Kingsley Manor

Allegation investigated: Staff do not serve residents food of good quality Staff do not ensure that residents' dietary needs are met

Licensing Program Analyst (LPA) Alberto Lopez made initial unannounced visit to investigate the above allegations. LPA met with Chia Demurjan, Interim Executive Director and Liyon O'Quinn, Administrator. LPA discussed the purpose of the visit. The investigation consisted of LPA obtaining and reviewing staff and resident rosters, R1 physicians report, facility menus, interviewed ten (11) residents (R#1 – R#11), four (4) staff (S#1- S#4), and took tour of dining hall during the lunch hour to observe the food served. The investigation revealed regarding allegation: Staff do not serve residents food of good quality. It is alleged that the food is not of good quality and consists of unhealthy food for resident. LPA interviewed ten (11) residents and nine (9) of ten (11) residents could corroborate the allegation. LPA interviewed four (4) staff, and all four (4) staff denied the allegation. (continued on 9099C) Unsubstantiated (continued from 9099) Administrator, (S1) stated that it is a personal taste preference of R1 and that the food served is nutritious and meets department requirements. S1 also stated that there are choices and that R1 eats at the facility every day. LPA toured the dining hall at lunch time and observed the food to appear fresh, varied and nutritious. Facility also has always available menu for residents that prefer to choose an alternative that is not on the daily menu. There is insufficient evidence to substantiate this allegation. Allegation: Staff do not ensure that residents' dietary needs are met. It is alleged that facility serves shrimp almost everyday and R1 cannot eat it due to high cholesterol content. LPA interviewed ten (11) residents and nine (10) of ten (11) residents could corroborate the allegation. LPA interviewed four (4) staff, and all four (4) staff denied the allegation. S1 stated that shrimp is not served every day and that R1 can make choice to have something else. LPA reviewed the menu for this week 08/24/2026, and shrimp was on the menu once for lunch and once for dinner on separate days. Menu shows other items available if resident does not want shrimp. LPA observed menu to have at least two main course items every day to choose for lunch and dinner every day. Facility also has always available menu for residents that prefer to choose an alternative that is not on the daily menu. R1 does not have doctor’s order for special diet on file. There is insufficient evidence to substantiate this allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with the Administrator. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Aug 25, 2026 · control 28-AS-20260818151148

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced required 1-yr inspection. LPA met with Chia Demurjan, Interim Executive Director and Milka Osorio, Director of Health Services, and explained the purpose of the visit. The facility is licensed to serve (285) ambulatory residents, (14) non-ambulatory residents, and hospice waiver for (14). Rooms 100, 101-108, 110, 11, 113, 115, 117 are provided for non-ambulatory. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility has Infection prevention and control plan, process, procedures and training plan. Staff are trained in the emergency infection control plan and following hand hygiene techniques. Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a sign-in station located in the main entrance lobby. Emergency and disaster plan was completed and up to date. Operational Requirements: Infection prevention and control plans have been added to the Plan of Operation. Liability insurance in the amount of ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires on 01/01/2027. Fire and disaster drills are conducted quarterly, and the last drill was last conducted on 06/25/2026. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the residents with special needs were observed. Physical Plant/Environment Safety: The facility contains multiple buildings such as the Administration Building (Main building), Kingsley Manor Care Center, Margaret Hall, Dining Hall, Leitzell Hall, Holly Cottage (Activities area) and the White house. The facility has (5) separate buildings that house residents, a dining room, a kitchen and several public restrooms located throughout the facility. LPA toured random resident rooms in different buildings and observed each bedroom to contain the necessary furnishings and linens. Bathrooms were observed to be clean and equipped with operational grab bars. ***CONTINUED FROM LIC 809**** The signal system is in various locations and is interconnected with the Fire Department. LPA checked the hot water temperature in random resident rooms and measured within 97.5 – 121.0 Degrees F which is out of range of 105.0 -120.0 degrees F required by Title 22 regulations, Additionally, the facility maintains a log of the water temperature. The common areas, covered patio, movie theater, family room and the main activity room are all located on the top/sixth floor of Leitzell Hall, while the main laundry for residents is in the basement of the building. certain buildings have elevators. The facility has cameras in common areas. The facility is gated with a parking lot that is connected to the main building, and the grounds are well landscaped. The facility has an emergency sprinkler system throughout. All the fire extinguishers were observed to be fully charged, last serviced on 04/06/2026 and in compliance. Cleaning supplies and disinfectants were kept locked and inaccessible to residents. During lunch preparation for residents, kitchen staff were observed wearing hairnets and disposable gloves. Exit doors are free of any obstruction and there are no pools or large bodies of water. There are no security bars or weapons on the premises. provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated with the facility. Night shift staff are trained and able to assist in care and supervision of the residents in case of an emergency. Personnel Records-Training: Ten (10) staff files were reviewed and confirmed fingerprint clearances, health screenings, vaccinations and 1st Aid/CPR training are current, Administrator certificate is valid and will expire on 05/02/2028. Residents Rights-Information: The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Notice of visiting policy is posted. The facility provides internet services to all residents and has access to the facility phone. Planned Activities: Activities calendar is up to date and posted. The facility has a Resident Council/Club and meet on a monthly basis. Facility provides equipment and sufficient space to accommodate both outdoor and indoor activities. CONTINUED (continued from 809C) Food Service: Director of dining services and LPA toured the kitchen, dining area and food storage in the basement. Sufficient food supply is stored in the kitchen, pantry areas and basement consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness were observed. Kitchen staff workers were observed to be wearing hairnets and using disposable gloves while working and preparing food. Incidental Medical & Dental: Medications were reviewed containing 30-day supply of medications. Medications are centrally stored, properly labeled and are in their original containers. First aid kit is maintained. Some residents get regular visits from their respective physicians. One resident’s PRN medication did not have labels on. Resident Records-Incident Reports: A total of (10) resident files were reviewed. They contained Admission Agreements, current Physician's Reports, Pre Placement Appraisal, TB clearance, Functional Capability Assessment, Identification & Emergency Information, Physician's Orders, Medical Consent, and Medication Records. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and there is an evacuation chair at the stairwell. LIC610 needs updating on assignments during emergencies. Residents with Special Health Needs: Director of Health Services stated that the facility retains residents with dementia if they are determined to be appropriate for the facility. One deficiency cited. Technical violations issued. Exit interview was held and a copy of the report was provided to Chia Demurjan, Interim Executive Director and Milka Osorio, Director of Health Servicesthe state’s words, verbatim · CDSS document, Jul 6, 2026

The state marks this report as 9 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Unlawful eviction Staff did not ensure and identify residents care needs were being met Staff did not ensure a care plan meeting was conducted with resident Staff did not ensure resident was free of retaliation after filing a complaint

Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent complaint visit to investigate the above allegations. LPA met with Milca Osorio and explained the purpose of today's visit. The investigation consisted of the following: On 8/19/26 LPA E.Irra conducted initial visit and obtained a copy of the staff/resident rosters, reviewed Resident #1 (R1's) file, and conducted interviews with 3 Staff. On 5/14/26 LPA Herrera conducted telephone interviews with R1 and 1 Staff (S2), obtained copies of R1’s Eviction Notice, Admission Agreement, yearly Needs and Service Plans from 2021-2025, Charting Notes, Court Documents and Seriff's Department Eviction Notice. LPA also obtained copies of Staff and Resident Rosters, all documents were received via email. During todays visit 5/18/26, LPA interviewed 3 Staff (S3-5) and 10 Residents (R2-R11), obtained a copy of the Activity Schedule and delivered findings on the reported allegations. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Unlawful eviction It is alleged that R1 was provided with an eviction notice that fails to provide a list of resources available to assist in providing alternative housing and care options. LPA interviewed R1 and they stated that they were not provided with resources for alternative housing and that the courts sided with facility on eviction. LPA was provided with a copy of Eviction Notice given to R1 dated 7/24/2025, the eviction notice documented reasons for eviction, the complaint contact numbers, and 3 different resources that could be used to find alternative housing. LPA obtained the Proceedings with Rulings on R1s eviction from the Los Angeles Superior Court dated May 1st 2026, stating that the Motion to Set Aside/Vacate Judgment filed by R1 on 04/20/2026 is Denied. LPA obtained a copy of the Sheriff's Department Eviction notice dated 4/22/26 with a eviction date of May 7, 2026 at 8:30am. LPA interviewed 5 staff and each denied the allegation S1 and S2 stated that R1 had a series of disruptive and aggressive behaviors towards both staff and residents, R1 would refuse to be assisted and multiple residents and guests would complain of the aggressive behaviors, stating that they felt distress when R1 was present. LPA interviewed 11 Residents and 10 out of the 11 residents denied the allegation and stated they have never been issued an eviction notice or observed any other residents be unlawfully evicted. Allegation: Staff did not ensure and identify residents care needs were being met. It is alleged that staff do not assist R1 with their needs and do not provide activities that can assist with promoting R1’s quality of life. LPA interviewed R1 and they stated that they have a musical background and staff at the facility made no efforts to provide musical activities for R1. LPA obtained a copy of the facility’s Activity Calander and observed that every Tuesday there was sing along, Concerts on Wednesdays or Thursdays, Musical activities with Composers on Saturdays and Opera Singers on Sundays. LPA interviewed 5 staff and each denied the allegation, S1 and S2 stated that R1 never mentioned a musical interest and that the facility does provide activities that involve music. Interview with S5 revealed that although R1 stated that they enjoyed music, R1 never participated in any of the musical activities, even after reminders of the schedule were given and participation was encouraged. LPA interviewed 11 Residents and 10 out of 11 Residents denied the allegation and stated their needs are being met, the facility provides and promotes many activities that include music, poker, karaoke, holiday parties, literature and many more. (Continued on LIC9099-C) Allegation: Staff did not ensure a care plan meeting was conducted with resident. It is alleged that there have been no meaningful efforts to create a care plan or have a meeting to assist R1 with their needs. LPA interviewed R1 and they stated that staff did not assist R1 with medical appointments or have meetings with R1 to create any care plans, R1 stated they are fairly independent and do not need assistance with ADL’s. LPA obtained copies of R1’s yearly assessments from 2021-2025, each assessment documented that R1 does not require assistance with Activities of Daily Living (ADL’s) such as grooming, bathing, toileting or assistance with transfers. LPA reviewed R1’s Charting Notes, there were notes stating that on 6/30/25, 7/11/25, and 10/7/25 staff provided assistance with scheduling visits for R1, however, R1 would refuse to attend. Charting Notes also detailed that R1 was on an unusual monitoring due to behavioral outbursts and aggression. LPA interviewed 5 staff and each denied the allegation and stated that R1 frequently refused any assistance and would close the door on staff or not let staff enter their room for regular cleaning. LPA interviewed 11 Residents and 10 out of 11 Residents denied the allegation and stated that staff constantly check in with them, offer support and although their care hasn’t changed since admission staff have met with them to ensure no additional care is needed. Allegation: Staff did not ensure resident was free of retaliation after filing a complaint. It is alleged that R1 was retaliated against as shortly after it was discovered that they filed a complaint they were issued an eviction notice. LPA interviewed R1 and they stated that they personally feel targeted and retaliated against by S1 and this stems from complaints that R1 has made verbally with S1 and complaints that S1 has discovered that R1 made with licensing or ombudsman. LPA interviewed 5 staff and each denied the allegation, S1 stated that they have never retaliated against R1 and that there is zero tolerance for residents utilizing their rights. LPA interviewed 11 Residents and 10 out of 11 Residents denied the allegation and stated they have never felt retaliated against by staff and have never seen other residents be retaliated against. Interviews with R9 and R10 revealed that they have complained about small things they were unhappy about, staff addressed their concerns and they never felt retaliated against by staff after voicing their opinions. Based on statements and interviews conducted with staff/residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 18, 2026 · control 28-AS-20250812093517

Allegation investigated: Staff inappropriately entered resident's room without permission Staff inappropriately woke resident up

*** This Licensing Report LIC-9099/LIC-9099C supersedes the LIC-9099/LIC-9099C LIC that was issued on 04/03/2026. The reason for the superseded licensing report is to separate the allegation into two allegations.*** Licensing Program Analysts (LPA) Luis De Leon conducted an unannounced subsequent complaint investigation visit for the allegations listed above to re-deliver report and findings for two separate allegations. LPA met with the Director of Health Services Milca Osorio and explained the reason for the visit. Administrator Liyon O'Quinn was not available during today's visit. During the initial visit on 01/15/2026, Resident’s (R1's) file documents were reviewed. Copies of relevant documents were obtained. LPA conducted a physical plant inspection of residents’ bedrooms, dining room, and activity areas. Residents (R1-R10) and staff (S1-S9) were interviewed. During visit on 04/03/2026, LPA delivered finding for one allegation on complaint. (Report continues on page LIC-9099C...) Unsubstantiated On today’s visit, LPA issued the superseded licensing report and re-delivered the licensing report. The findings will remain the same. Regarding allegation: Staff inappropriately entered resident's room without permission. It is alleged that staff entered resident’s room at night without resident’s invitation or permission. The investigation consisted of physical plant tours, interviews with staff, residents, and review of R1 facility file, including admission agreement, physicians report, needs and service plan, and facility staff training. The investigation revealed the following: On 11/15/2025, R1 pendant malfunctioned and staff took R1’s pendant for repair. S9 stated that S9 on 11/15/2025, around 10:30 PM, S9 was asked by facility shift nurse to return emergency call pendant to R1 at the beginning of S9’s shift. R1 is an independent resident, therefore, S9 does not normally enter R1’s room. S9 knocked on R1’s door two times to announce S9’s presence to R1, before entering R1’s room. S9 stated that S9 did not ring R1’s doorbell in case that R1 was already asleep. Upon S9 entering R1s room, R1 awoke and was startled and in distress after seeing an unknown staff member (S9), had entered R1’s room. R1 was aware that staff would return R1s pendant, however, R1 reported not being aware that staff would return R1s pendant on the same night the pendant was taken for repair. Interviews with residents revealed that nine (9) out of ten (10) residents stated that residents are not aware of staff entering residents’ rooms without permission. Six (6) out of ten (10) residents stated that staff sometimes wake residents at night to do welfare checks, but residents stated that residents understand the reason for staff doing welfare checks at night. Interviews with staff revealed that nine (9) out of nine (9) staff stated not to be aware of staff entering residents’ rooms without permission. Staff always knock on the door or ring the doorbell before entering residents’ rooms and staff announce themselves. At night, some residents may wake up during welfare checks, but staff try not to wake up residents. LPAs document review revealed that the facility has provided staff training on proper room entry on 11/17/2025, and 01/05/2026-01/12/2026. Based upon the investigation, client and staff interviews, document review, and LPA observations, there is no preponderance evidence to show that staff enters residents’ rooms without permission. Regarding allegation: Staff inappropriately woke resident up. It is alleged that staff entered residents’ room at night without the residents invitation or permission, causing the resident to wake up startled and become distressed when staff shone a light on the residents’ face. The investigation consisted of physical plant tours, interviews with staff, residents, and review of R1 facility file, including admission agreement, physicians report, needs and service plan, and facility staff training. (Report continues on page LIC-9099C...) The investigation reveals the following: On 11/15/2025, R1 pendant malfunctioned and staff took R1’s pendant for repair. S9 stated that S9 that on 11/15/2025, around 10:30 PM, S9 was asked by facility nurse to return emergency call pendant to R1 at the beginning of S9’s shift. R1 is an independent resident, therefore, S9 does not normally enter R1’s room. S9 knocked on R1’s door two times to announce S9’s presence to R1, before entering R1’s room. S9 stated that S9 did not ring R1’s doorbell in case that R1 was already asleep. Upon S9 entering R1s room, R1 awoke and was startled and in distress after seeing an unknown staff member (S9) had entered R1’s room at night and shone a light towards R1’s face. S9 denies shining a flashlight onto R1’s face. S9 reported being unfamiliar with the layout of R1’s room, therefore, S9 used a personal flashlight to assist with walking into the R1s room. S9 reported being in possession of a flashlight while in R1s room and shone the light onto the ceiling of R1’s room. S9 was following staff’s orders to return R1’s pendant and did not mean to disturb R1 or cause R1 any distress. S9 stated that the facility did not provide S9 with a flashlight and used the flashlight to assist with navigating R1s room. Additionally, S1 stated that the flashlights are not issued to staff by the facility. Interviews with residents revealed that nine (9) out of ten (10) residents stated that residents are not aware of staff entering residents’ rooms without permission. Six (6) out of ten (10) residents stated that staff sometimes wake residents at night to do welfare checks, but residents stated that residents understand the reason for staff doing welfare checks at night. The same six residents stated that no staff have shone a light on their faces at night or startled residents in their sleep. Interviews with staff revealed that nine (9) out of nine (9) staff stated not to be aware of staff entering residents’ rooms without permission and shining a flashlight on residents’ faces. Staff always knock on the door or ring the doorbell before entering residents’ rooms and announce themselves. At night, some residents may wake up during welfare checks, but staff try not to startle residents. Eight (8) out of nine (9) staff denied using a flashlight during welfare checks. LPAs document review revealed that the facility has provided staff training on proper room entry on 11/17/2025, and 01/05/2026-01/12/2026. Based upon the investigation, client and staff interviews, document review, and LPA observations, there is no preponderance evidence to show that staff wakes residents up inappropriately in the performance of staff duties. 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 held with Director of Health Services Milca Osorio. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 18, 2026 · control 28-AS-20260109150138

Allegation investigated: Staff do not keep facility free from bedbugs.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 05/15/2026 regarding the above allegation. On 04/03/2026, LPA De Leon conducted an initial complaint investigation, and a need for further investigation was documented. During today’s visit LPA Ramirez was greeted by Liyon O'Quinn and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster, Staff#1 - 5 interviews (S1 – S5), Resident#1-6 interviews (R1 – R6), Pest Control Technician interview (W1), Pest Control Service Reports from October 2025 through May 2026, and physical plant tour. SEE 9099-C Unsubstantiated The investigation revealed the following: regarding the allegation “Staff do not keep facility free from bed bugs.” It is alleged that R1 and other residents’ bedrooms have bed bugs and staff do not keep the facility free from bed bugs. Five (5) out of the five (5) staff interviewed denied this allegation. Staff interviews revealed that if residents suspect they may have bed bugs in their room, the facility contacts their contracted Pest Control company to come out and treat the resident’s room immediately. Staff interviews revealed that when bed bugs have been discovered in a resident’s room, staff instruct the resident to discard items that cannot be treated, however some residents refuse to discard their items. Interview with W1 revealed that they are the facility pest control technician and conduct pest control services monthly and as needed for immediate concerns. W1 revealed that the facility has followed all recommendations to eliminate bed bugs in resident rooms. W1 revealed that after an initial treatment for bed bugs, the resident room is then re-treated again in 2 to 3 weeks. W1 revealed that they have witnessed residents’ refusal to dispose of certain items that they have seen infested with bed bugs and the bed bugs return even after bed bug treatment was provided to the room. Two (2) out of nine (9) residents interviewed corroborated this allegation. Resident interviews revealed that the facility does provide treatment for bed bugs, and they have seen pest control technicians at the facility at least once a month. R8 revealed they currently have bed bugs in their room and staff are not treating the infestation. LPA Ramirez and S5 toured R8’s room and did not observe bed bugs in R8’s mattress or bedroom furniture. S5 revealed that R8 has never mentioned they have bed bugs or that R9 has seen bed bugs in their room. R9 revealed they had bed bugs twice in 8 months but that recently their room had been treated and no longer have bed bugs. LPA toured R9’s bedroom and did not observe bed bugs in R9’s mattress or in nearby furniture. Record review of pest control services report revealed that on 05/11/2026, no live bed bugs were observed in R9’s room and pest control recommended staff monitor R9’s room. 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 conduct. A copy of this report was provided. No deficiencies were cited during this investigation.the state’s words, verbatim · CDSS document, May 15, 2026 · control 28-AS-20260402090409

Allegation investigated: Staff do not keep the facility free of pests.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation regarding the allegation that staff do not keep the facility free of pests. LPA arrived unannounced and met with the Executive Director, Liyon O’Quinn. The purpose of the visit was explained. LPA toured the facility and selected ten (10) rooms to inspect. LPA obtained copies of the resident and staff rosters as well as pest control reports. Interviews were held with the Administrator, four (4) Staff, ten (10) residents, and the pest control specialist. Allegation – Staff do not keep the facility free of pests. It is alleged that a resident has not been able to sleep in their own bed for months due to having bed bugs, and the facility does not keep free it of roaches. LPA interviewed the administrator and four (4) staff who stated that they will treat the areas where pests are found immediately. The facility has regular pest control services to spray the buildings at least monthly. Unsubstantiated Any rooms that are reported to have bed bugs or other pests are also inspected and serviced by the specialist. Staff stated that the residents are relocated to another room as their rooms are being treated. For one resident, it was recommended that the resident dispose of the bed because the bed bugs could be embedded in the wooden frame. However, the resident would not allow the removal of the bed to help eradicate the bed bugs. LPA spoke to the pest control specialist, who stated that they visit the facility every other week to inspect and treat for cockroaches and other pests, as well as bed bugs if needed. LPA reviewed pest control invoices for March, April, and May. The reports show that the specialist has been inspecting and treating any sightings of roaches and bed bugs. Based on information gathered, the facility is taking action to prevent pests in the facility and continuing to treat rooms where pests are observed. 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. An exit interview was conducted with the Administrator. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, May 12, 2026 · control 28-AS-20260504170528

Allegation investigated: Staff entered resident's room without permission and awoke resident

Licensing Program Analysts (LPA) Luis De Leon conducted an initial unannounced subsequent complaint visit for the allegations listed above. LPA met with Executive Director Liyon O’Quinn and explained the reason for the visit to deliver findings. During the initial visit on 01/15/2026, Resident’s (R1's) file documents were reviewed. Copies of relevant documents were obtained. LPA conducted a physical plant inspection of residents’ bedrooms, dining room, and activity areas. Residents (R1-R10) and staff (S1-S9) were interviewed. On today’s visit, LPA delivered findings on above allegations. (REPORT CONTINUES ON PAGE LIC-9099C...) Unsubstantiated Regarding allegation: Staff entered resident's room without permission and awoke resident. It is alleged that staff entered R1’s room at night without R1’s invitation or permission which caused R1 to wake up and get startled and distressed when S9 shone a light on R1’s face. Investigation consisted of physical plant tours, interviews with staff, residents, and review of R1 facility file, including admission agreement, physicians report, needs and service plan, and facility staff training. The investigation reveals the following: Interviews with residents revealed that eight (8) out of ten (10) residents stated that residents are not aware of staff entering residents’ rooms without permission. Six (6) out of ten (10) residents stated that staff sometimes wake residents at night to do welfare checks, but residents stated that residents understand the reason for staff doing welfare checks at night. The same six residents stated that no staff have shone a light on their face at night or startled residents at night. Interviews with staff revealed that nine (9) out of nine (9) staff stated not to be aware of staff entering residents’ rooms without permission. Staff always knock on the door or ring the doorbell before entering residents’ rooms and announce themselves. At night, some residents may wake up during welfare checks, but staff try not to startle residents. Eight (8) out of nine (9) staff denied using a flashlight during welfare checks. S9 denied shining a flashlight on R1’s face, and instead, S9 stated that S9 shone the light onto the ceiling. On 11/15/2025, S9 stated that S9 was asked to return the emergency call pendant to R1 at beginning of graveyard shift. Since R1 is an independent resident, S9 does not normally enter R1’s room. S9 stated that S9 was not familiar with R1’s room layout, and therefore, S9 use a flashlight to assist walking into the room. S9 stated that a flashlight is not provided by facility but S9 uses a flashlight because of S9’s poor vision. LPA document review revealed that the facility has provided staff training on proper room entry on 11/17/2025, and 01/05/2026-01/12/2026. S1 stated that facility does not issue flashlights to staff. Based upon the investigation, client and staff interviews, document review, and LPA observations, there is no preponderance evidence to show that staff is entering residents’ rooms without permission and waking up residents. 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 the Director of Health Services Milca Osorio. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 3, 2026 · control 28-AS-20260109150138

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Luis De Leon conducted a Health and Safety check visit in response to a Special Incident Report (SIR) that was submitted to Licensing on 03/31/2026. The SIR indicated that Resident #1 (R1) contacted the police department on 03/28/2026 in regard to a personal right violation that R1 experienced. LPA met with Executive Director Liyon O’Quinn and explained the reason for the visit. Investigation consisted of the following: LPA De Leon requested a copy of Staff roster and Resident roster and conducted a tour of the facility and common areas. LPA obtain copies of R1 and S1 relevant documents. During tour of the facility, LPA observed the residents to identify any signs of neglect, abuse, or other immediate health and safety risks. LPA did not observe any immediate Health and/or Safety concerns. Exit interview conducted and copy of this report was provided to the Director of Health Services Milca Osorio.the state’s words, verbatim · CDSS document, Apr 3, 2026

Allegation investigated: Staff are threatening resident. Staff had resident sign a document without resident's authorized representative present

** This report supersedes report dated 10/07/2025 to clarify details of findings but there is no change to investigation findings. ** On today’s visit, Licensing Program Analyst (LPA) Luis De Leon conducted a subsequent complaint visit and met with HR Director Connie Wilson. LPA explained the reason for today’s visit was to redeliver the licensing report. LPA was informed that Administrator Liyon O’Quinn was not available for today’s visit. LPA toured residents’ common areas and observed no health and safety risks. On 10/07/25, Licensing Program Analysts (LPAs) Luis De Leon conducted a subsequent complaint visit to continue investigation for the allegations listed above. LPA met with the Director of Health Services Milca Osorio and explained the reason for the visit. Ms. Osorio stated the Administrator Liyon O’Quinn was not available for the 10/07/25 visit. Report continues on page LIC-809c Unsubstantiated During the initial visit on 08/19/2025, LPA De Leon obtained a copy of the staff and resident rosters and reviewed resident #1 (R1) file and obtained relevant documentation. LPA interviewed Staff #1 (S1) through Staff #3 (S3). LPA obtain copies of communication between billing department and R1 family members, invoices. Regarding allegation: Staff are threatening resident. It is alleged that the facility is threatening resident 1 (R1) with eviction, if R1 does not pay in full the amount owed for basic services and additional memory care services. Investigation consisted of interviews with staff, residents and review of R1 facility file, including an eviction notice issued to R1 dated 08/27/2025, and R1’s physician report dated 08/21/2024. The investigation reveals the following: Seven (7) out of seven (7) staff denied the allegation and stated that staff have never threatened residents. LPA interview with residents revealed that nine (9) out of ten (10) residents denied the allegation above and stated that residents have never been threatened by staff and staff deny issuing an eviction notice to R1 as a threat to R1. LPA interviewed R1 along with R1’s family member who R1 called via telephone, however, R1 did not address LPAs questions regarding the staff threatening R1. LPA record review revealed that R1’s physician report dated 08/21/2024 indicates that R1 is able to leave facility unassisted, able to follow instructions, able to communicate needs, and able to manage R1s own cash resources. Review of R1’s Physician report indicates the R1 is self-responsible and handles R1’s own finances. Additionally, R1’s physician’s report identifies R1 as having Mild Cognitive Impairment (MCI). The facility issued R1 with an eviction notice dated 08/27/2025 due to R1s non-payment for basic services for the period of September 2024 through August 2025, the charges include charges for memory care services. Report continues on page LIC-809C On 09/01/2024, an incident occurred when R1 went out into the community and R1 was unable to find a way back to the facility. R1 contacted the staff at facility via telephone to request assistance to find R1s way back to the facility. Staff located R1 around three blocks away from the facility and brought R1 back to the facility. On 09/01/2024, staff reassessed R1 as a result of the 09/01/25 incident, staff determined to place R1 in memory care services to prevent R1 from getting lost in the community and updated R1’s needs and services plan. R1’s additional charges for memory care services included additional charges for wearing a wander guard device that alerts staff in the event that R1 attempts to leave the facility. It was observed that R1 signed the agreement/form titled “Health and Wellness Review” and on 09/03/25, staff notified R1’s family member via email of the form being signed by R1. Since the 09/01/25 incident, the facility reports incidents where staff observed R1 wandering around the facility and knocking on doors to other residents’ room and pulling the facility’s fire alarm. As a result of R1 being lost in the community, and R1 being confused, the facility placed R1 in memory care services for R1’s health and safety. LPA reviewed R1s signed admission agreement dated 08/28/24, which R1 signed on 09/09/24, and LPA observed, under section B of R1s admissions agreement, that the facility is able to terminate the admission agreement for residents’ failure to pay monthly fees. Based upon the investigation, residents and staff interviews, document reviews, and LPA observations, there is no evidence to support that the facility staff are threatening a resident, the investigation revealed that R1 was given an eviction notice which complies with Title 22 regulations. Regarding allegation: Staff had resident sign a document without resident's authorized representative present. It is alleged that a resident #1 (R1) cannot speak or read English and the facility staff did not ensure that R1 had an authorized representative present when the R1 signed the notice for additional memory care services, which included new monthly fee charges. Investigation consisted of interviews with staff, residents and review of R1 facility file, including an Health and Wellness Review dated 08/16/2024 (Initial assessment) and 09/01/2024 (Facility Reassessment), and R1’s physician report dated 08/21/2024. Report continues on page LIC-809C The investigation reveals the following: Based on review of R1’s physician’s report dated 08/21/2024, R1’s is able to follow instructions, able to communicate needs, and able to manage own cash resources and R1’s physician’s report dated 08/21/2024 identifies R1 as self-responsible. R1’s Initial Health and Wellness Review dated 08/16/2024, indicates the facility assessed R1’s speech communication status as R1 is able to speak Korean and English is R1’s second language. R1’s Health and Wellness Review dated 09/01/2024, indicates R1’s additional charges for memory care services. It was observed that R1 signed the agreement/form titled “Health and Wellness Review” and on 09/03/25, staff notified R1’s family member via email of the form being signed by R1. Interviews with staff reveal that seven (7) out of seven (7) staff denied the allegation. Staff denied knowing that staff prevent residents, including R1 from consulting a third party before signing facility documents. Interviews with six (6) out of seven (7) staff reveal that interaction between staff and R1 were in English, and R1 English skills are limited. Staff described that R1 can communicate R1’s needs to staff. Interviews with residents reveal that nine (9) out of ten (10) residents feel that they are free to consult with anyone, including a family member or senior assistance center for help if residents prefer to have assistance regarding the review of a facility document, prior to singing the document. Residents stated that they have not felt compelled or forced to sign a document. All nine residents denied the allegation above. LPA interviewed R1 along with R1’s family member who R1 called via telephone, however, R1 did not address LPAs questions regarding the signing of facility documents. Based upon the investigation, client and staff interviews, document review, and LPA observations, R1 is self-responsible and able to sign documents; therefore, R1 does not need to have a representative present to sign documents. 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 held with Director of Health Services Milca Osorio. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 22, 2025 · control 28-AS-20250818141614

Allegation investigated: Facility staff do not ensure the facility is free of pest. Facility staff are not meeting the residents’ needs. Facility staff do not answer the facility phone.

Licensing Program Analysts (LPAs) Luis De Leon conducted a subsequent complaint investigation visit to deliver findings for the allegations listed above. LPA met with the Human Resources Director Connie Wilson and explained the reason for today’s visit. Ms. O'Quinn was notified over the phone of today's visit. During the initial visit on 10/07/2025, LPA De Leon requested and obtained copies of Resident/Client Roster, Staff Roster (LIC 500), staff interviews (S1 – S7), Interview of residents#1-10 (R1 – R10), copies of Resident#1 (R1): Admission Agreement, recent Physician Report, face sheet, and wellness report. LPA obtained invoices for pest control services for last six months. LPA toured the physical plant including random resident rooms, kitchen, dining area, dried food storage, produce and dairy storage. On today’s visit, LPA delivered findings on above allegations. Report continues on page LIC-9099C... Unsubstantiated Regarding allegation: Facility staff do not ensure the facility is free of pest. It is alleged that the facility does not ensure resident room to be cleared of bedbugs and that the facility has not provided a resolution for the issue. In addition, it is alleged that residents have cockroaches in their rooms. The investigation reveals the following: LPA interviews with residents revealed that six (6) out of ten (10) residents denied knowing any residents having pests in resident’s rooms or common areas. Six of the same residents denied having bedbugs, ants, or cockroaches in their rooms. Three (3) out of ten (10) residents recounted past experiences where residents had seen or known about cockroaches in residents’ rooms. However, residents stated that the facility had done a good job clearing the problem. LPA interviews with staff revealed that four (4) out of seven (7) staff denied the allegation above. Staff reported that when pests are observed in the rooms, the main office is notified, and pest control will treat the affected area. LPA observations revealed that kitchen, dining area, and storage were cleared from any pests. LPA observed pest control devices placed in the storage area and exterior of building to prevent pests. LPA reviewed the pest control service invoices for the past six months and observed that pest control services are done bi-monthly and as per need basis. LPA observed in the invoices that when the exterminator observed pest activity, the area was treated. Pest control invoice dated 9/26/2025 reports that the exterminator found bedbugs in R1’s room and the room has been treated three times since first reported. The facility is following pest control recommendations to clear room of bedbugs. The facility discussed with R1 the options that the pest control exterminator provided to clear R1’s room. On pest control invoice dated 9/29/2025, the exterminator stated in the treatment notes that the exterminator had spoken with R1 with recommendation to clear bedbugs and the exterminator notes that R1 agree to recommendation. PA random tour of residents’ rooms found no live pest, bedbugs, roaches or ants. Based upon the investigation, resident and staff interviews, document review, and LPA observations, the facility ensures that pest found in residents’ rooms and common areas are treated in a timely manner. Report continues on page LIC-9099c... Regarding allegation: Facility staff are not meeting the residents’ needs. It is alleged that staff are not providing escorts to dining area in a timely manner and are not assisting residents to obtain a seat to eat. The investigation reveals the following: LPA interview with residents revealed that eight (8) out ten (10) residents denied the above allegation. Five (5) out of ten (10) interviewed residents with walkers or wheelchairs stated that staff do not take too long to assist residents to escort them to activities in the community including dining room. Residents stated that sometimes staff take too long because staff is assisting other residents, but for the most part, residents stated that residents don’t have any concerns getting assistance from staff. A resident stated that resident sets up escorts appointments for services in the community and residents gets picked up on time. LPA interviews with staff revealed that seven (7) out of (7) staff denied the above allegation. Staff provide services to residents as soon as a request is received from nurse station. Staff providing support explained that staff promptly go to residents’ rooms, even if staff are busy with another resident. If the staff is assisting another resident, the staff will inform the resident requesting support that the staff will be back as soon as staff finishes with resident. If staff cannot respond, the staff informs the nurse station to assist checking with resident calling for support. Staff denied taking long to escort residents to dining area. Staff described having made themselves a schedule for dining escorts to prevent residents from being late for their meals. LPA observed dining area during lunch meals and observed residents sitting themselves at any available table. Staff stated that seating arrangements are on a first-come basis. LPA observed that staff assisted residents with mobility devices; staff helped residents to the table and stored away the devices so that the walkways were free of hazards. LPA did not observe any residents waiting to be seated. Based upon the investigation, resident and staff interviews, and LPA observations, the facility provides assistance with resident’s needs including activities in the community. Report continues on page LIC-9099c... Regarding allegation: Facility staff do not answer the facility phone. It is alleged that staff at front desk are not picking up the phone to answer residents’ phone calls and that the front desk has hanged up on residents’ calls. The investigation reveals the following: LPA interviews with residents revealed that nine (9) out of ten (10) residents denied the above allegation. All nine residents denied knowing any other residents who may have had issues calling the front desk. Five (5) out of ten (10) residents stated that residents don’t need to call the front desk; instead, residents use the pendant to call for assistance. Four (4) out of ten (10) residents stated that residents have called the front desk and the front desk have answered resident’s calls and all four residents stated that front desk has never hung up on their calls. Interview with staff revealed that seven (7) out of seven (7) staff denied the above allegation. All staff denied knowing of any resident having issues calling the front desk or that the front desk has hanged up on their call. LPA called the facility prior and during the visit at different times of the day and LPA did not experience any issues with front desk answering the call. During phone calls, LPA observed that a voice recorded message will greet the caller and asks the caller to wait to be transferred to a representative. Music will play while waiting for the front desk to respond. LPA observed front desk during the visit, and the front desk answered the phone for every call that was received. LPA observed that the phone system provides caller ID information, and during interviews, LPA learned that front desk could recognize caller names. Staff denied ever ignoring phone calls based on caller ID names because it could be an emergency. Staff pointed out that caller ID is disabled while the staff is on another call. LPA observed R1 placing call to front desk, but R1 hang up during music playing and before front desk staff picked up the call. R1 called front desk a second time and R1 was able to connect with front desk. Staff explained that it may be possible to miss calls when staff is already on the phone with another call. Staff stated that the front desk has a staff assigned during after hours. In addition, even if front desk does not pick up the phone, the call will automatically be transferred to the nurse station where some staff will answer the call. There is insufficient evidence to support this allegation. Based upon the investigation, resident and staff interviews, and LPA observations, the facility ensures that phone calls are answered. 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 allegations are unsubstantiated. Exit interview was held with Human Resources Director Connie Wilson. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 14, 2025 · control 28-AS-20251024124552

Allegation investigated: Staff are threatening resident Staff had resident sign a document without resident's authorized representative present

Licensing Program Analysts (LPAs) Luis De Leon conducted a subsequent complaint visit to continue investigation for the allegations listed above. LPA met with the Director of Health Services Milca Osorio and explained the reason for today’s visit. Ms. Osorio stated the Administrator Liyon O’Quinn was not available for today’s visit. During the initial visit on 08/19/2025, LPA De Leon obtained a copy of the staff and resident rosters and reviewed resident #1 (R1) file and obtained relevant documentation. LPA interviewed Staff #1 (S1) through Staff #3 (S3). LPA obtain copies of communication between billing department and R1 family members, invoices. On today’s visit, LPA toured residents’ common areas and observed no health and safety risks. LPA conducted interviews with residents and staff. Report continues on page LIC-809c. Unsubstantiated Regarding allegation: Staff are threatening resident. It is alleged that the facility is threatening resident 1 (R1) with eviction if R1 does not pay the full amount owed for unpaid monthly fees and additional charges to prevent R1 from eloping. It is alleged that the responsible family member was not present to sign off for additional fee and family member did not agree with R1 needing additional services. The investigation reveals the following: After an incident where R1 eloped from the facility on 09/01/2024, the facility reassessed R1. On 09/01/2024, the facility identified R1’s risk of eloping which resulted in staff providing additional service to prevent R1 from eloping from the facility. Due to change of condition, R1 agreed to wear the monitor bracelet and signed the rate increases form with the effective date of 09/01/2024. The facility added services to R1, which consisted of frequent wellness check and monitoring bracelet to alert staff when R1 is attempting to exit the facility. The facility informed R1’s family member on 09/03/2024 via email of fee increase. Based on initial physician’s report dated 08/21/2024, R1’s assessment was reported to be able to follow instructions, able to communicate needs, and able to manage own cash resources. The physician’s report identifies R1 as self-responsible. In addition, LPA’s facility’s invoice review for the period of 08/29/2024 through 08/01/2025 reveals that R1’s last payment for basic service was made on 04/07/2025, which did not pay the outstanding balance in full. Interview with residents reveal that ten (10) out of ten (10) residents denied the allegation. Seven (7) out of seven (7) staff denied the allegation. Based upon the investigation, client and staff interviews, document review, and LPA observations, the facility’s notice to collect on past due account and warning R1 or family member that evection process may be started is not a threat. Report continues on page LIC-809C Regarding allegation: Staff had resident sign a document without resident's authorized representative present It is alleged that the facility did not ensure that an authorized representative was present when R1 signed off the notice for additional services that were added to the monthly basic service fees. It is alleged that R1 cannot speak or read English. The investigation reveals the following: Based on initial physician’s report dated 08/21/2024, R1’s assessment was reported to be able to follow instructions, able to communicate needs, and able to manage own cash resources. The physician’s report identifies R1 as self-responsible. Based on initial Health and Wellness Review dated 08/16/2024, the facility assessed R1’s speech communication status as able to “speak Korean English is second language.” Interviews with staff reveal that seven (7) out of seven (7) staff denied the allegation. Staff denied knowing any staff preventing residents from consulting a third party before signing a facility document. Interviews with six (6) out of seven (7) staff reveal that interaction between staff and R1 were in English, although R1 English skills are limited, R1 was able to communicate his needs. Interviews with residents reveal that ten (10) out of ten (10) residents feel that they are free to consult with any family or senior assistance center for help in the event that residents do not understand a document. All residents denied the allegation above. Residents stated that they have not felt compelled to sign a document without reading it before or getting assistance if they don’t understand the document. LPA’s document review revealed that based on initial physician’s report dated 08/21/2024, R1’s assessment was reported to be able to follow instructions, able to communicate needs, and able to manage own cash resources. The physician’s report identifies R1 as self-responsible. Based upon the investigation, client and staff interviews, document review, and LPA observations, R1 is self-responsible and able to sign documents. The residents are free to consult family before signing any document as stated by residents’ interview. 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 held with Director of Health Services Milca Osorio. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 28-AS-20250818141614

Allegation investigated: Facility is charging resident for services not rendered

***This LIC-9099 report supersedes the LIC-9099 report dated 07/29/2025 to clarify the findings of only this allegation; However, the findings will remain the same.*** Licensing Program Analysts (LPAs) Luis De Leon conducted an unannounced complaint investigation visit for the allegation listed above. LPA met with Director of Health Services Milca Osorio and reason of visit was explained. Director Osorio stated that Director Liyon O'Quinn was not available for today's visit. The investigation consisted of the following: On today’s visit, LPA De Leon obtained the following documents: Admission Agreement, Physician’s Report, Pre-Admission Appraisal, re-appraisal, Incidents Reports (SIRs), Nurse notes, Health and Wellness Review, and Face Sheet. Report continues with page 9099C... Unsubstantiated Regarding allegation: Facility is charging residents for services not rendered. It is alleged that the facility is charging a resident for services that are not needed. Staff did not inform the residents’ responsible party of the additional monthly fees and staff did not obtain consent for the additional fees from the residents’ responsible party. The additional monthly fees are not listed in the residents’ admission agreement. The investigation revealed that, based on Resident 1 (R1) physician’s report dated 08/21/2024, R1 is self-responsible, able to follow instructions, and able to manage own cash resources. The investigations revealed that seven (7) out of eight (8) residents denied the allegation. Residents did not know of a resident who is being charged for services not received. LPA interviewed R1 and introduced himself at start of interview, but towards the end of interview, LPA had to re-introduce himself after R1 asked who LPA was. R1 was unable to answer questions from LPA and R1 directed LPA to speak with R1’s family. Interview with R1’s family member revealed that R1’s family member identified themselves as R1’s responsible party. R1’s family member learned of the additional fee for R1 in April 2025 when Director Ms. Lyon provided R1’s family member a bill for unpaid fees. R1’s family member reported that R1 doesn’t need additional care, and R1 is not receiving service that R1 is being charged. Five (5) out of eight (8) staff denied knowing or being involved in the decision and process to determine resident rate increases. One staff member stated to be aware of rate increase for R1 but staff is not involved in the process to increase rates for residents. Two staff described the process to re-assess R1 medical condition which resulted in a rate increase for additional services. After an incident where R1 eloped from the facility on 09/01/2024, the facility reassessed R1. On 09/01/2024, the facility identified R1’s risk of eloping which resulted in staff providing additional service to prevent R1 from eloping from the facility. Due to change of condition, R1 agreed to wear the monitor bracelet and signed the rate increases form with the effective date of 09/01/2024. The facility added services to R1, which consisted of frequent wellness check and monitoring bracelet to alert staff when R1 is attempting to exit the facility. The facility informed R1’s family member on 09/03/2024 via email of fee increase. Additionally, the facility staff contacted R1’s primary doctor who requested R1 to visit the physician’s office. Based upon the investigation, resident and staff interviews, document review, and LPA observations, R1 is receiving the services as identified by R1’s re-assessment to prevent R1 from eloping from the facility. R1 is self-responsible, and R1 does not have a responsible party. 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 Director of Health Services Milca Osorio. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 28-AS-20250721131320

Allegation investigated: Staff did not provide adequate supervision to prevent resident from eloping.

Licensing Program Analysts (LPAs) Luis De Leon conducted a subsequent complaint investigation visit to deliver findings for the allegation listed above. LPA met with the Director of Health Services Milca Osorio and explained the reason for today’s visit. Director Osorio stated that Director Liyon O'Quinn was not available for today's visit During the initial visit on 07/29/2025, LPA De Leon obtained the following documents: Staff and Resident Rosters, admission Agreement, Physician’s Report, Nurse’s notes, Face Sheet, SIRs, and hospital discharge. LPA conducted Interviews with residents and staff. On today’s visit, LPA toured residents’ common areas and observed no health and safety risks. LPA delivered findings on above allegations. Report continues on page LIC-809C... Substantiated Regarding allegation: Staff did not provide adequate supervision to prevent residents from eloping. It is alleged that a resident was missing since 07/20/2025. As of the date of submitting the complaint report to CCLD, the resident (R1) had not returned and was missing. It is alleged that R1 had recently shown to be having issues with cognitive decline and had been hospitalized twice. It is alleged that facility should have provided supervision to prevent R1 from eloping. The investigation revealed that record review indicated the R1 left facility on 07/20/2025 at approximately 11:00 AM. LPA interview with residents revealed that four (4) out of seven (7) residents were aware of a resident missing from the community. However, residents did not personally know R1. Residents became aware of R1 missing from other residents’ comments. LPA interview with staff revealed that six (6) out of six (6) staff were aware of R1 missing. Records reviewed revealed that based on R1’s physicians report dated 04/29/2025, R1 was not able to leave facility unassisted. Staff 1 (S1) stated that R1’s physician report dated 04/29/2025 indicated that R1’s inability to leave facility was because of physical condition and not because of mental disability. S1 provided a physician’s progress note dated 07/22/2025 indicating to the effect of R1’s physical limitation as the reason to not leave the facility unassisted. R1 returned safely to facility on 07/23/2025. On 07/29/2025, R1 was reassessed, and a new physician report was issued indicating R1 risk for elopement. Based upon the investigation, resident and staff interviews, document review, and LPA observations, the licensee did not ensure to follow physicians report to not allow R1 from leaving facility without adequate supervision even for reason of physical condition and not mental. Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC-9099D. Exit interview held with Director of Health Services Milca Osorio. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 28-AS-20250723092255

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 24, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on observation, interview, record review, the licensee did not comply with the section cited above in R1 was able to leave facility unassisted even though R1's physician's report stated that R1 was not to be allowed to go out of the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: Licensee/Administrator agreed to: 1. Adhere to approved Plan of Operation Staffing Plan and Hours. 2. Submit a written plan regarding staffing schedules, and a copy of staff in-service training to prevent eloping. Licensee shall provide CCLD with plan and training sign by all staff by POC date.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Elena Mallett and Luis De Leon conducted 24-hour Case Management incident visit and met with Administrator Liyon O'Quinn. LPAs explained the reason for today’s visit. LPAs conducted a physical plant tour of the common areas and did not observe any health and safety risks to residents in care. LPAs obtained resident 1 (R1) records and staff 1 (S1) records. LPA obtained R1’s face sheet, physician’s reports, appraisals, physician order, and admissions agreement. LPAs obtained S1’s background check, Front Porch Employment Application, clearance, resume, and health screening report. R1 alleges that an incident occurred on 9/7/2025 where staff 1 (S1) inappropriately touch resident 1 (R1). LPAs interviewed R1. Exit interview held with Administrator Liyon O’Quinn and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 9, 2025

Allegation investigated: Staff are not preventing resident from engaging in inappropriate behavior towards other residents in care.

Licensing Program Analyst (LPA) Daniel Konishi conducted a subsequent unannounced complaint visit at the facility and met with the Executive Director, Liyon O'Quinn to discuss the purpose for today's visit. The purpose of the visit is to investigate the above allegation. On 06/19/2025, the initial investigation visit was conducted. The investigation consisted of the following: Investigation consisted of the following: LPA requested a copy of staff and resident rosters. LPA also requested copies from Resident#1 (R1) file such as: Face Sheet, Physician’s Report, Admissions Agreement, Progress Notes, Assisted Living Waiver info, Incident Reports, Needs and Services Plan, Eviction Notice documents and court documents. LPA also received Face Sheets from Resident#5 (R5) to Resident#7 (R7) and former Resident #1 (FR1’s) files. LPA interviewed R1 to Resident #4 (R4), the Executive Director, and Staff #1 (S1) to Staff #5 (S5). Unsubstantiated On 08/26/2025, LPA Konishi spoke with the Executive Director over the phone. LPA obtained ongoing staff training on Preventing and Responding to Abuse and Residents’ Personal Rights by email. During today's visit, LPA obtained the following documents: staff and client rosters. LPA interviewed Resident #5 (R5) to Resident #18 (R18). The investigation revealed the following: In regards to the allegation, “Staff are not preventing resident from engaging in inappropriate behavior towards other residents in care.” It is alleged Resident #5 (R5) was pushed by Resident #1 (R1) in the dining hall since R5 was sitting at that R1’s preferred seat. It is also alleged that R1 was becoming more aggressive and yelled at other residents. It is alleged that R1 hit his hand on the table and threw a soda at another resident. LPA interviewed six (6) out of six (6) staff that all denied the allegation and stated the staff acted appropriately by immediately intervening, separating, and re-directing R1 and R5. Six (6) out of six (6) staff interviewed stated that R1 did not throw a soda can at another resident but slammed the soda can on the table. LPA interviewed R1 and R1 denied the allegation by stating not hurting R5 or anyone at the dining hall. R1 also stated that R1 did not throw any soda or object at R5. However, R1 stated that R1 was upset because R5 was sitting at R1's preferred seat and that the staff intervened and tried to de-escalate the situation by speaking to him and R5. LPA interviewed R5 and R5 denied the allegation stating that R1 did not yell at R5 or throw any soda or an object at R5 at the dining hall. LPA interviewed 18 out of 18 residents that denied the allegation and stated that the staff intervene whenever residents are involved in a physical or verbal altercation. LPA interviewed three (3) out of 18 residents that stated witnessing R1 and R5 involved in the verbal altercation in which staff immediately intervened to de-escalate the situation by separating the residents. Three (3) of the 18 residents interviewed stated witnessing the incident and no soda or object was thrown by R1 to another resident. LPA reviewed ongoing staff training on Preventing and Responding to Abuse and Residents’ Personal Rights in file. There was insufficient evidence to corroborate with the allegations. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, 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 allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to the Executive Director, Liyon O'Quinn.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 28-AS-20250618085712

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced required 1-yr inspection. LPA met with Liyon O'Quinn, Executive Director and Milka Osorio, Director of Health Services and explained the purpose of the visit. The facility is licensed to serve (285) ambulatory residents, (14) non-ambulatory residents, hospice waiver for (14). Rooms 100, 101-108, 110, 11, 113, 115, 117 are approvided for non ambulatory. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility has Infection prevention and control plan, process, procedures and training plan. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a sign-in station located in the main entrance lobby. Emergency and disaster plan was completed and up to date. Operational Requirements: Infection prevention and control plans have been added to the Plan of Operation. Liability insurance in the amount of ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires on 01/01/2026. Fire and disaster drills are conducted monthly, and the last drill was last conducted on 07/31/2025. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the residents with special needs were observed. Physical Plant/Environment Safety: The facility contains multiple buildings such as the Administration Building (Main building), Kingsley Manor Care Center, Margaret Hall, Dining Hall, Leitzell Hall, Holly Cottage (Activities area) and the White house. The facility has (5) separate buildings that house residents, a dining room, a kitchen and several public restrooms located throughout the facility. LPA toured random resident rooms in different buildings and observed each bedroom to contain the necessary furnishings and linens. Bathrooms were observed to be clean and equipped with operational grab bars. The signal system is placed in various locations and is interconnected with the Fire Department. LPA checked the hot water temperature in random resident rooms and measured within 105 – 120 Degrees F as required by Title 22 regulations, Additionally, the facility maintains a log of the water temperature. The common areas, covered patio, movie theater, family room and the main activity room are all located on the top/sixth floor of Leitzell Hall, while the main laundry for residents is in the basement of the building. Every building has a medication room, and certain buildings have elevators. The facility has cameras in the common areas. The facility is gated with a parking lot that is connected to the main building, and the grounds are well landscaped. The facility has an emergency sprinkler system throughout. All the fire extinguishers were observed to be fully charged, last serviced on 03/24/2025 and in compliance. During the tour, kitchen was inspected, knives, cleaning supplies and disinfectants were kept locked and inaccessible to residents. During lunch preparation for residents, kitchen staff were observed wearing hairnets and disposable gloves. Exit doors are free of any obstruction and there are no pools or large bodies of water. There are no security bars or weapons on the premises. ***CONTINUED ON LIC 809-C**** Staffing: A total of (107) staff members on the roster list including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Night shift staff are trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training: Ten (10) staff files were reviewed and confirmed fingerprint clearances, health screenings, vaccinations and 1st Aid/CPR training are current. One of the staff (Staff #3) does not have a current CPR/First aid training certificate, expired July 2025. Administrator certificate is valid and will expire on 10/11/2025. Residents Rights-Information: The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Notice of visiting policy is posted. The facility provides internet services to all residents and have access to the facility phone. Planned Activities: Activities calendar is up to date and posted. The facility has a Resident Council/Club and meet on a monthly basis. Facility provides equipment and sufficient space to accommodate both outdoor and indoor activities. Food Service: Director of dining services and LPA toured the kitchen, dining area and food storage in the basement. Sufficient food supply is stored in the kitchen, pantry areas and basement consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Kitchen staff workers were observed to be wearing hairnets and using disposable gloves while working and preparing food. Incidental Medical & Dental: Medications were reviewed containing 30-day supply of medications. Medications are centrally stored, properly labeled and are in their original containers. First aid kit is maintained. Some residents get regular visits from their respective physicians. Resident Records-Incident Reports: A total of (10) resident files were reviewed. They contained Admission Agreements, current Physician's Reports, Pre Placement Appraisal, TB clearance, Functional Capability Assessment, Identification & Emergency Information, Physician's Orders, Medical Consent, and Medication Records. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and there is an evacuation chair at the stairwell. Residents with Special Health Needs: Director of Health Services stated that the facility retains residents with dementia if they are determined to be appropriate for the facility. No deficiencies cited. Technical violation issued. Exit interview held and a copy of the report was provided to Liyon O'Quinn, Executive Directorthe state’s words, verbatim · CDSS document, Aug 12, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility is charging resident for services not rendered

Licensing Program Analysts (LPAs) Luis De Leon conducted an unannounced complaint investigation visit for the allegation listed above. LPA met with the Director Liyon O'Quinn and explained the reason for the visit. The investigation consisted of the following: On today’s visit, LPA De Leon obtained the following documents: Admission Agreement, Physician’s Report, Pre-Admission Appraisal, re-appraisal, Incidents Reports (SIRs), Nurse notes, Health and Wellness Review, and Face Sheet. LPA toured resident's common areas and observed no health and safety risks, Regarding allegation: Facility is charging residents for services not rendered. It is alleged that the facility did not inform R1’s responsible party of additional monthly fee and that R1’s responsible party did not consent to the additional services. It is alleged that the additional fee is not listed in R1's admissions agreement. R1’s responsible party learned of the additional fee in April 2025 when Director Ms. Liyon gave R1’s responsible party a bill for unpaid fees. R1’s responsible party stated that R1 doesn't need additional care and R1 is not getting service that are being charged. Report continues with page 9099C... Unsubstantiated The investigation revealed that R1 is self-responsible and it is able to manage own cash resources. The investigations revealed that seven (7) out of eight (8) residents denied that allegation above and that residents do not know anyone who is being charged for services not received. During R1 interview, LPA introduced himself at start of interview, but towards the end of interview, LPA had to re-introduce himself after R1 asked who LPA was. R1 was unable to answer questions from LPA and directed LPA to speak with family. Five (5) out of eight (8) staff denied knowing or being involved in the decision and process to determine rate increases. One staff member stated to be aware of rate increase for R1 but does not get involved in the process to increase rates to residents. Two staff described the process to re-assess R1 health condition which resulted in a rate increase for additional services. After an incident with R1’s eloping from the facility on 8/29/2024, the facility reassessed R1’s health condition. On 9/1/2024, the facility identified the risk of eloping which resulted in additional service to prevent R1’s from eloping. R1 signed off rate increases form which identified the effective date of 9/1/2024. Facility added service to do frequent wellness check and monitoring bracelet to alert staff when a resident is attempting to exit the facility. Facility Staff contacted R1’s primary doctor who requested R1 to visit the doctor’s office. Director Liyon O’Quinn requested R1’s family to set up appointment with R1’s primary care doctor. The facility has been requesting the latest physician report since 9/9/2024. R1’s family assists with R1’s medical appointments and transportation. On July 24, 2025, R1’s family stated via email that facility will get the latest physician’s report as soon as the doctor provides it to the family. Based upon the investigation, client and staff interviews, document review, and LPA observations, the residents is receiving the services as identified by re-assessment to prevent resident from eloping. 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 Director Liyon O'Quinn. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 28-AS-20250721131320

Allegation investigated: Staff did not provide adequate care and supervision to a resident Staff did not conduct a reassessment of a resident while in care

The purpose of this amended report dated 08/16/2025 is to remove specific medical and confidential information in regards to Resident R1 and in addition re- issue regulations that were cited incorrectly on 07/17/2025. The following was done on previous visit 07/17/2025: Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced subsequent complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Executive Director Liyon O'Quinn and explained the reason for the visit. The initial visit was conducted on 1/13/25 and the following was done: LPA collected copies of Staff and Resident Rosters. LPA conducted interviews with Executive Director Liyon O'Quinn, Client C1 and Staff S1 and Staff S2. Interviews were conducted with ALW Representative and Ombudsman Representative telephonically on 3/06/25. Interview with DCHS Representative telephonically on 7/16/25. At today's visit interviews were conducted with Residents R2- R10. In regards to the allegation Staff did not provide adequate care and supervision to a resident, based on Substantiated interviews conducted and information gathered it was revealed by ALW Representative that Resident R1's blood pressure is currently not checked. Stated due to age staff should check for safety on Resident R1 during rounds at nite, but they have not been. Resident R1 stated she does want to be checked by staff at night, but they have not been. Stated she is independent at alot of things but still needs help with blood pressure. Also said she has fallen in past and has had dizziness. Staff stated that R1 is independent with no services and does not need staff to assist her. Based on interviews conducted and document review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22. See LIC9099D. In regards to the allegation Staff did not conduct a reassessment of a resident while in care, based on interviews conducted and information gathered ALW Representative stated that Resident R1 has a care plan and was assessed by their nurse. Said facility was suppose to reassess and they didn't. Ombudsman stated that Resident R1 had a care plan and was assessed and met requirements for ALW program. It was revealed by ALW Representative that Resident R1's blood pressure is currently not checked. Stated due to age staff should check for safety on Resident R1 during rounds at nite, but they have not been. Staff stated that there was no change in condition so there was no need for reassessment. Based on interviews conducted and document review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22. See LIC9099D. In regards to the allegation Staff are unlawfully evicting a resident, based on interviews conducted and information gathered ALW Representative stated that there is an Official Form from the state that Resident R1 is enrolled in ALW dated 01/16/24. Interview with Department of Health Care Services (DHCS) Representative who stated Resident R1 is on the ALW Program and if conditions change (R1's husband passing away) and the resident has a contractual obligation signed at admission and the resident can not pay the rate to stay in the private room the facility can offer another room which allows the beneficiary to live in an RCFE approved room. Staff interviewed stated that Resident R1 is not being evicted at all. Said it is a transfer still in a private room and it has a shared bathroom. On 05/17/19 Resident R1 moved into Kingsley Manor and the Addendum To Resident Agreement Document was signed. On that document it states that if they become eligible for financial assistance they will be required to move to the first available private studio apartment with a shared bathroom as a condition of receiving assistance and continued residency at Kingsley Manor. On 1/10/24 the Amenity Form was submitted with no box checked to waive room. However, this does not supersede the Addendum fro 5/17/2019 signed at time of admission. Resident R1 stated she has stress and anxiety from possible move and said she spoke with ALW and Ombudsman who stated that she is enrolled in ALW. 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, Jul 17, 2025 · control 28-AS-20250103151505

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a)(b)(1)(D) · Plan of correction due date: Jul 24, 2025

Reappraisal The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101 The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition and significant including those required to be documented as specified in Section 87466, Observation of the Resident. Definitions, include, but are not limited, to: (D) A mental or social trauma, such as the loss of a loved one.” This requirement is not met as evidenced by: Appraisal wasn't updated and Resident R1 not being provided safety checks, proper assessment, which caused a potential risk to residents in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: Facility to submit a reassessment of Resident R1 and submit to Licensing by POC due date. Deficiency cleared. Assessment completed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 24, 2025

Basic Services Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Facility did not monitor Resident R1's blood pressure and didn't conduct room checks which caused a potential risk to residents in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: Facility to conduct room checks and check blood pressure for Resident R1 as noted on reassessment. Deficiency cleared. Assessment completed and room checks conducted.

Allegation investigated: Staff are not meeting resident's food service needs

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with Salinadou Krubally Care Service Manager and explained the reason for the visit. The investigation consisted of the following: On 2/18/25 LPA Flores and LPA Gonzalez conducted an initial complaint investigation visit. During the visit LPAs requested a copy of resident/staff roster, conducted a tour of the dining room, interviewed 5 residents and 5 staff, and requested copies of last two months of menus, alternative menu, and staff training. On 3/20/25 LPA Flores conducted additional interviews with 3 staff and 5 residents and delivered findings. (CONTINUED ON LIC 9099C) Substantiated The investigation revealed the following: Regarding allegation: Staff are not meeting resident’s food service needs. It is alleged staff are not allowing resident to open own cereal box as requested by the resident due to sanitization concerns. Interviews conducted with residents revealed, 8 out of 10 residents are satisfied with food service, residents do not have service food preferences, and do not have concerns with food not being clean or sanitized. There were 2 out of 10 residents that had concerns with the food and environment not being clean or sanitized and preferring their cereal box being closed rather than open when providing to them. Interviews with staff revealed 8 out of 8 staff stated that the food service is provided under a clean and sanitize environment. Residents have not complaint regarding their cleanness. However, 5 out of 8 staff interviewed stated a resident has requested their cereal box to have a closed lid rather than being provided open to them and have not follow their request as they have been directed to open the lids or boxes. Dining Room Manager stated that it is facility’s practice to peel the bowl’s lid prior to providing it to the residents, residents have not been allowed to do it themselves, and staff must pour the content of the boxes into bowls instead of providing the bowl to residents. Per Dining Room Director, the individual serving bowls of cereal are not always available. Therefore, cereal may be served in a bowl, also the service of the food at the dining room is provided as fine dining and therefore the staff try to assimilate that by providing the food in dishes. During the tour of the dining room LPAs observed individual bowls of cereal store which are provided to the residents for breakfast based on the menu and it was explained to LPA that there are times when they have boxes of cereal which are not for individual serving. Documents reviewed revealed residents are provided the option of dry cereal at least three times a week and have additional or alternative menus to provide a variety of meals per the residents’ choices. 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. Exit interview was conducted with Milca Osorio Director of Health Services and a copy of this report, LIC 9099D, and appeal rights were provided. The investigation revealed the following: Regarding allegation: Staff is harassing resident. It is alleged administrator has been bullying resident over the last three years. Interviews conducted with residents revealed, 8 out 10 residents are content with staff, have not observed or been treated disrespectfully by any of the staff members. Two (2) out of 10 residents stated to have either been harassed or have observed staff harassing resident verbally at the facility. Interviews conducted with staff revealed 8 out of 8 staff interviewed stated to address the residents respectfully and have not observed others treat the residents in a disrespectful manner or harassing them in any way. LPA reviewed staff training conducted on 1/9/25 regarding residents’ personal rights. 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 Milca Osorio Director of Health Services and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 20, 2025 · control 28-AS-20250210104613

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(a) · Plan of correction due date: Mar 27, 2025

87464 Basic Services: (a) The services provided by the facility shall be conducted so as to continue and promote ,... independence and self-direction for all persons... shall be encouraged to participate as fully... in daily living activities... This requirement is not met as evidence by: Based on interviews and observations licensee did not ensure staff were promoting resident's independence and self-direction by allowing choices during meal service which is a potential risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Mar 20, 2025

Plan of correction: Administrator has implemented dining staff allowing resident to be provide or bring own cereal if necessary into the dining room since LPAs last visit on 2/18/25 and training was provided to staff on resident's rights on 3/3/25. Deficiency cleared as of 3/20/25.

Allegation investigated: Staff's negligence led to resident's property being damaged. Staff do not follow infection control guidelines.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 02/25/2025 regarding the above allegations. LPA was greeted by Administrator Liyon O’Quinn and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster (LIC 500), Staff#1 - 4 interviews (S1 – S4), Interview of residents#1-10 (R1 – R10), copies of Resident#1 (R1): Admission Agreement, recent Physician Report, resident, family, or visitor concern/grievance form, signed statement from the Resident Services Director, copy of infection control plan and physical plant tour. SEE 9099-C for continued report. Unsubstantiated The investigation revealed the following. Regarding Allegation(s): Staff's negligence led to resident's property being damaged – It is alleged on or around 11/12/2024, staff knocked over R1’s denture container and caused the container to break and spill out contents inside. Four (4) out of the four (4) staff interviewed denied this allegation. Eight (8) out of the ten (10) residents interviewed denied this allegation. Interview with R1 alleged, R1 left their room and R1’s denture container was sitting on their bathroom sink when R1 left their room. R1 revealed when they came back into their room within the hour, R1 noticed their denture container had a crack and hole on the lower bottom corner and the fluid inside the container was now all over the bathroom floor. R1 revealed they tried to insert their dentures back into their mouth, but the dentures no longer fit due to shrinkage. Staff interviews revealed staff did not knock over or touch R1’s denture container. 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. Staff do not follow infection control guidelines- It is alleged staff do not follow facility infection control guidelines. Four (4) out of the four (4) staff interviewed denied this allegation. Eight (8) out of the ten (10) residents interviewed denied this allegation. During facility tour, LPA Ramirez observed staff wearing gloves while handling food, disinfecting high trafficked areas, and cleaning resident rooms. LPA Ramirez reviewed facility infection control plan. Staff interviews revealed staff is well versed on infection control practices. 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. No violations were cited for this investigation. Exit interview was conducted and a copy of this report was provided via email.the state’s words, verbatim · CDSS document, Feb 25, 2025 · control 28-AS-20250219110211

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management VISIT DEFICIENCIES on 02/25/2025, stemming from initial complaint investigation conducted on 02/25/2025. LPA was greeted by Administrator Liyon O’Quinn and explained the purpose of the visit. Case management deficiencies findings: On 02/25/2025, LPA Ramirez was conducting resident and staff interviews when it was revealed facility staff do not allow residents to bring outside food into the facility dinning room. Four (4) out of the four (4) staff interviewed corroborated they have been directed to tell residents that no outside food was allowed in the dinning room unless staff approves of the outside food first. Based on interviews conducted, LPA Ramirez will issue a Type B violation for violation of personal rights section 87468.2(a)(3). LPA Ramirez will assess a $250 civil penalty for repeat violations within a 12-month period. The facility was previously cited for violation of section 87468.2(a)(3) on 10/01/2024. One (1) violation was cited during this visit and one (1) repeat civil penalty was assessed. Exit interview was conducted and a copy of this report was provided via email.the state’s words, verbatim · CDSS document, Feb 25, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(3) · Plan of correction due date: Mar 4, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(3) To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights.the state’s words, verbatim · CDSS document, Feb 25, 2025

Plan of correction: This requirement was not met as evidenced by: staff is not allowing residents to bring outside food to eat, into the dinning room. Licensee will retrain all staff on this regulation and send proof of retraining by 3/04/2025 via email to LPA Ramirez.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nune Margaryan conducted Case Management - Incident visit and met with Administrator and DOHS (Director of Health Services). LPA explained the purpose of today's visit and conducted a health & safety check of residents in care. Unusual Incident report involving the former Resident 1 (R1) was submitted by the facility on 02/10/25. Incident report has indicating that R1's private caregiver was force feeding R1. R1 was passed away on 02/09/25 due to diagnosis End of Stage of Alzerheimers Disease. During today's visit LPA interviewed DOHS, Kaiser Hospice Social Worker (SW), Family Member 1(FM1). Family Member 2 (FM2) was interviewed on 02/19/25. LPA reviewed R1's file and obtained copies of the following documents: Admission Record Face Sheet Physician's Report Hospice order for R1 about NPO dated 07/09/25. LAPD Officers information / notes. Record of Death At the time of visit LPA did not observe nor identify signs of neglect, abuse or other immediate health and safety threats. An exit interview was conducted, and a copy of the report was provided to DOHS Milca Osorio.the state’s words, verbatim · CDSS document, Feb 20, 2025

Allegation investigated: Staff is illegally evicting resident. Staff confiscated resident's belonging.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 10/01/2024 regarding the above allegations. Licensing Program Analyst (LPA) Nune Margaryan conducted inital complaint investigation visit on 09/12/24 and needs further investigation was documented, LPA Ramirez was greeted Administrator Liyon O'Quinn and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 3 interviews (S1 – S3), Interviews of Residents#1-2 (R1-R2), copies of Resident#R1 (R1) Physician’s Report, R1’s Admission Agreement dated 09/23/2021, 30-Day Notice to Terminate dated 08/23/2024, Violation of Rental Agreement Notices from 09/06/2024 through 12/29/2023 for R1, Written witness statements dated 08/18/2024, and 08/17/2024, and campus site map and physical plant tour. See 9099-C for continued narrative. Unsubstantiated The investigation revealed the following. Regarding Allegations: Staff is illegally evicting resident- It is alleged the facility is illegally evicting R1. On 09/30/2021, R1 was admitted into the facility. R1 is not conserved and is self responsible. On 08/23/2024, R1 was served with a 30-Day Notice to Terminate. LPA Ramirez reviewed the 30-Day Notice to Terminate for R1 and observed this notice to contain the effective date of eviction, reasons relied upon for the eviction with specific facts to permit determination of the date, witness, and circumstances concerning those reasons and resources available to assist in identifying alternative housing and care options which include, but are not limited to, the following: Referral services that will aid in finding alternative housing, and case management organizations which help manage individual care and service needs. Three (3) out of the three (3) staff interviewed deny this allegation. One (1) out of the two (2) residents interviewed deny this 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. Staff confiscated resident's belonging- It is alleged staff confiscated R1’s walker while R1 dined in the dining room. Three (3) out of the three (3) staff interviewed deny the allegation. Interview with staff revealed dining room staff will temporarily relocate residents’ walkers to corner in the dining room or outside the dining room doors, as to not impede dining walkways. Staff revealed once residents are finished with their meals and request their walker back, staff will bring the walker to the resident. Interview with R1 revealed staff confiscate R1’s walker but returned it after R1 is finished dining. Two (2) out of two (2) residents interviewed deny this 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. No deficiency was cited for this investigation. Exit interview was conducted. A copy of this report was provided by via email due to printer problems.the state’s words, verbatim · CDSS document, Oct 1, 2024 · control 28-AS-20240903221616

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Deficiencies on 10/01/2024, stemming from subsequent complaint investigation conducted on 10/01/2024. LPA Ramirez were greeted by Administrator Liyon O'Quinn and explained the purpose of the visit. Case Management-Deficiencies findings: On 10/01/24, LPA Ramirez conducted a records review of R1’s file and it was revealed R1 received a notice of violation of Admission’s Agreement on 12/29/2023. According to the notice, R1 was observed to be smoking in front of the building by S1. Interview with S1 revealed, R1 was seen smoking under a tree near the sidewalk of the facility. S1 guided LPA Ramirez to the location where R1 was observed to be smoking. LPA Ramirez observed this location (tree/grass area/sidewalk) to be away from the facility main door entrance and on a public sidewalk. LPA Ramirez measured the distance from tree/grass area to the front door entrance and it measured to be 45’9 feet away from the main door entrance. Based on records reviewed, and interviews conducted, LPA Ramirez will issue a Type B violation for personal rights. Per Title 22, 87468.2(a)(3)- Additional Personal Rights of Residents in Privately Operated Facilities- (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (3) To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights. R1 was within their right as a citizen to smoke away from the facility. One (1) violation was cited for this visit. A copy of this report, 809-D and appeals rights was provided. Exit interview was conducted.the state’s words, verbatim · CDSS document, Oct 1, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(3) · Plan of correction due date: Oct 15, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(3) To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: Licensee will retrain staff on this regulation and send proof of retraining by 10/15/2024 via email to LPA Ramirez.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tyler Reyes conducted an unannounced case-management incident visit in regards to a Special Incident Report (LIC624) that was submitted to Regional Office (RO) on 08/01/24 by facility. LPA Reyes met with Administrator Liyon O’ Quinn and explained the reason for the visit. Per Special Incident Report on 7/27/24, Resident #1 (R1) reported to staff #1 (S1) that during dinner time R2 was crying, shaking, and stated was afraid of S2. S2 stated while R2 was in the elevator being transported to the dinning area R2 was agitated and tried standing up from wheelchair. S2 stated while in the elevator R2 stood up from the wheelchair, S2 pulled R2 back in the chair, then R2 was yelling and crying in dinning room. During the Case-Management review of records and interviews were conducted on 08/20/24. LPA Reyes obtained and reviewed documents related to S2’s training, nursing safety standards, and job responsibilities. LPA Reyes conducted interviews with S2-S4 and R1-R4. Administrator Liyon stated S2 is not employed with facility. Administrator Liyon provide S2’s last day of employment and letter resigning from the facility.LPA Reyes toured the facility and no health and safety concerns were observed during the visit. Based on interviews, a ciation is being issued. See LIC 809D. An exit interview was conducted. A copy of LIC 809, LIC 809D, & Appeal Rights were provided to Administrator Liyon.the state’s words, verbatim · CDSS document, Aug 20, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Aug 21, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature.. Based on record review and interviews that S2 grabbed R2’s arm while in the elevator which poses an immediate personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Aug 20, 2024

Plan of correction: Licensee shall provide In-Service Training for all staff focusing on Residents Personal Rights as defined by Title 22 regulations. Licensee shall provide CCL with a copy of the attendance sheet documenting the topics, duration of training, and person that conducted the training by POC Due Date.

Allegation investigated: Staff are not properly positioning a resident. Staff do not meet a resident's toileting needs. Resident developed pressure injuries while in care.

Licensing Program Analyst (LPA) Tao conducted an unannounced initial 10-day complaint investigation regarding the above allegations. LPA discussed the purpose of the visit with Liyon O'Quinn, Executive Director. The investigation consisted of the following: LPA interviewed staff from staff#1 (S1) to staff #4 (S4); interviewed residents from resident #1 (R1) to resident #8 (R8); obtained resident roster and staff roster; reviewed facility file of resident#1; and conducted a physical plant. The investigation revealed of the following: Regarding the allegation of staff are not properly positioning a resident, it was alleged that staff did not position resident#1 (R1) during the day. LPA interviewed residents, all eight (8) residents could not corroborate the allegation. (-continued on LIC 9099 C-) Unsubstantiated R1 was interviewed and stated resident could position by himself/herself. LPA interviewed staff and all staff denied the allegation. Staff interviews indicated that residents could position by themselves. Per record review, resident only needed assistance with transferring to/from bed to wheelchair/recliner. Therefore, staff did not fail to position residents while in care. Regarding the allegation of staff do not meet a resident's toileting needs, it was alleged that staff did not assist resident#1 (R1) for toileting needs during the day. Per resident interviews, all eight (8) residents could not corroborate the allegation. Resident interviews revealed staff assisted residents with toileting needs including checking on residents a few times day and changing residents’ briefs a few times. Per staff interviews, all staff denied the allegation. Staff interviews indicated that staff would check on residents for their toileting needs in the morning, afternoon, and bedtime. Per LPA’s observation, residents had no foul odor or urine smell during interviews. Residents were observed to be clean. Therefore, staff did not fail to meet resident’s toileting needs while in care. Regarding the allegation of resident developed pressure injuries while in care, it was alleged that resident had pressure injuries. LPA interviewed residents, all eight (8) residents could not corroborate the allegation. None of the residents had or aware of any pressure injuries. LPA interviewed staff and all staff denied the allegation. Staff interviews indicated that no residents had pressure injuries at the facility. Per record review, resident did not have pressure injuries. Therefore, resident did not develop pressure injuries while in care. 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 administrator. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 6, 2024 · control 28-AS-20240729195058

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) S Vaid conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to the Director of Health Services Milca Osorio, and the Assisted Living Supervisor Salimatou Krubally arrived shortly thereafter. There are currently one hundred ninety-nine (199) residents who currently reside within the facility. The facility is licensed to serve: 285 ambulatory, 14 non-ambulatory, hospice waiver for 14. Rooms 100,101-108,110,112,113,115,117 are approved for non-ambulatory. LPA toured the physical plant and environment with Supervisor Krubally and Health Services Director Osorio. The tour of the facility contains the following buildings: Administration Building, Leitzell Hall, Margaret Hall, Chapel, Holly Cottage (Library/Fitness Center), Dining Hall and Kingsley Manor Care Center. The following (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility has large supply of protective equipment. Physical Plant/Environment Safety: The contains multiple buildings on its campus including the Administration Building, the Dining Hall Building, Lietzell Hall, Margaret Hall, Kingsley Manor Care Center, and the Whitehouse. Continued on 809 C..... It is licensed for a capacity of 285 Ambulatory and 14 Non-Ambulatory residents. It consists of five (5) total buildings that house residents, a dining room, a kitchen and multiple private and public restrooms throughout the facility. Most of the buildings that house residents held water temperature readings that were within the 105 – 120 Degrees F range. The facility’s main laundry for residents is located in the basement of Lietzell Hall, and the 6th floor of Lietzell Hall contains the facility’s rooftop patio, movie theater, and main activity room. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility multiple fully charged fire extinguishers in each floor of the resident’s halls in their laundry room. Water temperature readings measured between the required 105 - 120 degrees Fahrenheit in all buildings that were toured. Operational Requirements: The Program Design was reviewed. Fire clearance was approved by LA County Fire Department for 285 Ambulatory and 14 Non-Ambulatory residents. Care and supervision to meet the clients’ needs was observed. Staffing: A total of one hundred and one (101) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: Eight (8) random staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training. Client Rights/Information: Physician orders were reviewed in client files. Client Records/Incident Reports: Eight (8) random client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. No restricted Health Care plan required for the clients in the facility. Continued on 809C...... Personnel Records/Staff Training: Facility Administrator Liyon O’Quinn certificate is active and effective through 10/11/2024. Eight (8) random staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training. Health Related Services: Clients are assisted with self-administration of prescription and non-prescription medications. Eight (8) random centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions. Disaster Preparedness, and Emergency Intervention: A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed. An emergency drill is conducted each quarter and was last conducted on 06/11/24 during various shifts , and Fire Alarms were check on 5/14/2023, fire alarms were updated to new systems in 04/2024. Inspection testing the new fire alarms were tested and inspected by the Los Angeles Fire Department in early May 2024. Outside vendor will perform the fire alarm checks and is scheduled for the coming weeks. No deficiencies were observed during today's visit. An exit interview was conducted and a copy of this report was provided to Salimatou Krubally and Milca Osorio.the state’s words, verbatim · CDSS document, Aug 2, 2024

Allegation investigated: Unlawful eviction.

Licensing Program Analyst (LPA) Nune Margaryan conducted unannounced initial visit to facility to investigate the above allegation. LPA met with Administrator Liyon O'Quinn and explained the purpose of visit. During today's visit LPA obtained copies of staff and residents roster. Interviews conducted with Administrator, Staff #1 - Staff #2 (S#1 - S#2) and Resident #2 -Resident #4 (R #2 - R #4). LPA also obtained copies of the following documents in reference to Resident #1: Admission Agreement, Physician report, Preplacement Appraisal Information, SIR dated 06/14/24. Continue 9099C Substantiated Regarding allegation: Unlawful eviction. It was alleged that R#1 was not allowed to return to the facility after was discharged from the hospital on 06/18/24. Kaiser staff and FM were told by unknown facility staff that R1 would not be allowed to return. Interviewed Administrator denied the allegation. Administrator stated that on 06/14/24 R1 was sent to Kaiser to be evaluated. R1 was placed on 72 hour hold at the hospital and was discharged on 6/18/2024. Interviewed S1 stated that they spoke with R1's Family Member (FM) and told FM that R1 needs high level of care and supervision because of R1's behavior. Interviewed Administrator and S#1 stated that they were in communication with R1's FM and discussed concern regarding R1 returning to the community with the fact they cannot provide one to one supervision for R1 with R1's behavior. Interviewed FM indicated that they were told by facility staff that facility will not be able to take R1 back to the facility due to R1's behavior. FM was told by S#1 that R1 needs high level of care and supervision, and the facility will not be able to meet R1's needs, and they are not accepting R1 back to the facility. Interviewed S#2 stated that because of R1 behavior S#2 called 911 on 06/14/24 and R#1 transported to the Kaiser for evaluation. S#2 stated that R#1 didn't came back from the hospital. S#2 stated doesn't have any discharge information or not accepting R#1 back to the facility. Interviewed R#2, R#3 and R#4 stated that they never had any issues or problems coming back to the facility after hospitalization. Due to the fact the staff refused to accept Resident #1 back to the facility after being discharge on 06/18/24 is considered an unlawful eviction. A review of the R1's file revealed no indication that R1 required a higher level of care. LPA did not observe any documentation of giving resident a 30-day notice of removal from the facility. Based on interviews conducted and document review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22. See LIC9099D. An exit interview was conducted with Liyon O'Quinn. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jul 2, 2024 · control 28-AS-20240625090311

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Jul 9, 2024

87224 Eviction Procedures (a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph... This requirement is not met as evidenced by: Based on LPA interviews and record review, Facility / administrator refusal to accept R1 back to the facility upon discharge from hospital and not providing R1 with the 30 day eviction notice which poses a potential health, safety or personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2024

Plan of correction: Administrator will review Title 22 Regulations, Section 87224 on Eviction Procedures, and submit a written statement to CCL ensuring that he/she understands and will comply with Title 22 Regulations pursuant to this section by the POC due date.

Allegation investigated: Questionable death of resident.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit to render findings for the allegation of questionable death. LPA met with Administrator, Liyon O'Quinn, and explained the purpose of the visit. The investigation consisted of the following: On 10/26/23, LPA Chan conducted a health and safety check and did not observe any immediate concerns. LPA toured the facility and randomly selected 8 rooms to inspect. The hot water temperature in the rooms were measured within the required range. Food supplies of perishable and non-perishable were sufficient. A copy of the staff and resident rosters were obtained. Documents for 5 residents were requested to be emailed to LPA. Unsubstantiated The complaint was investigated further by the Department of Social Services Investigator Veronica Padilla. During the course of the investigation, Investigator Padilla interviewed the administrator, 12 Staff members, a personal caregiver, a family member, and 2 Residents. Medical records, Emergency Patient Care report, and Medical Examiner case report for Resident #1 (R-1) were gathered and reviewed. The investigation revealed the following: Allegation – Questionable death of resident. It has been alleged that Resident #1’s (R-1) death was caused by Staff #1 (S-1) who was neglectful towards the resident. On 10/3/23 around midnight, R-1 was found on the bathroom floor and sustained injuries. R-1 died 4 days later in the hospital. Based on interviews and record review by Investigator Padilla, it was determined that 2 Staff failed to provide supervision for R-1 during their shifts. S-1, who works the overnight shift, did not check on R-1 until staff heard moaning noises coming from the room. S-1 immediately called 911 when R-1 was found on the bathroom floor. Another staff admitted that during the last 4 hours of the shift on 10/2/23, staff did not check on R-1. The approximate day and time in which R-1 fell was unknown since neither staff checked on resident when they were supposed to. Although R-1 fell and sustained injuries, there is no evidence to show a causal link between the failure to conduct timely rounds and the resident’s death. In addition, the Department of Medical Examiner case report ruled the death as an accident. 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. An exit interview was conducted. A copy of this report along with the appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, May 7, 2024 · control 28-AS-20231024160546

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit to issue a deficiency after the department followed up on the incident that occurred on 10/3/23. LPA met with Administrator, Liyon O’Quinn, and explained the reason for this visit. The Department of Social Services Investigation Branch Investigator Veronica Padilla investigated the death of Resident #1 (R-1). Based on the information gathered, it revealed that Staff #1 (S-1) and Staff #2 (S-2) had been neglectful towards R-1. R-1 was found on the bathroom floor on 10/3/23 and sustained injuries. R-1 died 4 days later in the hospital. Interviews with S-1 and S-2 revealed that they failed to check on R-1 timely during their shifts. R-1 had a fall and was discovered by S-1 at around midnight on 10/3/23. S-1, who works the overnight shift, did not check on R-1 until the staff heard moaning noises coming from the room. S-1 immediately called 911 and was transferred to the hospital. Another staff (S-2) admitted that during the last 4 hours of the shift on 10/2/23, staff did not check on R-1. During the investigation, S-1’s personnel file was reviewed. It was discovered that S-1 has a reputation for being neglectful and showed misconduct when the staff was found sleeping on the job and in a resident’s room. On 9/6/23, a staff assigned to work alongside S-1 stated that S-1’s attitude toward a higher authority was rude and unprofessional. On 9/7/23, a staff observed S-1 coming out of R-1’s locked room and appeared to have just woken up. On 12/6/23, 3 staff members witnessed S-1 sleeping on the job. Staff provided written statements to confirm their observations. Based on record review and interview, it is determined that the facility did not provide proper supervision to the resident in care. A deficiency is being cited on the LIC809D, per the California Code of Regulations, (Title 22, Division 6 and Chapter 8). An immediate Civil Penalty of $500.00 is being issued due to the violation that resulted in the injury of a person in care. Refer to LIC 421IM. An exit interview was conducted. A copy of this report, appeal rights, and Plan of Corrections were provided to the administrator.the state’s words, verbatim · CDSS document, May 7, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 8, 2024

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... Based on record review and interviews, the licensee did not ensure staff are providing the required needs and supervision to Resident #1 which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 7, 2024

Plan of correction: The licensee shall provide in-service training to all care staff to ensure they meet the needs of residents. The training log will be emailed to LPA by 5/8/24.

Allegation investigated: Facility staff did not keep the facility free of obstructions. Facility staff speak inappropriately to resident. Facility staff do not treat residents with respect and dignity Facility staff did not safeguard resident's property.

Licensing Program Analyst (LPA) Jose Villalobos conducted an initial complaint investigation visit for the allegation(s) above. LPA met with Executive Director Liyon O'Quinn and the purpose of the visit was discussed. The following was conducted on todays visit: LPA toured the physical plant, Interviewed Staff #1-#6 (S1-S6), Interviewed residents #1-#10 (R1-R10), collected and reviewed copies of documents from R1's file as well as the staff and resident roster. The investigations revealed the following: In regards to the allegation "Facility staff did not keep the facility free of obstructions" it was alleged that R1 tripped over a cord in their room possibly left by staff. (6) of (6) Staff interviewed denied the allegations. (10) of (10) Residents interviewed could not corroborate the allegation. Interviews state that R1 had an unwitnessed fall in their room on 2/24/24 but was able to get up on their own... Continued on LIC 9099-C Unsubstantiated R1 did not inform the staff until the following day and refused to be assessed or go out to the hospital. LPA reviewed a note on file from staff confirming the information. R1 stated to have tripped over the cable of their own heating pad. It was not an item left by staff or placed by her bed by staff. R1 stated no paths were obstructed by the staff. Based on interviews, observations, and file review; 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 "Facility staff speak inappropriately to resident" it was alleged a staff member spoke to R1 in an aggressive tone. (6) of (6) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Interview with R1 states that on 2/25/24 a staff member entered their room to provide their meal and spoke to them rudely. LPA was not provided with a name of the staff or what time of the day it occurred. Staff interviewed stated they have never spoken to residents in an aggressive tone or know of any staff to speak to residents in an aggressive tone. Residents interviewed stated that staff are very helpful and do not speak to residents inappropriately. LPA did not observe staff speaking to residents in any inappropriate manner throughout the visit. Based on interviews, observations, and file review; 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 "Facility staff do not treat residents with respect and dignity" it was alleged that staff yell at residents and barge into their rooms. (6) of (6) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Interview with R1 states that on one occasion a staff member bringing meals to residents rooms, barged into R1's room rudely and has yelled at other residents of the facility. Interviews with other residents conducted stated they have not seen staff enter rooms without knocking and have not seen or heard staff yell at residents. Staff interviewed denied that they have or know of other staff to ever yell at residents. Interviews with staff stated that they will always knocked and introduce themselves when going to any residents room. LPA observed staff knocking and introducing themselves before going into residents room throughout the visit. Based on interviews, observations, and file review; 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. Continued on LIC 9099-C In regards to the allegation "Facility staff did not safeguard resident's property" it was alleged that R1 had a plaque on the wall that is now missing. (6) of (6) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Detail provided was that there was a plaque with a copy of the Declaration of Independence inside it that passed down generations in R1's family that is now missing. Staff interviewed stated they have never seen a plaque of that description in R1's room. File review does not show a list of items that the facility would be responsible for, for R1. Residents interviewed stated they have not heard of anyone stealing items from residents in the facility. Based on interviews, observations, and file review; 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 conducted and copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 5, 2024 · control 28-AS-20240227143259

Allegation investigated: Staff pushed resident causing resident to fall. Staff threatened resident. Staff providing care to residents under the influence of illegal substance. Staff does not treat resident with dignity and respect. Resident caused injury to another resident while in care. Staff broke resident’s personal belongings. Unlawful eviction. Resident’s personal belongings are missing. Staff made inappropriate comments towards resident. Staff did not assist resident in a timely manner.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegations. The purpose of the visit was explained to Executive Director Liyon O'Quinn. The investigation consisted of: On 6/14/2022, A physical plant tour of the interior and exterior was conducted. Former resident (R1's) room 213 was inspected. Staff (S1- S6) and residents (R2- R6) were interviewed. Former resident (R1) was interviewed at a different time. LPA reviewed cell phone video dated April 27, 2022 involving R1. The incident occurred during dinner meal service. The following documents were obtained pertaining to former resident (R1): Face Sheet, Physician Report, Preplacement Appraisal, Appraisal, 30-Day notice, Admission Agreement, Writ of Execution, Police Arrests [3/6, 4/17, 4/19, 4/27, & 6/6/2022, June 14, 2022 Court Order "Receipt For Possession of Real Property", 23 incident reports, (5/31/22), LIC 500 Personnel Report, resident roster. ***Narrative continues next page.*** Unsubstantiated Allegation 1: Staff pushed resident causing resident to fall. It is alleged that the facility security guard/staff (S1) pushed resident (R1) hard two times because the resident wanted to close the dining hall, and as a result the resident fell to the carpet floor. Resident (R1) stated that the incident took place on May 11, 2022 and accused staff (S1) of physical injury. However, a total of six (6) staff were interviewed and all denied the allegation. Per staff interviews, the alleged incident occurred on April 27, 2022 at approximately 9:30 AM in the dining room area. Staff stated that R1 threw itself on the floor and started pushing the dining chairs, kicked the glass on the dining room door with a cane and it's legs. Staff (1) stated resident (R1) kicked their knee and accused staff of pushing the resident. Staff (S1) sustained injuries that required emergency room treatment and had to use crutches for 3 days. A total of five (5) residents were interviewed. Four of the residents interviewed were present during the incident, the four residents stated that they did not see the security guard (S1) push the resident. On the contrary, they witnessed R1 screaming and kicking S1's leg shins. Residents stated that S1 told the resident to stop, but never hit the resident. LPA reviewed cell phone video surveillance of the incident. It showed the resident acting aggressively towards staff and residents, and using their cane and legs to damage the main dining room doors. The resident fell because they lost their balance. Based on record review and interviews conducted, there is no evidence to corroborate the allegation. Allegation 2: Staff threatened resident. It is alleged that the Maintenance Director (S4) and staff (S5) Director of Sales and Marketing threatened resident (R1) by stating they hope the resident falls "down those stairs and kills" themselves, as well as also verbally threatening R1 and taunting the residents. A total of 6 staff were interviewed, of which all denied the allegation. Both staff (S4) and staff (S5) denied the allegation and stated that the resident frequently said horrific words to all staff and verbally abused staff and residents, and despite that all staff always treated R1 professionally. All residents interviewed stated staff treat residents well and reported that R1 is the person that threatens others. Based on incident report review, the findings indicate that R1 verbally and physically threatened and hurt staff and residents on multiple occasions that resulted in arrests. The allegation, has no merit. Allegation 3: Staff providing care to residents under the influence of illegal substance. It is alleged that staff were providing residents prescription "speed" and that the facility's security guard sells crystal methamphetamines to staff and outsiders in the parking lot. According to information obtained, the illegal drugs are available for staff if they are tired. It is also alleged at approximately 25 residents had been given prescription methamphetamines at the care center. All residents interviewed denied knowledge of the allegation. One (1) resident reported that R1 asked them if they could get cocaine for the resident. A total of six (6) staff were interviewed and all denied the allegation and stated they have never observed staff to be under the influence. Staff stated that R1 fabricates stories and the alleged staff name referenced in this complaint, is not one of the security guards employed. One (1) staff reported that on a separate occasion R1 accused the Maintenance Director of giving methamphetamines to nursing staff. There is insufficient evidence to corroborate the allegation. Allegation 4: Staff does not treat resident with dignity and respect. It is alleged that staff do not treat resident (R1) with respect because staff called the resident curse names and most of these conversations/interactions occurred in private. Based on interviews conducted, the findings indicate that resident (R1) often acted in a belligerent and disrespectful manner towards staff. There were multiple incidents between March 2022- May 2022 in which R1 yelled and cursed at residents and staff, as well as incidents were the resident attempted to hit staff. Most the incidents were a result of drunkenness. All staff interviewed denied the allegation, and reported that the resident verbally abused residents and staff. All the residents interviewed stated that R1 would get drunk and act violently towards residents by attempting to hit some residents and saying bad curse words to female residents. Based on file review, records indicate that R1 had history of alcohol intoxication that caused aggressiveness, and behavior problems. There is lack of evidence to support the allegation. Allegation 5: Resident caused injury to another resident while in care. It is alleged that resident (R5) assaulted resident (R1) by pushing the resident down into the dirt while the residents were smoking in the patio area after R1 referenced a racial slur to R5. It is also alleged that resident (R3) whom was present during the alleged incident, told R1 that if the resident was seen in the neighborhood they would hurt the resident. Resident (R1) stated that R5 was arrested. Per record review, resident (R1's) statement is false. Resident (R1) was arrested five (5) times during the time they resided at the facility for violent acts to others. All staff denied the allegation, and reported that R1 had multiple physical altercations with residents that resulted in physical injury. All residents interviewed stated R1 was a violent person that accused others of causing injuries, but most of the injuries the resident sustained were self inflicted during episodes on alcohol intoxication. There is insufficient evidence to corroborate the allegation. Allegation 6: Staff broke resident’s personal belongings. It is alleged that a security guard staff broke two of resident (R1's) CDs and sprayed wine on two of the resident's walls, and then kicked the door and broke the door jambs. According to information provided, the alleged security guard staff expressed remorse the following day and gave R1 $20.00 for the damage caused. There are a total of 6 security guards that work at the facility. All staff interviewed denied the allegation, and stated they had no knowledge of the alleged incident because R1 never reported personal belongings damage. Staff stated that R1's room was a mess and the resident always locked the room after leaving. Residents stated they have not had their belongings stolen or broken, and had no knowledge of R1's alleged issue with personal belongings. Record review, indicates that R1 has episodes of aggressiveness and property destruction. Allegation 7: Unlawful eviction. It is alleged that resident (R1) was evicted due to an incident involving a walking cane that was considered a deadly weapon. Resident (R1) denied the allegation and stated that they did not assault anybody. According to staff interviews and record review, the findings indicate that resident (R1) was lawfully evicted due to behaviors i.e., vandalism, drinking, verbal and physical abuse to staff and residents. Resident (R1) was arrested five times while living at the facility. The resident was issued an eviction notice on March 4, 2022. The resident did not move out on the date the tenancy terminated. Therefore, the facility had to file court documents. All staff and residents interviewed believe the eviction was lawful because the resident had destructive uncontrolled behaviors posing a health and safety risk to persons in care. Allegation 8: Resident’s personal belongings are missing. It is alleged that resident (R1's) eyeglasses, slippers, address book, checkbook, polo shirt, watch, 2 bottles of prescription medications, and a wine bottle were missing from the resident's room. Resident (R1) stated that three weeks later the Resident Services Coordinator informed the resident that the items had been turned in to the front desk. Based on interviews conducted, staff reported that when R1 would get drunk they would lose their things. Someone found R1's checkbook in the smoking area and returned it to the front desk, and another time the resident lost their eyeglasses for 3 weeks and they were found in the laundry room. According to staff interviews, when the resident got drunk things were thrown at staff when attempting to clean the room. Staff stated that when the resident moved out none of their personal belongings were removed, and as of 6/14/2022, the resident's belongings had still not been picked up. LPA inspected the room and confirmed the belongings were still in the room. LPA observed the room in disarray with multiple wine bottles and personal belongings on the room and bathroom floor. Allegation 9: Staff made inappropriate comments towards resident. It is alleged that staff made harassing statements and provoked resident (R1) in attempts to get the resident evicted. According to resident (R1), staff verbally abused the resident by calling the resident curse words and convinced many residents that R1 was a threat to their safety. All staff interviewed denied the allegation, and stated no facility staff speak to any residents inappropriately or curse at the resident. They stated they act professionally and courteously towards all residents even those with behavior problems. The residents that were interviewed stated all staff treat them in a courteous and respectful manner and do not address them in a bad way or use foul language Allegation 10: Staff did not assist resident in a timely manner. It is alleged that staff did not assist resident (R2) in a timely manner after they fell. Resident (R1) heard resident (R2) yelling saying they had fallen, so R1 called the front desk and after 45 minutes of no staff response, R1 decided to call 911 emergency. Resident (R2) denied the allegation and stated they have only pressed the pendant once and staff responded quickly. Per staff interviews and incident report review, there have been no injury incidents involving resident (R2), nor has the resident been transport to the hospital. The majority of residents stated that staff assist within 5-10 minutes after pressing the pendant, but there have been occasions in which it takes longer than that. Staff denied the allegation and stated they assist the residents as soon as possible after receiving the alert on their pager. There is insufficient evidence to corroborate the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted with Executive Director Liyon O'Quinn. A copy of the report was issued. Allegation: Staff not responding to residents call button. It is alleged staff take 45 minutes or longer to respond to the hallway phone calls and pendant calls. Two residents reported that they have fallen and pressed the pendant, but staff did not respond to the pendant alert for over 1 hour. Resident (R4) reported that they pressed the pendant and staff arrived 2 1/2 hours later. As a result, that incident was reported to the Director of Resident Services. Four (4) out of six (6) staff stated that most staff respond within 30 minutes, because the the pendant takes about 5-15 minutes to register on the staff pagers. It was also reported that some residents press the pendant, but staff cannot find them because they are walking around in the facility premises, so it takes a while for staff to find the residents. According to staff interviews, the pendant alert first goes to the nurse assistant, secondly LVN, then supervisor, and finally the executive director. If staff are tied up somewhere not near the resident it can take up to 30 minutes to respond to the call signal. Based on interviews conducted, it was determined that the problem is likely due to the pager system the facility uses. The facility shall utilize an alert system that meets the needs of the residents. There is sufficient evidence to corroborate the allegation. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22. See LIC 9099D. An exit interview was conducted with Executive Director Liyon O'Quinn. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Mar 1, 2024 · control 28-AS-20220613092610

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)B) · Plan of correction due date: Mar 8, 2024

Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met evidenced by: Four (4) out of (6) staff stated at times they respond within 30 minutes, because the staff pendants at times take 5-15 minutes to register/summons the call on staff pagers, and then it may take an additional 10 minutes to reach the resident. This poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Mar 1, 2024

Plan of correction: Executive Director agreed to: 1. Submit a written POC by tomorrow. 2. Proof of staff in-service due 3/8/2024. 3. Proof that the entire building's pager/ signal system and pendants were tested and are receiving the page within facility protocols response time.

Allegation investigated: Staff are not meeting resident's needs.

Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit to investigate the above allegations. The purpose of the visit was explained to Executive Director Liyon O'Quinn. The investigation consisted of the following: A physical plant tour of the interior and exterior of the facility was completed, Staff (S1-S6), residents (R1- R 11), and Assisted Living Waiver (ALW) program staff were interviewed. Resident (R1's) file documents were obtained [Face Sheet, Admission Agreement, Pre-Placement Appraisal, Resident Appraisal, Physician Reports [11/21/20 & 1/8/24], MAR [ Jan 2024- Feb. 2024], Service Plan/notes, ALW Individual Service Plan, Resident's Rights, resident roster, shower assignment list, and LIC 500 Personnel Report. Facility does not maintain an inventory of resident's Personal Property and Valuables. ***Narrative continues next page.*** Substantiated Allegation: Staff are not meeting resident's needs. It is alleged that facility staff are not meeting the needs of resident (R1) because staff are not addressing changes in condition that are causing the resident to have constipation and/or diarrhea, incontinence issues, and self use of over the counter medications. A total of 11 residents were interviewed. One (1) out of 11 residents stated that staff do not meet their care needs. Resident (R1) stated their needs are met and confirmed they require medication management. All staff denied the allegation. However, based on document review the findings indicate that staff are not following facility medication management procedures and physician's orders because R1's Physician's Reports indicate the resident is not able to administer their own medications. LPA observed multiple bins in the tables that contained over the counter medications like Omeprazole, Mylanta, Pepto Bismol, foot creams, Alka Seltzer, that are not part of physician's orders, and there was Mylanta spilled on the side dresser and floor. In addition, R1 has a diabetic wound on the bottom of the foot that requires care. The dressing covering was very dirty and appeared to have not been changed in over 1 week. LPA took pictures of the foot dressing and showed the photos to staff who acknowledged the foot dressing should have been changed. Based on record review and observations, there is sufficient evidence to corroborate the allegation. Based on interviews conducted and document review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22. See LIC 9099D. An exit interview was conducted with Liyon O'Quinn. A copy of the report and appeal rights were issued. Allegation: Staff did not safeguard resident's personal belongings. It was reported that resident (R1) has had their cell phone, tablet, and new clothes stolen by caregiver staff (S4). It was reported that the resident had knives that were removed from the room. According to interviews conducted, the findings indicate that resident (R1) has mental health conditions with periods of confusion and forgetfulness. All staff denied the allegation and stated that they just learned about the alleged missing cell phone yesterday. Staff (S4) denies stealing R1's phone, tablet, and clothing items. It was stated that the resident has asked S4 for assistance in finding the phone in the room. According to S4, the cell phone has been missing for months, and not 3 weeks. Staff (S4) stated that the resident orders many items and keeps cardboard boxes in the room, which are then removed with R1's permission. In regard to the knives that were removed by staff, it was stated that two large knives were removed and returned to a family member because they pose a threat to the resident. All staff deny the allegation. Resident (R1) stated that S4 has not stolen their cell phone. All other residents interviewed also denied the allegation. Resident (R1's) room was inspected and it was observed the resident has an operable land line telephone in their room, but no cell phone was observed. There is insufficient evidence to prove theft and loss of property. Allegation: Staff are harassing resident. It is alleged that the Director of Resident Services/Staff (S1) has been harassing resident (R1) about bad hygiene, "peeing" on the bed, bowel incontinence on pants/shorts when going to the dining room, and saying the resident is a horrible person that needs to move out." A total of six (6) staff were interviewed, of which all denied harassment of residents or knowledge that S1 has harassed resident (R1). Staff (S1) stated that they addressed hygiene to resident (R1) by trying to encourage the resident to take a shower and comb their hair, but it has always been done in private and in the resident's room. Staff (S1) denied ever asking R1 about bowel movement on their pants, mentioning any stains on R1's pants, or stating to R1 and family that the resident is horrible. Resident (R1) was the only resident that stated S1 harasses the resident. All other residents interviewed stated that staff (S1) treats the residents with respect and is accommodating to residents. Based upon record review and interviews conducted the findings indicate that, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview was conducted with Liyon O’Quinn. A copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 7, 2024 · control 28-AS-20240201113402

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Feb 7, 2024

Incidental Medical and Dental Care. For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. Based on observation, R1 has multiple over the counter medications in the room that are not listed on medication records, and the resident is self-administering without a physician's order. According to the MD report, R1 cannot administer their own medications; this poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Feb 7, 2024

Plan of correction: Staff shall remove all over the counter medications, conduct staff training, and contact MD to obtain physician's orders if applicable, and address foot care . Submit a written POC of how the deficiency was corrected. POC is due tomorrow.

Allegation investigated: Facility staff are interfering with the resident council

Licensing Program Analyst (LPA) Alberto Lopez conducted a complaint investigation for the allegation listed above. LPA arrived unannounced and met with Administrator, Liyon O'Quinn. The purpose for the visit was explained. LPA obtained copies of the Staff and Resident rosters. Interviews were held with 6 Staff, including administrator, 1 witness and 18 Residents. LPA obtained copy of facility policy on gifts, letter from Front Porch notifying residents of policy change and other pertinent documents and reviewed handbook. Allegation: Facility staff are interfering with the resident council. It is alleged that facility is interfering with residents council by changing policy as to how the employee appreciation fund is distributed to employees. Unsubstantiated The investigation revealed that the facility is not interfering with the resident council meeting. The issue at hand is that corporate office made a policy change in September 2023 regarding the way the Employee Appreciation Fund is handled. Each year in at least the last 20 years, the resident council would accept voluntary donations from residents and provide a lump sum to employees at the end of the year depending on how long the employee has been working at facility. On September 22, 2023, residents were sent a letter notifying them and the residents' council that donations to employees are being treated as "tips" and moving forward, the new policy is that the resident council provide Front Porch (Corporate) a check for the entire amount of donations from the residents and then HR would tax it and distribute it in the employees’ payroll as allocated by residents. LPA interviewed 18 residents R#1 – R18, six staff S#1-S#6 and COO from Front Porch W#1. All the residents interviewed stated they were notified about the change by letter that was placed in their mailbox. 6 of 6 staff stated they were aware of the changes and that it came from Front Porch. COO Jeff Sianko stated policy change was made after consulting with their legal department and was told by the legal department that the monies from the resident council employee appreciation fund had to be treated as "tips" and taxed. R5 stated that R5 never said it was interfering with resident council. There is no evidence that the facility is interfering with Resident Council meeting. 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. LPA observed a violation regarding plan of operation and addressed it in a Case Management 809 report.the state’s words, verbatim · CDSS document, Feb 7, 2024 · control 28-AS-20240201141123

Type of visit: Case Management - Deficiencies

During the course of a complaint investigation visit and during visits with residents and staff, it was discovered that the facility had made significant change in the facility policy and plan of operation. . One change was that facility would now make exception for accepting "tips" from the resident's council for the employee's appreciation fund and they would distribute those funds via payroll and tax it. Facility did not notify CCL about the policy change nor did the facility update the plan of operation or provided explanation on how they would safeguard the resident's monies. It is required that facility update their plan of operation and send it to CCL for approval before new policy can be implemented. Deficiency cited on 809D Exit interview conducted and copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 7, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a)(9) · Plan of correction due date: Feb 21, 2024

(a) 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. (9) A statement whether or not the applicant will handle residents' money and/or valuables. If money or valuables will be handled, the method for safeguarding pursuant to Sections 87215, Commingling of Money, 87216, Bonding and 87217, Safeguards for Resident Cash, Personal Property and Valuables. This requirement is not met as evidenced by: Facility is now classifying employee appreciation funds as tips and taxable and requiring the resident council to cut a check to corporate to distribute the funds. the plan of operation is not up to date and is missing a statement on how resident's cash will be safeguarded.the state’s words, verbatim · CDSS document, Feb 7, 2024

Plan of correction: Facility will update their plan of operation and send it to CCL for approval

Allegation investigated: Facility staff mismanaged resident's medication.

Licensing Program Analyst (LPA) Angelica Rea conducted another visit to issue the final results of the investigation. LPA met with Director of Health Services, Emyrose Lacuesta and Executive Director, Liyon O'Quinn who assisted with the visit. Regarding the allegation that faciliy staff mismanaged resident #1's medication, the investigation consisted of interviews with Staff #1 - Staff #4, and Resident #1 - Resident #9. The investigation revealed that Staff #1 went into Resident #1's room on 6/9/21 to administer resident #1's medication. Staff #1 stated she was not familiar with resident #1's medication, but was asked to assist on that day, due to the fact that the charge nurse was running late. Staff #1 stated that she had two medication cups with her when she went into resident #1's room. One of the medication cups was for Resident #1. Resident #1 indicated that she is only supposed to take two pills in the morning, and observed that staff #1 had four pills. Both Staff #1 and resident #1 stated that at some point, one of the pills fell out of one of the medication cups. Staff #1 stated that she was unable to find the pill. Substantiated Staff #1 stated that she left resident #1's room, without administering any medication, because she wanted to ask the charge nurse to verify the correct medication for resident #1. Both staff #1 and resident #1 stated that resident #1 found the pill that had fallen out of the medication cup, while staff was out of the room. The medication that fell out of the cup, was not one of resident #1's prescribed medications. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Ms. Lacuesta. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 7, 2023 · control 28-AS-20210611151332

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(5) · Plan of correction due date: Nov 17, 2023

(a) 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: (5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. This requirement was not being met as evidenced by : staff #1 dropped a medication pill belonging to another resident in resident #1's room. Staff then left the medication in the room. This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2023

Plan of correction: The administrator will ensure that staff who distribute medication to residents are properly trained in assisting with medication administratrion. Administrator will provide an inservice traininig to all staff that administer medication, and will provide proof of training to LPA by POC due date.

Allegation investigated: Facility will not accept monthly rent payments from resident when resident attempts to pay monthly rent.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit to the facility for the purpose of concluding the investigation regarding the above-mentioned allegation. LPA Maldonado met with Director of Health Services, Emyrose LaCuesta, and explained the purpose for the visit. On 02/02/23, LPA Maldonado made an initial complaint visit. During the visit, LPA Maldonado obtained a copy of the resident and staff roster, and the following documents for Resident# 1 (R1): Facesheet, Physician's Report, Pre-Placement Appraisal, Current Appraisal, 30-Day Notice to Pay or Quit for Amounts Due, Collection Letters issued in May, June and July of 2022, and Billing Notices for each month from September 2021-August 2022. LPA also interviewed Staff# 1-4 (S1-S4) and Resident# 1 (R1). Resident# 2 (R2) accompanied R1 to the interview. LPA informed R1 that the interview would be conducted in private; However, R1 informed LPA that R1 wanted R2 to also speak to LPA regarding the complaint. R2 was also interviewed. A telephone interview was also conducted with the facility's legal advisor. (Report continued on LIC9099-C...) Unsubstantiated The investigation revealed the following: Allegation: Facility will not accept monthly rent payments from resident when resident attempts to pay monthly rent. It is alleged that R1 has been attempting to make monthly rent payments to the facility since September 2022, due to payments owed, and the facility refuses to accept them. Per staff interviews, (4) of (4) staff state that an Eviction Notice was issued to R1 for non-payment of rent since R1's admission to the facility. (3) of (4) staff state that an unlawful detainer was filed and have been legally advised to not accept any payment from R1. LPA was able to confirm the Unalwful Detainer and the legal advise against accepting payment, per interview with facility's legal advisor. Per interview with R1, it was stated that R1 wanted the facility to obtain the difference of payment due from the Assisted Living Waiver program. However, the program does not assist in paying rent/board and care fees. After review of the documents received, it was discovered that R1 did not make a payment in full by the due date to quit, which prompted the Unlawful Detainer. 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 was conducted with Director of Health Services, Emyrose LaCuesta and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 7, 2023 · control 28-AS-20230127133004