Landmark Villa

Type of visit: Case Management - Health Checks

On this day, 8/27/26, at 12:00 noon, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection. LPA met with Executive Director (ED) Geraldine Tayo and informed the reason for visit. LPA also met with Assistant Administrator Heather Helton and Assisted Living Director (ALD) Leonora Ramos. LPA toured facility with ED and inspected including but not limited to dining room, activity area, library, kitchen, common areas, courtyards and common toilets. LPA selected 2 residents apartments each on first, second and 3rd floors. LPA observed facility has 7-day of non-perishable and 2-day of perishable food supplies. Facility has running water and electricity. LPA obtained copies of current resident roster and LIC500 Personnel Report. LPA checked 17 resident records and obtained copies of LIC601 Identification and Emergency Contact Information and LIC602A Physician Reports. At 2:00 pm, LPA observed Resident R6's medical assessment (LIC602A Physician's Report) indicated R6 is bedridden but R6 can reposition by self. Exit interview conducted and copy of this report provided to Geraldine Tayo.the state’s words, verbatim · CDSS document, Aug 27, 2026

Allegation investigated: Staff does not ensure carpets on the stairs are clean.

On this day, 08/07/2026, at 12:30 pm, Licensing Program Analyst (LPA) Delmundo arrived unnounced to investigate the above allegation. LPA met with Assisted Living Director (ALD) Leonora Ramos and Maintenance Director (MD) Sixo Antolin and informed the reason for visit. It was reported that facility staff regularly shampoo the carpets in the common areas to keep them clean and deodorized, but they do not shampoo the carpet on the staircases. The reporting party (RP) stated there is a terrible odor coming from the filthy carpets on the stairs. ............continued on 9099D Substantiated During investigation, LPA obtained copy of LIC500 Personnel Report and interviewed the Maintenance Director (MD). LPA inspected the 5 stairwells and the stair going to the parking garage with Assisted Living Director (ALD) and MD. All 5 stairwells and stair were observed with heavily soiled carpets. LPA also observed dried leaves on one of the stairwells and some of the edges of the stairs with black tape.Two of the 5 stairwells were also observed with dilapidated carpet. Therefore, the allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited from Title 22 California Code of Regulation and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed over the phone with Executive Director (ED) Geraldine Tayo in the presence of the MD and ALD. The ED authorized ALD to sign and receive this report. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Aug 7, 2026 · control 15-AS-20260805130538

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 4, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. -This requirement is not met as evidenced by: -Based on interview and observation, the licensee did not comply with the section in heavily soiled and dilapidated carpet on stairwells which pose a potential health, safety and/or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2026

Plan of correction: Executive Director (ED) stated she'll have the stairwells deep cleaned as a quick fix. In addition, ED stated she will talk to the licensees and will have carpets replaced. Proof to be submitted by 09/04/2026.

Type of visit: Case Management - Health Checks

On this day, 8/04/26, at 11:40 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct inspection to ensure the health and safety of residents. LPA met with Assistant Administrator (AADM) Heather Helton, and informed the reason for visit. LPA later met with Executive Director Geraldine Tayo. LPA toured the facility inside out with AADM. LPA inspected including but not limited to the dining room, kitchen, activity room, library, courtyard. Food supplies were observed adequate. LPA randomly selected 2 apartments each on first, 2nd and 3rd floors for inspection. Five stairwells checked. Facility has running water and electricity. Hot water in the one of the bathrooms was tested and measured at 109.7 degrees Fahrenheit. LPA interviewed 3 staff and 1 resident. LPA obtained copies of current LIC500 Personnel Report and resident roster. .....continued on 809C LPA observed the following: at 12:15 pm, unlocked and unattended laundry room on the first floor. at 12:16 pm, unlocked and unattended housekeeping room on the first floor where cleaning supplies are stored. at 12:24 pm, unlocked and unattended laundry room on the second floor. from 12:40 pm to 12:55 pm, 1 out of 5 stairwells has no evacuation chair. Deficiencies are cited from Title 22 California Code of Regulations and Health and Safety Code and listed on 809D. Failure to submit proof of corrections by plan of correction due dates and any repeat violations within 12 month period may result in civil penalty. Deficiencies and plan and proof of corrections were discussed with the Executive Director. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Aug 4, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Aug 5, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended...... -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above in unlocked and unattended laundry and housekeeping rooms which pose an immediate risks to persons in care.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: Staff locked the rooms immediately. Executive Director stated she'll in-service the staff. Copy of training topics with attendees signatures to be submitted by 8/05/26.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.695(f)(1) · Plan of correction due date: Aug 18, 2026

§1569.695 Emergency Plans (f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above in 1 out of 5 stairwells not having evacuation chair which pose a potential risk to persons in care.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: Executive Director stated she'll have an evacuation chair purchased. Proof of purchase and picture showing it is installed to be submitted by 8/18/26.

Type of visit: Office

At 3:00 p.m. on this day, July 27, 2026, a virtual meeting was called. The meeting was arranged to review the Decision and Order with Prema Thekkek, licensee, Ms. Thekkek was not able to attend. The meeting was attended by the following: Regional Manager Isaac Taggart Licensing Program Manager Jeremy Fong Acting Licensing Program Manager Grace Luk Licensing Program Analyst Alicia Delmundo Vinod Nichani, Legal Counsel for Prema Thekkek and Anthony Thekkek Attorney Vinod Nichani was informed that the meeting was originally scheduled to review a Decision and Order excluding Prema Thekkek. The Regional Office (RO) was informed by the attorney that the licensees would like to surrender the license. ....continued on 809C Regional Manager Taggart informed Mr. Nichani that two statues are involved, depending on whether a licensee forfeits the license, or sells the business with a prospective buyer submitting an application. The requirements of the two statutes (Health and Safety Codes) were reviewed with Mr. Nichani, who was also informed that the Decision and Order to remove Prema Thekkek from the current license must be done on this date, July 27, 2026. Mr. Nichani stated that he will begin immediately working with the Licensees for removal of Ms. Thekkek and a change of ownership. Mr. Nichani indicated that a prospective buyer has been identified and that he will work with licensees to finalize this arrangement. Mr. Nichani was also informed that if a license application is submitted by the prospective buyer, the current licensees will remain responsible until the new license is issued. Copy of this report provided via email along with copies of Decision and Order and H&S Codes 1569.191 1569.682 to Mr. Nichani on this same day.the state’s words, verbatim · CDSS document, Jul 27, 2026

Type of visit: Case Management - Incident

On this day, July 2, 2026, at 10:40 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit as a result of the Department receiving an Unusual Incident Report (UIR) for resident (R1). The Department received the UIR on June 25, 2026. LPA met with Executive Director Geraldine Tayo. UIR indicated R1 was found on JUne 23, 2026 on terrace lounge laying on their back with laceration on the head near eyebrow and was bleeding. R1 fell and hit head on the chair's arm rest. First aid was given to stop the bleeding and 9-11 was called. LPA conducted interview, reviewed resident record and obtained copies of following documents: LIC602A Physician's Report; Resident Appraisal; LIC625 Appraisal/Needs and Services Plan; After Visit Summary. LIC602A Physician's Report indicated R1 able to bathe (with supervision), dress/groom and feed self, able to leave the facility unassisted and communicate needs. No deficiency cited on this day. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Jul 2, 2026

Type of visit: Case Management - Deficiencies

On this day, July 2, 2026, at 10:40 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit in regard to the licensee transferring the operation and license of the facility. LPA met with Executive Director (ED) Geraldine Tayo and explained the purpose of the visit. LPA called and spoke over the phone with Prema Thekkek, licensee/corporate officer of HCRC, Inc. On January 1, 2026, Prema Thekkek submitted to the Department a copy of notification to the residents and residents family members dated January 1, 2026 pertaining to change of ownership, of which LPA received on January 2, 2026. The notification indicated that effective January 1, 2026, the facility was transitioning to new ownership, and that the new licensed operator will be Integral Community Care, LLC (DBA: Mission Community). Integral Community Care, LLC did not submit new application for license. LPA conducted case management visit on January 6, 2026 and the Department conducted an Office Meeting with Prema Thekkek and Executive Director at that time on January 13, 2026. Deficiency is cited from Title 22 Health and Safety Code and listed on 809D. Deficiency was discussed with Prema Thekkek over the phone in the presence of Geraldine Tayo. Exit interview conducted. Appeal Rights and copy of this report provided.the state’s words, verbatim · CDSS document, Jul 2, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.50(a)(3) · Plan of correction due date: Jul 16, 2026

§1569.50 Denial, suspension or revocation of license; grounds; application of remedies; temporary suspension pending hearing; exclusion from licensure without right to petition for reinstatement (a) The department may deny an application for a license or may ....suspend or revoke a license issued under this chapter upon any of the following...(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual ...... -This requirement is not met as evidenced by:the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: The licensee rescinded the notification after the Department conducted an Office Meeting.

From the deficiency page — Deficiency type: Type B · Section cited: CCR000000 · Plan of correction due date: Jul 16, 2026

BELOW IS A CONTINUATION OF THE DEFICIENCY ABOVE: -Based on document review, the licensee did not comply with the section above for conduct inimical to the health, safety and/or morals of persons in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Allegation investigated: Unlicensed Care Facility does not have active liability insurance

On 4/3/2026 at 9:00 AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Leonora Ramos AL Director. On the allegation: Unlicensed Care Based on LPA’s interviews and record review, the facility does still have a current license. Staff 1 (S1) stated that recently the facility owner was in talks to sell the business and transfer the property lease. S1 said that after talking with licensing and learning the sets for this process the owner and the potential buyer decided not to go through with the sale.. In a phone interview Staff 2 (S2) confirmed that they still have the license and control of property. Continued on LIC 9099C... Unsubstantiated ...Continued from 9099 On the allegation: Facility does not have active liability insurance Based on LPA’s record review, the facility does have current and active liability insurance. S1 stated they have no intention of letting it lapse when the renewal is due. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 3, 2026 · control 15-AS-20260218154818

Allegation investigated: Staff do not allow residents to participate in decision making regarding care provided. Staff did not communicate with responsible parties regarding residents' care.

On this day, March 19, 2026, at 11:20 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with Geraldine Tayo, interim administrator (IADM), and informed the reason for visit. LPA obtained copies of resident roster and staff schedule. LPA reviewed residents records and obtained copies of LIC601 Identification and Emergency Contact Information and LIC602A Physician's Reports. LPA interviewed Prema Thekkek (licensee), staff (IADM and S1), resident's family member (FM) and residents (R1, R2, R3). ....continued on 9099C Substantiated Allegation: Staff do not allow residents to participate in decision making regarding care provided. Allegation: Staff did not communicate with responsible parties regarding residents' care. The reporting party stated that the licensee had a doctor (DR) came to the facility on February 2026 and provided care to residents (R1, R2, R3, R4, R5) and that DR ordered physical therapy (PT) for the residents, however, the residents have their own physicians and the residents' responsible parties were not consulted prior to DR providing care. The licensee stated she remembers about DR coming to the facility, because the residents' LIC602A Physician's Reports need to be updated in order to be in compliance and residents needing assessment due to falls. The licensee further stated that her understanding was Geraldine Tayo (IADM) and another staff had contacted the residents' family members. Review of R1, R2, R3, R4 and R5 records showed these residents have their primary care physician, not DR. One of the resident's responsible person, FM, stated not getting a call from the facility about a different doctor checking on the resident. R1 and R2 indicated being seen by a different doctor and that they were not given prior notice. Records also showed R1 and R2 are seen by PT. IADM confirmed that DR came on the said date and an instruction were disseminate to the facility staff by staff (SS) night prior. Both IADM and S1 stated they were not able to call the residents' family members nor informed the residents that a different doctor is coming for assessment due to information was sent late night and that DR came the following day. Review of document confirmed both S1 and IADM's statements regarding the time the information was disseminated. Document also showed there was no instruction from SS to contact the residents' responsible persons nor inform the residents. Document also showed SS asking the staff for copies of LIC602 and insurance and to have them ready by 9:30 am on the day DR is coming. Based on records review and interviews, the preponderance of evidence standard is met, therefore the 2 allegations are substantiated. Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violations within 12 month period may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with IADM, Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 19, 2026 · control 15-AS-20260311122815

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(20) · Plan of correction due date: Apr 2, 2026

§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (20) To select their own physicians, pharmacies, privately paid personal assistants, hospice agency, and health care providers....... -This requirement is not met as evidenced by: - Based on records review and interviews, the licensee did not comply with the section above in having the residents seen by different doctor without consent from the residents and resident's responsible person which pose a potential personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: Licensee and IADM to read the Regulation and self certify compliance. Proof to be submitted by 4/02/26.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(9) · Plan of correction due date: Apr 2, 2026

§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (9) To fully participate in planning their care, including the right to attend and participate in meetings or communications regarding the care and services -This requirement is not met as evidenced by: - Based on records review and interviews, the licensee did not comply with the section above in not having the residents and resident's responsible person participate regarding residents' care which pose a potential rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: Licensee and IADM to read the Regulation and ensure compliance. Self-certification to be submitted by 4/02/26.

Type of visit: Case Management - Incident

On this day, March 19, 2026, at 11:20 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced in response to the Unusual Incident Report (UIR) submitted by the facility on March 2, 2026. LPA met with Geraldine Tayo, interim administrator (IADM), and informed the reason for visit. UIR indicated that on February 28, 2026, at around 2:35 pm, resident (R1) was found on the floor in his living room by care staff during safety check. R1 presented with confusion and bruises on the back and face. R1 was sent out and came back the same day. R1 was diagnosed with a transverse process fracture on lower back which will heal on his own time. LPA reviewed R1's file and obtained copies of including but not limited to LIC602A Physician's Reports before and after fall incident; Notification of Hospice Initiation; Death Report; Appraisal; LIC625 Appraisal/Needs and Services Plan; hospital After Visit Summary LPA conducted interview. IADM stated R1 was placed on hospice care on March 4, 2026 and passed away after few days. Death Report showed R1 passed away on March 7, 2026. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 19, 2026

Type of visit: Case Management - Health Checks

On 02/10/2026 at 9:35 AM, Licensing Program Analyst (LPA) J. Clancy-Czuleger conducted an unannounced Case Management Health and Safety check. LPA met with Administrator, Geraldine Tayo and explained the purpose of the visit. During the health and safety check, LPA observed a total of nine (9) Staff throughout the facility. Residents were gathered in the front common areas preparing for the social activity of Bingo. LPA conducted a tour of the facility, including but not limited to residents' bedrooms, bathrooms, common areas, kitchen, and outdoor areas. LPA observed that the kitchen was clean and the food supply was sufficient. Refrigerator temperature was observed at 33 degrees Fahrenheit and the walk-in freezer at negative 10 degrees Fahrenheit. Clients in care appear to be safe and there are no imminent health/safety concerns on today's date. LPA checked four resident files and four staff files, and 4 of 4 were fingerprint cleared and associated to the facility. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 10, 2026

Type of visit: Case Management - Deficiencies

On 02/02/2026 at 3:15PM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct a case management visit. LPA met with Administrator, Geraldine Tayo. While LPA Carol Fowler was at the facility for a complaint investigation (#15-AS-20260130110921), the following deficiencies were observed. During the complaint investigation, LPA observed that the facility didn't have an adequate supply of hygiene supplies. While LPA was conducting a record review and the Administrator informed LPA that the former staff file was missing from the facility. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report, and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 2, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(D) · Plan of correction due date: Feb 11, 2026

(a) Living accommodations ...function. The facility shall be large enough to provide comfortable living ... ...e residents, staff, and others who may reside in the facility. The following provisions shall apply: (3)... supplies necessary for personal care and maintenance of adequate hygiene ...resident. The resident may provide the following items; ... shall ... (D) Hygiene items of general use such as soap and toilet paper. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by not having adiquate hygiene supplies avaliable for residents in care which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 2, 2026

Plan of correction: Administrator will read and understand the regulation self certifity. Facility will purchase hygiene supplies and submit a photo to the Department by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a)(f)(h) · Plan of correction due date: Feb 11, 2026

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following ...(f) All personnel records shall be available to the ..., audit, and copy upon demand during normal .... Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: (h) All personnel records shall be retained for at least three (3) years following termination ... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not having former staff file avaliable which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 2, 2026

Plan of correction: Administrator to read and understand regulation self certify and conduct in-service with all staff responsible for staff records and provide the Department with a copy of the sign in sheet by the POC date.

Type of visit: Office

At 2:00 p.m. on this day, January 13, 2026, a virtual meeting was called. The meeting was attended by the following: Licensing Program Manager Jeremy Fong Licensing Program Analyst Alicia Delmundo Licensee/Corporate Officer Prema Thekkek Executive Director Diane Pederson The following were discussed: 1. Subletting of Lease Agreement - shall be withdrawn within 24 hours and submit proof by January 14, 2026. 2. Non-transferability of license (Title 22 section 87109). 3. Letter dated January 1, 2026 sent to the residents and residents' families to be rescinded and proof to be provided to LPA by January 20, 2026. 4. Outstanding annual fee due and late fee charge - Prema Thekkek indicated she is going to pay on this day. Proof to be submitted by tomorrow, January 14, 2026. 5. Process in having the prospective buyer of the property being brought in as management company and abbreviated application and documents to be submitted to Sacramento. Fingerprint clearance and association requirements for the 2 individuals who are/will be in the facility while application is in the process. A copy of this report provided via email to Prema Thekkek and Diane Pederson.the state’s words, verbatim · CDSS document, Jan 13, 2026

Type of visit: Case Management - Other

While at the facility for other reason, Licensing Program Analyst (LPA) Delmundo discussed with Executive Director (ED) Diane Pederson the copy of notification to the residents and residents family members dated January 1, 2026 pertaining to change of ownership. The copy was received by LPA on January 2, 2026. LPA discussed the process with the ED and refer the ED to Title 22 Regulations 87109 and Health and Safety Code 1569.191. LPA also discussed the submission of application for new license. LPA requested ED to have LPA updated. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Jan 6, 2026

Type of visit: Required - 1 Year

On this day, September 11, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Executive Director (ED) Diane Pederson, and informed the reason for visit. LPA toured the facility inside out with ED. Facility is a 3 story building. LPA inspected the common areas, library, kitchen, dining room, yard, common bathroom and laundry room on the second floor. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Freezers and refrigerators temperatures are checked by kitchen staff and recorded daily, and records showed temperatures were within Regulations range. LPA randomly selected 8 residents apartments for inspection - 2 on the first floor, 3 on the second floor and 3 on the third floor. Hot water temperature in one of the resident's apartments was tested and measured at 110.6 degrees Fahrenheit. The 2 in 1 carbon monoxide and smoke detectors in another resident's apartment was tested and observed in working condition. Facility has evacuation chairs on stairwells. Facility conducts disaster drills at least every quarter, and records showed last conducted August 16, 2025 LPA reviewed 5 staff and 5 resident's files, and interviewed 4 residents. Medications checked, and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Record. Facility does not handle resident's cash resources/P&I. .....continued on 809C LPA received the following updated/current documents on this same day: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. $3M Liability Insurance certificate No deficiency cited during today inspection. Exit interview conducted, and copy of this report provided.the state’s words, verbatim · CDSS document, Sep 11, 2025

Allegation investigated: -Resident (R1) sustained pressure injuries while in care. -Resident's diapering needs are not being met. -Resident's hygiene needs are not being met. -Staff does not assist resident when requested. -Staff does not treat resident with dignity and respect.

On this day, May 14, 2025, at 11:35 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Executive Director (ED) Diane Pederson, and informed the purpose of visit. During the course of investigation, LPA reviewed residents’ records and obtained copies of including but not limited to the following residents’ documents: LIC601 Identification and Emergency Information; LIC602 Physician's Report; Pre-admission Appraisal; Reappraisal; facility notes; hospital After Visit Summary. LPA obtained copies of staff schedule, resident roster, and obtained records from Home Health agency that attended to R1 from 2021 to 2022. ....continued on 9099C (page 2) Unsubstantiated Page 2 LPA conducted inspection with ED on 2/07/22. LPA interviewed the following: staff (ED, S1, S2, S4, S5, S6) on 2/07/22, 9/28/23, 9/05/24, 9/13/24 and 4/30/25; R1’s family member (FM1) on 9/13/24; residents (R2, R3, R4, R6, R7, R8) on 2/07/22, 9/28/23 and 4/30/25. LPA tried to reach staff (S3) and home health nurse (HH1), but they did not return LPA’s calls. Allegation: Resident (R1) sustained pressure injuries while in care. S1 stated she does not remember if R1 had pressure injury but thinks R1 had some redness which is usual when one is staying long on the chair and R1 was attended by home health. S2 stated she was not assigned to R1 but observed caregivers attended to R1. S4 stated she does not remember R1 because residents come and go but if she observes skin issue, she reports to the med-tech and she repositions resident every 2 hours. S5 and S6 stated R1 had pressure injury. S6 also stated that that was also the reason R1 was visited by home health which was also stated by FM1. S5 and S6 stated R1 was a difficult resident. S5 further stated when R1 was repositioned, R1 returned to her original position. R1 was provided wedge; however, R1 asked the staff remove it. Review of home health records showed R1 was certified and re-certified for home health care from 2021 to 2022 and at some point, during these periods, R1 was visited by home health due to pressure injury. On 3/08/22 document indicated R1 was discharged from Home Health. It was noted on the document that R1 has no unhealed or stage 2 or higher pressure injury and had no stasis ulcer. Based on interviews and records review, and LPA unable to obtain information from R1, S3 and HH1, the allegation is unsubstantiated. Allegation: Resident's diapering needs are not being met. It was reported that when HH1 asked R1 to stand up so HH1 can see R1’s buttock wound, R1 said, “Let me first pee in my diaper” and when R1 was done, HH1 helped remove the diaper and amount of urine was weighing 2-3x of urine episode and that was causing the stage 2 pressure injury in the buttock. ..............................continued on 9099C (page 3) Page 3 FM1 stated once or twice R1 called her and told her she was not changed but FM1 said it was something she was not aware of. Although FM1 stated that she run a couple of times when she visited and saw used diaper in a plastic bag in R1's bed, she never observed R1 soaked in urine nor not changed. S1 stated when R1 does not come down to the dining room, S1 goes to R1's room to give R1 medications and S1 observed caregiver changing R1's diaper. There were times when R1 will call for assistance and S1 hears the front desk calling for caregiver to attend to R1. S2 stated she never visually observed R1 soaked in urine or soiled and not being attended. S2 also stated she saw caregivers come and go to R1's room to attend to R1. S4 stated she changes residents’ diapers 3x during her shift and as needed. S5 stated residents who need assistance in changing diaper are changed regularly and as needed. S6 stated she changed residents' diapers every 2 to 3 hours and more often if resident is a frequent wetter. S6 further stated that R1 was a frequent wetter and a lot of time, R1 refused to be changed. Six of the residents interviewed stated the staff assist them when they need help. One of this 6 residents has been living in the facility for 8 years and stated that she needs assistance in changing diaper and staff change her 4 to 5 times and as needed. This resident further stated she never had rashes, UTI and/or pressure injury. Based on information gathered, and LPA unable to obtain information from HH1, S3 and R1, the allegation is unsubstantiated. Allegation: Resident's hygiene needs are not being met. It was reported that HH1 observed feces between R1’s buttock and some part at R1’s back which showed that the feces had been sitting there and that when staff wiped off, R1 was not cleaned entirely. .......continued on 9099C (page 4) Page 4 FM1 stated R1 complained about the water being cold and would not want to take a bath, but FM1 tested the water and the temperature was okay. FM1 also stated that when FM1 started coming to the facility, R1 started taking a bath. All 6 residents interviewed stated the staff assist them when they need help. When LPA conducted inspection during the 10-day visit, when LPA and the ED entered one of the residents’ apartment, LPA observed a caregiver present and assisting the resident in that apartment. Based on information gathered, and LPA unable to obtain information from HH1, S3 and R1, the allegation is unsubstantiated. Allegation: Staff does not assist resident when requested. All 6 residents interviewed stated the staff assist them when they need help. When LPA conducted inspection during the 10-day visit, when LPA and the ED entered one of the residents’ apartment, LPA observed a caregiver present and assisting the resident in that apartment. Based on information gathered, and LPA unable to obtain information from HH1 and R1, the allegation is unsubstantiated. Allegation: Staff does not treat resident with dignity and respect. It was reported that HH1 observed the staff being disrespectful to R1. All staff interviewed denied being abusive to any residents. They stated they never observed other staff not treating residents with dignity and respect. ..............continued on 9099C (page 5) Page 5 FM1 stated she never heard any staff being disrespectful to R1 or other residents. All 6 residents interviewed stated staff were never abusive to them and other residents. LPA reviewed Home Health records and documentation and didn’t observe any notes indicating HH1 observed abuse by facility staff. Based on information gathered, and LPA unable to obtain information from HH1, S3 and R1, the allegation is unsubstantiated. Based on interviews, observations and records review, there’s not a preponderance of evidence standard to prove that violations occurred, therefore, the 5 allegations are closed as unsubstantiated. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, May 14, 2025 · control 15-AS-20220203093410

Type of visit: Case Management - Incident

On this day, May 14, 2025, at 11:35 am, Licensing Program Analyst arrived unannounced to continue the case management visit that was started on January 23, 2025 to obtain additional information. LPA met with Executive Director (ED) Diane Pederson, and informed the purpose of visit. LPA conducted interviews. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, May 14, 2025

Type of visit: Case Management - Incident

At 12:30 pm on this day, 1/23/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced in response to the Unusual Incident Report (UIR) submitted by the facility on 1/20/25. LPA met with Executive Director (ED) Diane Pederson, and informed the reason for visit. LPA also met with Resident Care Director Geraldine Tayo. UIR indicated that on 1/19/25 at approximately 5:00 am, staff (S2) stated she witnessed the caregiver (S1) physically and verbally handling resident (R1) roughly. S1 was removed from schedule and the ED notified R1's daughter, Ombudsman and Community Care Licensing. Investigation was conducted and S1 was terminated. LPA reviewed R1's file and conducted interviews. LPA obtained copies of resident roster, staff schedule, facility staff's statements, and including but not limited to the following R1's documents: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; Appraisal and Re-appraisal No deficiency cited on this day. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Jan 23, 2025

Type of visit: Required - 1 Year

On this day, September 5, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Executive Director (ED) Diane Pederson, and informed the reason for visit. LPA also met with Resident Services Director Geraldine Tayo. ED submitted an updated Infection Control Plan on September 28, 2023. LPA toured the facility inside out with ED. Facility is a 3 story building. LPA inspected the common areas, activity room, library, kitchen, dining room. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Freezers and refrigerators temperatures are checked by kitchen staff and recorded daily. Medication room was observed attended by staff. LPA randomly selected 12 residents apartments for inspection - 4 on the first floor, 4 on the second floor and 4 on the third floor. Hot water temperature in one of the common bathrooms was tested and measured at 113.6 degrees Fahrenheit. Facility has carbon monoxide and smoke detectors that were observed in working condition. Fire extinguisher in the kitchen checked, observed fully charge with tag showed serviced January 11, 2024. Facility has evacuation chairs on stairwells. Facility conducts disaster drills at least every quarter, and records showed last conducted June 11, 2024. LPA reviewed 5 staff and 5 resident's files. Medications checked, and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Record. Facility does not handle resident's cash resources/P&I. .....continued on n809C Page 2 LPA received the following updated/current documents on this same day: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. $3M Liability Insurance certificate No deficiency cited during today inspection. Exit interview conducted, and copy of this report provided.the state’s words, verbatim · CDSS document, Sep 5, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Executive Director (ED) Diane Pederson, and informed the purpose of visit. LPA also met with Resident Services Director Geraldine Tayo. Facility has an approved LIC808 Mitigation Plan but has not submitted the updated Infection Control Plan. LPA toured the facility inside out with Diane Pederson, Facility is a 3 story building. LPA inspected the common areas, activity room, library, kitchen, dining room and yard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Freezers and refrigerators temperatures are checked by kitchen staff and recorded daily. Medication room was observed attended by 3 staff. LPA randomly selected 8 residents rooms for inspection - 2 on the first floor, 2 on the second floor and 4 on the third floor. Facility has carbon monoxide and smoke detectors. Hot water temperature in one of the common bathrooms was tested and measured at 113.6 degrees Fahrenheit. Fire extinguisher in the kitchen checked, observed fully charge with tag showed serviced December 28, 2022. Facility has evacuation chairs on stairwells. Facility conducts disaster drills every quarter. LPA reviewed 5 staff and 5 resident's files, and interviewed 2 staff and 2 residents. Medications checked, and compared with records and doctor's orders. Facility does not handle resident's cash resources/P&I. At 12:36 pm, LPA observed chest rub in resident's (R1) room. .....continued on n809C LPA received the following updated/current documents on this same day: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. $3M Liability Insurance certificate 5. Infection Control Plan Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalties. Deficiency and plan and proof of correction were discussed with the ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.the state’s words, verbatim · CDSS document, Sep 28, 2023