Lakewood Gardens

Allegation investigated: Resident was sexually abused while in care.

Licensing Program Analysts (LPA) Christian Gutierrez conducted a subsequent unannounced complaint visit in response to the above allegations. LPA met with Administrator Jenne De Castro who assisted with today’s visit. The investigation consisted of the following: During the initial visit conducted on 06/12/2026 LPA interviewed Administrator, obtained copies of Staff/Resident Rosters, toured facility alongside of Administrator; there were no concerns, obstructions, or anything out of the ordinary witnessed during the visit. During today’s visit LPA Gutierrez obtained copies of preplacement appraisal information, doctor’s notes, current physician’s report LIC 602, and ID/emergency information, interviewed Administrator, staff #1-staff #7 (S1-S7), resident #1-Resident #7 (R1-R7), and witness #1-witness #2 (W1-W2). LPA delivered findings. See LIC 9099 Unsubstantiated In regard to the allegation “Resident was sexually abused while in care”, it is alleged that resident was touched by staff while in care. During interviews with witnesses, Administrator and staff all stated that R1 has a history of hallucinations and fabricating stories. W1 stated that this has been ongoing even before R1 came to facility. S2 stated R1 accuses staff of things and that staff is not even working that day. Administrator stated that R1 has a diagnosis of dementia and schizophrenia and these behaviors are part of the illness. During interviews with residents five (5) out of seven (7) residents stated they have never been touched and are treated well at the facility. Two (2) residents could not answer LPA’s questions. During the record review, it was revealed that R1 shows moderate signs of altered mental status with lapse in memory recall. R1 also has a history of paranoia and grandiose delusions, in addition to auditory hallucinations. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Jenne De Castro.the state’s words, verbatim · CDSS document, Aug 4, 2026 · control 28-AS-20260612091638

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christian Gutierrez conducted the required annual inspection. LPA arrived unannounced and met Jeene De Castro and explained the purpose for today’s visit. The facility is licensed to serve 150 non-ambulatory residents ages 60 years and above. Facility has a Dementia Special Program with Delayed Egress System and an approved Hospice waiver for 27 residents. Facility currently has 10 residents under hospice care.The Facility is a single story building located in Downey, CA. A tour of the facility included: main entrance/lobby, Administrator Office, Administrative Assistant Office, this is a locked facility that requires code to access inside, there are 75 resident bedrooms with private bath, 2 activity rooms, 2 changing rooms, 1 shower room, beauty shop, craft room/staff training room, staff lounge, 2 storage rooms, oxygen tank closet, Medication Room, Doctors Office, 1 large dining room, 1 small dining room, kitchen, linen room, laundry room, 2 visitor restrooms and an outdoor patio area that is enclosed within facility. LPA toured the facility and observed the following: LPA toured a total of nine (9) resident bedrooms, and all had the required furniture and bedding. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The resident bathrooms have the required grabs bars and non-skid mats. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents in back patio area. Facility provides scheduled activities with a monthly calendar and the required full-time staff that conducts/evaluate planned activities. LPA reviewed Infection Control Plan and Emergency Disaster Plan. Last emergency drill was conducted on 03/05/2026. ***Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection. ***Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 7, 2026

Allegation investigated: Staff did not ensure that the facility was free of scabies.

**This report supersedes report dated 12/02/2025. The purpose of this report is to change findings from substantiated to unsubstantiated and to include additional information that was not included on 12/02/2025 Licensing Program Analyst (LPA) Gutierrez met with Marie Jeene De Castro and explained the purpose of this visit. ***** Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced complaint visit in response to the above allegations. LPA met with Administrator Marie Jeene De Castro who assisted with today’s visit. On today’s visit, LPA interviewed Administrator, Staff 1-staff 6 (S1-S6) and residents 1- residents 5 (R1-R5). LPA obtained copies of the following documents: Staff roster, resident roster, R1’s physicians reports, identification information, hospital discharge paperwork, wound progress notes, unusual incident report (LIC 624), and body assessment charts. LPA Gutierrez also delivered findings. SEE LIC 9099C Unsubstantiated In regard to the allegation “Staff did not ensure that the facility was free of scabies”, It is alleged that R1 was admitted to emergency for an unwitnessed fall and upon exam it was discovered R1 had scabies. During interview with Administrator, and staff five (5) out of seven (7) stated that they did not observe R1 to have any rash. Administrator stated that the Dermatologist came on 11/19/2025 and only treated R1 for redness around sacral/buttocks. S1 and S3 stated there was a little rash on back but was not reported only documented on body assessment chart. During interviews with residents four (4) out of five (5) residents stated that they have had no rash. LPA obtained documents that facility has ongoing pest services on a monthly basis. There is no evidence of a current scabies outbreak or documentation or evidence obtained that any other resident is currently diagnosed with scabies. LPA did not obtain any evidence that R1 obtained the scabies due to staff neglect and/or lack of care and supervision. It is undetermined how R1 contracted the scabies. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was proved. In regard to the allegation “Staff did not address resident's change in condition”, It is alleged that R1 was not treated for skin condition prior to be admitted to hospital on an unrelated manner. Treating physician reported R1 had scabies and treatment was initiated due to the resident's skin condition/symptoms. During interview with Administrator, and staff seven (7) out of seven (7) stated that there was no report of a change of condition. Administrator stated that dermatologists are at facility weekly and no report of rash was reported. During interviews with residents five (5) out of five (5) residents stated that they have had no problems with rashes. During record review it was revealed that on 11/18/2025 body assessment chart taken by caregiver indicated little red spots on lower neck. On 11/19/2025 there was no evidence that R1’s NP addressed the redness caregiver observed as notes provided do not discuss this new red area observed or addressed. On 11/24/2025 R1 was discharged to facility with PIH document with scabies diagnosis. NP notes dated 11/26/2025 once again do not mention anything about the redness around the back neck or scabies. NP finally documents potential scabies on 12/03/2026 notes after R1 had been discharged from hospital with scabies diagnosis. 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 according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 28-AS-20251125123813

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Feb 20, 2026

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains 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 observations and interviews, on 11/18/2025 S1 observed R1 to have red spots on lower neck area. No evidence was provided by the facility that these observed changes were brought to the attention of R1’s physician, licensed medical professional, and/or R1’s responsible party on 11/18/2025.This poses an immediate risk to the health, safety, and personal rights of the persons in care.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: Administartor will conduct training on section 87466 and submit to LPA by POC due date.

Allegation investigated: Staff refusing to allow resident to return to facility after hospitalization.

Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced complaint visit in response to the above allegations. LPA met with Administrator Jeene De Castro who assisted with today’s visit. On today’s visit LPA’s obtained copies of the following documents: Staff roster, resident roster, special incident report (SIR) R1’s hospital discharge paperwork, psychiatric progress notes, emails between case worker and facility, and facility notes. LPA interviewed Administrator and staff #1(S1) and residents 1-8 (R1-R8). LPA delivered findings. SEE LIC 9099C Unsubstantiated In regard to the allegation “Staff refusing to allow resident to return to facility after hospitalization.”, It is alleged that facility did not allow R1 to return to facility. During interviews with Administrator and staff two (2) out of two (2) staff stated resident was never denied re-entry. Staff both stated that because of behavior issues facility was requesting a psychiatric evaluation for the safety of R1 and of other residents. Administrator provided emails between hospital caseworker and facility stating they would gladly accept R1 back as long as Psych MD stated R1 was able to return. During interviews with residents five (5) out of eight (8) residents stated they have never had any problems returning to facility after a hospital visit. Three (3) residents were confused by LPA’s questions. During record review of hospital notes there was no indication that facility was refusing to accept R1 back to facility. LPA observed Psychiatric behavior notes dated 02/10/2026 from So Cal Hospital. R1 returned to the facility as of 02/12/2026. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 28-AS-20260212125011

Allegation investigated: Staff did not ensure that the facility was free of scabies. Staff did not address resident's change in condition.

Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced complaint visit in response to the above allegations. LPA met with Administrator Marie Jeene De Castro who assisted with today’s visit. On today’s visit, LPA interviewed Administrator, Staff 1-staff 6 (S1-S6) and residents 1- residents 5 (R1-R5). LPA obtained copies of the following documents: Staff roster, resident roster, R1’s physicians reports, identification information, hospital discharge paperwork, wound progress notes, unusual incident report (LIC 624), and body assessment charts. LPA Gutierrez also delivered findings. SEE LIC 8099C Substantiated In regard to the allegation “Staff did not ensure that the facility was free of scabies”, It is alleged that R1 was admitted to emergency for an unwitnessed fall and upon exam it was discovered R1 had scabies. During interview with Administrator, and staff five (5) out of seven (2) stated that they did not observe R1 to have any rash. Administrator stated that the Dermatologist came on 11/19/2025 and only treated R1 for redness around sacral/buttocks. S1 and S3 stated there was a little rash on back but was not reported. During interviews with residents four (4) out of five (5) residents stated that they have had no rash. During record review LPA obtained hospital discharge paperwork that stated R1 had scabies along with instruction for medications and the need for isolation. In regard to the allegation “Staff did not address resident's change in condition”, It is alleged that R1 was not treated for skin condition prior to be admitted to hospital on an unrelated manner. Treating physician reported R1 had scabies and treatment was initiated due to the resident's skin condition/symptoms. During interview with Administrator, and staff seven (7) out of seven (7) stated that there was no report of a change of condition. Administrator stated that dermatologists are at facility weekly and no report of rash was reported. During interviews with residents five (5) out of five (5) residents stated that they have had no problems with rashes. During record review it was revealed that on 11/18/2025 body assessment chart indicated little red spots on lower neck.In house Dermatologist was at facility on 11/19/2025 and did not address body part that was reported by caregiver 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 according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 28-AS-20251125123813

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 3, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Based on observations and interviews licensee did not ensure, R1 was fee and clear of scabies in facility which poses an immediate risk to the health, safety, and personal rights of the persons in care.the state’s words, verbatim · CDSS document, Dec 2, 2025

Plan of correction: Administrator will insure residents are checked for rashes and insure proper training with staff on section 87468.1(a)(2) is conducted. Administrator will submit training to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Dec 3, 2025

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains 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 observations and interviews licensee did not ensure, R1 was checked for a change of conditon like rashes on body which poses an immediate risk to the health, safety, and personal rights of the persons in care.the state’s words, verbatim · CDSS document, Dec 2, 2025

Plan of correction: Administartor will conduct training on section 87466 and submit to LPA by POC due date.

Allegation investigated: Staff did not dispense medications as prescribed

Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced complain visit on 09/23/2025, in regard to the allegations listed above. LPA met with Administrator Jeenne De Castro and explained the purpose of the visit. The investigation consisted of the following: LPA did a random medication check on four residents, interviewed Administrator, staff 1- 4, attempted to interview residents R1-R6 and interviewed R1’s family. LPA obtained copies of the following documents: staff roster, resident roster, R1’s physicians reports, identification information , appraisal needs and service plan, hospital discharge paperwork, medication list, and facility notes. During today’s visit LPA delivered findings. See 9099C Substantiated In regard to the allegation” Staff did not dispense medications as prescribed”, It is alleged that staff administered wrong medication to R1 resulting in a positive urine test of an opioid causing R1 to be hospitalized. During interview with Administrator, and staff three (3) out of five (5) stated that to their knowledge no medication error has occurred. Two staff stated that they do not give out medication. During interviews it was revealed that R1 took Morning medication at 8:00 AM given by med-tech and that by 9:20 AM R1 appeared weak and was slurring. S3 stated that in the early morning R1 was awake and given breakfast with no problems. S4 stated the night before R1 was taken to hospital there were no signs of any problems during his/her shift. LPA attempted to interview six (6) residents but due to their cognitive condition LPA was unable to interview them. LPA interviewed R1’s family and it was revealed that R1 only takes two medications omeprazole in the morning, and Zoloft (sertraline) which him/her dispenses in the afternoon and when tested at hospital Tricyclic was found in urine. 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 according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was given to Administrator.the state’s words, verbatim · CDSS document, Sep 23, 2025 · control 28-AS-20250915201751

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 24, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Based on interviews conducted and documents review R1 received wrong medication which poses an immediate risk to the health, safety, or personal rights to the persons in care.the state’s words, verbatim · CDSS document, Sep 23, 2025

Plan of correction: Administrator will conduct medication training to med-techs and send to LPA by POC due date.

Allegation investigated: Staff did not address a resident's change in medical condition

Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced complaint investigation regarding the above allegations. LPA was met by Rita Rena Assistant Administrator and explained the purpose of the visit. Administrator Jeene De Castro arrived shortly. The investigation consisted of the following: LPA Gutierrez requested and obtained copies of staff roster, resident roster, R1’s identification and emergency information, physicians report, body assessment documentation, SIR reports, caretakers notes, and city of Downey police Officer business card. LPA conducted interviews with Administrator, staff 1- staff 2 (S1-S2), and resident’s 1 – 8 (R1-R8). SEE 9099C Unsubstantiated In regard to the allegation “Staff did not address a resident's change in medical condition “, it is alleged that R1 arrived at hospital and had suffered a fracture from a fall. During interviews with Administrator, and staff three (3) out of three (3) stated that R1 had not fallen to their knowledge. Caregiver in the early morning had noticed swelling and redness and immediately acted by giving doctors order pain medication and calling for ambulance for pick up. Administrator stated that when asked R1 stated he/she had not fallen. During interviews with residents five (5) out of six (6) stated that staff seek medical attention if needed. R1 stated that he/she fell and that they did not tell staff. During investigation it was revealed that RP did not suspect abuse or neglect with resident however they were told that any fall should be reported. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was proved.the state’s words, verbatim · CDSS document, May 20, 2025 · control 28-AS-20250519093602

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Rita Pena and Jeene De Castro and explained the purpose for today’s visit. The facility is licensed to serve 150 Non-Ambulatory residents ages 60 years and above. Facility has a Dementia Special Program with Delayed Egress System and an approved Hospice waiver for 27 residents. Facility currently has 20 residents under hospice care. The Facility is a single story building located in Downey, CA. A tour of the facility included: main entrance/lobby, Administrator Office, Administrative Assistant Office, this is a locked facility that requires code to access inside, there are 75 resident bedrooms with private bath, 2 activity rooms, 2 changing rooms, 1 shower room, beauty shop, craft room/staff training room, staff lounge, 2 storage rooms, oxygen tank closet, Medication Room, Doctors Office, 1 large dining room, 1 small dining room, kitchen, linen room, laundry room, 2 visitor restrooms and an outdoor patio area that is enclosed within facility. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility has sufficient PPE supplies and the required Infection Control Plan on file. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Dementia Plan and training, and facility maintains the required liability insurance, expires 7/2025. Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. (Continued on LIC809-C) Physical Plant & Environment Safety: LPA toured facility, a total of 9 residents’ bedrooms were checked and had the required closet/drawer space to accommodate each resident comfortably available. The resident rooms have signal systems located in each bathroom and near their bed that were tested and operating properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility resident private bathrooms and measured within the required range of 105-120 degrees. There is a large shaded patio area for residents. Personnel Records-Training: Staff have criminal record clearance, current First-Aid training along with training in postural supports, Alzheimer’s and Dementia, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 7 staff files with no issues observed. Administrator Marie "Jeene" De Castro certificate expires on 6/10/25, has already begun the renewal process. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 8 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities with a monthly calendar and the required full-time staff that conducts/evaluate planned activities. There is sufficient space both indoor and outdoor for activities. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled and are centrally stored and are in their original containers. LPA reviewed 10 residents medications with no issues. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The last drill was conducted on 5/8/25. Residents with Special Health Needs: Facility admits residents with dementia and hospice, staff files reviewed today all have required training documented. Residents under hospice care had the required documentation on file. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held, a copy of the report was provided.the state’s words, verbatim · CDSS document, May 16, 2025

Allegation investigated: Staff physically assaulted resident.

Licensing Program Analyst (LPA) Elizabeth Irra conducted a complaint visit to investigate the above allegation. LPA met with Jeenne De Castro/S-1 and discussed the purpose of today’s visit. During today’s visit, LPA obtained a copy of the resident and staff rosters, staff contact information, reviewed R-1’s file and obtained relevant documentation, interviewed Staff #1 (S-1) through Staff #5 (S-5) and interviewed Resident #1 (R-1) through Resident #7 (R-7). LPA left a message for Staff #6 (S-6) for a return call. LPA also attempted to interview Resident #8 (R-8) and was unsuccessful. Refer to LIC 9099C for the continuation of this report. Unsubstantiated Allegation: Staff physically assaulted resident. It has been alleged that a staff member (unknown) “punched” R-1 on R-1’s face. Staff interviews revealed that staff do not physically assault/hit any residents. Interviewed staff indicated that they have not received reports from other residents pertaining to staff allegedly hitting residents. Interviewed staff indicated that they have not witnessed any staff hitting any residents. Interviewed staff also reported that R-1 was not observed to have any signs of bruising, discoloration, swelling or scratches. Staff interviews revealed that they are trained in mandated reporting and resident rights. Resident interviews revealed that staff do not physically assault/hit residents. Interviewed residents indicated that staff are nice, treat them well and are respectful. Interviewed residents indicated that they feel safe and comfortable residing at this facility. Resident interviews revealed that they have not witnessed any staff hitting anyone. Interviews do not corroborate this allegation. Based upon interviews and records reviewed, the findings indicate that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted. A copy of the report and appeal right was provided to Jeenne De Castro.the state’s words, verbatim · CDSS document, May 1, 2025 · control 28-AS-20250424095324

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA's) Tyler Reyes and Valeria Maldonado conducted an unannounced required annual inspection using the CARE tools. LPAs met with Administrator Jeene De Castro and explained the reason of the visit. The facility is an Residential Facility for the Elderly (RCFE) licensed to serve (150) non-ambulatory residents, ages 60 years and above. Hospice waiver was approved for for (27) residents. Administrator Jeene has an RCFE Certificate issued for 6/11/23 with an expiration date of 6/10/25 . LPA and Administrator Jeene toured the facility and the following was observed: the 2 outside patios are clean and there are shaded seating areas for the residents. Passageways and exits are free of obstruction. The water temperature was tested in the 3 residents’ bathrooms and 1 common bathroom and measured between at 112 and 118 degrees F, which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have the required non-skid mats. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. Smoke detectors were observed in each room and throughout the facility and are properly operating. There are multiple carbon monoxide detectors throughout the facility and are properly operating. There are multiple fire extinguishers throughout the facility, which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are kept in the kitchen and are inaccessible to the residents. Cleaning supplies and toxins are kept in a locked storage. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. First Aid kit was fully stocked with current manual and it is kept in the medication room. Residents medication are centrally stored in the medication room. Residents and staff files are centrally stored in the administrator’s office. (CONTINUED TO LIC 809C) LPA reviewed medication for six residents and observed that medications are documented properly and given as prescribed. LPA reviewed files for five residents and five staff and observed all required documentation on file. Required signs are posted throughout the facility, and hand-washing signs were observed in bathroom. Sufficient hand soap, hand sanitizer, and paper towels were observed. Supply of 30-day Personal Protective Equipment (PPE) was observed in the storage room. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during today's visit. Exit interview was conducted with Jeenne De Castro administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 11, 2024

Allegation investigated: Facility has bed bugs. Resident was prohibited from using their bathroom. Resident's Representative was prohibited from installing a safety bed alarm for resident. Resident was forced to wear diapers while in care. Facility has bad odor

Licensing Program Analyst (LPA) Sanjay Vaid conducted a subsequent complaint visit regarding the allegations and discussed the findings of the complaint investigation. LPA Vaid met with Administrator Jennie De Castro and discussed the purpose of the visit, which was to deliver complaint investigation findings. On 01/28/2022 LPA Nina Galarza toured the physical plant, including rooms 11,43,34,74,33,25, and 75 with Staff #1 (S1). LPA conducted interviews with Administrator, S1 and Resident #1 (R1). LPA obtained copies of; staff roster resident roster, and most recent pest control receipt. On todays visit, LPA Vaid interviewed residents and Administrator, and staff, and toured the physical plant with administrator DeCastro and LPA observed the facility to be in good repair and cleanliness all around, rooms included in tour were Rm 11, 13, 25, 33, 34, 43, 44, 52, 74 and 75. LPA requested and obtained a copy of staff schedule and rsident roster, including a list of any residents receiving incontinent care and pest control invoices. LPA Vaid observed the facility has no malodor. LPA tour was comprised of interviews with R#1-R#10 residents in the above rooms and interviewed S#2-S#7 staff (administrator, caregivers, housekeepers, maintenance) working today. Con't on 9099C Unsubstantiated Regarding allegation: Facility has bed bugs. It is alleged, a resident was observed by medical staff whom indicated resident appeared to have been bitten by bed bugs. 10 out of 10 resident interviews revealed the residents are unaware of bedbugs in the facility. 7 out of 7 staff interviews revealed that the facility is free of pests including bedbugs. Interviews with Administrator revealed monthly pest control invoice show no detection of pests. LPA observed bedding and linens on beds to be clean and no bed bugs were seen today. Review of pest control invoices indicate monthly pest control checks are made to the facility, no pests found on both visits according to Pest Control Company dated 2/26/24 and 3/14/24. Regarding allegation: Resident's Representative was prohibited from installing a safety bed alarm for resident. It is alleged that resident family requested a bed alarm be placed on resident bed due to resident falls, however, the staff delayed processing the request and ignored the request. 10 out of 10 resident interviews revealed they are not aware of this. 7 out of 7 staff interviews revealed bed alarms are placed only after physician’s order is reviewed and verified. Interview with Administrator revealed R1’s physician report dated 10/22/2021 revealed no written order for bed alarm was given. The report indicates use of low bed, therefore bed alarm was not approved by physician. No written order on file. Regarding allegation: Resident was forced to wear diapers while in care. It was alleged, staff placed adult briefs on resident in order to keep resident in bed during the time resident bathroom access was blocked. 10 out of 10 resident interviews revealed they are not forced to wear adult briefs. 7 out of 7 staff interviews revealed if there is a physicians order on file only then can staff provide adult briefs/ diapers to residents. Interviews with Administrator revealed the residents are provided adult briefs only upon physician’s orders and as indicated in Needs and Service plan, Physicians report for R1 dated 10/22/2021 recommended use of adult briefs due to use Foley catheter and to prevent resident from soiling self. Con't on 9099 C.... Regarding allegation: Facility has bad odor. It is alleged, that a visitor smelled urine coming from a sliding door due to a resident urinating by the sliding door. 10 out of 10 resident interviews revealed the residents has not experienced bad odor from the facility. 7 out of 7 staff interviews revealed only bad smell occurs when residents have bladder/bowel movements in the clothes, the staff acts quickly to clean and eliminate the smell of urine and/or feces. Interviews with Administrator revealed the facility to be clean and odor free, housekeeping is very good at keeping facility clean and odor free. Caregivers assist residents if the clothes become soiled after bladder/bowel accidents. Based upon records review and interviews conducted, the findings indicate that, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted with Administrator Jennie De Castro. A copy of the licensing report was provided at time of visit.the state’s words, verbatim · CDSS document, Mar 29, 2024 · control 28-AS-20220126151537

Allegation investigated: Staff are not addressing an outbreak of scabies Staff are allowing residents to wear other residents' clothing

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced subsequent complaint visit to determine the validity of the above-mentioned allegations. LPA met with Jeenne De Castro (Administrator) and explained the reason for the visit. The investigation consisted of the following: LPA Lopez obtained copies of the resident and staff rosters, Public Health Rash/Scabies Outbreak notification dated 12/04/2023, skin sweep assessment for all staff and all residents except 3 residents that became agitated and refused. West Coast Wound and Skincare Assessments for staff and residents dated 12/12/2023, In-service sign in sheet for scabies and reportable diseases and conditions dated 12/05/2023, Scabies line list dated 12/13/2023. Labcorb examination results for 12 residents that required followed up dated. 12/08/2023, and copy of email from DPH allowing new admissions dated 12/18/2023 (continued on 809C) Unsubstantiated West Coast copy of letter to Public Health Nurse (PHN) that no evidence of scabies was found at facility dated 12/12/2023, and Letter addressed to LPA Lopez from West Coast FNP-BC, Jason Kreider confirming test results of no evidence of scabies. LPA toured the activity room and random rooms, and interviewed six staff including Administrator, Staff#1 - Staff#6 (S1 – S6), and Resident #11 - R#8 (R1 - R8), and 2 witnesses (W#1-W#2). The investigation revealed the following: Regarding the allegation. Staff not addressing an outbreak of scabies. It is alleged that facility has scabies outbreak. LPA contacted Los Angeles County Department of Public Health (DPH) to notify them of the allegation on 12/04/2023 and LPA had contact with assigned nurse (W1) from DPH on same date. DPH made visit to facility on 12/04/2023 and provided facility with list of actions for facility to take immediately. Facility complied with all the actions recommended by DPH including precautionary treatment for all staff and residents until results of test came back. On 12/06/2023 all residents and staff were provided with skin sweep assessment and scabies was ruled out for all staff and all residents tested. 3 residents refused test and were isolated and precautions taken according to Administrator. Six of Six staff interviewed stated that they do not have scabies symptoms and did not know of any residents or staff that had or have scabies symptoms. LPA interviewed and observed 8 residents (R#1- R#8) and all 8 residents could not collaborate the allegation and all 8 denied any itching or rash. LPA did not observe any residents or staff with rash. W2 which is family member stated they were notified of the allegation and kept up to date throughout the ordeal. There is no evidence that facility failed to address the scabies outbreak because there was not a scabies outbreak at facility. Therefore, this allegation is UNSUBSTANTIATED. Allegation: Staff are allowing residents to wear other residents' clothing. It is alleged that staff are allowing residents to wear other resident’s clothing. LPA interviewed six staff S1 – S6 including administrator and they all denied the allegation. Administrator stated that all clothing is labeled with resident’s name to prevent other resident’s from using other resident’s clothing. Several staff stated that at times, residents will put on a piece of clothing that does not belong to them and staff will attempt to correct the issue and most of time will do it without further incident. 6 of 6 staff stated they do not allow residents wearing other resident’s clothing. LPA interviewed 8 residents and all 8 could not collaborate the allegations. LPA inspected random rooms and resident’s clothing and they all had the resident’s name on the clothing. W2 which is a family member stated that W2 has not noticed her love one wearing other’s clothing or other resident’s wearing resident's clothing. There is not evidence that staff is allowing residents to wear other resident’s clothing, therefore the allegation is UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 12, 2024 · control 28-AS-20231130123048