La Posada

Allegation investigated: Staff neglect resulted in resident’s death. Staff did not report a change in condition to resident’s representative. Staff did not follow isolation procedures for illness. Facility did not provide records to resident’s representative.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation visit regarding the above allegations. The purpose of the visit was explained to Executive Director Colleen Rozatti. The investigation consisted of the following: On 7/15/2026, record review was completed, resident (R1's) file documents and infection control plan were obtained, and staff (S1-S4) were interviewed. During today's visit, the physical plant was toured, additional record review was completed and staff (S5-S7) and residents (R2- R9) were interviewed. Report continuation- see LIC 9099C Unsubstantiated Allegation: Staff did not follow isolation procedures for illness. It is alleged that the Memory Care Unit did not have infection control isolation procedures in place because on January 31, 2026, during a visit no staff or residents were observed wearing masks, and no PPE containers were observed in the unit. According to information obtained, only a suction canister was observed inside deceased resident (R1's) room. Based on interviews conducted, the findings indicate that once Memory Care Unit staff learned that R1's roommate had RSV, infection control practices were put in place. R1's roommate was isolated in a different room, and when R1 returned from the hospital the resident was isolated by themselves in their room. Records indicate that R1's roommate returned to the facility on 1/7/2026, and was isolated and quarantined for 5 days. Per interviews, doctors determine the number of isolation days, and if the facility is unable to accommodate the resident(s) the hospital transfers residents to a skilled nursing facility. Staff denied the allegation and stated they follow orders. There is insufficient supporting information to confirm the allegation. Allegation: Facility did not provide records to resident’s representative. It is alleged that on March 12, 2026, resident (R1's) representatives met with Resident Care Coordinator, new Wellness Director, and hospice nurse to discuss the reason R1's was sent out to the emergency room on January 26, 2026 despite being enrolled in hospice care. The complaint alleges that R1's representative was informed that R1 and their roommate were not fully isolated due to capacity constraints. According to information obtained, R1's records were requested on March 9, 2026 and no response was received. Based on staff interviews, a meeting was held because R1's representative requested documents. Staff stated that the resident's Medical Assessment, hospice documents, and medication list was provided to the representative. According to staff, facility provides a summary email to representatives regarding incident report details, but no internal documents. Administration staff stated families/authorized representatives have access to resident file documents via August Health electronic health records, and are able to print the documents. The facility requires all document requests be emailed, unless it is a request from a law firm. There is insufficient evidence to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Executive Director Colleen Rozatti. A copy of the report was issued. Allegation: Staff neglect resulted in resident’s death. The complaint alleges that on January 26, 2026 resident (R1) was sent to the emergency room with a fever and unresponsive, but earlier that day the resident was alert, communicative, and in stable health. A total of 7 staff were interviewed. Six out of seven staff denied the allegation. Staff interviews revealed that resident (R1's) roommate had Respiratory Syncytial Virus (RSV) without symptoms, but changes to their baseline were noted. According to staff interviews, a few days later resident (R1) began displaying changes to their baseline and was sent out to the hospital for an evaluation because a change in condition was noted. Record review was completed. The findings indicate resident (R1) was enrolled in hospice at the time of death. According to facility records, on January 12, 2026, care staff noted changes in R1 i.e., lethargy and change in appetite. Resident (R1's) roommate was diagnosed with RSV on January 2,/2026, and returned to the facility on January 7, 2026. Upon return R1's roommate was isolated in a different room and quarantined for 5 days. Resident (R1) was sent out to the hospital on January 26, 2026 at approximately 11:56 PM and returned to the facility on January 27, 2026 at approximately 2:40 AM with oxygen. Hospice was notified. Resident (R1) showed signs of decline. Care staff notified hospice accordingly. On January 29, 2026, hospice sent out a bed side nurse for the night. Resident (R1) passed away on January 30, 2026 at 6:15 AM. The Death Certificate lists the cause of death as acute cardiopulmonary arrest and Senile Dementia. There is insufficient evidence to support the allegation. Allegation: Staff did not report a change in condition to resident’s representative. It is alleged facility staff did not communicate or was honest with the resident's representative that resident (R1) was experiencing changes and decline, until before transporting R1 to the hospital because the resident had a fever. It is also alleged that facility staff did not inform R1's representative that the resident was exposed to RSV. Based on staff interviews, former Executive Director did not immediately notify Memory Care Unit staff that R1's roommate had confirmed RSV. According to staff, once they received information, they started isolating resident (R1). Staff stated that resident's responsible parties are immediately notified of any change in condition. Records indicate that R1's representative was contacted telephonically by facility staff whenever there was a change in condition. Residents interviewed did not agree with the allegation. They stated that staff promptly notify their responsible parties when there are changes in condition. The findings indicate their is insufficient information to support the allegation.the state’s words, verbatim · CDSS document, Aug 13, 2026 · control 28-AS-20260713153031

Allegation investigated: Questionable Death. Staff did not respond to resident's requests for assistance in a timely manner.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate and deliver findings on the above allegations. The purpose of the visit was discussed with Executive Director Colleen Rozatti. The investigation consisted of: On 3/16/2026, resident (R1's) records were reviewed and collected. The Department investigated the allegations and interviewed a total of 10 staff and 9 residents. No signs of neglect, abuse or other immediate health and safety concerns were noted during the visits. *Report continues on LIC 9099C. Unsubstantiated Allegation: Questionable death. It is alleged that on March 10, 2026, resident (R1) pushed the necklace alert button ten (10) times and staff did not respond. The complaint alleges the resident then pulled the wall alert cord, staff responded and called paramedics who performed CPR. According to information obtained, the resident passed away and was left lying in the bedroom floor for approximately 9 hours with a CPR tool in their mouth until the coroner arrived at the facility. The Department investigated the allegation. According to staff interviews, a caregiver responded immediately and observed the resident was sitting on the bed complaining of chest pain. While the medication technician was getting the vital machine the caregiver reported to the medtech that the resident was seizing and had a change in condition. The caregiver was instructed to turn the resident on their side, and 911 emergency were immediately called and responded within two minutes. Life saving measures were provided for approximately 45 minutes, but the resident was pronounced dead at 5:17 AM. According to the death certificate, resident (R1's) immediate cause of death was non-traumatic brain injury and central nervous system suppression. Based on the interviews conducted and supporting documents, there is insufficient evidence to support the allegation. Allegation: Staff did not respond to resident's requests for assistance in a timely manner. The complaint alleges that resident (R1) used the emergency call system several time over a lengthy period but facility staff failed to respond to R1's multiple requests while experiencing cardiac arrest. The Department investigated the allegation. The findings revealed that resident (R1) pressed the pendant four (4) times on March 10, 2026, at 2:15 AM, 3:55 AM, 4:06 AM, and 4:24 AM. A total of nine residents were interviewed, of which all reported that staff respond to pendant/emergency call system requests within a reasonable time frame of 5-15 minutes. According to staff interviews and record review, staff are to respond promptly to calls for assistance. Staff reported that depending on the situation sometimes staff respond immediately, and other times it may take a little longer if they are busy assisting other residents. Facility staff are trained to respond within 10 minutes or less. Based on the interviews conducted and call system record review, facility staff responded to R1's medical emergency accordingly in a timely manner. There is insufficient evidence to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was discussed and provided to Colleen Rozatti.the state’s words, verbatim · CDSS document, Jul 30, 2026 · control 28-AS-20260312165432

Allegation investigated: Staff neglect resulted in resident deaths Staff are not properly trained Staff mishandle the residents medications Staff member consumes alcohol during work hours, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care Staff are not addressing a resident's change in medical condition

Licensing Program Analyst (LPA) Daniel Konishi conducted a subsequent unannounced complaint visit in response to the above-mentioned allegations. LPA met with the Executive Director, Colleen Rozatti, and explained the reason for the visit. On 2/10/2026, the initial investigation visit was conducted. The investigation consisted of the following: LPA requested a copy of staff and resident rosters. LPA conducted a tour of facility and common areas with the Office Manager. LPA also requested copies of staff and resident rosters. LPA obtained death reports from November 2025 to February 2026. LPA reviewed and obtained documents from Staff #1 (S1’s) file such as job description duties, employment application, and other pertinent documents. LPA observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns. Unsubstantiated On 3/05/2026, the initial investigation visit was conducted. The investigation consisted of the following: LPA Konishi obtained the following documents: staff and resident rosters. LPA interviewed the Former Executive Director, Staff #1 (S1) to Staff #7 (S7), and Resident #1 (R1) to Resident #9 (R9). LPA reviewed a random sample of nine (9) residents’ medications. LPA obtained Death Reports, Outside Agency/Services Documentation, Resident Charting Notes, and other pertinent documents. On 3/20/2026, LPA interviewed Staff #8 (S8) over the phone. On 03/23/2026, LPA interviewed Staff #9 (S9) over the phone. On 03/25/2026, LPA interviewed Staff #10 (S10) over the phone. On 5/15/2026, LPA interviewed Staff #9 (S9) over the phone. On 5/27/2026, LPA requested documentation from Staff #2 (S2). S2 sent documentation to the LPA by email on 5/27/2026. During today's visit, the investigation consisted of the following: LPA obtained staff and resident rosters, and other pertinent documents. The investigation revealed the following: in regard to the allegation, “Staff neglect resulted in resident deaths.” It is alleged that the facility has had three (3) recent deaths due to staff neglect and not being sure how to handle situations. LPA was only provided the details of and name of one (1) of the three (3) residents that were deceased in the past three months which per death report, Former Resident #1 (FR1) passed on 02/08/2026 and cause of death was listed as respiratory decline. No information was provided regarding the identities of the other two (2) alleged residents that passed away due to staff neglect. LPA interviewed the Former Executive Director, and an additional nine (9) staff that denied the allegation stating that the three (3) recent deaths were not questionable stating that residents passed due to decline in health, being under hospice care, and not under unusual causes. LPA reviewed recent death reports from the facility. LPA reviewed five recent death reports in which cause of death were due to natural causes or under hospice care. LPA could not find any death reports that had causes that were questionable. Former Resident #2 (FR2) passed away on 01/09/2026 and cardiac arrest and Alzheimer’s Dementia were the cause of death. [Continue to LIC9099-C] Former Resident #3 (FR3) passed away on 01/30/2026 and acute cardiopulmonary arrest was the cause of death. Former Resident #4 (FR4) passed away on 01/30/2026 and end stage renal failure was the cause of death. Former Resident #5 (FR5) passed away on 03/10/2026 and cardiac arrest was the cause of death. Per review of documentation the reported deaths don’t seem suspicious as all three (3) deaths seemed to be of natural causes. LPA interviewed nine (9) out of nine (9) residents that could not confirm or deny the allegation stating that they don’t know of any questionable deaths due to staff neglect. There is not enough evidence to substantiate. Allegation: ”Staff are not properly trained.” It is alleged that the facility has a med tech without any med tech certification. LPA interviewed the Former Executive Director, nine (9) out of ten (10) denied the allegation stating that all med techs have med tech certification and on-going staff training completed. One (1) out of ten (10) staff was not sure about med tech certification as they are a caregiver and not a med tech but stated that medications are provided from staff to residents as prescribed. LPA reviewed documentation of five (5) med techs file that included valid med tech certification and ongoing staff training completed such as the following topics: California Prohibited and Restricted Conditions, Assisted with Self Administration of Medications, Dementia 101, An Overview of Quality Dementia Care, Alzheimer’s Disease and Related Disorders: ADL Care, Alzheimer’s Disease and Related Disorders: The Environment, Dementia Care: Normal Aging vs. Alzheimer’s/Dementia, Dementia Care: Activities for People with Memory Problems, and Abuse: Preventing, Recognizing, and Reporting. LPA interviewed nine (9) out of nine (9) residents that stated that the staff properly provide care and services and not neglect care. There is not enough evidence to substantiate. Allegation: “Staff mishandle the residents medications.” It is alleged that the facility staff administer morphine to a patient without a nurse present. It is also alleged that the facility staff puncture a resident with pre-filled syringes and they also pop medications from other residents medication packs. LPA interviewed the Former Executive Director, and six (6) out of ten (10) staff that denied the allegation stating that morphine is properly administered to the residents at the facility and that liquid morphine is provided by a licensed medical professional. The Former Executive Director, and six (6) out of ten (10) staff also stated that the staff does not pre-pour syringes and do not pop medications from other residents medication packs. LPA interviewed three (3) out of ten (10) staff who stated that they are not involved with handling medication administration so they were unable to provide an answer regarding this allegation. [Continue to LIC9099-C] LPA interviewed one (1) out of ten (10) staff that corroborated with the allegation stating that they were being told that the staff were pre-pour syringes and pop medication from other residents medication packs. However, that one (1) staff was not direct a witness to this. LPA interviewed eight (8) out of nine (9) residents that denied the allegation stating that staff does not mishandle medications and medications are given as prescribed. LPA interviewed one (1) out of nine (9) residents that corroborated with the allegation stating being given the wrong medication by staff but this occurred four (4) years ago. LPA reviewed a random sample of medications of nine (9) residents and all medications are given as prescribed. There is not enough evidence to substantiate. Allegation: “Staff member consumes alcohol during work hours, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care.” It is alleged that S1 drank alcohol while on duty. LPA interviewed one (1) out of ten (10) staff that corroborated with the allegation stating on witnessing Staff #1 (S1) an alcoholic drink on duty at the facility and also stated that Staff #2 (S2) gave this drink to S1. However, that one (1) out of ten (10) staff was unable to provide any evidence. LPA interviewed S1 that denied the allegation stating not drinking alcohol while on duty and was not given the alcohol drink from S2 or any staff. LPA interviewed S2 that also denied the allegation stating not drinking alcohol while on duty and did not hand any alcoholic drink to S1 or any other staff. LPA interviewed the Former Executive Director and seven (7) additional staff that denied the allegation stating not witnessing S1 drinking alcohol while on duty. Per licensee, there was no investigation nor employee suspension since there was no credible evidence provided. LPA interviewed nine (9) out of nine (9) residents that denied the allegation stating not witnessing S1 or any staff drinking alcohol while on duty. There is not enough evidence to substantiate. Allegation: “Staff are not addressing a resident's change in medical condition.” It is alleged that the facility staff LVN (Licensed Vocational Nurse) that refuses to do wound care. LPA interviewed the Former Executive Director, and nine (9) out of ten (10) staff that denied the allegation stating that the LVN staff does not refuse to do wound care but wound care is done by a licensed medical professional nurse, hospice care specialist, or home health care specialist. One (1) out of ten (10) staff stated not sure who handled wound care treatment but stated that the caregivers of the facility does not treat wound care. LPA interviewed nine (9) out of nine (9) resident that stated they do not need nor require wound care treatment. [Continue to LIC9099-C] However, one (1) out nine (9) residents denied the allegation stating that wound care treatment is provided by home health specialist. LPA observed during the visit that a home health care specialist visit to help conduct wound care for one (1) resident. LPA also reviewed records of a document of a home health visit for wound care treatment. There is not enough evidence to substantiate. 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 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 was held, and a copy of this report was provided to the Executive Director, Colleen Rozatti.the state’s words, verbatim · CDSS document, Jul 14, 2026 · control 28-AS-20260208231203

Allegation investigated: Staff did not properly report incidents involving residents. Staff do not meet and have updated services plans for the residents. Staff do not perform proper reassessments for the residents.

Licensing Program Analyst (LPA) Galarza conducted a subsequent visit to investigate and deliver findings on the above allegations. Executive Director Colleen Rozatti was explained the purpose of the visit. The investigation consisted of: On 2/13/2026 an initial visit was conducted. Subsequent visits were conducted on 4/24/2026 and 7/10/2026. During the visits a physical plant tour of activity rooms, resident rooms, common areas, dining room/kitchen meal service, laundry rooms, and Memory Care Unit. Resident and facility records were obtained. A total of nine (9) staff and nine (9) residents were interviewed. *Report continuation on LIC9099C. Substantiated Allegation: Staff did not properly report incidents involving residents. It is alleged that facility staff did not submit incident reports within reporting requirements time frame. According to information obtained, multiple incident reports and/or death reports were not submitted to CCLD within 7 days. Based on staff interviews, in December 2025 the Wellness Director resigned. The Resident Care Coordinator was appointed facility designee on December 25, 2025. According to staff, the Wellness Department team and Executive Director are responsible for oversight of the medication room and Wellness Department responsibilities i.e., submitting incident reports. Based on record review, the findings revealed that from December 2025- February 2026 a total of 30 incident reports and one (1) death report were submitted late; not within Title 22 reporting requirement of 7 days. Therefore, there is sufficient evidence to support the allegation. Allegation: Staff do not meet and have updated services plans for the residents. It is alleged that multiple residents' service plans are not updated despite documented changes in condition, and staff are not following existing service plans. For instance, facility procedure is to develop a service plan within 48 hours of move-in date, and routinely update every 3 months and/or as needed. Personnel and licensee were interviewed. The findings indicate that the Executive Director, Resident Care Coordinator, and Wellness Director are accountable for the service plan assessments. The Resident Care Coordinator is responsible for completing services plans. Once the service plan is completed August Health electronic health record (EHR) software automatically send the service plan to the resident's authorized representative/responsible party for review and signature. Staff stated that some residents service plans are not completed because their authorized representative has not signed it electronically. On February 13, 2026, ten (10) August Health service plans were audited by LPA. The findings indicate that residents (R1- R4's) service plans were completed late and/or there was no service plan in the file. For example, resident (R2) moved in to the facility on September 26, 2025 and their service plan was completed on February 1, 2026. The allegation is supported. Allegation: Staff do not perform proper reassessments for the residents. The complaint alleges staff are not conducting reassessments when residents have a change in condition. For instance, when residents are discharged from the hospital and return to the facility a reassessment is to be completed. Personnel interviews confirmed that after a change in condition that results in hospitalization or skilled nursing facility care resident's are to be reassessed prior to returning to the facility. Based on record review conducted on February 13, 2026 of August Health records, resident (R4) had a change in condition on December 29, 2025, resulting in hospitalization. The resident returned to the facility on December 31, 2025. As of February 13, 2026 no reassessment had been completed after R4's change in condition. Resident (R5's) was hospitalized on 1/2/26- 1/4/26, again on 1/5/26 and returned on 1/13/26, but as of 2/13/26 no reassessment documentation had been completed. The allegation is supported. Based on record review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, deficiencies are cited. An exit interview was conducted with Anahi Reyes. A copy of the report and appeal rights were provided. Allegation: Staff allowed unauthorized individuals access to the residents medications. The complaint alleges individuals not employed by the facility had unauthorized access to the medication room and resident medications. It was reported that the individuals toured the building, offices and spent time in the medication room providing feedback to the Wellness Department. Based on interviews conducted the findings indicate that on February 4, 2026 Omnicare Pharmacy audited the medications. On February 9, 2026, licensee, Wellness Director, and a former medication technician staff were present in the medication room while Omnicare pharmacy personnel conducted medication reconciliation. According to interviews, the former staff was invited by the Licensee to show the new Wellness Director medication room documentation and inventory procedures. Interviews revealed that former staff and licensee did not handle any medications. Per interviews conducted, Omnicare pharmacy conducts quarterly medication audits. There is insufficient information to support the allegaiton. Allegation: Staff consumed a resident's medication. It is alleged that former Wellness Director took and consumed a resident's PRN "as needed" medication for personal use. Staff interviews revealed that on February 9, 2026, two (2) medtechs witnessed former Wellness Director take a PRN "Tums" from resident (R1)'s PRN medication supply. It is alleged surveillance cameras captured the incident. Interviews revealed the incident was reported to the facility’s Human Resource Department. The facility initiated an internal investigation, but the former Wellness Director resigned without notice following the February 9, 2026 incident. LPA was unable to interview the former Wellness Director. Based on record review, an additional medication issue 2/6/2026 there a narcotic count discrepancy. The facility cross reported the incident to Whittier Police and CCLD and med-tech staff was terminated. During the February 9, 2026 incident the medication was removed from the resident’s bottle and taken for personal use, constituting misappropriation of resident property and improper medication handling. However, there is insufficient information to support the allegation. Allegation: Facility does not have a qualified and certified administrator. The complaint alleges the facility did not have an Administrator beginning February 3, 2026. It is alleged the licensee appointed an unqualified individual as the facility Administrator/Executive Director that did not have the required education and experience to oversee an RCFE of +50 residents. Staff and licensee were interviewed. Licensee stated the former Wellness Director was re-hired and appointed facility Designee because Executive Director Beatriz Romeo-Lui went on leave on February 9, 2026. Per licensee's request, the former Wellness Director visited the facility on February 9, 2026, but signed the employment contract on February 11, 2026. Licensee stated the Designee/Former Wellness Director was not appointed Administrator/Executive Director, but they do have an Administrator Certificate. Former Wellness Director stated they were appointed Designee/Interim Executive Director during Ms. Romeo-Lui's absence leave. Based on record review, the findings indicate the licensee did not appoint former Wellness Director as the facility Administrator/Executive Director. On April 6, 2026, a new Executive Director was hired. The allegation cannot be supported. Allegation: Staff allow access to confidential information. It is alleged that overseas individuals have access to electronic health records (EHR) and are accessing the facility "August Health" software that contains confidential resident information. Based on interviews, the licensee, Executive Director, Resident Care Coordinator, Wellness Director, business office manager, and lead medication technician have full access to records. There are additional personnel that have access i.e., medication technicians, caregivers, corporate personnel, and facility consultants. Licensee stated everyone that accesses electronic health records work for the company. During the initial complaint visit (2/13/26) administrative staff accessed August Health and demonstrated it's functions, systems, and analytics. There is insufficient evidence to prove that unauthorized persons accessed confidential health records. Allegation: Staff are not meeting the residents hygiene needs. It is alleged several residents do not have shower schedules and are not consistently receiving showers. Personnel interviews revealed that the Resident Care Coordinator is responsible for creating the shower schedule. If a resident is enrolled in home health or hospice care and is bed bound the outside agencies bathe the residents and change their bed sheets. Staff stated if any resident has an incontinence accident staff assist and provide personal hygiene care. Staff interviews revealed there are bed bound residents that smell and their bed sheets are dirty. According to staff, hospice and home health staff bathe the residents and change their sheets, but facility staff assist when needed. In April 2026, the facility had 9 bed bound residents enrolled in hospice and/or home health. Facility shower schedule and service plans were reviewed. The findings indicate some residents' service plan bathing needs/enhanced needs indicate there is 3-tier assistance. For instance, if a resident requires minimal bathing assistance they are provided bathing assistance 1x week, if a resident requires moderate/max assist (1-person assist), they are bathed 2x week, and when a resident requires moderate/max assist with bathing (2-person assist) is provided 1x week. A total of 9 residents were interviewed, all denied the allegation. Caregivers shower residents and if needed medication technicians assist. There is insufficient evidence to support the allegation. Allegation: Staff do not have planned activities for the residents. It is alleged that in early 2026 the Memory Care Unit was not providing social, physical, and cognitive/sensory activities for residents regularly because the Activities Director was only able to assist in the Assisted Living side of the facility. All staff and residents denied the allegation. A total of 9 residents were interviewed. Residents stated they are offered activities daily and are encouraged to participate. None of the residents had any concerns with planned activities/activity calendar. Staff interviews revealed that prior to the hiring of the current Activities Director activities were being planned and conducted by the Activities Assistant. However, the staff person went on an extended leave of absence, that according to staff did not affect activities because other facility staff such as, Memory Care Unit and Assisted Living caregivers lead resident activities. Staff acknowledged that sometimes due to unforeseen circumstances staff that lead facility activities call off. Therefore, planned activities may have been affected, but alternate staff covered and lead the activities. The current Activities Director was hired on 10/6/2025. They are responsible for creating activity calendars for the Memory Care Unit and Assisted Living residents, plans holiday events, and coordinates activity snacks with the facility dietician. Activities Director said that when they began working at the facility there were on-going activities. They stated that when they are off activities is still conducted and staff have been trained to follow the monthly activities calendar. Based on observation, both the Memory Care Unit and Assisted Living area have posted activity calendars and resident engagement was observed. Record review confirmed the Activity Director is experienced and is knowledgeable about social, physical, and cognitive/sensory activities. Therefore, there is insufficient information to support the allegation. Allegation: Staff did not afford a resident privacy. The complaint alleges facility staff infringed upon residents' privacy when they contacted a resident's family member without documented consent after an incident. It is also alleged that residents' privacy was impacted because resident's electronic health records were being accessed by corporate and other 3rd party personnel. A total of 9 residents were interviewed, none stated they feel their privacy has been compromised. Staff stated that a resident was observed drinking alcohol while parked in the parking. Their car keys were not taken away. Staff called the resident's family member, who was listed as an emergency contact in their file. A care plan meeting that included the resident's physician advised the resident shall not drive due to frequent consumption of alcohol. Based on record review, the family member that was contacted regarding the incident is listed as the resident's responsible party in the resident's file. There is insufficient information to support the allegation. Allegation: Staff do not ensure the facility is properly maintained. The complaint alleges the building has on-going roof leaks that are not addressed in a timely manner. Resident interviewed stated the facility is well maintained and acknowledged their was a water leak that was repaired right away. Staff interviews revealed that the building does have water leaks especially after heavy rain, but all leaks are immediately addressed by the maintenance director and/or 3rd party vendors. Staff said the kitchen had an overflow of water because a resident in the 2nd floor left a toilet tank opened causing a leak that traveled directly beneath to the 1st floor. The maintenance director used a snake to tool to unclog the toilet, which then caused a pipe to break. Plumbers were immediately called and repaired the pipe and the leak was fixed. Based on maintenance invoice review and interviews, there is insufficient evidence to support the allegation. Allegation: Staff do not meet the residents laundry needs. It is alleged the laundry machines break down often and there is insufficient laundry machines to handle the laundry needs of the residents. All residents interviewed stated their laundry needs are met and reported no issues with their laundry. All staff interviewed denied the allegation. Staff interviews revealed that the facility previously had washer and dryers that at times not able to handle the laundry needs of the building, and a result they broke down. Maintenance and housekeeping staff stated that despite occasions in which the laundry machines were in disrepair there was enough operable machines to complete all laundry tasks. According to staff, the 1st floor has 2 washers and 2 dryers, and the 2nd floor has 4 washers and 3 dryers. The 1st floor washers were replaced earlier this year and are under commercial warranty. Based on interviews conducted, the findings indicate when a washer and/or dryer breaks down maintenance staff and 3rd party company immediately make repairs. LPA inspected laundry rooms during the visits, and did not observe any machine disrepair or laundry issues. There is insufficient evidence to support the allegation. Allegation: Facility is in financial distress. It is alleged several employees resigned due to not being paid on time. It is also alleged that utility and commercial food distributors were not paid on time. As a result, the facility received notice that power would be shut down, and kitchen personnel had to substitute meals because commercial food orders were no being delivered due to lack of payment. Residents interviewed had no knowledge of alleged financial difficulties. License and all staff interviewed denied the allegation. Licensee stated the company Chief Financial Officer is responsible for paying all bills. Utilities have never been shut down and personnel is paid via auto-pay. None of the staff interviewed reported non-payment of salary or knowledge of any financial distress. Interviews revealed the building had a power outage due to city utilities, and not due to non-payment of utility bill. There is insufficient evidence to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was discussed and provided to Executive Directorthe state’s words, verbatim · CDSS document, Jul 10, 2026 · control 28-AS-20260211084916

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jul 31, 2026

Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below..... This requirement was not met evidenced by: Based on record review, the findings indicate from December 2025- February 2026 a total of 30 incident reports and one (1) death report were submitted late, which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 10, 2026

Plan of correction: Executive Director agreed to: 1. Submit a written plan of correction addressing incident reports/death reporting requirements and facility procedures. 2. Staff in-service training on regulation 87211

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(17)(E) · Plan of correction due date: Jul 31, 2026

Resident Records. Each resident’s record shall contain at least the following information: Documents and information required by the following: (E) Section 87463, Reappraisals; and... This requirement was not met evidenced by: Based on record review of electronic health records, multiple residents' service plans were not updated despite documented changes in condition. Service plans were completed late and/or there was no service plan in the file; this poses a potential health and safety risk to persons in car.the state’s words, verbatim · CDSS document, Jul 10, 2026

Plan of correction: Executive Director agreed to submit a written plan of correction /certification that residents (R1 -R4's) services plans are updated and proof of staff in-service training in resident records and service plans.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(b)(1)(E) · Plan of correction due date: Jul 31, 2026

Reappraisals. The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition.....Significant changes in condition...Illness or injury that results in a significant change in the health care or dietary needs of the resident. This posed a potential health and safety risk. Based on record review, residents (R4 & R5) had a change in condtion that resulted in hospitalizations. Documentation of completed reassessments upon return were not observed or provided during the 2/13/26 initial complaint visit. This posed a potential health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Jul 10, 2026

Plan of correction: Executive Director agreed to submit copies of R4 & R5's reappraisals and proof of staff in-service training.

Allegation investigated: Staff do not administer residents' medications as prescribed. Staff do not change soiled residents in a timely manner. Staff are smoking in the facility. Staff do not ensure that the facility is free of pest.

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced initial complaint investigation visit regarding the above allegations. LPA Gonzalez was greeted by staff, and the purpose of the visit was explained. The investigation consisted of the following: LPA toured the facility and inspected residents’ rooms on the first, second and third floor. LPA requested and obtained copies of Personnel Roster, Resident Roster, reviewed pest control logs, smoking/vaping policy, reviewed Medication Administration Record (MAR) log and notes, interviewed staff #1-6 (S1- S6) and residents #1- 8 (R1-R8). continued on LIC9099C Unsubstantiated The investigation revealed the following: Regarding allegation “Staff do not administer residents' medications as prescribed,” it was reported night Med Techs often do not provide residents with their medications on time. 7 out of 8 residents interviewed deny the allegation. R1 stated “they bring it on time.” R5 stated they always receive medication timely and “always exactly what it’s supposed to be.” R7 stated med techs are timely with medication. R8 stated it varies with the med tech and the shifts, but R8 stated they always get all their medications. 6 out of 6 staff deny the allegation. S1 stated residents are very vocal and will let us know. S2-S6 stated they had not received complaints from residents stating they do not receive their medication in a timely manner. Regarding allegation “Staff do not change soiled residents in a timely manner,” it was reported night staff often do not change residents in a timely manner. 7 out of 8 residents interviewed denied the allegation. R6 stated they see staff regularly checking on their roommate that needs assistance with changing. R7 stated they have not been left in soiled diapers and are changed in a timely manner. R7 stated “Even if I went just a little bit, they still change me.” R8 stated staff usually change R8 in a timely manner. R8 stated “it has happened but not regularly. Rarely.” 6 out of 6 staff interviewed deny the allegation. S2 and S3 stated residents are checked and changed every 2 hours and as needed. S1 and S6 stated they had not received any complaints from residents about not being changed in a timely manner. Regarding allegation “Staff are smoking in the facility.” It was reported that a staff member was often vaping inside the facility. 8 out of 8 residents interviewed denied the allegation. R1 stated “I’ve only seen it outside. I could smell it.” R3 stated they’d “never seen that.” R5 stated they had not seen anyone smoking or vaping in the building. 6 out of 6 staff interviewed denied the allegation. Staff interviewed stated they had not seen any staff vaping in the building and had not received any complaints regarding staff vaping inside the building. continued on LIC9099C page 3 Regarding allegation “Staff do not ensure that the facility is free of pest,” it was reported that facility has had a roach infestation throughout the facility for several months and that management has done nothing to address the issue. 7 out of 8 residents interviewed deny the allegation. R1 stated they had not seen any roaches in their room or anywhere else. R2 stated they had not seen any roaches in their room or in the building. R5 staff they saw one little roach but didn’t let staff know. R6 stated their neighbor had a roach problem “but it’s been handled.” R5 stated a company comes once a month to spray and R5 hasn’t seen any more roaches since. LPA reviewed pest control service invoices. Services are scheduled monthly. Invoices dated 04/15/26 and 05/11/26 stated “No live pest activity was observed at time of visit.” Invoice dated 06/18/26 the technician stated they hadn’t seen anything of concern at the time of visit. 4 out of 6 staff interviewed denied the allegation. S1 stated a pest control company treats the facility monthly. S5 and S6 stated they had not received any complaints regarding a roach infestation at the facility. LPA toured the facility lobby, dining area, and rooms on the first, second and third floors and did not observe any roaches. Based on observation, interviews and record review, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Executive Director Colleen Rozatti.the state’s words, verbatim · CDSS document, Jun 26, 2026 · control 28-AS-20260617154556

Allegation investigated: Facility does not provide a comfortable temperature to residents in care. Air conditioner is in disrepair.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the above allegations. The purpose of the visit was explained to Executive Director Colleen Rozatti. The investigation consisted of: A physical plant tour of the facility common areas and 15 resident rooms was completed. Staff (S1- S7), Licensee, and residents (R1 - R9) were interviewed. Copies of air conditioning invoices, mitigation plan, and rosters were obtained. During today's visit, the facility temperature was comfortable in common areas and resident rooms. The weather forecast today is mostly cloudy with a high of 78DF. The general temperature in the facility measured 72 Degrees Fahrenheit. *Report continuation on 9099C. Unsubstantiated Allegation: Facility does not provide a comfortable temperature to residents in care. The complaint alleges residents have been very uncomfortable with the heat. According to information obtained, during the past week some resident rooms and areas were 85 degrees during warm days. Staff and residents were interviewed. A total of nine (9) residents were interviewed. The majority of residents interviewed stated their rooms have a comfortable temperature, but said the dining room temperature has been very warm. None of the residents interviewed reported major discomfort as a result of the air conditioning disrepair. Residents said facility staff have been proactive in offering and providing them with fans if needed. Residents stated that the weather has been on the cool side the last several days. Therefore, they feel the their rooms and facility has had a comfortable temperature in the last several days. Staff stated fans were placed in areas that are warmer, such as, the dining room and certain east side resident rooms. Staff are opening all hallways and resident room windows, and circulation fans have been placed in common areas. The facility temperature during the visit was on average 72 Degrees Fahrenheit. There is insufficient evidence to corroborate the allegation. Allegation: Air conditioner is in disrepair. It is alleged the air conditioner has not worked since Friday, June 12, 2026 and as of Monday June 15, 2026 the air conditioning issue was still not repaired. Staff interviews revealed the air conditioning unit that is in disrepair is affecting certain rooms and areas i.e., dining room, 3rd floor rooms, and rooms/areas located on the east side of the building. Licensee stated that a technician assessed the problem on June 12, 2026, but was unable to fix the issue because in order to fix the broken part a plumber needed to first replace a valve. The technician contacted the air conditioning manufacturer to assist with the diagnosis of the problem. The plumber replaced the valve yesterday night. Technicians are scheduled to return on Monday, June 22, 2026. Some residents stated their rooms are not affected, and some residents stated their rooms have been affected. All residents confirmed the facility has been addressing the issue, and due to recent pleasant weather the issue has not affected them greatly. Per staff and resident interviews, residents and their responsible parties were notified via email that the air conditioning is in disrepair in certain areas. Based on air conditioning invoice review, the findings indicate the Licensee immediately contracted technicians to fix the problem. Staff implemented a heat mitigation plan that includes, providing residents with fans, increase resident checks, and added hydration areas. The facility maintenance director is buying portable air coolers that will be placed in the dining room and resident rooms if needed. There is insufficient evidence to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was discussed and provided to Colleen Rozatti.the state’s words, verbatim · CDSS document, Jun 19, 2026 · control 28-AS-20260616094406

Allegation investigated: Licensee listed an incorrect facility license number on the public website.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the above allegation. he purpose of the visit was explained to Executive Director Colleen Rozatti. The investigation consisted of: Record review was completed and a physical plant tour of the facility common areas was completed. Licensee and staff (S1- S4) were interviewed. Copies of the Admission Agreement, Resident Handbook, and marketing materials were obtained. LPA searched the facility website and printed the facility number listed. *Report continuation on 9099C. Substantiated Allegation: Licensee listed an incorrect facility license number on the public website. The complaint alleges the facility license number publicized on the website is incorrect. The website was viewed and R1’s records were reviewed. Administration staff and licensee were interviewed. Administration staff and licensee acknowledged the facility license number listed on website https://www.laposadasl.com is not correct. Based on record evaluation, the findings indicate that the facility number listed on the website belongs to a Riverside facility named “Buena Vista Assisted Living” # 331880902, that also has an incorrect facility number listed on the website. The allegation is supported by sufficient evidence. Based on record review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, a deficiency is cited. An exit interview conducted, copy of the report and appeal rights was provided to Executive Director Colleen Rozatti.the state’s words, verbatim · CDSS document, Jun 19, 2026 · control 28-AS-20260612094052

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87206(a) · Plan of correction due date: Jun 26, 2026

Advertisements and License Number. In accordance with Health and Safety Code Sections 1569.68 and 1569.681, licensees shall reveal each facility license number in all public advertisements, including Internet, or correspondence. This requirement was not met evidenced by: Based on record review and interviews, the findings indicate the facility website has listed an incorrect license number that belongs to another Licensee's facility. In addition, the Resident Handbook lists the previous operator/ licensee's number. This poses a potential, health, safety risks to persons in care.the state’s words, verbatim · CDSS document, Jun 19, 2026

Plan of correction: Licensee agreed to correct the website license number and the Resident Handbook license information. *The website license number was fixed during the visit. Submit picture evidence of corrections.

Allegation investigated: Questionable death. Staff does not serve residents meals on time. Staff are not providing residents assistance in a timely manner.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit investigate and deliver findings on the above allegations. The purpose of the visit was discussed with new Executive Director Colleen Rozatti. The investigation consisted of: On 8/28/2025, LPA conducted a physical plant inspection of kitchen, dining room, and laundry areas. Resident (R1's) file documents were reviewed and obtained. Residents (R2-R6) and three (3) staff were interviewed. Resident (R1) is deceased and was not interviewed. Their room was inspected. During the course of the investigation, the Deparment Investigations Branch obtained R1's County of Los Angeles Medical Examiner Death Investigation Summary and Death Certificate. During today's visit, kitchen, resident rooms, common areas, and laundry areas were inspected. LPA interviewed staff (S4 & S5) and residents (R7-R9). No health and safety concerns were observed. Unsubstantiated Allegation: Questionable death. The complaint alleges that on August 15, 2025, at approximately 6:46 AM, a medication technician found resident (R1) deceased in their room after sustaining a fall. The resident was found unresponsive laying supine on the floor with their head/neck area on the TV stand, blood present on the mouth, floor, back of head, and on the floor. LA County Fire Department arrived on scene and pronounced the resident dead. An injury was noted on the back of the decedent's head. The Department of Social Services Investigation Branch obtained the County of Los Angeles Medical Examiner Death Investigation Summary and Death Certificate. The cause of death was deemed accidental/natural. Per record review, R1 had mild cognitive impairment, used a quad cane, was independent in mobility/transfer, was not a fall risk, and there were no observable safety awareness deficits. The findings indicate there is insufficient evidence to corroborate the allegation. Allegation: Staff does not serve residents meals on time. It is alleged that in August 2025 residents were being served meals late and residents were complaining about being hungry. On 8/28/25, five residents were interviewed. The residents said their meals were now being served on time, but acknowledged that in the month of July 2025 there was delays in meal serving times. Three staff were interviewed on 8/28/25, whom stated that the dining services department had been short staffed for approximately 2 months, thus meals were served late at times, and the Dining Services Director asked caregivers to help serve residents meals. The kitchen was toured, and on that day there was sufficient staffing in the dining room and meals were served on time. During today's visit, 3 additional residents and 2 additional staff were interviewed. The findings indicate that during Summer 2025 there were kitchen staffing shortages that affected meal times. Based on interviews and record review, this allegation was investigated in July 2025 and already substantiated under complaint, control # 28-AS-20250716151740. Allegation: Staff are not providing residents assistance in a timely manner. It is alleged that the residents laundry was "backed up" and some residents did not have any clean clothes or linens. A total of 5 staff were interviewed, of which all stated that all residents clothes was being washed as required. According to interviews, during Summer 2025 there were 3 housekeepers on the day shift, but towards the end of August 2025 a fourth housekeeper was hired. Five residents were interviewed on 8/28/25, all stated their clothes is washed regularly and reported no laundry issues. On 8/28/2025, LPA toured the laundry rooms. The laundry machines were operable and residents clothes was being washed. No large piles of resident's clothes and linens were observed in the laundry rooms. During today's visit, LPA checked all 3 laundry room areas and did no observe backed up laundry. The residents and staff interviewed today denied the allegation. Therefore, there is insufficient information to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was discussed and provided to Executive Director Colleen Rozatti.the state’s words, verbatim · CDSS document, Apr 24, 2026 · control 28-AS-20250826162347

Allegation investigated: Questionable Death. Staff did not take precautions to prevent a scabies outbreak. Staff did not provide residents self care products. Staff did not ensure that residents had access to their prosthetic teeth. Staff do not follow reporting requirements.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the investigation on the allegations listed above. LPA met with Administrator Colleen Rozatti and explained the purpose of the visit. The investigation consisted of the following: On 11/20/25, LPA Chan conducted the initial visit. LPA toured the facility and inspected 12 rooms. The facility had sufficient food supplies. The hot water temperature in the rooms was measured between 105-120 degrees F. There were no immediate health and safety concerns at that time. LPA interviewed four (4) staff. Four additional (4) staff interviews were held on other dates. During the visit today, LPA interviewed eight (8) residents. Unsubstantiated The investigation revealed the following: Allegation – Questionable death. It was alleged that Resident #1 (R1) died from an infection a week later that she sustained from not removing or cleaning her dentures. LPA interviewed staff regarding this allegation. Staff who had remembered R1 stated that R1 resided in the assisted living side. Staff stated that R1 went to the hospital in November 2024 due to a cough and did not return to the facility. R1 was discharged from the facility on 11/25/2024. LPA obtained and reviewed the death certificate for R1. R1 passed away several months later at a different facility, and the cause of death was due to respiratory distress, congestive heart failure, and Alzheimer’s Dementia. Since R1 was not under the care of the facility during the time of death, the allegation is deemed unsubstantiated. Allegation - Staff did not take precautions to prevent a scabies outbreak. It was alleged that the facility had an outbreak of scabies around November 2025. LPA interviewed eight (8) staff, and they did not recall any outbreak of scabies at the facility. Staff stated that there was only one individual who came from the hospital and was treated for scabies. Staff took measures to prevent the spread of scabies by wearing proper PPE supplies and cleaning and disinfecting the impacted areas. Staff also redirected the resident back to the room or distanced other residents to avoid contact. Staff stated that they received training on infection control for any outbreaks and always take precautions to prevent the spread of contagious diseases. Allegation - Staff did not provide residents with self-care products. It was alleged that the facility is constantly short on supplies such as incontinence supplies and hygiene supplies like shampoo and conditioner. Staff interviewed stated that the facility has extra supplies of incontinence products and shampoo, conditioner, body wash, and soap. The facility has never run out of any of the supplies, and staff would order them before they run out. Staff stated that most of the residents’ responsible parties purchase their briefs/pull-ups, including hygiene supplies for the residents. LPA interviewed eight (8) residents. Seven (7) out of eight (8) indicated that their family members purchase and bring their incontinence and hygiene products to them. Residents have never run out of supplies. Allegation - Staff did not ensure that residents had access to their prosthetic teeth. It was alleged that residents went out without their dentures because staff could not find the keys to the closet where the dentures are stored. Per the staff interviewed, the caregivers store and clean the residents’ dentures daily. The staff put them in the storage container for cleaning at night. Staff stated that some residents can manage their own dentures and do not need staff assistance. For those who need assistance, the staff will clean the dentures and place them either in the residents’ rooms or a med cart. Staff interviewed do not recall any residents not wearing their dentures due to misplacing them or not being able to access the locked drawer. The residents interviewed did not wear dentures or did not need staff assistance with dental care. Allegation - Staff do not follow reporting requirements. LPA interviewed eight (8) staff for this allegation. The alleged unreported incidents were the death of a resident, the scabies outbreak, or a lockdown by the health department due to a water issue. Based on interviews and record review, the incidents indicated did not occur at the facility, so licensing would not be informed. Staff stated that they would report any outbreaks to the proper agencies and Community Care Licensing. In addition, the facility would submit incident reports regarding death, hospitalization, and any unusual incidents involving the residents. LPA observed that the facility has been consistently submitting incident reports to licensing for review. 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, Apr 23, 2026 · control 28-AS-20251119091202

Allegation investigated: Staff prevents residents from using the public restroom by locking the doors. Staff did not provide residents meal in a timely manner. Facility does not have a full time Activity Director.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegations. The purpose of the visit was discussed with new Executive Director Colleen Rozatti. The investigation consisted of: On 7/22/25, a physical plant tour of common areas, activity areas, public restrooms, dining room meal service and kitchen was conducted. Residents (R1- R11) and staff (S1-S13) were interviewed. Documents consisting of Activities Director & Activities Associate job description, 4 week meal menu, meal serving hours schedule, weekly activities calendar, resident roster, and LIC 500 Personnel Report were obtained. NOTE: The facility did not have any activity calendar posted in a central location accessible to residents *Narrative continues next page. Substantiated Allegation: Staff prevents residents from using the public restroom by locking the doors. The complaint alleges that in early July 2025 the community/public 1st floor restroom was being locked so that staff had less of restroom assignments because at that time there was only one housekeeper in the building. It is alleged that a resident informed staff that the 1st floor restroom was locked, the resident was told to go upstairs to use the restroom in their room, and the inaccessibility and closure of the 1st floor public restroom caused the resident to have a couple of incontinence accidents on two different occasions. A total of 11 residents were interviewed. Seven (7) out of 11 residents confirmed the allegation. Resident interviews revealed that they were told by staff the 1st floor restroom was locked because residents were falling in the restroom. Residents said that some residents had incontinence accidents because they were not allowed to use the 1st floor restroom. The restroom closure affected residents in care and their visitors. A total of 13 staff were interviewed. Staff acknowledged the 1st floor restroom was locked and inaccessible to residents in order to "prevent injury". Staff interviews revealed that in early July 2025 Executive Director and medication technicians ordered housekeepers to keep the 1st floor restroom locked because a resident fell twice in the 1st floor restroom. Staff said that previous to the restroom closure directive, the restroom was only closed during maintenance or cleaning. It was established that residents who were able to to to the restroom on their own may be given access to the public restroom, and those that required incontinence assistance were to be escorted by staff to their room bathroom. According to interviews, there were several residents that had incontinence accidents because they did not get to their room bathroom in time. Staff interviews revealed that residents and visitors did not have access to the 1st floor public restroom without getting the key from the lobby receptionist. The findings revealed that the day receptionist shift is not 24 hours a day, and once their shift was over, there was no staff at the front to give residents access to the 1st floor public restroom. Allegation: Staff did not provide residents meal in a timely manner. It is alleged that in July 2025 meals were not being served on time and on July 16, 2025, lunch service was served at 12:38 PM, instead of 12:00 PM, and as a result residents and their families made attempts to reach out to Administration staff about the late meals, but they did not receive a response. A total of thirteen (13) staff were interviewed, of which nine (9) staff acknowledged that meals have been served late due to staff shortages. Staff interviews revealed that there was one occasion in which the lunch meal was served very late, close to 1 hour after the regular lunch time of 12 PM. The Dining Service Director confirmed that in the month of July 2025 meals were not being served on time because they were not familiar with the schedule since they had just began working at the facility on June 26, 2025. All kitchen staff interviewed confirmed the allegation and stated that on days where there are staffing shortages meals may be served late. For instance, during Summer 2025 there were kitchen/dietary aide staff shortages and at times there was only 1 or 2 dietary aides. According to staff, there are supposed to be 2 cooks and four aides per shift. Additionally, a new directive from Administration and Dining Services Director instructed kitchen staff to take meal trays to resident rooms, and previous practice had caregivers take the meal trays to the resident rooms. A total of 11 residents were interviewed, of which 8 confirmed the allegation. They stated that meals were being served late and cold during July 2025 because there was staffing shortages. Residents stated that meal serving times were not being followed because lunch service is supposed to be at 12:00 PM and during several weeks in July 2025 lunch and sometimes dinner meals were served approximately 30 minutes late but staff still wanted residents to be in the dining room by 12 PM and 5 PM despite meal service delays. The findings indicate that in 2025 there were changes to the Dining Services Director position that resulted in meal time and staff shortages. There is sufficient information to support the allegation. Allegation: Facility does not have a full-time Activity Director. It was reported that the facility did not have a full-time Activity Director for "a long time". In July 2025, the facility Activity Assistant went on leave and as a result there were limited or no resident engagement activities. According to 13 staff interviews, the facility did not have an Activity Director since the end of 2024 through October 2025. A staff member was appointed the Activities Assistant position in 2024, but went on leave in July 2025. As a result, there were no formal resident engagement activities like., exercise classes, bingo, arts and crafts, music programming, tea with friends, and board games. Receptionists were instructed to place coloring pages in the common areas as "independent activities" for residents. Weekend receptionists make popcorn & lemonade. During the initial complaint visit (7/22/25), LPA reviewed the weekly and monthly activities calendar. On 7/22/25, arts and crafts, manicures, bingo, nostalgic movies, ice cream/milk shake, and cocktail music was scheduled, but no activities were observed during the visit. A total of 11 residents were interviewed, of which 8 residents stated that there has not been an Activity Director "in a very long time" and the Activity Assistant was off on leave. Residents said there was no activity calendar posted and LPA confirmed during the visit that there was no activity calendar posted. Therefore, there is sufficient information to support the allegation. Based on observation and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, a deficiencies are cited. An exit interview conducted, copy of the report and appeal rights was provided to Executive Director Colleen Rozatti.the state’s words, verbatim · CDSS document, Apr 16, 2026 · control 28-AS-20250716151740

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(b) · Plan of correction due date: May 7, 2026

Personal Accommodations and Services. Toilets and bathrooms shall be conveniently located...... This requirement was not met evidenced by: In July 2025, staff began locking the 1st floor public restrooms because a resident fell twice in the public restroom. Housekeepers were instructed to lock the restroom. As as result, some residents had incontinence accidents because they were not allowed to use the restroom and did not make it in time to their room bathroom. This posed a potential health, safety, and personal rights risk.the state’s words, verbatim · CDSS document, Apr 16, 2026

Plan of correction: Executive Director agreed to submit a written plan of correction that addresses the July 2025 1st floor public bathroom closure, and rectification. A staff in-service will be conducted.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(18) · Plan of correction due date: May 7, 2026

General Food Service Requirements. The following food service requirements shall apply: Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. This requirement was not met evidenced by: Based on interviews, in the month of July 2025 the facility experienced staff shortages that affected meal service preparation and meal times services, causing residents to wait from 20-45 minutes for their lunch and/or dinner meals. This posed a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 16, 2026

Plan of correction: Executive Director agrees to oversee delivery of meals and meal times. Staff in-service will be provided.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(f) · Plan of correction due date: May 7, 2026

Planned Activities. In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities....This requirement was not met evidenced by: Based on record review and interviews, the findings indicate that the facility did not have an Activity Director since the end of 2024. An activity assistant was responsible for activities, but the staff member went on leave and was off occassionally, and as a result planned activities did not occur. This posed a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 16, 2026

Plan of correction: Executive Director agrees to oversee activity calendar on a monthly basis and submit a written plan of correction.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Galarza conducted a subsequent unannounced Annual Continuation visit to finish reviewing staff and resident records and issue citations observed during yesterday's visit. Interim Executive Director Anahi Reyes assisted with the visit. The Residential Care for Elderly (RCFE) facility serves residents ages 60 and over. There is a Memory Care Unit for cognitively impaired residents. Infection Control: The facility has an Infection Control Plan and ample PPE supplies. Operational Requirements: The facility has a Dementia plan, a fire clearance for 114 non-ambulatory residents age 60 and above, of which 15 residents may be bedridden, and a hospice waiver for 30 residents. Facility does not handle resident money. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 6/2/2026. Physical Plant/Environment Safety: The facility is a three (3) story building consisting of 77 resident rooms. The 1st floor consists of a lobby, dining room with outdoor courtyard, kitchen, medication room, administrative offices, electrical room, public restrooms, laundry room, 21 resident rooms, shaded outdoor courtyard area, and a Memory Care unit with multi-purpose room, and outdoor courtyard. The 2nd floor consists of 28 resident rooms, Bistro area, game room, public restrooms, 2 storage rooms, laundry/housekeeping room, outdoor shaded balcony area, and 2 common areas. The 3rd floor consists of 28 resident rooms, fitness room, theater room, lounge, beauty shop, and outdoor shaded balcony area. Delayed egress is in place in the 1st floor Memory Care unit. continuation - Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. Twenty eight (28) resident rooms, common areas, and kitchen were inspected. Resident rooms have required furniture, bedding, linens, and lighting. Exit doors are free of any obstruction. The signal system was tested and is operational. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. There are evacuation chairs on 2nd and 3rd floor stairwells to be used during an emergency as a path of egress from the facility to safety. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and fire extinguishers. The last fire inspection was conducted by Code Red Fire Inc. The Memory Care Unit tweezers were found in an unlocked dirty refrigerator freezer in the multi-purpose room, as well as unlocked nail polish & nail polish remover in the arts/crafts cabinet. Room 112's ceiling does not have dry wall, and 204 has a hole above the bathtub ceiling. This issue is currently being investigated in complaint control # 28-AS-20260211084916. Rooms 101, 104, 106, 107,110, 111, 112, 113, 202, 211, 311, 320 beds did not have mattress pads. Staffing: A total of 42 staff members provides care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 2/28/2026. Staff have criminal background clearance and training. Nine (9) staff files were requested. Three (3) files were not provided, including the Executive Director/Administrator's file. Staff (S2, S3 & S5) do not have current 1st Aid/CPR training. Staff (S4 & S6's) files did not have health/TB screenings. Resident Records/Incident Reports: 12 resident files were reviewed. They contained Admission Agreements, Service Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, and centrally stored medication records. Five resident files did not have current medical assessments. There were resident files that did not have service plans; however, there is an opened complaint investigation that addresses that issue. RCFE & Ombudsman complaint posters are posted. However, the CCLD RCFE complaint poster posted in the 1st floor hallways does not meet the size 20 x 26 requirement. A technical advisory was issued. Planned Activities: The facility has a posted activity calendar. Sufficient space to accommodate both indoor and outdoor activities was observed in the Memory Care Unit and Assisted Living floors. The facility has a Resident Council. Food Service: Food supply was checked in the kitchen and pantry storage areas, consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Dining Services Director has a current Food Handling Certificate. Residents have physician orders for modified diets. A diet list was obtained. However, residents (R4 & R8) require a renal diet and they are not receiving renal diet meals. Per Dining Services Director med-tech/nursing staff have not communicated R4 & R8's renal diet needs to the kitchen staff. Incident Medical and Dental: Centrally stored resident medications were reviewed. Missing medications were observed during yesterday's visit. Citation was issued. Medical and dental transportation is provided by family or 3rd party transportation companies. The facility has a non-operable van and no staff driver. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed and is updated. Facility has a First Aid Kit and Manual. Proof of last emergency disaster drill was not provided. Residents with Special Health Needs: There are currently 14 residents receiving hospice services and 15 residents receive home health services, and no residents have prohibited health conditions. Individual Service Plans, Appraisals, and postural support physician orders are on file. Pursuant to Title 22, deficiencies were observed and are cited. Exit interview was conducted with Interim Executive Director Anahi Reyes. A copy of report and appeal rights was issued.the state’s words, verbatim · CDSS document, Feb 27, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Galarza and Jewel Baptiste conducted an unannounced Required- 1 year. The purpose of the visit was explained to Business Office Manager Michelle Armendariz. Interim Executive Director Anahi Reyes arrived later. During today's visit the following was completed: A physical plant tour of the entire facility was conducted. Staff files were reviewed. There were three missing files. Some staff files were missing 1st Aid/CPR and health screening/TB tests. Resident files were reviewed. Need and Services plans were missing. Centrally stored medications were reviewed. Four residents were missing physician ordered medications. *Type A citation was issued today. Fire Inspection report was not provided and is pending. Deficiencies were observed and will be cited during the Annual Continuation visit. Exit interview was conducted with Anahi Reyes. A copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Feb 26, 2026

Allegation investigated: . Staff do not ensure that residents' incontinence needs are met. 2. Staff do not assist residents with showering. 3. Staff are not addressing pests at facility. 4. Staff are not safeguarding resident's personal belongings. 5. Staff do not provide residents with personal care supplies. 6. Licensee does not designate a substitute to manage facility during absence from facility.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the investigation on the allegations listed above. LPA arrived unannounced and met with the administrator, Beatriz Romeo-Lui. The purpose of the visit was explained. On 9/23/25, LPA Chan collected the staff and resident roster. LPA inspected ten (10) resident rooms and interviewed a staff member and five (5) residents. Documents were requested to be sent to LPA. Additional staff interviews were held on 11/20/25. During the visit today, LPA interviewed three (3) more staff and five (5) residents. The investigation revealed the following: Allegation - Staff do not ensure that residents' incontinence needs are met. Staff interviewed stated that they always change the residents if the briefs are soiled and check on them at least every 2 hours. Unsubstantiated When residents press their pendants and request a diaper change, staff will change them right away. Staff stated they also change the bed pads and ensure the residents are clean and dry. LPA interviewed ten (10) residents and all of them stated that staff change them frequently and never ran out of diapers. Allegation - Staff do not assist residents with showering. Per the administrator and staff, residents are showered on their assigned days. Some residents get more days depending on what they request during admission or their care plan. However, it was noted that residents will also get showered if they are extremely soiled and require one. Staff stated that all showers completed or refused are documented. The residents interviewed stated that staff shower them at least twice a week or provide supervision for those who can shower on their own. Allegation - Staff are not addressing pests at the facility. The administrator and staff stated that the pest control company provides services at least once a month and have not observed any pests at the facility. Records of monthly pest control services were provided. LPA reviewed the service reports from the Pacific Shore Pest Control company. Records showed that the technician sprayed the exterior foundation of the facility and treated the interior of certain rooms/units for general pests. There were no indicators of live/new activity or infestation of pests at the facility. Nine (9) out of ten (10) residents interviewed have not seen any roaches, spiders, or gnats in their rooms or facility. One (1) stated he/she has seen gnats in the room, but staff sprayed the room to prevent them from coming back. Allegation - Staff are not safeguarding the resident's personal belongings. It is alleged that staff take the resident’s incontinence supplies to care for other residents. Per the administrator, the facility has a house supply of diapers/briefs, wipes, and chuks/bed pads. Administrator stated that many of the residents’ families will bring incontinence supplies, which are stored in the residents’ rooms. Staff stated they do not take any resident’s incontinence supplies to use on another resident. The facility has extra supplies of briefs, wipes, and under pads that staff stated they will access if the resident runs out of supplies. The residents interviewed have not seen staff take someone else’s products to use on them. Residents stated they have not run out of their incontinence supplies. LPA observed sufficient supplies of pull-ups/briefs, wipes, and bed pads in storage at the facility. Allegation - Staff do not provide residents with personal care supplies. It is alleged that staff do not have supplies of toilet paper at the facility. All the staff interviewed stated that the facility has ample supplies of toilet paper in storage. The bathrooms get replenished when housekeepers do the cleaning. If residents ask for additional rolls, they are provided with them. Staff have not observed or heard of staff not willing to give them an extra roll when requested. LPA toured the storage room and observed boxes of toilet paper. During the inspection of residents’ rooms, all the bathrooms had toilet paper. Nine (9) out of (10) residents stated that they have not run out of toilet paper, while one (1) stated that the staff did not give a roll when asked. Allegation - Licensee does not designate a substitute to manage the facility during absence from the facility. LPA obtained a copy of the designation of facility responsibility form with the name of the individual who is authorized to represent the facility when the administrator is not available. Staff interviewed stated the administrator is often at the facility. If the administrator is not present, there is a designated backup person is to manage the facility. The residents interviewed are not sure who the administrator is and there has not been a need to speak with her. 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 Staff B. Randolph. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 28-AS-20250917113435

Type of visit: Case Management - Other

Licensing Program Analyst(LPAs) Galarza conducted an unannounced Case Management-Other visit for the purpose of amending findings to complaint control # 28-AS-20240829114254. The purpose of the visit was explained telephonically to Executive Director Beatriz Lui. Business Office Manager Alyssa Morales assisted with the visit. Exit interview and copy of the report was issued to Alyssa Morales.the state’s words, verbatim · CDSS document, Sep 11, 2025

Allegation investigated: Staff are not repositioning resident every 2 hours. Resident received an unexplained injury.

**This report supersedes the report issued on 5/2/2025. The purpose is to provide a corrected finding on the above allegations. Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit was explained to Resident Care Coordinator Breanna Randolph. Executive Director Beatriz Romeo-Lui was not available. The investigation consisted of: On 1/31/2025, a physical plant tour of the interior common areas, record review, and staff interviews with (S1- S7) was completed. Resident (R1) passed away on 1/29/2025 and was not interviewed. Resident (R1's) files documents [Face Sheet, Hospice Care Plan, Charting Notes, Skin Integrity Monitoring Form, LIC 500 Personnel Report, and resident roster were obtained. During today's visit, LPA toured the physical plant, with special focus on bedridden resident rooms. Residents (R2- R6) were observed and interviewed. Unsubstantiated Allegation: Staff are not repositioning resident every 2 hours. It was reported that hospice resident (R1) required repositioning every 2 hours due to a sacral pressure injury, but despite regular hospice wound care the pressure injury was getting worse. Seven (7) staff were interviewed. Caregiver staff stated they checked on the resident every 2 hours, and as the resident's health declined staff were checking on the resident at least every hour. Staff stated sometimes R1 refused to be repositioned every 2 hours because the resident preferred to lay in bed in a flat position due to pain when rotated to the side. Staff acknowledged that sometimes the NOC shift caregiver staff did not log in routine checks. It is unknown if they performed rotations on the resident. One of the NOC shift staff (S8) in question was terminated on January 24, 2025 for misconduct and suspicions of improper handling of cognitively impaired residents during incontinence changes. Bedridden residents were interviewed. One (1) resident stated staff are not repositioning every 2 hours, especially during night time. Charting notes [1/1/25 - 1/29/25], records indicate that the majority of the time R1 was routinely being checked every 2 hours. Record review revealed that on several dates staff checked the resident past the required repositioning time, and many of the documented checks did not specify whether the resident was repositioned every 2 hours. However, staff interviews revealed that R1 at times preferred not to be repositioned. Allegation: Resident received an unexplained injury. On January 17, 2025, AM shift caregiver staff observed a bruise under resident (R1's) right eye. The injury was documented on a Skin Integrity Monitoring Form and med-tech staff were notified. None of the residents interviewed reported staff rough handling incidents that have caused bruising. All seven (7) staff interviewed confirmed that resident (R1) had a bruise under the right eye. Staff interviews revealed that former NOC shift staff (S8) stated that when the resident was being turned the resident's hand hit their own face. Staff stated that R1 was experiencing agitation behaviors during repositioning assistance, and may have unintentionally hit themselves. The majority of staff interviewed do not believe the bruise was intentionally caused by malicious intent, but confirmed the resident sustained an unexplained bruise. Picture evidence of the injury was obtained. 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 and a copy of this report was discussed and provided to Resident Care Coordinator Breanna Randolph.the state’s words, verbatim · CDSS document, Jul 31, 2025 · control 28-AS-20250122154956

Allegation investigated: Staff are not properly reporting incidents to responsible party Staff are not assisting resident with showering Staff do not allow resident access to bedroom Staff are not providing resident with activities

Licensing Program Analyst (LPA) Alberto Lopez conducted a subsequent unannounced complaint visit regarding the above allegations. LPA discussed the purpose of the visit with Maria Nunez, Front Desk. On 07/03/2025 - The investigation consisted of a physical plant tour of the interior common areas, interviewed six (6) staff (S#1 - #6), Eight (8) residents (#1 - #8) obtaining and reviewing staff and resident rosters, R1 progress notes, admission agreement, and other pertinent information. Due to time constraints, LPA will conclude the investigation at a later date. The investigation consisted of a physical plant tour of the interior common areas, interviewed six (6) staff (S#1 - #6), Eight (8) residents (#1 - #8) obtaining and reviewing staff and resident rosters, R1 progress notes, admission agreement, and other pertinent information. (continued on 9099C) Unsubstantiated (continued from 9099) The investigation Revealed: Allegation: Staff are not properly reporting incidents to the party responsible. It is alleged that the facility is not notifying the responsible party of incidents involving resident. LPA interviewed six (6) staff members and six (6) of six (6) staff members denied the allegation. Several staff members stated that they are responsible for reporting incidents to their supervisor and that their supervisor is the person responsible to report incidents to responsible party. LPA interviewed eight (8) residents and six (6) of eight (8) residents stated that their responsible parties are notified or could not corroborate the allegation, two (2) residents could not answer due to cognitive impairment. LPA interviewed W1 which is a family member, and asked W1 how W1 is aware of incidents that are not reported to W1. W1 stated that the facility verbally notifies W1 of all incidents, but not in writing. There is not sufficient evidence to substantiate this allegation. Allegation: Staff are not assisting resident with showering. It is alleged that the facility does not assist resident with showering. LPA interviewed six (6) staff, and all six (6) staff denied the allegation. Several staff stated that resident will refuse to shower and provided LPA with documentation that showed resident refused showers on 06/11/2025, 06/18/2025, and 07/02/2025. LPA interviewed eight (8) residents and six (6) of eight (8) residents could not corroborate the allegation, two (2) residents could not answer due to cognitive impairment. There is not sufficient evidence to substantiate this allegation. Allegation: Staff do not allow resident access to bedroom. It is alleged that facility locks the resident’s door in the memory section of facility, denying resident use of bathroom. LPA interviewed six (6) staff, and all six (6) staff denied the allegation. Several staff stated that the doors are locked to protect the residents’ privacy and prevent other residents from wandering into rooms that are not theirs. LPA interviewed eight (8) residents and six (6) of eight (8) residents could not corroborate the allegation, two (2) residents could not answer due to cognitive impairment. During the tour of facility memory are section, LPA observed resident’s door to be unlocked. There is not sufficient evidence to substantiate this allegation. Allegation: Staff are not providing resident with activities. It is alleged that resident is not provided with activities. LPA interviewed six (6) staff, and all six (6) staff denied the allegation. Several staff stated that resident refuses to participate in activities most days and they cannot force residents to participate. LPA interviewed eight (8) residents and six (6) of eight (8) residents could not corroborate the allegation, two (2) residents could not answer due to cognitive impairments. LPA observed the residents participating in activities during tour of visit, obtained and reviewed activity calendar, and observed activity supplies in the facility. There is not sufficient 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 violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted, and a copy of this report was discussed and provided to Maria Nunez, Front Desk, who was authorized to sing by Executive Director Beatrice Luithe state’s words, verbatim · CDSS document, Jul 19, 2025 · control 28-AS-20250626121231

Allegation investigated: Staff are not providing adequate food service for resident.

Licensing Program Analysts (LPAs) Galarza and Elena Mallet conducted a subsequent complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Executive Director Beatriz Romeo-Lui. The investigation consisted of: On 2/6/2025, a physical plant tour of the interior common areas, record review, inventory of Memory Care Unit & AL kitchen food/snack supply; interviews with staff (S1- S3), residents (R1- R5), and family (F1) was completely. Resident (R1's) Face Sheet, Admission Agreement, email communication w/ authorized representative, Charting Notes, Hospice Benefit Revocation Form, LIC 500 Personnel Report, and resident roster was reviewed. During today's visit, a physical plant tour of the kitchen, snack areas, and Memory Care Unit, as well as record review and interviews with staff (S4-S9), family (F1), and residents (R5- R10) was completed. Substantiated Allegation: Staff are not providing adequate food service for resident. The complaint alleges residents in the memory care unit are not provided adequate snacks because staff are not always providing snacks to residents, and resident (R1's) authorized representative was asked to buy snacks for the resident. Resident interviews revealed that in January 2025- February 2025 drinks were available in the 1st floor lobby area and/or kitchen. On 2/6/2025, during the physical plant inspection after lunch meal the kitchen, common areas, and Memory Care Unit cabinets and refrigerator, it was observed that the 1st floor lobby area only offered drinks to residents, and the Memory Care Unit refrigerator did not have an adequate supply of snacks in the refrigerator. Staff stated they have never asked R1's authorized representative to pay for snacks. However, staff interviews revealed that the memory care unit did not at that time have on hand snacks for residents every day, and only some staff took initiative to request snacks from kitchen staff if needed. Staff stated that when family request specific snacks that are not typically provided by the facility they are encouraged to bring those snacks to the facility. Staff also stated that snacks should be provided in between regular meal times. Per Admission Agreement, the facility "will serve three (3) nutritionally balanced meals and snacks daily to residents at La Posada." Based on observations and picture evidence, there is sufficient evidence to support the allegation. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is cited according to Title 22. See LIC 9099D. Exit interview was conducted with Executive Director Beatriz Rome Lui. A copy of the report and appeal rights were provided. Allegation: Staff are retaliating against resident's authorized representative. The complaint alleges that staff told resident (R1's) authorized representative that transfer/move in arrangements and belongings pick-up from another RCFE would be taken care of by the facility. According to information obtained, Administrator was unprofessional and argued with authorized representative about move-in transfer issues, instructions on hospital bed pick-up and hospice enrollment. It is alleged that Administration staff are retaliating by ending hospice services for R1. A total of nine (9) staff were interviewed. Based on interviews conducted the findings indicate that resident (R1) moved in on December 20, 2024 with active hospice enrollment, but on February 5, 2025 hospice agency terminated services due to "family no longer wishes to receive hospice services." On 2/5/2025, Administration staff notified authorized representative of change. Per record review, the findings indicate that the facility made numerous telephonic and email attempts to speak to R1's authorized representative about care plan, hospice enrollment, and admission agreement, but did not receive a response to meeting requests. Resident (R1's) file was reviewed, it revealed the facility made multiple attempts via telephone calls, texts, emails, and scheduled meetings to communicate with authorized representative regarding representative concerns. However, R1's authorized representative cancelled meetings and/or did not reply to emails and telephone calls. There is insufficient evidence to corroborate the allegation. Allegation: Staff did not have resident or authorized representative sign an admissions agreement upon admission. It is alleged that resident (R1's) authorized representative did not sign an admission agreement when the resident moved in and was emailed an admissions agreement until January 30, 2025. Staff interviews revealed that resident (R1's) authorized representative electronically signed the admission agreement on December 15, 2024, with the exception of page 18. According to interviews and file review, there were multiple attempts made by former Administrator and administration staff to address the missing admission agreement signature. Staff interviews revealed there were multiple meetings scheduled with R1's authorized representative to obtain the missing signature, but the authorized representative denied signing the admission agreement electronically, and accused staff of forging their signature. Executive Director stated the resident moved out on June 4, 2025, and the authorized representative never signed the missing signature on page 18 of the admission agreement. Based on file review conducted today, Dropbox Sign records indicate that the admission agreement was sent electronically to R1's authorized representative on 12/13/2024, and the admission agreement was signed and completed on 12/15/2024. None of the residents interviews supported the allegation. Therefore, there is insufficient evidence to corroborate the allegation. Allegation: Staff are not treating resident equally. The complaint alleges that memory care resident (R1) is not being treated equally during snack time because if the resident is in their room staff do not give the resident a snack, since residents have to be in the common activity room to receive a snack. Staff interviews revealed that residents in the Memory Care Unit and Assisted Living floors are provided snacks every day. For instance, in the memory care unit staff pass out snacks in the common area room, and if a resident is in their room they are offered snacks or encouraged to pick them up in the common area activity room. Staff stated residents are provided bananas, juice, water, and coffee. According to staff, R1 constantly repeated to staff that they were hungry even after they finished eating their regular meal. Resident (R1) did not require a special diet. When resident (R1) was interviewed they stated staff did not give them snacks, but the resident was not oriented to time or place. Resident interviews revealed all residents are offered snacks in between meals. None of the residents stated they are not treated equally. There is insufficient evidence to support the allegation. Allegation: Staff are not following resident's authorized representative's directives about visitors. It is alleged the facility keeps allowing resident (R1's) other family member to visit the resident despite the authorized representative's directive to restrict the family member from visiting the resident. Staff interviews revealed residents are asked by staff if they would like to see a visitor that arrives at the facility. Resident (R1) resides in the memory care unit and the resident agreed to the family member's visits. Additionally, Administration staff stated the authorized representative did not present a restraining order against the family member they wanted restricted. Based on file review, LPA confirmed there is no restraining order in place. Therefore, staff did not prohibit any family and/or visitors from seeing resident (R1). None of the residents interviewed supported the allegation. 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 violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was discussed and provided to facility Executive Director Beatriz Romeo Lui.the state’s words, verbatim · CDSS document, Jul 7, 2025 · control 28-AS-20250131105725

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(3) · Plan of correction due date: Aug 4, 2025

General Food Service Requirements. The following food service requirements shall apply: Between-meal nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician. This requirement was not met evidenced by: Based on observation on 2/6/2025, the Memory Care Unit did not have adequate inventory of snacks in the refrigerator or cabinet, and interviews revealed snacks in the memory care unit were not always provided in between meal times. This poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2025

Plan of correction: Executive Director agreed conduct staff in-service training on Title 22 regulation 87555 and facility procedure regarding snack inventory and distribution. Submit plan of correction.

Allegation investigated: Staff inappropriately removed resident from palliative care Staff did not notify resident's POA of incident

Licensing Program Analyst (LPA) Alberto Lopez conducted a subsequent complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Wellness Director Anahi Reyes 06/06/2025 Licensing Program Analysts (LPAs) Lopez and Mallett conducted an initial 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Wellness Director Anahi Reyes. The investigation consisted of: A physical plant tour of the interior common areas, obtaining and reviewing staff and resident rosters, and R1 progress notes. LPA asked for Palliative Care termination paperwork. (continued on 9099C) Unsubstantiated (Continued from (9099) 07/03/2025 The investigation consisted of LPA taking a tour of facility, interviewing six (6) staff, eight (8) residents (#1 – #8), R9 Power of Attorney (POA). Obtaining and reviewing staff and residents rosters, R9 Physicians report dated 06/04/2024, emails from Executive Director and Resident Care Coordinator responding to POA regarding POA questions about services provided to R9, R9 Service plan, letter from Calstro Hospice dated 05/06/2025 addressed to La Posada regarding R9 discharge from services. Charting notes for R9 from 12/24/2024 to 06/04/2025 The investigation revealed, regarding allegation: Staff inappropriately removed resident from palliative care. It is alleged that the facility removed R9 from palliative care without notifying POA. Resident was admitted to the facility on 12/24/2024 and was on Bristol Hospice. On 02/06/2025, charting notes show that family asked for Hospice services to be terminated for R9. On 02/07/2025 R9 signed up for Calstro palliative care. On 02/19/2025 R9 was admitted to Med Choice Home Health. Charting notes show that on 05/09/2025, R9 received a final bath from Calstro palliative care on 05/09/2025. On a letter dated 05/06/2025 addressed to resident at facility address, it provided a termination of services date of 05/12/2025. One staff stated they were not aware that resident was terminated from Calstro palliative care and that when they inquired about this on 06/06/2025 after LPA asked for verification, Calstro palliative care sent copy of termination latter dated 05/06/2025. However, staff stated that the facility has no authority to terminate Calstro palliative care since that is between the resident’s doctor and resident or resident’s responsible party. There is insufficient evidence to substantiate this allegation. Allegation: Staff did not notify resident's POA of incident. It is alleged that the facility did not notify residents Power of Attorney (POA) that resident had been terminated from Calstro palliative care. LPA interviewed six (6) staff members and two (2) of six staff members stated that the facility was not aware that resident had been terminated from Calstro palliative care and that it is not the facilities responsibility to notify the POA or responsible party as Calstro palliative care deals directly with the family. Four (4) staff members stated they did not handle notifications to POA or responsible parties. LPA interviewed eight (8) residents and all eight (8) were not able to corroborate the allegation. 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 violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was discussed and provided to Brenna Randolph, Resident Care Coordinatorthe state’s words, verbatim · CDSS document, Jul 3, 2025 · control 28-AS-20250530124235

Allegation investigated: Staff did not notify authorized representative of incident. Staff are not repositioning resident every 2 hours. Resident received an unexplained injury.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit was explained to Business Office Manager Andrea Lopez. The investigation consisted of: On 1/31/2025, a physical plant tour of the interior common areas, record review, and staff interviews with (S1- S7) was completed. Resident (R1) passed away on 1/29/2025 and was not interviewed. Resident (R1's) files documents [Face Sheet, Hospice Care Plan, Charting Notes, Skin Integrity Monitoring Form, LIC 500 Personnel Report, and resident roster were obtained. During today's visit, LPA toured the physical plant, with special focus on bedridden resident rooms. Residents (R2- R6) were observed and interviewed. Substantiated Allegation: Staff did not notify authorized representative of incident. It is alleged that on January 20, 2025, resident (R1's) authorized representative observed a bruise under the resident's right eye and questioned staff about the incident. A total of seven staff were interviewed. Based on interviews conducted, the findings indicate that on January 17, 2025 at approximately 7:30 AM, morning shift caregiver staff (S3) observed the bruise. Caregiver immediately reported the observation to AM shift med-techs, whom typically contact the resident's physician, hospice, and responsible party. However, in this case the two (2) AM med-techs on duty on January 17, 2025 failed to report the incident to family and forgot to communicate the incident with the next shift med-tech. Additionally, the bruise incident was not documented on the facility electronic software system or charting notes. Per Charting Notes records, staff did not document the bruise that was observed on January 17, 2025, but a Skin Integrity Monitoring Form was completed. Staff acknowledged the incident was not reported to R1's responsible party and documentation/communication protocols were not followed. Therefore, there is sufficient evidence to corroborate the allegation. Allegation: Staff are not repositioning resident every 2 hours. It was reported that hospice resident (R1) required repositioning every 2 hours due to a sacral pressure injury, but despite regular hospice wound care the pressure injury was getting worse. Seven (7) staff were interviewed. Caregiver staff stated they checked on the resident every 2 hours, and as the resident's health declined staff were checking on the resident at least every hour. Staff stated sometimes R1 refused to be repositioned every 2 hours because the resident preferred to lay in bed in a flat position due to pain when rotated to the side. Staff acknowledged that sometimes the NOC shift caregiver staff did not log in routine checks. It is unknown if they performed rotations on the resident. One of the NOC shift staff (S8) in question was terminated on January 24, 2025 for misconduct and suspicions of improper handling of cognitively impaired residents during incontinence changes. Bedridden residents were interviewed. One (1) resident stated staff are not repositioning every 2 hours, especially during night time. Charting notes [1/1/25 - 1/29/25], records indicate that the majority of the time R1 was routinely being checked every 2 hours. However, on several dates staff checked the resident past the required repositioning time. In addition, many of the documented checks did not specify whether the resident was repositioned every 2 hours. There is sufficient evidence to corroborate the allegation. Allegation: Resident received an unexplained injury. On January 17, 2025, AM shift caregiver staff observed a bruise under resident (R1's) right eye. The injury was documented on a Skin Integrity Monitoring Form and med-tech staff were notified. None of the residents interviewed reported staff rough handling incidents that have caused bruising. All seven (7) staff interviewed confirmed that resident (R1) had a bruise under the right eye. Staff interviews revealed that former NOC shift staff (S8) stated that when the resident was being turned the resident's hand hit their own face. Staff stated that R1 was experiencing agitation behaviors during repositioning assistance, and may have unintentionally hit themselves. The majority of staff interviewed do not believe the bruise was intentionally caused by malicious intent, but confirmed the resident sustained an unexplained bruise. Picture evidence was obtained. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Business Office Manager Andrea Lopez. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 2, 2025 · control 28-AS-20250122154956

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

Additional Personal Rights of Residents in Privately Operated Facilities...... shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and records review, the findings indicate that on several dates in the month of Jan. 2025 caregiver staff did not reposition hospice resident (R1) every 2 hours as required. R1 had a pressure injury. This posed an immediate health and safety risk to the resident.the state’s words, verbatim · CDSS document, May 2, 2025

Plan of correction: Executive Director shall conduct staff training on incontinence care, repositioning, care and supervision, and adherence to facility Plan of Operation protocol procedures. Submit a written plan by tomorrow, and proof of staff training by Tue. May 6, 2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 9, 2025

Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below..... This requirement was not met evidenced by: Based on record review and interviews conducted staff did not notify R1's responsible party of the bruise staff observed on 1/17/25 under R1's right eye. Responsible party observed the bruise on 1/20/25. Note: Staff did not submit an incident report to CCL as required. This posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 2, 2025

Plan of correction: Executive Director shall provide in-service training regarding reporting procedures/requirements. Please submit a written plan and proof that all caregiver and med-tech staff were trained.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: May 9, 2025

Personnel Requirements - General. All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following....(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. Based on interviews and record review, the findings indicate noc shift (S8) repositioned bedridden resident (R1), and the following day (1/17/25) staff observed bruising under R1's eye. This posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, May 2, 2025

Plan of correction: Executive Director shall ensure that all staff receive repositioning and procedure training of bedridden residents. Submit plan of correction and proof of staff training.

Allegation investigated: Facility did not accept resident back to the facility after a hospitalization.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit to Executive Director Beatriz Lui. The investigation consisted of: On 3/17/25, LPA toured the facility, reviewed and obtained records, and interviewed staff (S1 & S2). Resident (R1) was not interviewed because they were at a higher level of care facility. Copies of Face Sheet, Admission Agreement, Preplacement Appraisal, Physician's Report, incident report date [3-12-25], Service Plan, LIC 500 Personnel Report, and resident roster were obtained. During today's visit, records were reviewed, staff (S3) was interviewed and email records of R1's higher level of status progress were obtained. Resident (R1's) family removed the resident's belongings from the facility today. Therefore, R1's admission contract ends today. Unsubstantiated Allegation: Facility did not accept resident back to the facility after a hospitalization. The complaint alleges that facility staff refused to accept resident (R1) back despite hospital psychiatrists deeming the resident stable. According to information obtained, the resident was transported to the hospital on March 12, 2025 on a psychiatric hold due to aggressive behavior towards roommate, staff, and danger to self and others. The resident resided in the Assisted Living (AL) floor and not the Memory Care unit. Based on staff interviews, resident (R1) has Dementia. Staff stated that R1's authorized representative did not disclosed history of psychiatric issues prior to moving in, nor did the resident's Physician's Report include mental health history. Staff stated that within 3 hours of 5150 (psychiatric) hospitalization, hospital staff notified facility staff that the resident would be discharge back because the resident did not meet psychiatric criteria at that time. Facility staff informed hospital staff that in order for the facility to accept the resident back, an updated Physician's Report would need to be completed by hospital staff, and then facility staff would need to complete an assessment in order to determine suitability and compatibility after the change in condition. Staff explained to hospital staff that the facility does not provide 1 to 1 care and the health and safety of R1's roommate would be at risk if the resident is accepted back without a through physician evaluation. Staff interviews revealed that facility staff reached out to local higher level of care facilities attempting to find an appropriate placement for R1 until they were medically stable. Initially, the hospital discharged R1 to a regular Skilled Nursing Facility (SNF), but within 48 hours the resident had to be transferred to a geriatric psychological unit where the resident has resided since March 31, 2025. On April 1, 2025, staff obtained information indicating that there had not been any improvement in the resident. On April 7, 2025, authorized representative provided a 30-day move-out notice because the resident will likely remain at the geriatric psychological unit long-term. Family removed all of R1's belongings from the facility today. There is insufficient evidence to corroborate the allegation. 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 are Unsubstantiated. An exit interview was conducted and a copy of this report was discussed and provided to Business Office Manager.the state’s words, verbatim · CDSS document, Apr 24, 2025 · control 28-AS-20250317110912

Allegation investigated: Staff are prohibiting resident from having visitors.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Business Office Manager. Executive Director Beatriz Romeo-Lui arrived later. The investigation consisted of: A physical plant tour of the interior common areas was conducted. Residents (R2-R8), and staff (S1-S4) were interviewed. Resident (R1) was not interviewed. The resident died on April 6, 2025. Former staff (S5) was interviewed and their file was reviewed. Copies of Employee Handbook, Residence and Care Agreement, Employee Termination Form, LIC 500 Personnel Report, and resident roster were reviewed/obtained. Substantiated Allegation: Staff are prohibiting resident from having visitors. It is alleged that on April 3, 2025 facility staff did not allow a former staff (S5) to visit resident (R1). According to information obtained, the resident's family notified the former staff that resident was "transitioning" i.e., nearing the end of their life and invited the former staff to visit R1. The complaint alleges Executive Director and Administration staff prohibited former staff (S5) from visiting R1 by stating that per Admission Agreement and Human Resource policy no former staff are allowed to visit residents because it is a conflict of interest. Resident (R1) passed away on April 6, 2025; therefore was not interviewed. A total of seven (7) residents were interviewed, of which two (2) stated that former staff were previously allowed to visit residents, but are no longer being allowed. One resident (1) stated they now have to go outside the facility to talk to former staff. Another resident stated that a former staff came to visit the resident, but was not allowed. Four (4) out of seven (7) staff stated they believe former staff should be allowed to visit them. Employee Handbook [April 18, 2023] page 40, "Visitors in the Workplace" states 'To provide for the safety and security of our residents, employees, and the general facility, only authorized visitors are allowed in the workplace. The Residence and Care Agreement, page 14, states "All visitors must register at the front desk when entering La Posada. We reserve the right to remove or deny entry to La Posada to any visitor whom we determine is disruptive or dangerous." Based on record review, the Plan of Operation, Employee Handbook, Residence Care Agreement do not explicitly state that a former employee is not allowed to visit. Therefore, there is evidence to corroborate the allegation. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Executive Director Beatriz Lui. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 8, 2025 · control 28-AS-20250404073117

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Apr 22, 2025

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. Based on record review, the findings indicate that resident (R1) was prohibited visits from former staff (S5). R1's family invited former staff to the facility when R1's was close to dying. This posed a potential health, safety, and personal rights risk to the resident in care.the state’s words, verbatim · CDSS document, Apr 8, 2025

Plan of correction: Executive Director agreed to submit a written plan of correction that addresses policy regarding former employee visits after separation from employer and proof of staff training. If changes to the Employee Handbook and Residence and Care Agreement will be made, submit updated forms for approval.

Allegation investigated: Staff handled resident in a rough manner resulting in an injury. Staff did not prevent a resident from falling out of a window.

***This amended report 9/11/2025 supersedes the report dated 3/14/2024 in reference to citation 87411(a). The citation is dismissed. On 3/14/2025 & 3/11/2025, Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visits to deliver findings on the above allegations. The purpose of the visit was discussed telephonically with Executive Director Beatriz Lui. Alyssa Morales met with LPA. The investigation consisted of: On 9/6/24, LPA reviewed medications/medication administration records, and conducted a physical plant tour that included inspection of 17 resident rooms, kitchen, common areas, and Memory Care Unit. During subsequent visits Memory Care Unit, common areas, and random resident residents were inspected. A total of 7 staff (S1-S7) and 8 residents (R4- R11) were interviewed. Residenst (R1 & R3) moved out and were not interviewed and R2 is cognitively impaired. Former staff (S8 - S11) were not interviewed. Resident files were reviewed and relevant documents were obtained[Medication Administration Records (MARs) & pest control service invoices]. While the incident and resulting injuries are not disputed to have occurred, there is insufficient evidence to prove the resident required additional supervision. Exit interview was conducted with Business Office Manager Alyssa Morales. A copy of the report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 14, 2025 · control 28-AS-20240829114254

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Mar 15, 2025

Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of: On 7/1/2024, at approximately 6:30 PM Memory Care Unit resident (R1) climbed out of a 1st floor bedroom window, fell, and sustained head injuries and dislocated shoulder. Staff responsible for supervision of residents in activity room was assisting another resident in the bathroom. This posed an immediate health, saferty, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 14, 2025

Plan of correction: Executive Director shall submit a plan of correction that includes in-service training regarding elopement, wandering behavior, methods of redirection, resident care and supervision procedures, and staff/resident ratio in Memory Care unit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Mar 18, 2025

Personal Rights of Residents in All Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents ..... shall have all of the following personal rights: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. Based on interviews, on 5/30/24 former staff (S10) handled Memory Care Unit resident (R2) in a rough manner by grabbing arm which caused bruising, instead of using redirection techniques. S10 was terminated. This posed a potential health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Mar 14, 2025

Plan of correction: Executive Director shall conduct staff training in Title 22 Personal Rights 87468, 87468.1, & 87468.2 and will submit training log with staff signatures. Submit proof of staff training.

Allegation investigated: Staff handled resident in a rough manner resulting in an injury. Staff did not prevent a resident from falling out of a window. Staff altered residents medications. Staff did not administer medications to residents. Staff did not store files for residents in care.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegations. The purpose of the visit was discussed with Executive Director Beatriz Lui. The investigation consisted of: On 9/6/24, LPA reviewed medications/medication administration records, and conducted a physical plant tour that included inspection of 17 resident rooms, kitchen, common areas, and Memory Care Unit. During subsequent visits Memory Care Unit, common areas, and random resident residents were inspected. A total of 7 staff (S1-S7) and 8 residents (R4- R11) were interviewed. Residenst (R1 & R3) moved out and were not interviewed and R2 is cognitively impaired. Former staff (S8 - S11) were not interviewed. Resident files were reviewed and relevant documents were obtained, as well as Medication Administration Records (MARs), and pest control service invoices. Substantiated Allegation: Staff handled resident in a rough manner resulting in an injury. It is alleged that on 5/30/2024, resident (R2) left the Memory Care Unit to the Assisted Living side of the facility and staff (S10) grabbed the resident's arm in a rough manner that caused injuries. According to information obtained, staff (S8) was terminated because of their actions. A total of 8 residents were interviewed. Two (2) out of 8 residents stated that former staff (S8) handled residents in a rough manner. A total of 7 staff were interviewed. Staff interviewed reported knowledge that former staff (S8) handled resident in a rough manner. Administrator Bautista stated staff (S8) was terminated due to excessive absences. Therefore, S8 was not interviewed. Staff interviews revealed that R2 was being transitioned into the memory care unit from the AL unit and often tried to elope by pushing hard the delayed egress doors. Staff (S8) grabbed the resident away from the door and as a result caused shoulder bruising. Staff interviewed stated R2 takes blood thinner medications that make the resident susceptible to bruising. In addition, according to information obtained on a different date S8 was observed being forceful when trying to get R2 in the bath. Based on interviews conducted on 5/30/2024, S8 used rough physical contact instead of redirection techniques. There is sufficient evidence to corroborate the allegation. Allegation: Staff did not prevent a resident from falling out of a window. It is alleged that in July 2024 Memory Care Unit resident (R1) climbed out of a bedroom window due to lack of supervision. A total 7 staff were interviewed, of which all staff confirmed the incident. Based on record review and interviews conducted the findings indicate that on July 1, 2024, at approximately 6:30 PM cognitively impaired resident (R1) attempted to elope by going out of another resident's bedroom window in the 1st floor Memory Care Unit. The resident fell and hit their head while climbing out the window. The resident sustained an open laceration to forehead and a dislocated shoulder. Memory Care Staff did a resident count and noticed the resident was missing and went looking for the resident. Resident (R1) was found outside the facility on the steps of the right side of the building. The resident was bleeding from the head and 911 was immediately called. According to staff interviews, on the date of the incident there were 3 staff in charge of supervising 22 Memory Care residents. One (1) staff was out to lunch, another staff staff was doing incontinence changes, and the 3rd staff was responsible for watching the residents that were in the dining/activity area. The staff watching the residents in the activity area had to leave to the restroom to assist a resident. The findings indicate that at that time six (6) residents in the Memory Care Unit were a fall risk and staff were not to leave them unsupervised. There is sufficient evidence to corroborate the allegation. Allegation: Staff altered residents’ medications. It was reported that med-tech staff (undisclosed name) removed names of residents off medication labels and put R3’s name on the medications to make it appear as if the facility had R3’s medications on site during LPAs review of medications pertaining to a different complaint investigation. The complaint alleges that during Summer 2024 some residents went two (2) months without receiving their medications due to pharmacy changes. A total of 7 staff were interviewed. Med-tech staff (S5) stated they have never altered medications and was unaware of the alleged incident. Med-tech staff interviews revealed that when the facility switched from Yorba Linda Pharmacy to Omni Care Pharmacy med-techs were having a hard time figuring things out in the medication room because some residents did not have medications during the transition. Staff requested an emergency supply of medications for some affected residents, but it took days for the facility to receive the medications. As a result, med-techs used house supply of some medications like, cough syrup and printed a QuickMar order and placed it on the medication, until the ordered medication was received. Since then, the facility has implemented a pharmacy medication consent waiver that allows med-techs to order the medications from the facility pharmacy "Omni Care" for residents whose families use a different pharmacy, so that when resident's medications are running low physician orders are obtained and families are notified that medications need to be refilled. The findings indicate facility med-techs did not order on time medications for some residents, and decided to alter physician orders by labeling medications improperly. Allegation: Staff did not administer medications to residents. Information received alleges that med-tech staff (S5) was logging in the electronic medication administration records software database that medications were administered but did not administer the medications. It is also alleged that med-tech staff were logging that medications were administered under employees that no longer worked at the facility. A total of 7 staff were interviewed. Staff (S5) denied the allegation. According to staff interviews, former med-tech staff (S9) reported to Administrator Bautista that "someone" was signing the Medication Administration Records (MARs) under another staff name that no longer worked at the facility. Administration staff did an investigation and discovered that staff (S9), whom reported the incident was the person that was signing off that meds were dispensed, under former staff (S11). Administration staff inventoried medications and completed a narcotic count and findings indicated that no narcotic medications were missing. Med-tech staff acknowledged that during the pharmacy change there medication errors. Based on Medication Administration Record (MAR) review, there is supportive evidence to corroborate the allegation. Allegation: Staff did not store files for residents in care. It is alleged that the facility did not have required resident file documents because a resident's file went missing from the medication room. A total of 7 staff were interviewed. Staff interviews indicated the facility maintains two (2) files, a business file and medical file. The medical files are kept in the medication room. Administration staff confirmed that during Summer 2024 one resident's file was misplaced/lost and unavailable for staff review. Therefore, there is sufficient evidence to corroborate the allegation. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited according to Title 22. See LIC 9099D. Exit interview was conducted with Andrea Lopez. A copy of the report and appeal rights were provided. Allegation: Staff did not address water damage in the facility. It is alleged that the facility walls had water damage since Spring 2024 and as of August 2024 repairs had not been completed. Based on staff interviews and review of facility maintenance records the findings indicate there have been plumbing issues that are immediately addressed by in-house maintenance staff and contractors. There was water damage in the 3rd floor ceiling hallway due to a roof leak. Maintenance staff removed the ceiling to prevent mold. It was left opened for approximately one week. Large fans were placed in the area to speed up the drying of the drywall. Licensee’s hired contractors in a timely manner to complete repairs. Residents interviewed stated repairs were completed promptly. There is insufficient evidence to corroborate the allegation. Allegation: Staff did not ensure that residents rooms are kept clean and sanitary. It is alleged that there are two (2) residents whose rooms are unsanitary. It was reported that resident (R4) is a hoarder, has spoiled food in the room, and infestation of cockroaches. According to the report, there is another resident (R5) whose room is also not kept clean and sanitary. During LPA visits, the rooms reported to be dirty and not sanitary were observed being cleaned by housekeeping staff. Resident (R4’s) room was cluttered, but at the time of the visits floors and bathroom appeared to be regularly cleaned. The other rooms reported to be unsanitary were not observed dirty. All the rooms reported to have cleanliness issues are inhabited by resident's that like to discard food and other items on the floors. All residents interviewed stated housekeeping staff clean the rooms regularly and have no complaints about room and/or facility cleanliness. Based on observation, resident rooms appear to be regularly cleaned by housekeeping staff, and those reported to be unsanitary are due to resident’s hoarding behaviors, which are continuously addressed. All residents interviewed stated staff regularly clean resident rooms, and none reported any issues. There is insufficient evidence to corroborate the allegation. Allegation: Staff did not keep facility free of insects. It is alleged that some resident rooms had an infestation of cockroaches. A total of 7 staff were interviewed. Staff reported that in the past there were several rooms that had cockroach infestation despite the rooms being cleaned regularly. A room on the 1st floor that was identified with the cockroach infestation was kept tidy and clean by the resident, but a crack in the baseboard was the entry point of the cockroaches from the room above on the 2nd floor. The 2nd floor rooms were being treated by extermination company. Records indicate the facility addressed pests’ issues by contracting regular pest control services. The facility is actively mitigating cockroach and insect reports. Residents interviews revealed the facility has ongoing pest control services in place. Proof of pest control invoices was provided showing the facility mitigates the issue when needed and also maintains prevention pest control services. 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. An exit interview was conducted and a copy of this report was discussed and provided to Business Office Manager Andrea Lopez.the state’s words, verbatim · CDSS document, Mar 11, 2025 · control 28-AS-20240829114254

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a)(8) · Plan of correction due date: Mar 18, 2025

Personal Rights of Residents in All Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents ..... shall have all of the following personal rights: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. Based on interviews, on 5/30/24 former staff (S10) handled Memory Care Unit resident (R2) in a rough manner by grabbing arm which caused bruising, instead of using redirection techniques. This posed a potential health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Mar 11, 2025

Plan of correction: Executive Director shall conduct staff training in Title 22 Personal Rights 87468, 87468.1, & 87468.2 and will submit training log with staff signatures. Submit proof of staff training.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 18, 2025

Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of: On June 4, 2021 at approximately 1:30 pm resident (R1) eloped out of the facility after exiting the memory care unit delayed egress door without staff knowlede when staff (S6) exited out, and did not ensure the door closed properly. This posed an immediate safety risk to this resident in care.the state’s words, verbatim · CDSS document, Mar 11, 2025

Plan of correction: Executive Director shall submit a plan of correction that includes in-service training regarding elopement, wandering behavior, methods of redirection, and resident care and supervision procedures.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(4) · Plan of correction due date: Mar 12, 2025

Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored: All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. Based on interviews and record review, med-tech staff altered resident medications by using house supply and labeling the medications with electronic MAR information instead of obtaining medication refills in a timely manner. This posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2025

Plan of correction: Executive director shall conduct in-service training for all med-tech staff. Submit proof of correction by tomorrow.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Mar 12, 2025

Incidental Medical and Dental Care Services. If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. Based on record review and interviews, med-tech staff were logging in the electronic (MAR) database that medications were administered but did not administer the medications. This posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2025

Plan of correction: Administrator shall: 1. Submit proof of staff training. 2. Submit a written plan that addresses centrally stored record keeping/inventory protocols, refill procedures, and facility auditing of medications.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Mar 18, 2025

Resident Records. The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on interviews, a resident's medical file was lost/missing from the med-tech room. Staff did not find the file. A new file was created. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2025

Plan of correction: Executive Director shall provide in-service training to all staff that access and update resident files. Submit proof of staff training.

Allegation investigated: Staff did not properly transfer a resident resulting in an injury. Staff did not seek timely medical attention for a resident. Staff did not ensure that resident's toileting needs were met. Staff mismanaged resident's medication. Staff do not ensure a safe environment is provided for residents.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegations and deliver findings.The purpose of the visit was discussed with Executive Director Beatriz Romeo Liu. The investigation consisted of: On 8/15/2024 & 10/25/2024, a physical plant tour of the interior common areas and resident (R1's) room was conducted. Record review and interviews with staff (S1- S7) and residents (R1 & R2) were completed. Resident (R1's) [Admission Record/Identification and Emergency Information, Admission Agreement, Service Plan, Physician's Report, Chart Notes, Incident reports, Medication Administration Records (MARs) [ June 2024- October 2024], incontinence care Narrative Charting logs [July 2024- Oct. 25, 2024] appraisals, call light system records and staff and resident rosters were reviewed/obtained. Record review was completed today. ***Narrative continues next page. Substantiated Staff did not properly transfer a resident resulting in an injury. It is alleged that on July 31, 2024, resident (R1) sustained a right hand injury that resulted in an open flesh wound tear of approximately 4 inches, while the resident was transferred from the shower chair to the toilet. According to information obtained, when the wet resident was being transferred out of the bath chair to the toilet, the resident was only assisted by one (1) staff (S1) instead of two staff, and staff (S1) gripped R1's hand in order to prevent the resident from falling. According to information obtained, R1 was assessed as a 2-person assist after a previous incident in March 2024 determined the resident was in need of two staff assistance during bathing and transfers. A total of seven (7) staff were interviewed. Staff (S1) stated that on 7/31/24 at approximately 7 AM, R1 was assisted into the bath by two staff, S1 & S2, but left the room to check on the resident next door, and was not present for assistance out of the bath chair. Staff (S2) stated that S1 screamed for S2's help. R1 had a hand a long and thin skin tear on the right hand. Staff (S1) said that R1's son had instructed staff to transfer the resident out of the bath by holding their hands. Both staff stated they immediately notified former med-tech staff (S8) of the incident and 1st Aid care was provided to the resident. Staff (S1) stated a skin integrity assessment form was completed, it was documented on the end of shift book and shower chart located in R1's room. Wellness Director and Administrator confirmed that former med-tech (S8) did not notify Administrator or Wellness Director, write any chart notes, notify R1's Physician or family, nor mentioned the injury at change of shift. Administrator stated that S8 communicated with PM med-tech former staff (S9) to monitor and change the bandage, but said the tear was minor and 1 cm in length. Staff (S)9 did not check the wound until late at night and discovered the wound needed medical attention. At approximately 10:30 PM, R1 was sent out to the hospital as non-emergency. Based on the picture of the injury, staff agreed the hand injury required a medical assessment by a physician after AM med-tech (S8) assessed the hand injury during the 1st Aid assessment. Therefore, there is sufficient evidence to corroborate the allegation. (2 of 7) Allegation: Staff did not seek timely medical attention for a resident. It is alleged that on 7/31/2024, resident (R1) sustained a hand injury at approximately 7 AM that required medical attention because the skin tear was approximately four inches with exposed flesh. According to information obtained, PM caregiver staff (S9) called Kaiser Permanente Hospital for an ambulance until approximately 10 PM. The hospital doctor applied glue and wrapped the wound with gauze. The resident returned to the facility at approximately 4 AM. Based on seven (7) staff interviews the findings revealed that former AM med-tech staff (S8) failed to call R1's physician for directions regarding the skin tear, and did not seek timely medical attention for the hand wound tear that required medical attention. Caregiver staff interviewed stated they followed protocol by immediately reporting the incident to the AM med-tech staff, whom after the initial injury assessment should have seek out medical advice and/or medical attention. All staff acknowledged R1's physician should have been contacted immediately after the injury. There is sufficient evidence to corroborate the allegation. Allegation: Staff did not ensure that resident's toileting needs were met. The complaint alleges that resident (R1) requires full assistance with incontinence care and is supposed to be changed at least every 2 hours. It was reported that the incontinence logs in the resident’s room had 6-hour gaps of missing staff documentation indicating incontinence care was performed. The resident’s responsible party and/or other family members arrive at the facility daily at 9 AM and stay until approximately 9:30 PM. According to the report, family have observed the resident soiled primarily during early morning hours. On Saturday August 10, 2024, the responsible party arrived at approximately 9 AM, it was observed that the bed sheets were soiled with urine. Six (6) out of 7 staff denied the allegation and stated resident (R1) is being checked every 2 hours and changed, but that sometimes staff forget to document the completed task. Two (2) staff stated that during Summer 2024 there were reports that night shift caregivers were not completing incontinence care as required. LPA reviewed and gathered pertinent documentation that revealed that facility caregivers did not perform 2 hour checks on the resident on numerous occasions in the month of July 2024.Therefore, the allegation is deemed substantiated. (3 of 7) Allegation: Staff mismanaged resident's medication. It was reported that on July 6, 2024, AM med-tech staff left R1’s responsible party a note asking them to contact Kaiser requesting a refill for eye drop medication “Latanoprost 0.005 %” because the medication ran out. The medication was picked up by family until July 9, 2024, because staff informed family staff were not able to pick up the medication. According to the report, the facility has authorization to request refills from Kaiser and Yorba Linda pharmacy. Moreover, it is also alleged that on August 8, 2024, at 6 PM, R1 was administered bedtime medication Donepezil HCL 5mg, which is supposed to be administered between 8 PM – 9PM. Family was in the room when Wellness Director went into R1’s room at 9 PM to administer the bedtime medication that had already been administered by the med-tech at 6 PM. A total of seven (7) staff were interviewed. It was acknowledged that some of R1’s medications were not administered on August 8, 2024, and that med-tech administered a bedtime medication at 6PM but failed to document on the Medication Administration Report (MAR). Wellness Director confirmed that on August 8, 2024, R1’s family stated the medication had already been administered at 6 PM. Therefore, Donepezil was not administered. According to staff interviews, bedtime medications are typically dispensed at 7:30 PM. MAR records indicate eye drops Latanoprost 0.005% appear to have not been given consistently. Staff acknowledged that med-techs should have requested the eye drop refill in a timely manner. Records indicate there is sufficient evidence to corroborate the allegation. Allegation: Staff do not ensure a safe environment is provided for residents. It is alleged that In July 2024 the front doors of the facility were being left unlocked 24 hours a day even though the front door entrance is supposed to be locked at 7 PM, and young male (18-22) outsiders have been observed entering the facility after 8PM to use the 1st floor public restroom. On August 1, 2024, resident (R1’s) responsible party emailed Administrator notifying her of the safety concerns regarding the unlocked doors, and she immediately addressed the issue with PM staff. However, on August 3, 2024, R1’s responsible party went to the facility at midnight to check if the front door was locked. It was found to be unlocked and accessible to outsiders. All seven (7) staff confirmed that the front doors were being left unlocked by PM staff. According to staff interviews, PM med-techs are responsible for locking the doors at 7PM but have been known to leave the doors unlocked when they exit the facility for breaks. Staff reported that on several occasions homeless in the area have tried entering the building, and after 6 PM there is no receptionist on duty. Therefore, the allegation is substantiated. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Pursuant to Title 22 California Code of Regulations, the following deficiencies were cited (refer to LIC 9099D). Exit Interview was conducted, citations issued, appeal rights discussed, and a copy of the report was issued to Administrative Assistant Katie Manriquez. Allegation: Staff did not report incident involving resident as required. It was reported that resident (R1’s) responsible parties were not immediately notified of the hand tear injury sustained at approximately 7 AM on July 31, 2024. The complaint alleges that R1’s son/responsible party arrived at the facility at approximately 9 AM and that is when staff informed the responsible party of the injury. A total of seven (7) staff interviews were conducted. The findings reveal that when a resident sustains a serious injury the residents’ responsible party is immediately notified if the resident is being transported by emergency services. However, if the resident’s injury is not deemed serious then, then med-techs may notify the responsible party a little later. In this case, former med-tech (S8) did not categorize the injury as serious, and since R1’s family members and responsible party visited the resident at approximately 9 AM daily, staff waited to communicate to the responsible party upon arrival to the facility. Based on information gathered there is insufficient evidence to prove the allegation, because the resident’s responsible party was notified within a reasonable time according to records reviewed. Allegation: Staff failed to provide adequate food service. It is alleged that on Saturday, August 10, 2024, resident (R1) informed their responsible party that they had not eaten breakfast because staff dropped the cereal on the floor, picked it up, and attempted to feed the cereal to the resident, but the resident refused. Based on staff interviews, R1’s responsible party notified staff that there were Cheerios on the floor and when a staff person went into the room Cheerios were observed on the floor. However, it is unknown if only a few Cheerios fell on the floor or the whole bowl fell. Since there were no witnesses and resident (R1) has cognitive impairment there is insufficient evidence to prove that service procedures were not followed. 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 and a copy of this report was discussed and provided to Administrative Assistant Katie Manriquez.the state’s words, verbatim · CDSS document, Feb 18, 2025 · control 28-AS-20240805162120

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 21, 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 was not met evidenced by: Based on record review and interviews conducted, the findings indicate that on 7/31/2024 (R1) sustained a right hand injury while the resident was transferred from the shower chair to the toilet by 1 staff instead of 2 staff, which posed an immediate health and safety risk to the resident.the state’s words, verbatim · CDSS document, Feb 18, 2025

Plan of correction: Executive Director agreed to: 1. Submit a written Plan of Correction by tomorrow explaining facility procedures pertaining to 2-person assist responsibilities while bathing and care coordination. 2. Conduct in-service training for all caregiver staff regarding transfers, and body check assessments.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Feb 21, 2025

Incidental Medical and Dental Care...The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met evidenced by: Based on interviews and records review, facility staff did not comply with the section above. On 7/31/2024, R1 sustained a hand injury at 7AM, and med-tech staff failed to arrange for timely medical attention which resulted in R1 being transported to the hospital until after 10 PM. This posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Feb 18, 2025

Plan of correction: Executive Director agree to the following 1. Staff are retrained in regulation 87465. 2. Submit proof of staff training. 3. Submit a written plan that specify facility procedures.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Feb 21, 2025

Incidental Medical and Dental Care Services. A plan for incidental medical and dental care shall be developed by each facility…..the licensee may assist persons with self-administration as needed. This requirement is not met as evidenced by: Based on interviews and MAR record review, med-tech staff failed to order and obtain a refill for “Latanoprost 0.005 %” eye drops and on 7/6/24 asked family to order the refills and pick up the medication. Additionally, on 8/8/24 medication Donepezil HCL 5mg was not administered at the physician order time, and was given at 6 PM, instead of bedtime. This posed an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Feb 18, 2025

Plan of correction: Executive Director agreed to: 1. Ensure all med-tech staff take state approved vendored training on incidental medical and dental care. 2. Submit proof of completed staff training to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Feb 25, 2025

Managed Incontinence.... the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met evidenced by: Based on record review and interviews the findings indicate that on multiple dates R1 was not provided incontinence care at least every 2 hours as required, and on 8/10/24, R1’s bed sheets were soiled with urine and the resident had not received incontinence care. This posed a potential health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Feb 18, 2025

Plan of correction: Executive Director agrees to conduct staff training in incontinence care, responsibilities, and facility protocols. Submit proof of staff training.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Feb 21, 2025

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews, during (Jun 2024-Aug. 2024, PM staff were not locking the front doors at 7 PM as required. On 8/3/24, at midnight R1’s family stopped by the facility to check if the front doors were locked. They were found unlocked. On 8/1/24, Administration staff were notified of the concern. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 18, 2025

Plan of correction: Executive Director is to ensure that all residents are afforded a safe, comfortable, and healthful environment to reside in. Please submit a written plan on how the facility has and/or will address the issue of individuals entering the facility after 7 PM.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Galarza conducted a Case Management- Deficiencies visit due to record review findings while investigating complaint control #: 28-AS-20240805162120. The purpose of the visit was explained to Administrative Assistant Katie Manriquez. On 7/31/2024, resident (R1) sustained a right hand injury that resulted in an open flesh wound tear of approximately 4 inches, while the resident was transferred from the shower chair to the toilet. An incident report was not submitted to Community Care Licensing within 7 days of the occurrence. Per 87211(a)(B) Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.... Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. Pursuant to Title 22 California Code of Regulations, a deficiency was cited (refer to LIC 9099D). Exit interview held with Katie Manriquez. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(B) · Plan of correction due date: Feb 21, 2025

Reporting Requirements. Each licensee shall furnish to the licensing agency such reports..... A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.... Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement was not met evidenced by:On 7/31/2024, resident (R1) sustained a right hand injury that resulted in an open flesh wound tear of approximately 4 inches, while the resident was transferred from the shower chair to the toilet. Facility faxed the incident report until 8/14/24, which posed a potential health and safety risk.the state’s words, verbatim · CDSS document, Feb 18, 2025

Plan of correction: Executive Director shall ensure all Unusual Incident Reports are reported to CCL within 7 days of the occurrence of any reportable events. 1. Submit a written Plan of Correction 2. Proof of staff in-service training *Note: LPA obtained a file copy of the incident report.

Allegation investigated: Staff did not provide adequate furniture in room for resident. Staff are threatening not to make resident's bed. Staff are not properly disinfecting the facility. Staff did not interview prospective resident and authorized representative before siging admissions agreement.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Licensee Michael Radnia. Administrator Diana Bautista shortly after. The investigation consisted of: A physical plant tour of the interior common areas, with focus on Memory Care Unit. Residents (R1-R6) and staff (S1-S5) were interviewed. Resident (R1's) files documents [Face Sheet, Admission Agreement, Preplacement Appraisal, Medical Equipment delivery order, Service Plan, LIC 500 Personnel Report, and resident roster were obtained. Unsubstantiated Allegation: Staff did not provide adequate furniture in room for resident. It is alleged that the facility marketing director promised resident (R1's) responsible party that the Memory Care unit rooms would be fully furnished when the resident moved in and the facility would make arrangements to move R1's furniture from previous Assisted Living residence. According to information obtained, the resident moved in on Monday, December 23, 2024 at approximately 6 PM and the Memory Care unit only had a hospital bed, cabinet, and a lamp, and did not offer the resident a full size bed. As a result, responsible party arranged movers to deliver a full size bed and dresser, but was told by med-tech/staff (S3) and Business Office Manager that the full size could not be moved in. A total of five (5) staff were interviewed, of which all denied the allegation stating R1's responsible party was informed that the room does not come furnished, but the facility would be providing a dresser, bedside table, twin sized bed, and lamp, with the exception of hospice residents. Hospice residents get a hospital bed in their rooms that is ordered by the hospice agency. Marketing Director stated when prospective residents and their families visit the facility for a tour they are always informed the rooms are not furnished, but the facility provides basic furniture as a courtesy if needed. Marketing Director stated that R1's family was never promised a fully furnished room, nor offered to transport the resident's belongings from previous placement. Resident (R1) was transported to the facility by hospice transport arranged by previous placement. Five (5) out of 6 residents stated the facility does not provide fully furnished rooms and they are expected to bring their own furniture. Based on observation, R1's room currently has a queen size bed, bedside table, dresser, and sufficient lighting. The facility provided a copy of the hospice medical equipment order dated 12/21/2024, in which the hospital bed was delivered to the facility per Bristol Hospice order. There is insufficient evidence to corroborate the allegation. Allegation: Staff are threatening not to make resident's bed. It was reported that the Business Office Manager told R1's responsible party that the resident's queen size bed would not be made unless family came in to make the bed. A total of 5 staff were interviewed, of which all denied the allegation by stating that staff in the Memory Care unit make all resident beds regardless of bed size. Staff stated that R1's responsible party disclosed to staff that they wanted a larger size bed in order to sleep there when they visit. Staff stated that they informed the responsible party that family are not allowed to sleep over at the facility unless a resident is actively dying, and as a result R1's responsible party got very upset and was verbally abusive towards staff. A total of 6 residents were interviewed, of which all stated staff assist with bed making if needed. There is insufficient evidence to substantiate the allegation. Allegation: Staff are not properly disinfecting the facility. According to information provided, the facility had a virus outbreak in which many of the residents and some staff had vomiting and diarrhea, but they were not following proper cleaning protocols. Of great concern was that during previous visits earlier in the year the facility had another notice that informed visitors that the building had an outbreak. Based on staff interviews, all staff denied the allegation and stated that the facility had a Norovirus outbreak that began early November 2024 and was cleared December 9, 2024. Therefore, when resident (R1) moved in on December 23, 2024, the outbreak had already been cleared by Department of Public Health, and normal disinfecting protocols were in place. Five (5) out of 6 residents stated that the facility cleaned often during the Norovirus outbreak and have not concerns about facility cleanliness. Allegation: Staff did not interview prospective resident and authorized representative before signing admissions agreement. It is alleged that Administration staff did not meet with resident (R1) and responsible party to discuss paperwork prior to signing admission agreement and moving in. It was reported that the admission agreement was emailed and responsible party with the expectation it would be read and signed. Staff interviews revealed that resident (R1) had been placed on a waiting list for the Memory Care Unit for approximately one year, and when there was a room available they received notification. On November 26, 2024 at 3:30 PM, the Marketing Director met with R1 and their responsible party at the facility to complete an in-person assessment. The Admission Agreement is signed after the facility completes the assessment and provides a copy of a current Physician's Report. All the residents interviewed stated that their loved ones met with Administration staff prior to moving in. Resident (R1's) Admission Agreement was signed on 12/14/2024, and the resident moved in on 12/23/24. Therefore, 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 violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was discussed and provided to facility Administrator Diana Bautista.the state’s words, verbatim · CDSS document, Jan 9, 2025 · control 28-AS-20241230112709

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Galarza conducted an unannounced Annual Continuation visit. The purpose of the visit was explained to Administrator Diana Bautista. There facility serves residents 60 years and older. The following 12 (CARE) tool domains were utilized during the inspection. The following were observed/inspected: Infection Control: The Infection Control Plan was reviewed. The facility has a supply of Personal Protective Equipment (PPEs). Operational Requirements: The facility has a Dementia plan, a fire clearance for 114 non-ambulatory residents age 60 and above, of which 15 residents may be bedridden, and a hospice waiver for 30 residents. Facility does not handle resident money. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 5/20/2025. Physical Plant/Environment Safety: The facility is a three (3) story building consisting of 77 resident rooms. The 1st floor consists of a lobby, dining room with outdoor courtyard, kitchen, medication room, administrative offices, electrical room, public restrooms, laundry room, 21 resident rooms, shaded outdoor courtyard area, and a Memory Care unit with multi-purpose room, and outdoor courtyard. The 2nd floor consists of 28 resident rooms, Bistro area, game room, public restrooms, 2 storage rooms, laundry/housekeeping room, outdoor shaded balcony area, and 2 common areas. The 3rd floor consists of 28 resident rooms, fitness room, theater room, lounge, beauty shop, and outdoor shaded balcony area. Delayed egress is in place in the 1st floor Memory Care unit. There are evacuation chairs on 2nd and 3rd floor stairwells to be used during an emergency as a path of egress from the facility to safety. *See 809C pages. continuation - Physical Plant/Environment Safety: 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. Cleaning supplies and toxic substances are inaccessible to residents. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has fully charged fire extinguishers. Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. 12 out 22 resident rooms and a kitchen sink hot water readings measured between 120 DF 124.2 DF. On 6/28/2024, County of LA Fire Department conducted an annual inspection.The sprinkler system, alarms, fire connections, kitchen hood, and water flow alarms were inspected. Violations were found. All maintenance records shall be kept in the facility. Re-inspection will be conducted on 11/20/2024. Staffing: A total of 63 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expired 8/15/2024 and is pending approval from CCL Recertification Unit. Staff have criminal background clearance. Eleven (11) staff files were reviewed. 9 out 11 staff files had expired 1st Aid/CPR training or no proof of training. 6 out 11 staff files do not have required annual training hours. 2 out 11 staff files do not have health and TB clearance. Resident Records/Incident Reports: Ten (10) resident files were reviewed. They contained admission agreements, Service Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. Centrally stored medication records are in place. RCFE & Ombudsman complaint poster were observed posted. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted in the entrance area. The facility has a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Twenty six (26) residents have physician orders for modified diets. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Dining Services Director's Food Handling Certificate expires 11/16/2025. Incident Medical and Dental: Centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family or 3rd party transportation companies. The facility has a non-operable van and no staff driver. An medication error was observed during medication review. Two (2) of Resident (R1's) medications listed on the Medication Administration Record were not filled. Acetaminophen 325 mg, 2 tabs every 4 hours PRN for fever over 100DF & Acetaminophen 325 mg 2 tabs every 6 hrs PRN for mild pain. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 9/23/2024.. Residents with Special Health Needs: There are currently 19 residents are receiving hospice services, 6 receive home health services, and no residents have prohibited health conditions. Individual Service Plans and Appraisals are on file. Postural support physician orders are on file. Half bed rails for mobility assistance were observed in some resident rooms, as well as full rails were observed in hospice residents. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights was issued.the state’s words, verbatim · CDSS document, Nov 15, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year . The purpose of the visit was explained to Business Office Manager Andrea Lopez. Administrator Diana Bautista arrived later. There facility serves residents 60 years and older. During today's visit the following was completed: 11 out of 12 Care Tool Domains were completed. One (1) domain "Resident Records/Incident Reports" is pending review. Deficiencies were observed and will be cited during Annual Continuation visit. Due to time constraints, LPA will conduct an Annual Continuation visit. Exit interview was conducted with Administrator Diana Bautista. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 14, 2024

Allegation investigated: Staff did not provide resident’s authorized representative a copy of the admission agreement in a timely manner.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegation.The purpose of the visit was discussed with Administrator Diana Bautista. The investigation consisted of: LPA completed a physical tour of the common areas and resident (R1's) room. Interviews with family (F2) and Administrator was conducted. Record review of incontinence care Narrative Charting logs [July 2024- to present] and August 2024- to present Medication Administration Records (MARs), and Admission Agreement was completed. Copies of the MARs and Narrative Charting logs, and rosters were obtained. ***Narrative continues next page. Substantiated Allegation: Staff did not provide resident’s authorized representative a copy of the admission agreement in a timely manner. The complaint alleges that resident (R1's) responsible party never received a copy of the signed Admission Agreement after multiple requests addressed to Administration staff. Based on record review, the findings indicate that resident (R1) moved in to the facility on November 17, 2023. The Admission Agreement was provided until August 5, 2024. LPA obtained a copy of the Admission Agreement, and it was determined the Admission Agreement signed and provided to R1's responsible party is the former licensee's Admission Agreement. On 12/7/2023, the facility was issued a citation for issuing Admission Agreements that were in place when the facility was owned by a previous licensee. Administrator acknowledged they did not provide a copy, and the copy provided is not the correct form. Therefore, there is sufficient evidence to corroborate the allegation. A civil penalty is being assessed. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 25, 2024 · control 28-AS-20240805162120

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(e) · Plan of correction due date: Nov 1, 2024

Admission Agreements. The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. This requirement was not met evidenced by: Based on record review of email correspondence, R1's family never received a copy of the admission agreement after it was signed, until multiple requests later. On 8/5/24, the copy was provided, but R1 was admitted on 11/17/23.the state’s words, verbatim · CDSS document, Oct 25, 2024

Plan of correction: Administrator shall submit a copy of the plan of operation addressing Admission agreements, a written plan, and proof that R1's authorized representative were issued the copy of the admission agreement. *This is a repeat violation. Civil penalties are being assessed.

Allegation investigated: Facility staff are not making arrangements to meet residents' health needs. Facility staff are not ensuring that residents are receiving an annual medical assessment as required.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegations and deliver findings. The purpose of the visit was discussed with Wellness Director. Administrator Diana Bautista arrived shortly after. The investigation consisted of: On 7/25/24, LPA interviewed resident (R1). On 8/23/24, staff (S1-S3) were interviewed and additional documents were reviewed/collected. During today's visit, record review was completed and residents (R2- R7) were interviewed. Records collected were: Face Sheet/Identification and Emergency Information, Preplacement Appraisal, Resident Appraisal, Needs and Services Plan [12/12/22], Physician's Report [12/6/22], Hospice orders, Physician's Orders, ALW Individual Service Plan (ISP), Home Healthnotes, Physician Communication (6/13/24), Admission Agreement, Charting Notes, resident roster and LIC 500 Personnel Report. During the course of the investigation, R1's authorized representative was interviewed. Mulitple attempts to interview R1's Medical Doctor were made. *** Narrative continues next page. Substantiated Allegation: Facility staff are not making arrangements to meet residents' health needs. It was reported that resident (R1's) primary care physician informed staff that the resident's healthcare plan was contacted requesting a Cardiologist and Pulmonologist consult, but the facility did not follow through because staff stated that they do not provide transportation to medical appointments. Based on record review, resident (R1) has had a decline in health during the past year, and was hospitalized from June 21, 2024 - June 24, 2024 and placed on home health upon return to the facility. The resident had been enrolled in home health services earlier in the year. Per record review, on July 9, 2024, there was communication between Wellness Director and R1's Medical Doctor, in which MD informed staff that a Cardiologist and Pulmonologist consult referral was sent to R1's insurance provider, as well as a transportation referral. Three staff were interviewed, they confirmed the facility got verbal notification from Medical Doctor that R1 required a Cardiologist and Pulmonologist consult, but stated that they did not receive written referral information for the specialists. Facility charting notes confirm that R1's Doctor informed staff. Resident (R1's) family member was interviewed. They confirmed R1 has not been seen by specialist doctors and was not notified by facility staff that the primary care physician made the facility aware of the referrals on July 9, 2024. Therefore, the residents health needs are not being met. Allegation: Facility staff are not ensuring that residents are receiving an annual medical assessment as required. According to information obtained on June 13, 2024, facility med-tech staff contacted resident (R1's) primary care physician requesting medication refills for 4 medications. However, R1's physician informed staff that the resident has not been seen at the doctor's office in over 2 years. Therefore, the medications would not be refilled. Records indicate the resident moved in 12/12/2022, and upon move-in a Physician's Report dated 12/6/2022 was obtained. A total of 7 residents were interviewed, none reported issues pertaining to the allegation. Based on record review, resident (R1) has mild cognitive impairment and no Dementia. However, record review and staff interviews revealed that resident (R1) was sent out to urgent care in December 2023. A change in condition was noted. On 2/21/2024, the resident was enrolled in home health services, and was sent out to the hospital in early March 2024. In May 2024, staff observed physical changes in need of medical attention. On June 21, 2024, R1 was sent out to the hospital and returned on June 24, 2024, with physical therapy physician order. On July 22, 2024, R1 was enrolled in hospice care. Staff acknowledged R1 had changes in condition since early January 2024, but did not the contact the resident's primary care physician to schedule an annual medical exam. LPA conducted a visit on 7/25/2024 and collected R1's Physician's Report dated 12/6/2022. After that visit, staff obtained an updated Physician's Report dated (7/29/2024) from hospice MD, which indicates the resident has heart failure and requires total care. Staff observed deterioration of physical health condition for months but did not bring to the attention of R1's physician. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 10, 2024 · control 28-AS-20240725102607

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Oct 17, 2024

Incidental Medical and Dental Care. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. Based on record review and interviews conducted, the findings indicate that R1 had a decline in health since Jan. 2024, with change in condition, which prompted R1's doctor to inform staff on 7/9/24, that a Cardiologist and Pulmonologit consult was needed. Per record review, staff did not follow up or obtain referral documentation.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Administrator agreed to: 1. Submit proof the MD specialist consult appointments have been scheduled. 2. Submit a written plan of correction. 3. Conduct med-tech staff training on physician referral follow-up protocols, note charting, and requesting updated physician's reports when there is a change in condition.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Oct 17, 2024

Observation of the Resident . The licensee shall ensure ...When changes ... or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. Based on record review, staf observed deterioration of physical health condition in R1 since early Jan. 2024, but did not bring to the attention the resident's change in condition, nor was a medical exam requested. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Administrator stated that on 7/30/24, facility requested an updated Physician's Report from hospice MD. 1. Submit proof that all caregiver and med-tech staff were trained in regulation 87466, and change in condition.

Allegation investigated: Staff are not administering medications as prescribed.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Wellness Director. Administrator Diana Bautista arrived later. The investigation consisted of: A physical plant tour of the interior common areas and interviews with residents (R1-R8), and staff (S1-S7) was completed. Resident (R1- R4) files documents, ten (10) Medication Administration Records (MARs), LIC 500 Personnel Report, and resident roster were reviewed and obtained. *Narrative continues next page. Substantiated Allegation: Staff are not administering medications as prescribed. It is alleged that medication technicians were not refilling medications in a timely manner, pills were being popped but not given to residents, or the pills were not popped at all during the months of May 2024- June 2024. Information obtained alleges that there were at least 10 residents that were not receiving medications as directed by their physicians. Staff interviews revealed that the facility has been experiencing issues with medication technicians during the last 4- 6 months, because med-tech's were not fulfilling their job responsibilities i.e., documenting on the electronic Medication Administration Record (MAR) that the medications were dispensed, or calling for refills with advance notice. Staff stated medications were being administered but there were MAR errors, and lack of documentation on the MAR to prove staff dispensed the medications. A total of 8 residents were interviewed, none reported knowledge of inappropriate dispensing of medications. However, per record review of Medication Administration Records (MAR) of 10 residents, the findings indicate that multiple residents went days without medication administration by med-tech staff. The lack of documentation was observed in all shifts. There is sufficient evidence to corroborate the allegation. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided. Allegation: Lack of supervision resulted in residents assaulting other residents in care. It is alleged that the facility is failing to ensure the health and safety of residents because residents have been sexually assaulted by resident(s). According to information obtained, management staff have knowledge that there is a known registered sexual offender residing at the facility and were made aware of incidents of sexual inappropriateness by resident (R1) towards resident (R2), and possibly towards resident (R3). Additionally, another resident (R4) allegedly verbally assaults residents with sexual comments and conducts themselves in an inappropriate manner towards staff. It was reported that R1 was observed entering the room of a cognitively impaired, non-ambulatory resident. A total of seven (7) staff were interviewed, of which none reported knowledge of suspected sexual assaults towards residents by R1 or R4. Staff stated they have not observed R1 & R4 act inappropriately with other residents. However, all staff stated that R4, has cognitive impairment and frequently says sexual comments to female staff, but stated none of the residents have reported sexual inappropriateness or assault. A total of 8 residents were interviewed, of which all denied the allegation. Residents (R1 & R2) denied the allegation. There is insufficient evidence to corroborate the 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. An exit interview was conducted and a copy of this report was discussed and provided to facility Administrator Diana Bautista.the state’s words, verbatim · CDSS document, Sep 20, 2024 · control 28-AS-20240917111252

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Sep 25, 2024

Incidental Medical and Dental Care Services. If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. Based on record review, med-tech staff did not dispense medications to at least 10 residents as directed by Physician; records indicate some residents went 2-5 days without medications, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 20, 2024

Plan of correction: Administrator agrees to: 1. Submit proof of staff training. 2. Submit a written plan that addresses centrally stored record keeping/inventory protocols, refill procedures, and facility auditing of medications.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Galarza & Mayra Cota initiated a case management visit due to observations during complaint investigation control #: 28-AS-20240829114254. The purpose of the visit was explained to Administrator Diana Bautista. Rooms 301, 314 & 326 have oxygen tanks in their rooms, and a "No Smoking-Oxygen in Use" sign was not posted outside resident room doors, which poses/posed a potential health, safety or personal rights risk to persons in care. Per Title 22, a deficiency was cited. Exit interview conducted with Diana Bautista. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Sep 6, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87618(b)(3)(B) · Plan of correction due date: Sep 11, 2024

Oxygen Administration - Gas and Liquid. (3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by: Based on observation, rooms 301, 314 & 326 have oxygen tanks in their rooms, and a "No Smoking-Oxygen in Use" sign was not posted outside resident room doors, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 6, 2024

Plan of correction: Administrator shall ensure that a No Smoking-Oxygen In Use sign is posted on resident doors when oxygen tanks are used inside the room. Submit picture proof that the signs are posted and staff in-service training.

Allegation investigated: Staff does not ensure care needs of resident are being met.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate and deliver findings on the above allegation. The purpose of the visit was discussed with Administrator Diana Bautista. The investigation consisted of: On 7/2/24, LPA toured the facility, collected resident (R1's) file documents and interviewed staff (S1- S3) were interviewed. Resident (R1) was not at the facility at the time of the visit. On 7/16/2024, medical providers were interviewed, and on 7/22/2024, resident (R1) was interviewed telephonically. During today's visit, record review was completed and staff (S4- S5) were interviewed. ***Narrative continues next page. Substantiated Allegation: Staff does not ensure care needs of resident are being met. It is alleged that resident (R1) has missed multiple dialysis clinic appointments as a result of transportation issues. According to information obtained, on dates June 6, 2024, June 18, 2024, June 20, 2024, June 22, 2024, and July 4, 2024 the resident was not dialyzed at Davita Dialysis clinic. Resident (R1) was interviewed and they stated that they require dialysis treatment three times a week, and is transported to the appointments via Access transportation services. The resident stated that in the recent month three (3) appointments have been missed. A total of five (5) staff were interviewed, of which all confirmed the resident has missed several dialysis appointments due to transportation issues with Access transport services. On Thursday, June 6, 2024, the resident was waiting outside in the patio area for Access van, and the van drove off without picking up the resident. Staff noticed the resident had not been picked up. Staff (S3) notified Access transportation and R1's family. Staff were on hold for 1 hour with Access, and they were told that pick-up appointments require 24 hour advance scheduling. Therefore, would not be able to transport the resident that day. Family was not able to make alternate arrangements for transport. Medical providers were interviewed, it was confirmed that resident (R1) missed dialysis appointments on June 6, 2024 and July 4, 2024. The facility has a transportation van parked in the parking lot, but does not provide transportation services to residents because they do not have an assigned driver. Per admission agreement, the facility is to "make available to residents, or otherwise assure the provision of, scheduled transportation to the nearest facilities for medical and dental appointments...." Therefore, 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. Deficiency is being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 25, 2024 · control 28-AS-20240626134937

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(6) · Plan of correction due date: Aug 1, 2024

Basic Services. Basic services shall at a minimum include: Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met evidenced by: Based on interviews conducted and record review, the findings indicate that resident (R1) missed dialysis appointments on June 6, 2024 & July 4, 2024, because the facility did not ensure the resident was transported to appointments via Access transport, and/or facility van, or other alternate arrangement. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Licensee shall ensure the admission agreement is adhered to, makes available transportation to medical appointments, and a contigency plan is in place when 3rd party transportation services do not pick-up residents. Submit written POC and staff training.

Allegation investigated: Resident sustained a fracture while in care. Staff did not seek medical attention for resident in a timely manner.

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent visit in response to the above-mentioned allegations. LPA met with Executive Director, Diana Bautista-Martinez and explained the reason for the visit. Investigation consisted of the following: On 02/01/2023, LPA Pena conducted a health and safety check, tour of the facility's common areas and requested a copy of the Staff roster and Resident roster. LPA also reviewed and obtained files for Resident #1 (R1). LPA did not observe any immediate Health and/or Safety concerns. On 2/27/2023, LPA Pena conducted a subsequent visit and obtained copies of the current Staff/Resident rosters, interviewed Resident #2-Resident #9 (R2-R9), Staff #1-Staff #7 (S1-S7), attempted to interview a potential witness (W1) but phone number was no longer in service. LPA also checked a random resident's MAR/medication and toured the medication room. LPA delivered findings for the other allegations. On today's visit, LPA obtained copies of the current Staff & Resident rosters, delivered findings and issued deficiencies and civil penalty. *****CONTINUED ON LIC9099-C***** Substantiated When an overnight shift caregiver last checked on R1 at 0530 hours on 10/14/2022, she noted R1 was fine. A staff entered R1’s bedroom at 0600 hours to give her Ativan as a matter of course, not because of documented agitation, and it appears R1 was left in bed after the interaction. The majority of staff interviews conducted revealed that R1 was always checked first at the beginning of the morning shift (0600 hours) precisely because of being a fall risk. It is unclear why R1 would be left unattended in her bedroom after she was known to be awake. A morning shift staff documented that her first check was at 0630 hours, but based on an Internal Incident Report, this staff checked on R1 at 0700 hours, which is more consistent with her past checks but still within the facility’s safety check window of every two hours. Though R1 appears to have fallen in between staff rounds, sometime between 0600 and 0700 hours, her wandering behavior and attempts to get out of bed without assistance should have warranted attention. R1 was transported to the hospital and was diagnosed with a left hip fracture for which she underwent a left hemiarthroplasty. The allegation facility Neglect/Lack of Supervision resulted in R1’s fall is therefore Substantiated. In regards to the allegation: “Staff did not seek medical attention for resident in a timely manner.” It is alleged that R1 did not receive timely medical attention after suffering a fall and being in pain for several days. This allegation was investigated and completed by Investigator Santana with the Investigations Branch. Interviews conducted revealed that after R1 was found on her bedroom floor sometime between 0600-0700 hours on 10/14/2022, S3 assessed R1 and concluded she had not sustained injury, since there was no visible injury and R1 was able to take a few steps with her walker without complaining of any pain. S3 did not call 911 despite the fall having been unwitnessed because there was no apparent injury and R1 was on hospice, but S1-S2 conceded that the S3 should have called 911 even though R1 was on hospice because of uncertainty about whether R1 hit her head. S3 instead notified VITAS Hospice, likely at 0805 hours that same day, but a VITAS nurse did not arrive to assess R1 until 10/17/2022. Interviews, facility phone records, and VITAS records suggest the facility did not inform VITAS about R1’s change of condition despite calls from VITAS nurse on 10/15/2022 and 10/16/2022 to ask about R1. R1’s change of condition was evident based on facility staff member interviews and documentation, noting that after the fall, R1 was no longer attempting to get up from her wheelchair to bang on windows, which she had done as recently as the day prior. Additionally, R1 was noted as being sleepy and as sleeping the majority of the day on the three days following the fall. While the facility suggested this lethargy could have been attributed to Ativan, R1 had been taking the same amount of Ativan since 10/10/2022, when R1 was still agitated. A VITAS nurse assessed R1 on 10/17/2022 but did not get R1 out of bed. When a staff attempted to get R1 out of bed, at family member’s request, on the afternoon of 10/17/2022, R1 screamed out “in excruciating pain,” saying her back hurt. R1 was transported to the hospital on 10/17/2022 for congestion and left lower abdominal pain and was found to have a fractured left hip that was within two weeks old. R1 ultimately underwent a hip replacement. Had the facility called 911 on 10/14/2022, it is likely R1 could have been treated sooner. The allegation that facility Neglect/Lack of Supervision contributed to a delay in obtaining medical attention for R1 is therefore Substantiated. ***An immediate civil penalty will be issued today, in the amount of $500 due to neglect/lack of supervision which contributed to a delay in obtaining medical attention in which resident sustained a hip fracture. *** At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(f) and may be assessed at a later date. An exit interview was conducted, and a copy of this report was provided to the Administrator along with the Appeals Rights.the state’s words, verbatim · CDSS document, May 17, 2024 · control 28-AS-20230131141908

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 20, 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: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews, records review conducted by Investigator Santana, the licensee did not comply with the section cited above in which due to lack of care and supervision, R1 sustained a left hip fracture as a result of a fall while under the care of the facility.the state’s words, verbatim · CDSS document, May 17, 2024

Plan of correction: Licensee/Administrator shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 87468.2(a)(4). Written POC must be submitted to CCL/LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: May 21, 2024

87468.2 Additional Personal Rights of Residents...(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:(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement is not met as evidenced by: Based on interviews, records review conducted by Investigator Santana, the licensee did not comply with the section cited above in which due to lack of care and supervision contributed to a delay in obtaining timely medical attention for R1.the state’s words, verbatim · CDSS document, May 17, 2024

Plan of correction: Licensee/Administrator shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 87468.2(a)(1). Written POC must be submitted to CCL/LPA by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Deficiency visit in conjunction with a complaint visit, 28-AS-20230131141908. This report is being generated to address the deficiency observed. During the course of the complaint investigation, Investigative branch and CCL found out that the facility failed to meet the reporting requirements in which facility did not submit an Unusual Incident/Injury Report concerning R1' fall on 10/14/2022. Deficiency is cited on LIC 809D. An exit interview was conducted, and a copy of this report was provided to Diana Bautista-Martinez, Executive Director along with the Appeals Rights.the state’s words, verbatim · CDSS document, May 17, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: May 24, 2024

87211 Reporting Requirements..(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in ..(B) Any serious injury as determined..and occurring while the resident is under facility supervision. This requirement is not met as evidenced by: Based on interview and records review, the Administrator failed to meet the reporting requirement and did not submit an Unusual Incident/Injury Report to CCL concerning R1's fall on 10/14/2022 which poses/posed a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 17, 2024

Plan of correction: Administrator will ensure that the reporting requrements are met and to send a written/signed statement that Title 22 Regs. 87211 has been read, reviewed and understood to CCL/LPA by POC due date.

Allegation investigated: Staff did not refill residents medication timely. Staff gave resident another residents medication. Facility staff falsified documents.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegations and deliver findings.The purpose of the visit was discussed with Administrator Diana Bautista. The investigation consisted of the following: On 11/6/23, the physical plant was toured and R1's medications were reviewed. There was a COVID-19 outbreak in the building and all communal dining and activities were postponed at the time of the visit. Residents were quarantined and interviewed in their rooms. LPA interviewed residents (R1- R6) and Staff (S1- S6). Resident (R1's) file documents [Identification and Emergency Information/Face Sheet, Medication Administration Records [Sep. 2023 - Nov. 2023], Physician's Reports, Preplacement Appraisal, Resident Appraisal, ALW Individual Service Plan, Narrative charting notes, Incident Reports, admission agreement, resident roster, and LIC 500 Personnel Report. During today's visit, R1's medications were reviewed, record review was conducted, resident (R1) was interviewed, and common areas were inspected. Rosters were obtained as well. *Narrative continues next page. Substantiated Allegation: Staff did not refill residents medication timely. It is alleged that on October 5, 2023 at approximately 9:30 PM, resident (R1's) blood sugar level was 534 because facility staff failed to reorder insulin medication. According to information obtained PM shift facility staff did not dispense the insulin medication before the resident's dinner meal, which resulted in a dangerous blood sugar level. A total of seven (7) staff were interviewed, which included the staff (S1) that was on shift on 10/5/23. Staff (S1) stated that R1's blood sugar was checked in the early afternoon hours and "it was high". Staff (S1) stated they went to the medication room and there was no insulin left, and the insulin order indicated "zero refills". Therefore, S1 called the pharmacy and they were not able to refill the medication without a current physician order. According to S1, they faxed R1's MD, but did not receive a response. Staff (S1) stated that they spoke to R1 and informed the resident that they could wait for the emergency insulin delivery and/or offered to transport the resident to the hospital. Staff acknowledged they waited "4 hours" to notify the Wellness Nurse and family because they were the only med-tech on duty in the PM shift. All staff interviewed acknowledged that the med-tech staff failed to order insulin medication when it was observed the resident was running low. According to facility protocol, med-techs are supposed to contact the doctor when medication refills are needed. Wellness Director acknowledged that med-tech staff knew the day before R1 ran out of insulin that a new order would be needed. It was stated that the AM med-tech staff should have ordered the insulin, but none of the staff documented the medications needed to be ordered. Family was contacted and they transported R1 to the hospital in order for the resident to be evaluated and so they could receive insulin medication. Facility staff did not call 911 emergency. The findings indicate med-tech staff failed to order R1's insulin medication after observing the insulin supply was running low. There is sufficient evidence to corroborate the allegation. Allegation: Staff gave resident another residents medication. It is alleged that on Sunday, October 29, 2023, med-tech staff (S2) dispensed four (4) wrong medications to resident (R1). According to information obtained, R1 was dispensed their evening medications, and also dispensed another resident's medications. Staff interviews revealed that staff (S1) left another resident's medications in R1's room, and asked other caregivers to check in on R1 and to get the other resident's medications that were left in the room. When staff (S2) went to the room, the other resident's medications were there, and staff assumed they belonged to R1. Therefore, S2 asked the resident to take their medications. According to interviews, staff (S2) misunderstood the instructions given by S1. Per file review, R1 has a diagnosis of early on-set Dementia. All staff interviewed acknowledged the medication error. Per facility protocol, staff cannot leave medications unlocked. Family was notified of medication error and transported the resident to the local hospital. Staff did not call 911 emergency. Therefore, staff negligence is corroborated. Allegation: Facility staff falsified documents. It is alleged that the incident report furnished upon request of R1's authorized representative pertaining to the October 5, 2023, in which med-tech staff failed to order and obtain insulin medication for R1 omitted the fact that insulin medication was not dispensed because the facility failed to refill and obtain a new physician order for the medication. LPA obtained a copy of the 2 incident reports provided to R1's authorized representative and compared it to what was submitted by staff to the Department of Social Services Community Care Licensing Division (CCLD) Regional Office. CCLD received a handwritten incident report completed by staff (S1), that stated that R1 wanted to be sent out to the hospital due to high blood sugar level readings, is waiting for insulin refill medication, and that paramedics were called and resident was transported to PIH Whittier Hospital. Staff (S1) stated that they called the paramedics for another resident and mistakenly mixed up the incidents. Med-techs, caregivers, and Wellness Director are in charge of filling out incident reports, which are then submitted to CCLD. In this case, the Wellness Director faxed the handwritten incident report that had incorrect information. A 2nd incident report was created and typed, and then provided to R1's authorized representative after family brought the false statements noted on the incident report to facility staff. However, the 2nd incident report was never faxed to CCLD. Therefore, there is sufficient evidence to corroborate that staff (S1) falsified documents. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 25, 2024 · control 28-AS-20231109122933

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Apr 25, 2024

Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions. Based on records review and interviews, med-tech staff failed to order R1's insulin medication and on 10/5/23 the resident ran out of insulin resulting in dangerously elevated blood sugar levels; which posed an immediate health and safety hazard to the resident.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Administrator submitted proof of staff in-service training "CCLD Medication Guide" that was conducted on 12/6/2023 by former Wellness Director. Administrator agreed to ensure that medication administration procedures are being evaluated routinely, especially when new med-tech staff are hired. Licensee shall provide medication admininstration in-service training to all staff that dispense medications. This training shall be provided by pharmacy and/or registered nurse. Submit proof of training by POC due

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(4) · Plan of correction due date: May 2, 2024

Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them.... (4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement was not met evidenced by: Based on interviews and record review, on 10/29/23 med-tech left another resident's medications in R1's room and asked the resident to take the medications, which posed an immediatel health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Administrator shall ensure that all staff are trained in job responsibilities,facility procedures, and all med-techs are adhering to company procedures. Administrator provided in-service training that was conducted on 12/6/23. However, new med-tech staff have been onboarded. Therefore, new staff in-service training shall be submitted by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: May 2, 2024

False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met evidenced by: Based on record review, the findings indicate that on 10/10/23, staff faxed to CCLD an incident report that contained falsified information and omitted details of R1's incident (10/5/23), in which staff did not refill in time R1's insulin. The report stated that paramedics were called, but they were not. This poses a potential health and safety risk to persons.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Administrator agreed to conduct staff in-service training on emergency call protocols, and incident report writing and oversight. Submit proof of staff training.

Allegation investigated: Facility is understaffed.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegation. The purpose of the visit was discussed telephonically Administrator Diana Bautista. The investigation consisted of: On 2/15/2022, LPA toured all areas of the facility. Staff (S1-S7), residents (R1- R7), and Family (F1) were interviewed. Copies of Shower Lists [Hospice Shower Names, AM Shower list, PM Shower list], List of residents on 2-hour checks [17 residents], Assisted Living Dining Room Census, Staff Shift Schedule Dates- 1/3/2022- 2/13/2022 , LIC 500 Personnel Report and Resident Roster were obtained. During today's visit, no health and safety issues were observed. ***Narrative continues next page.*** Substantiated Allegation: Facility is understaffed. It is alleged that due to staffing shortages staff are working 12 hour shifts and are still not meeting the bathing, incontinence care, and feeding needs of residents in a timely manner. According to information obtained, the facility hired registry staff to fill major staffing shortages, but the staffing numbers have insufficient to meet the needs of residents, especially during early January 2022 COVID -19 outbreak. A total of 7 residents interviewed, of which five (5) stated the facility was very short staffed and were not responding to their needs in a timely manner. All seven (7) staff confirmed the allegation. Administrator stated that the facility had staffing shortages since August 2021- through February 2022, which resulted in assigning all staff 12-hour shifts, and assigning med-tech staff caregiver duties in the Assisted Living floors. Registry staff were discontinued on Feb. 14, 2022, and the facility planned to keep the 12-hour shifts until all regular staff vacancies were filled. Staff reported that although registry staff were hired, sometimes they did not show up, and/or new staff were hired and they quit right away due to long hours and work load responsibilities. In addition, at least one staff was working 12-hours a day, 6 days a week in order because of staff shortages. Based on record review, the allegation was supported. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited. Exit interview was conducted and a copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Feb 23, 2024 · control 28-AS-20220210145845

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 1, 2024

Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of: Based on interviews conducted and record review, between Aug. 2021- Feb. 2022, there were staff shortages, and so the facility hired registry staff, but still could not meet the needs of residents. This posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: Administrator agreed to submit a plan that ensures sufficient staffing is in place at all times, and staff receive continuous training in personnel responsibilities.

Allegation investigated: Staff are not following resident's care plan appropriately. Staff does not provide proper meal service to residents in care.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegation. The purpose of the visit was discussed telephonically with Diana Bautista. The investigation consisted of: On 2/15/2022, LPA toured all areas of the facility. Staff (S1-S7), residents (R1- R7), and Family (F1) were interviewed. Copies of Shower Lists [Hospice Shower Names, AM Shower list, PM Shower list], List of residents on 2-hour checks [17 residents], Assisted Living Dining Room Census, Staff Shift Schedule Dates- 1/3/2022- 2/13/2022 , LIC 500 Personnel Report and Resident Roster were obtained. During today's visit, no health and safety issues were observed. ***Narrative continues next page.*** Substantiated Allegation: Staff are not following resident's care plan appropriately. It is alleged that the facility has been understaffed for several months and staff are falling behind on their work responsibilities i.e., shower assistance, distribution of medications in a timely manner, and checks on hospice and home health residents. Seven (7) residents were interviewed, of which four (4) stated that they are not being bathe as indicated in their care plans and admission agreements. Two (2) residents stated that they they had not been bathe in over 1 week, and they never know when they are going to be bathe because staff are not following their regular shower schedule. A total of seven (7) staff were interviewed. Four (4) out of seven staff confirmed that resident's care plans are not being followed as a result of staffing shortages. Staff reported that due to the staffing shortages staff are working 6 days a week, and they are still not meeting their needs. For example, a resident's wound was only being cleaned during day shift hours because there was insufficient staffing in the NOC shift, and other residents were not being provided incontinence care as required because when staff started their shift they were observing that the residents on the rotation log were not being changed because their clothes were soiled and wet. Staff stated that weekends and evenings are very challenging for staff because of staff shortages. It was reported that sometimes the NOC shift only had 1 staff in the Assisted Living floors, and 2 staff in the Memory Care unit, but at times 1 Memory Care staff has to be pulled to help the Assisted Living floors. Per document review, the findings indicate that facility caregiver staff have been working 12-hour shifts since at least November 2021, and has been using a total of 15 registry staff as a result of staffing shortages. Staff scheduling documents indicated that the Administrator and Wellness Director were scheduled to work as caregivers on at least 2 different dates. Per staff interviews, residents are to be showered a minimum of twice weekly. Allegation: Staff does not provide proper meal service to residents in care. It is alleged that staff are delivering the meals late to residents, the food is cold, and residents that require feeding assistance are awaiting at least 40 minutes after food is delivered to receive assistance from staff. Based on document review, the findings indicate that there are 5 residents that require feeding assistance. Three (3) out of seven (7) residents stated that their food has been delivered late. Per staff interviews, meals were being provided to residents in their rooms as a result of a COVID-19 virus outbreak. On 2/14/2022, residents resumed dining services in the dining room. Administration staff stated that residents that require feeding assistance take approximately 30 minutes - 1 hour for meal consumption. Five (5) out of seven (7) staff stated that it is taking staff at least 30 minutes to go feed the residents that require assistance, because they are busy attending other resident needs. It was reported that on Sunday February 13, 2022, staff began passing breakfast meals at 9:15 am, and they finished at about 10:00 AM. The residents that needed assistance began eating their breakfast until past 10:00 AM, and on that day staff began serving lunch at an earlier time in order for lunch service to be on time. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited. Exit interview was conducted and a copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Feb 23, 2024 · control 28-AS-20220210150135

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 1, 2024

Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on interviews and record review, between Nov. 2021- Feb. 2022, residents were not being showered at least 2 times per week due to staffing shortages related to the COVID-19 pandemic. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: Administrator agrees to conduct staff training on care plans and bathing schedules. Submit a written POC and proof of staff training.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Mar 1, 2024

Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications..., as specified in Section 87608, Postural Supports. Based on record review and interviews conducted residents that required feeding assistance were being fed 30 minutes after food was serveda as a result of staff shortages between Nov. 2021 - Feb. 2022. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: Administrator agreed to conduct staff training in Basic services and submit a contigency plan that addresses potential staff shortages and meal assistance.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Galarza conducted an unannounced Annual Continuation visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Diana Bautista. The facility serves residents ages 59 and older. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is still in place at the front desk. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Operational Requirements: An Infection Control Plan has been added to the Plan of Operation. The facility has a Dementia Waiver in place and an approved Hospice Waiver for 20 residents. There are presently 23 residents enrolled in hospice care, which exceeds the approved waiver. Citation was issued. A fire clearance for 114 non-ambulatory residents; of which 15 may be bedridden is in place. There are 4 bedridden residents in care. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 6/2/2024. No Surety bond is in place. Facility does not handle resident monies. ***Narrative continues next page.***** Physical Plant/Environment Safety: 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. Cleaning supplies and toxic substances are inaccessible to residents. The facility is a three (3) story building consisting of 77 resident rooms. The 1st floor consists of a lobby, dining room with outdoor courtyard, kitchen, medication room, administrative offices, electrical room, public restrooms, laundry room, 21 resident rooms, shaded outdoor courtyard area, and a Memory Care unit with multi-purpose room, and outdoor courtyard. The 2nd floor consists of 28 resident rooms, Bistro area, game room, public restrooms, 2 storage rooms, laundry/housekeeping room, outdoor shaded balcony area, and 2 common areas. The 3rd floor consists of 28 resident rooms, fitness room, theater room, lounge, beauty shop, and outdoor shaded balcony area. Delayed egress is in place in the 1st floor Memory Care unit. There are evacuation chairs on 2nd and 3rd floor stairwells to be used during an emergency as a path of egress from the facility to safety. On 7/24/2023, an annual fire inspection was conducted by Code Red Fire, Inc. The sprinkler system, alarms, fire connections, water flow alarms were inspected. The facility has fully charged fire extinguishers. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Beds in rooms 107, 110, 115, 218 did not have mattress pads. Citation was issued. Staffing: A total of 49 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 8/15/2024. Staff have criminal background clearance and training, with exception of staff (S1). Citation was issued. Ten (10) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training was reviewed. Staff (S2-S6) did not have current 1st/Aid certificates. ***See next page. Resident Records/Incident Reports: A total of 10 resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, Individual Service Plans, and medication records. NOTE: Previous licensee's admission agreements are being used. Citation was issued. RCFE complaint poster and Personal rights were observed posted. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted in the entrance area. The facility has a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Incident Medical and Dental: Eleven (11) centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medication errors were observed on 12/5/23, citations were issued. Medical and dental transportation is not provided at this time because the facility does not have staff/driver. Per Plan of Operation the facility shall provide transportation. Citation was issued. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Evacuation chairs in each floor were observed. Records of resident Appraisal and Needs services plans are part of Emergency training. *****See next page. Residents with Special Health Needs: Twenty three (23) residents are receiving hospice services, which exceed the approved waiver total of 20 residents. Five (5) residents receive home health services. Postural support physician orders are on file. Half bed rails for mobility assistance were observed in some resident rooms. Full rails were observed in hospice residents. Individual Service Plans and Appraisals are on file. No residents have prohibited health conditions. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Dec 7, 2023

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Galarza and Sanjay Vaid conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Business Office Manager Andrea Lopez. Administrator Diana Bautista arrived later. During today's visit the following was completed: LPAs toured the interior and exterior physical plant. All common areas, activity rooms, common bathrooms, kitchen, dining room, 20 resident rooms, med-tech room, and laundry rooms were inspected. The Memory Care Unit had an unlocked drawer with 2 pairs of scissors and sharp office supplies. Citation was issued. Review of medications and Medication Administration Records were reviewed. A total of 11 medication records were reviewed. Residents (R1 & R2) did not have PRN medications at the facility. Citation was issued. A total of 4 resident files were reviewed. Upon return LPA will finish reviewing resident files, and will review all staff files. One (1) resident was interviewed. Other resident interviews and staff interviews are pending. Due to time constraints, an annual continuation visit will be conducted at a future date. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Dec 5, 2023

Allegation investigated: Facility staff stole resident's money.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the above allegation.The purpose of the visit was discussed with Business Office Manager Andrea Lopez. Administrator Diana Bautista arrived shortly after. The investigation consisted of the following: A tour of the facility was conducted. Staff (S1- S6) and residents (R1- R9) were interviewed. Resident (R1's) file documents [Identification and Emergency Information/Face Sheet, Cash and Jewerly Policy, Resident Theft and Loss Record & Physician's Report], as well as staff (S1's) Personnel Record, termination notice, Personal Property Procedures, resident roster, and LIC 500 Personnel Report. * ***Narrative continues next page.*** Substantiated Allegation: Facility staff stole resident's money. According to information received Activities Director/Staff (S1) took $10.00 from resident (R1) last week with the purpose of buying Poweball and Mega Millions lottery tickets. As of October 10, 2023, staff (S1) had not given the resident the lottery tickets, and has not been seen working at the facility. It is suspected that staff (S1) was fired as a result of the theft. A total of six (6) staff were interviewed. None of the staff had suspicions that Activities Director stole money and/or personal belongings from residents. However, yesterday a staff person was approached by resident (R2) asking for Activities Director, and reported to staff that the resident gave a silver necklace that needed it repairs to staff (S1). Resident (R2) stated that the silver necklace had not been returned until today. Staff (S1) was not able to repair the necklace, but had forgotten to return it to R2. The approximate worth of the necklace was $40 dollars. A total of nine (9) residents were interviewed. Only resident (R1) reported that S1 took money from the resident. Staff (S1) stated that when resident (R1) asked them to buy lotto tickets they told the resident "No", but the resident insisted and staff took the money. Staff (S1) stated that they have not worked at the facility in over 1 week and had not had a chance to bring the lotto ticket, or returned the resident's phone calls. Administrator reported that staff (S1) is being terminated from employment today because they did not call or show up to work 3 scheduled days. The termination is not related to the allegation, because Administration staff learned about the allegation after the decision to terminate was made. Per facility Personal Property Procedures, documentation of resident Theft and Loss Record was completed. However, a police report was not filed because the value of the loss was $10; not more than $100.00. Staff (S1) stated they plan to drop off the tickets sometime this week. As of today resident (R1) has not been given the lotto tickets that were purchased last week by staff (S1). Therefore, 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. Deficiency is being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 28-AS-20231010134131

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(25) · Plan of correction due date: Oct 19, 2023

Additional Personal Rights of Residents in Privately Operated Facilities.... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To protection of their property from theft or loss according to Health and Safety Code sections 1569.152, 1569.153, and 1569.154. This requirement was not met evidenced by: Based on record review and interviews, the findings indicate that staff (S1) took $10 from resident (R1) to buy lottery tickets, but never gave the lottery tickets to the resident. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: Administrator agreed to conduct staff training regarding Personal Property Procedures and Theft and Loss. Submit proof of staff training by POC due date.