing residents in care. At today's visit medication was reviewed for Resident R1- Resident R7. Interviews were conducted with Resident's R4-R6. Attempts were unsuccessful to interview Resident's R1-Resident R3 who were unable to respond to questioning being non-verbal. Review of Special Incident Report's (SIR's) from 3/12/2025-3/12/2026. The initial visit was conducted on 2/19/2026 and included the following: Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Ana Gallegos and explained the reason for the visit. The purpose of the visit is to investigate the above allegations. At today's visit the following was done: On 2/19/26 Resident and Staff Roster submitted. Unsubstantiated Documentation titled Outings and Activity Log and also Menu and Outing Planning were submitted. Interviews were conducted with Administrator, Staff S1- Staff S6 and Resident's R4- R7. Resident R1- Resident R3 were unable to respond to questioning being non-verbal. Law Enforcement El Monte visit 01/26/26 Case # 26-003369 In regards to the allegation Staff did not prevent a resident from sexually assaulting another resident in care. based on interviews conducted and information gathered 6 of 6 staff who have been working at the facility in the range of 3 to 12 years all stated that there has never been a sexual assault. All stated the only incident ever occurring was a resident touching another resident on the inside of the knee and leg. All stated that the resident was relocated immediately. Resident's R4-R7 all stated the staff are great and they never saw anything bad by staff. Said they never heard or saw anything inappropriate between residents. Administrator stated that one resident had touched another resident on the inside of her leg and the Regional Center automatically relocated the resident. Stated that was the only incident here. Corrective Action Plan (CAP) was given on 2/7/24 for late reporting, but no action taken regarding the incident involving the 2 residents and touching. 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. In regards to the allegation Staff are bribing residents in care, based on interviews conducted and information gathered Resident's R4-R7 all stated that staff will take them to where they want to go and never bribe them. Staff S1- S6 all stated that there has never been a bribe and that all residents can choose where to eat at when they go on outings .Administrator stated that there is documentation titled Outings and Activity Log and also Menu and Outing Planning that were submitted. On those documents are resident's names and where they want to go. On the Menu and Outing Plan LPA observed that there was a list with residents names and their choosing of El Pollo Loco, Carl's Junior and In and Out. Also was listed foods they want such as albondigas, chile rellenos and mole y arroz. On the Outing and Activity Log there ranging from 7/28/25- 12/25 activity at different fast food locations such as El Pollo Loco Yum Yum Donuts and Mariscos. At today's visit 3/12/2026 Resident's R4-R6 all stated they have always received their medication and never has there been a mistake of getting someone elses medication and have never been bribed. Staff S1-S4 all stated that there has been no medication errors and no resident has ever been bribed. Review by LPA of Special Incident Report's (SIR's) from 3/12/2025-3/12/2026 resulted in there being 0 SIR's submitted related to medication errors. Medication was reviewed for Resident R1- Resident R7 and contained 0 medication errors. 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. In regards to the allegation Staff left residents in soiled clothing for a long period of time, based on interviews conducted and information gathered Staff S1- Staff S6 all stated that only 1 resident needs their diaper changed. All said that they will check on that resident every hour at the maximum. Also said there has never been any irritation or rashes observed. Resident R4- R7 all stated that they do not need diaper changes. Resident R1 was non-verbal and unable to respond to questioning. Resident R5 stated that Resident R1 gets his diaper changed and is his roommate. Said they do a good job. Administrator stated that only Resident R1 needs diaper changes and they routinely check on him every hour and there has never been any problems with irritation and rashes. Said it is always dry and clean. 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.the state’s words, verbatim · CDSS document, Mar 12, 2026 · control 28-AS-20260122125344

Allegation investigated: Staff did not prevent a resident from sexually assaulting another resident in care. Staff are bribing residents in care. Staff left residents in soiled clothing for a long period of time.

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Ana Gallegos and explained the reason for the visit. The purpose of the visit is to investigate the above allegations. At today's visit the following was done: On 2/19/26 Resident and Staff Roster submitted. Documentation titled Outings and Activity Log and also Menu and Outing Planning were submitted. Interviews were conducted with Administrator, Staff S1- Staff S6 and Resident's R4- R7. Resident R1- Resident R3 were unable to respond to questioning being non-verbal. Law Enforcement El Monte visit 01/26/26 Case # 26-003369 In regards to the allegation Staff did not prevent a resident from sexually assaulting another resident in care. based on interviews conducted and information gathered 6 of 6 staff who have been working at the facility in the range of 3 to 12 years all stated that there has never been a sexual assault. All stated the only incident ever occurring was a resident touching another resident on the inside of the knee Unsubstantiated and leg. All stated that the resident was relocated immediately. Resident's R4-R7 all stated the staff are great and they never saw anything bad by staff. Said they never heard or saw anything inappropriate between residents. Administrator stated that one resident had touched another resident on the inside of her leg and the Regional Center automatically relocated the resident. Stated that was the only incident here. Corrective Action Plan (CAP) was given on 2/7/24 for late reporting, but no action taken regarding the incident involving the 2 residents and touching. 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. In regards to the allegation Staff are bribing residents in care, based on interviews conducted and information gathered Resident's R4-R7 all stated that staff will take them to where they want to go and never bribe them. Staff S1- S6 all stated that there has never been a bribe and that all residents can choose where to eat at when they go on outings. Administrator stated that there is documentation titled Outings and Activity Log and also Menu and Outing Planning that were submitted. On those documents are resident's names and where they want to go. On the Menu and Outing Plan LPA observed that there was a list with residents names and their choosing of El Pollo Loco, Carl's Junior and In and Out. Also was listed foods they want such as albondigas, chile rellenos and mole y arroz. On the Outing and Activity Log there ranging from 7/28/25- 12/25 activity at different fast food locations such as El Pollo Loco Yum Yum Donuts and Mariscos. 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. In regards to the allegation Staff left residents in soiled clothing for a long period of time, based on interviews conducted and information gathered Staff S1- Staff S6 all stated that only 1 resident needs their diaper changed. All said that they will check on that resident every hour at the maximum. Also said there has never been any irritation or rashes observed. Resident R4- R7 all stated that they do not need diaper changes. Resident R1 was non-verbal and unable to respond to questioning. Resident R5 stated that Resident R1 gets his diaper changed and is his roommate. Said they do a good job. Administrator stated that only Resident R1 needs diaper changes and they routinely check on him every hour and there has never been any problems with irritation and rashes. Said it is always dry and clean. 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.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 28-AS-20260122125344

Allegation investigated: Staff mismanaged resident's medication Staff did not administer resident's medication as prescribed.

Licensing Program Analyst (LPA), Glenn Trueman, made a visit to Kendall Guest Home 2. The purpose of today's visit is to investigate the allegations above. On today's visit LPA met with Administrator Ana Gallegos and explained the reason for the visit. Medication was reviewed for Resident R1. Resident R2 no longer resides at the facility. Interviews were conducted with Administrator Ana Gallegos and Staff S1 (telephonically.) LPA received a report from the SG/Pomona Regional Center dated May 19, 2025. The report states that on February 12th, 2025 the Quality Assurance Specialist made an unannounced visit. The following issue was identified: On the evening of February 08, 2025, Staff S1 was not prepared with the water pitcher when starting to provide medication to the residents. Staff S1 left the room to get water, with Resident R1's medication in hand. Staff S1 was asked for water by Resident R2 and inadvertently gave Resident R2 medication in her hand that belonged to Resident R1. Medication included Atorvastatin 40MG Tablet, Amlodipine 5MG Tablet and Clonazepam 0.5MG Tablet. Staff S1 immediately contacted the administrator. Substantiated In regard to the allegation Staff mismanaged resident's medication, based on interviews conducted and information gathered Staff S1 confirmed that an error did occur on 02/08/2025. Stated that Resident R2 was given R1's medication after she had left the room to get water. Administrator stated that Resident 1's medication was given to Resident R2 and that it was a mistake. Said that Staff S1 notified her immediately of the error. San Gabriel Pomona Regional Center on an unannounced visit during a review of resident's medication observed there to be an error. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per Title 22, deficiencies are cited. In regards to the allegation Staff did not administer resident's medication as prescribed, based on interviews conducted and information gathered Staff S1 confirmed that Resident R2 did miss evening medication. Administrator stated that per physician's advice Resident R2 was asked to skip medication Mapa 500MG Tablet, Atorvastatin 20MG Tablet for the evening and resume with medication as prescribed the following day 2/09/2025. San Gabriel Pomona Regional Center's unannounced visit revealed the medication error and in the Corrective Action Plan dated May 19, 2025 a substantial Inadequacy and citation was issued for failure to administer medication as prescribed. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per Title 22, deficiencies are cited.the state’s words, verbatim · CDSS document, Jun 3, 2025 · control 28-AS-20250528163808

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jun 3, 2025

Incidental Medical and Dental A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: Medications usually prescribed for self-administration which have been authorized by the person's physician. This requirement was not met as evidenced by: Based on documentation and interview licensee failed to provide assistance with self administered medication with Resident R2 missing evening dose of medication and Resident R1's meds mismanaged which posed an Immediate Health and Safety Risk to residents in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: Administrator is to provide in-service training to all staff on appropriate medication dispensing procedures and email the materials and list of attendees to LPA by the POC due date. Proof of training submitted to LPA dated 02/11/2025. Deficiency cleared.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Administrator Ana Gallegos and explained the reason for the visit. The purpose of the visit is to complete the required inspection. LPA Trueman toured the facility along with Administrator Ana Gallegos today 05/08/2025 at 1:15 PM and the following was observed: Facility contains 6 Client Bedrooms and 4 Client Bathrooms, dining room, living room, TV room, and activity room. Annual Inspection includes the following Domains: Infection Control, Physical Plant and Environment Safety, Operational Requirements, Staffing, Personnel Records- Staff Training, Resident Records- Incident Reports, Resident Rights/Information. Food Service, Planned activities, Incidental Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Interviews were conducted with 4 clients and 3 staff. 4 client files and 4 staff files were reviewed All staff were cleared and associated. Medication was administered per physician's directions. Signage for hand washing and proper sanitizing were posted. Staff have been trained in hand washing. Staff responsible for providing care and supervision received training in First Aid. Licensee maintained an individual admission agreement for each client. Fire Clearance has been maintained. Facility had sufficient supply of 2 day perishable and 7 day non-perishables meeting regulations. Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature. Program site was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors. No deficiencies Exit interview conducted.the state’s words, verbatim · CDSS document, May 8, 2025

Allegation investigated: Facility failed to meet reporting requirements

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Ana Gallegos and explained the reason for the visit. The purpose of the visit is to investigate the above allegation. At today's visit the following was done: Resident and Staff Roster submitted. Interview was conducted with the Administrator. LPA reviewed Resident R1 and Resident R2's file and the following was submitted: Resident ID Notes, Physician's Report, and Face Sheet. Special Incident Report (SIR) dated 01/02/24 was submitted. In regards to the allegation Facility failed to meet reporting requirements, based on interview conducted and information gathered it was confirmed by the Administrator that the Special Incident Report (SIR) was not submitted within the 7 day time frame. Administrator stated that staff documented the incident in client notes, but did not inform the Administrator or any other agencies. Substantiated Administrator upon reading through Resident ID notes at a later date immediately issued the SIR and contacted Regional Center and APS. The incident involved Resident R1 inappropriately touching Resident R2. It should be noted that Resident R1 was relocated to another facility. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per Title 22, deficiencies are cited.the state’s words, verbatim · CDSS document, Aug 8, 2024 · control 28-AS-20240731141906

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)1(D) · Plan of correction due date: Aug 12, 2024

Reporting Requirements Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Facility failed to report a Special Incident Report involving Resident R1 inappropriately touching Resident 2 which is caused a potential risk to residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2024

Plan of correction: Facility to submnit by POC due date, training regarding the reporting of special incidents and submit the signed log of those who attended. Facility submitted proof of training that was given by the Regional Center on 01/25/24. Deficiency cleared.

Allegation investigated: Resident was not treated with dignity Resident was not provided privacy Facility did not follow plan of operation Resident did not have control his/her own cash resources

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced subsequent visit to the facility and was greeted by Administrator Ana Gallegos and explained the reason for the visit. The purpose of the visit is to deliver findings in regards to the above allegations. At today's visit the following was done: On 06/11/2024 Resident and Staff Roster submitted. Interviews were conducted with Administrator, Staff S 1 and Residents R1 and R2 from 09:30 AM to 11:50 AM. The remaining residents were at Day Program. In regards to the allegation Resident was not treated with dignity, based on interviews conducted and information gathered Administrator confirmed that staff had taken pictures of the client's and then sent to her. Stated that she wants them to look nice and outfits to look good for them. Administrator confirmed that the San Gabriel Pomona Regional Center conducted a facility visit and said no more pictures. Substantiated Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per Title 22, deficiencies are cited. In regards to the allegation Resident was not provided privacy, based on interviews conducted and information gathered Administrator confirmed that the Regional Center Representative did observe a resident in the bathroom with the door open. Stated she was aware of it and would ensure privacy for all residents. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per Title 22, deficiencies are cited. In regards to the allegation Facility did not follow plan of operation, based on interviews conducted and information gathered Administrator stated that there were cameras in common areas and she did not notify San Gabriel Pomona Regional Center or Licensing. Staff S1 stated that there have been cameras in facility to ensure client safety. Administrator confirmed that San Gabriel Pomona Regional Center on a past visit observed the cameras. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per Title 22, deficiencies are cited. In regards to the allegation Resident did not have control his/her own cash resources., based on interviews conducted and information gathered Administrator stated that on birthday celebrations each client would get a candy bag and $5 would be taken from P and I without all client's approval. Said on occasions client might want a certain food for their celebration and all client's P and I will be used without their approval. Administrator confirmed that San Gabriel Pomona Regional Center on a past visit spoke about not using client's P and I without their input. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per Title 22, deficiencies are cited. as a facility entrance. 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. In regards to the allegation Staff did not maintain a comfortable temperature at the facility, based on interviews conducted and information gathered Administrator stated that the temperature is comfortable at the facility. Staff S1 stated that the temperature is comfortable and they try to keep it average for everyone because some get cold and some get hot. R1 and R2 stated the temperature is good at the facility and if hot they put on the air conditioner and if cold they will put on the heater. LPA measured temperature in the common area at 72.3F meeting Title 22 Regulations. 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. In regards to the allegation Staff did not meet resident's needs, based on interviews conducted and information gathered R1 and R2 stated that there is 1 English speaking staff and 1 Spanish speaking staff. Administrator stated that there has been a staff speaking English at this facility. Interview with Staff 1 who spoke English and Spanish and stated he communicates in both languages whenever needed to be able to meet all residents needs. 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.the state’s words, verbatim · CDSS document, Jun 11, 2024 · control 28-AS-20230829130550

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a) · Plan of correction due date: Jun 13, 2024

Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. Based on interviews conducted Administrator confirmed that staff take pictures of client's and send to her, also resident did not have privacy with the door open when using the restroom and Residents’ monies are being used to purchase clothing and birthday decorations, without resident input. which causes a potential risk to residents in care.the state’s words, verbatim · CDSS document, Jun 11, 2024

Plan of correction: Administrator to review 87468.1 Personal rights and self certify by POC due date that pictures will not be taken of client's by staff, residents will have privacy, and resident monies will not be used without their consent. Deficiencies cleared on 09/11/2023 with the same allegations for Kendall 1.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Jun 13, 2024

Plan of Operation Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. This requirement was not met as evidenced by: Based on interviews conducted Administrator stated that cameras were in common areas and was not approved by licensing which posed a potential risk to client's in care.the state’s words, verbatim · CDSS document, Jun 11, 2024

Plan of correction: Administrator had removed all cameras before initial visit conducted on 09/11/2023. Deficiency cleared.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Administrator Ana Gallegos and explained the reason for the visit. The purpose of the visit is to complete the required inspection. LPA Trueman toured the facility along with Administrator Ana Gallegos today 05/14/2024 at 1:15 PM and the following was observed: Facility contains 6 Client Bedrooms and 4 Client Bathrooms, dining room, living room, TV room, and activity room. Annual Inspection includes the following Domains: Infection Control, Physical Plant and Environment Safety, Operational Requirements, Staffing, Personnel Records- Staff Training, Resident Records- Incident Reports, Resident Rights/Information. Food Service, Planned activities, Incidental Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Interviews were conducted with 2 clients and 3 staff. 6 client files and 8 staff files were reviewed All staff were cleared and associated. Medication was administered per physician's directions. Signage for hand washing and proper sanitizing were posted. Staff have been trained in hand washing. Staff responsible for providing care and supervision received training in First Aid. Licensee maintained an individual admission agreement for each client. Fire Clearance has been maintained. Facility had sufficient supply of 2 day perishable and 7 day non-perishables meeting regulations. Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature. Program site was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors. No deficiencies Exit interview conducted.the state’s words, verbatim · CDSS document, May 14, 2024