Legacy Lane Senior Living II

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Michael Hood arrived at the care home and met with Caregiver, Deaja Malcolm, to obtain a signature relative to amending a report for an inspection conducted on July 15, 2026. Signature was obtained for amended document during visit. During visit, LPA toured the premises and observed multiple items in disrepair, including downspout detached from roof gutter and side gate in disrepair. LPA observed microwave to be unsanitary in kitchen area. LPA also observed trash and debris on the side of the house. LPA observed one (1) black widow on the premises in resident (R2's) bedroom. LPA conducted interviews with residents (R3 and R4) who stated that they have also observed spiders in their rooms and have had to kill the spiders themselves. During visit, LPA observed resident (R1) request PRN medication that was missing from the premises. LPA reviewed R1's medications on site and observed two (2) medications that were identified on R1's medication list but missing from the premises (Hydroxyzine and Varenicline). LPA reviewed R1's Medical Assessment dated March 12, 2026 and observed that R1 is unable to administer their own prescription medications and unable to store their own medications. LPA reviewed R1's Centrally Stored Medication Form (CSMF) and observed R1's last bottle of Varenicline was filled on April 21, 2026 with 56 tabs and R1's last bottle of Hydroxyzine was filled on May 2, 2026 with 60 tabs. R1's Medication Administration Record (MAR) does not show any tabs of Hydroxyzine being administered for R1. R1's MAR shows 62 tabs given of Varenicline for July 2026 and 56 tabs given for August 2026, ending on August 29, 2026, despite only one (1) bottle of 56 tabs being documented on R1's CSMF. LPA did not observe any evidence on site that R1's Varenicline was refilled or discontinued. ** Report continued on 9099-C ** As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Two (2) civil penalties in the amount of $250 were assessed for today's date due to repeat violations. Deficiencies are listed on 809-D pages. Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Sep 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 16, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on LPA's observations and records reviewed, the facility did not ensure that residents were receiving medications as prescribed as two (2) medications for R1 were missing from the premises, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Care home will create a plan on how they will ensure that medications are refilled and maintained on site, and documentation for medications is maintained and accurate. Care home will submit plan to LPA by POC due date of September 16, 2026. A civil penalty in the amount of $250 was assessed for today's date due to repeat violation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Oct 5, 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 observations, the care home did not ensure the premises was clean and in good repair in multiple areas of the care home, and did not ensure the premises was free of pests, which poses a potential health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Care home will increase pest control services as needed to address infestation. Care home will also address all concerns observed during visit. LPA will conduct a future visit to clear deficiency. A civil penalty in the amount of $250 was assessed for today's date due to repeat violation.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Caregiver, Deaja Malcolm, to obtain a signature relative to amending a report for an inspection conducted on July 15, 2026. Signature was obtained for amended document during visit. Exit interview was conducted. A copy of this report and was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Aug 19, 2026

Type of visit: POC

Licensing Program Analyst (LPA) arrived at the care home and met with Overseer, Christina Allen, to follow-up regarding citations previously issued at the care home. During visit, LPA reviewed plan of corrections and cleared deficiencies. No deficiencies are being cited as a result of today's visit. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Aug 12, 2026

Type of visit: POC

Licensing Program Analyst (LPA) Michael Hood arrived at the care home and met with Administrator, Shanice Downer, to conduct a POC visit to follow-up on deficiencies previously issued. LPA received plan of corrections (POCs) prior to visit regarding citations issued on July 15, 2026. LPA observed that documents obtained did not follow instructions regarding POCs agreed to on July 15, 2026. LPA spoke with Overseer, Christina Allen, via telephone call to inform Overseer that POCs need to be submitted to the Department that reflected the instructions documented with the deficiencies issued on July 15, 2026. LPA will need to initiate civil penalty process if they do not receive POCs in accordance with the deficiencies cited on July 15, 2026. During visit, LPA observed floors to be dirty in multiple resident rooms, kitchen, and common areas. LPA observed resident's bedroom floors to be dirty as a result of incontinence needs. LPA also observed bagged trash on floor in resident's room. As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. A civil penalty in the amount of $250 was assessed for today's date due to repeat violation. Deficiency is listed on 809-D page. Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jul 22, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 27, 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 observations, the care home did not ensure the premises was clean and sanitary in multiple areas of the care home, which poses a potential health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jul 22, 2026

Plan of correction: Facility will address all concerns observed during visit. LPA will conduct a future visit to clear deficiency. A civil penalty in the amount of $250 was assessed for today's date due to repeat violation.

Allegation investigated: Resident was neglected by staff, resulting in hospitalization Facility staff mismanaged residents' medications Facility staff did not treat residents with dignity Facility staff did not provide adequate food services to the residents in care Facility staff sleep while on duty Staff are not ensuring facility is clean and in good repair

Licensing Program Analyst (LPA) Michael Hood arrived at the care home and met with caregiver, Deaja Malcolm, to deliver findings regarding the complaint allegations listed above. LPA spoke with Administrator, Shanice Downer, via telephone call, who gave permission for caregiver to sign report. During investigation, the Department conducted interviews, toured the premises, conducted a medication count, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: According to facility documents, staff member (S1) was responsible for client care from December 5, 2025 to December 10, 2025. Based on interviews conducted by the Department with resident (R1’s) family and residents in care, as well as facility documents reviewed, R1 needed to be spoon fed their meals. ** Report continued on 9099-C ** Substantiated Residents (R2 and R3) reported that, on December 5, 2025, they informed S1 that R1 needed to be spoon fed their meals. Staff member (S2) reported in their interview that, on December 5, 2025, they stopped by the facility to review files and informed S1 that R1 needed to be spoon fed their meals. S2 reported that no one answered the door for them as they arrived at the care home and they observed S1 lying on the couch, looking at their phone while R1 was sitting at the dining table with food in front of them. S2 stated that they asked S1 what they were doing, and S1 stated that they were on break from cleaning. S2 reported that they asked S1 if they fed R1 and S1 responded, “[R1] can feed themselves.” S2 stated that they explained to S1 that R1 is incapable of feeding themselves and R1 could not eat unless staff spoon feed them, to which S1 responded, “I didn’t know that,” and proceeded to spoon feed R1. S2 stated that R1 “seemed weak” and not at baseline, as well as unkempt in relation to the care provided by Administrator, Moria Gaunavou. S2 stated that they didn’t contact EMS for R1 as they explained that R1’s condition didn’t require medical attention at the time, despite appearing weak and not at baseline. Between December 6, 2025 and December 7, 2025, R2 and R3 reported to the Department that they witnessed R1 sitting at the dining table around lunchtime with a bowl of untouched oatmeal still in front of them from breakfast. On December 8, 2025 at around 1200 hours, R1’s family visited R1 and found them unresponsive at the dining table with a bowl of oatmeal sitting in front of them. S1 called 9-1-1 and R1 was transported to the hospital. Based on medical records, R1 was diagnosed with severe dehydration, starvation ketoacidosis, urinary tract infection (UTI), and right basilar atelectasis. S2 visited the facility approximately one (1) week prior to December 5, 2025 and recalled R1 being at baseline, walking, and smiling. R1’s family visited R1 on December 3, 2025 and R1 appeared “normal” and interacting like they typically would. The Department was unable to locate S1 for an interview regarding the allegations. Handwritten Care Note authored by Administrator Gaunavou dated December 10, 2025 indicated that, upon returning from vacation, Administrator was notified by residents that S1 did not provide the residents with their medications and residents had to dispense their own medications. ** Report continued on 9099-C ** The Department conducted interviews with the residents in care. During interview, R2 stated that they never witnessed S1 give R1 their medications. R3 stated that R1 and resident (R4) never received their medications when S1 was working at the care home. R4 confirmed that S1 did not provide them with their prescribed medications while S1 was the sole caregiver at the care home for approximately four (4) to five (5) days. During interview, resident (R5) indicated that they missed medications while S1 was working at the care home. R1’s Medical Assessment dated September 10, 2025 states that R1 is unable to administer their own prescription medications and is unable to store their own medications. R1’s Admission Agreement dated February 14, 2025 and R1’s Appraisal/Needs and Services Plan dated February 15, 2025 indicated that R1 required staff assistance with all activities of daily living (ADLs). R4’s Medical Assessment dated January 22, 2026 states that R4 is unable to administer their own prescription medications and is unable to store their own medications. R5’s Medical Assessment dated February 5, 2026 states that R5 is unable to administer their own prescription medications and is unable to store their own medications. During visit conducted on December 17, 2025, LPA conducted a medication count for R1, comparing the resident's Centrally Stored Medication Forms (CSMFs) and Medication Administration Records (MARs) with medications centrally stored for the resident. LPA observed that four (4) of four (4) medications counted for R1 were off count when comparing count to R1’s CSMF and MAR. LPA observed two (2) medications to be over the amount that was documented, and two (2) medications to be under the amount documented. Care home was unable to provide any records during visit to justify medication count being off. During mediation count, LPA observed that R1’s MAR showed signatures from S1 indicating medications were given to R1 while R1 was out of the community due to hospital visit from December 8, 2025 to December 13, 2025. LPA conducted interviews with residents during investigation, including R2, R3, and R4. R2 and R3 reiterated that S1 did not provide assistance with medication administration while being the sole caregiver from December 5, 2025 to December 10, 2025. R3 stated that R4 never got their medications the entire time S1 was working. R4 confirmed with LPA that they did not receive their medications while S1 was working at the care home. R3 stated that medications were accessible to everyone and never locked while S1 worked at the care home. ** Report continued on 9099-C ** On April 22, 2026, LPA conducted a case management visit to follow-up regarding observations made during separate inspections conducted on April 21, 2026 and April 22, 2026. During visit conducted on April 21, 2026, LPA observed medications accessible to the residents located in residents' (R6 and R7's) bedrooms. LPA observed R6's nighttime medications pre-poured in R6's bedroom. LPA observed multiple prescription bottles stored in R7's bedroom. Interview with R7 indicated that they had a week's worth of medications pre-poured for them. LPA observed a week's worth of medications pre-poured stored in R7's bedroom. During visit, LPA reviewed records, including four (4) resident records. Per Physician's Report (LIC 602A) dated January 29, 2025, R6 is not "able to store own medications." Per LIC 602A dated December 11, 2025, R7 is not "able to administer own prescription medications," not "able to administer own PRN medications," and not "able to store own medications." Pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency was cited per Section 87465 Incidental Medical and Dental Care (h) “The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.” This requirement was not met based on interviews conducted and observations, which determined that care home did not ensure that residents’ medications were kept in a safe and locked place. On May 7, 2026, LPA conducted a case management visit in relation to a separate inspection conducted on May 7, 2026. During visit, LPA observed centrally stored medication unlocked and accessible to the residents in care. LPA reviewed resident records and observed three (3) of six (6) residents were assessed to be unable to have access to centrally stored medications. Pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency was cited per Section 87465(h) based on LPA's observations and records reviewed, which determined that the care home did not ensure that residents' medications were kept in a safe and locked place. A civil penalty in the amount of $250 was assessed due to repeat violation. On June 16, 2026, LPA and Licensing Program Manager (LPM) Lauren Crocker conducted a visit to follow-up regarding citations previously issued at the care home. ** Report continued on 9099-C ** During visit, LPA and LPM observed a vial of Xylocaine in a resident's room readily accessible for a resident who should not have access to medications according to their most updated medical assessment. LPA and LPM also observed accessible medications stored in the staff bedroom. Pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency was cited per Section 87465(h) based on observations, which determined that the care home did not ensure to keep medications inaccessible to the residents in care when resident had a vial of Xylocaine accessible in their bedroom and medications were accessible in staff bedroom. A civil penalty in the amount of $250 was assessed due to repeat violation. During interviews conducted by the Department, R2 indicated that they attempted to inform S1 that R1 needed to be spoon fed, in which S1 responded to R2, “Don’t tell me how to do my job.” R3 stated that, if any of the residents tried to tell S1 what needed to be done, S1 would tell them, “Don’t’ tell me how to do my job.” LPA conducted interviews with residents, including R2, R3, and R6. R2 stated that S1 would tell R2 “don’t tell me what to do” in regards to them assisting with multiple activities of daily living, including assistance with showers and cleaning. R2 stated that, if they didn’t advise S1 how to assist them, S1 would "just stand there and not do anything." R3 stated that they witnessed R2 telling S1 what to do for R1, and S1 told R2 "don't tell me how to do my job." R3 stated that they had to provide feeding assistance for R1 themselves because S1 wouldn't assist R1. R3 stated that S1 was "very disrespectful." R6 stated that care staff are violating their personal rights, including not treating the residents with dignity. Handwritten Care Note authored by Administrator Gaunavou dated December 10, 2025 indicated that, upon returning from vacation, Administrator was notified by residents that S1 only served oatmeal for breakfast and never served the residents drinks. Care Note also stated that S1 did not feed R1. “To Do List for Legacy Lane II” authored by Administrator Gaunavou and provided to S1 shows that Administrator advised S1 to provide R1 assistance with feeding for all meals from December 5, 2025 to December 9, 2025. R1’s Medical Assessment dated September 10, 2025 states that R1 is unable to feed themselves. During interviews conducted by LPA, both R2 and R3 reiterated that S1 did not provide feeding assistance to R1. R3 stated that S1 would bring R1 out to sit at the kitchen table and put food in front of them even though they could not eat on their own. R3 stated that S1 left R1 sitting at the table, sometimes soiled. R3 stated that they had to provide feeding assistance to R1 while S1 was working at the care home because S1 wouldn’t do it. ** Report continued on 9099-C ** The Department conducted interviews with the residents in care and relevant parties. R2 stated that, on December 8, 2025, when S1 contacted 9-1-1 for R1 and was questioned by EMS regarding the last thing that R1 ate, S1 stated that R1 last ate “oatmeal.” R2 stated that oatmeal was what was provided to the residents for breakfast and EMS arrived during lunchtime to transport R1. R1 was transported to the hospital around 1430 hours. During interviews, multiple relevant parties reported that they witnessed R1 sitting at the dining table by themselves with food placed in front of them untouched. Multiple relevant parties acknowledged that R1 needed to be spoon fed by care staff. Relevant party stated that they visited R1 on December 8, 2026 at around 1200 hours and found R1 sitting at the dining table with their face down and oatmeal in front of them and around their mouth. Relevant party stated that R1 was unresponsive. Relevant party stated that they asked S1 what was wrong with R1, and S1 stated “I don’t know” and continued to mop the floor. Relevant party stated that they had to request S1 to contact 9-1-1. Interviews conducted with residents R2, R3, R4, and R5 indicated that they have witnessed staff sleeping on the couch in the common areas. R2, R3, and R4 stated that they have observed S1 sleeping while on duty. Handwritten Care Note authored by Administrator Gaunavou dated December 10, 2025 indicated that, upon returning from vacation, Administrator was notified by residents that S1 did not clean the residents’ bedrooms or bathrooms from December 5, 2025 to December 9, 2025. The Department conducted interviews with residents R2 and R3, who stated that S1 did not do any cleaning at the care home while being the sole caregiver from December 5, 2025 to December 10, 2025. LPA conducted interviews with residents, including R2 and R3, who stated that they saw the cleanliness of the care home deteriorate while S1 was working at the care home. R2 stated that bathroom was dirty and malodorous and towels and clothes were not laundered. R3 stated that S1 never cleaned once while working at the care home. R3 stated that bathrooms and floors were dirty while S1 worked at the care home. ** Report continued on 9099-C ** On June 16, 2026, LPA and LPM conducted a visit to follow-up regarding citations previously issued at the care home. During visit, LPA and LPM observed concerns regarding cleanliness and repair of the care home, including cleanliness of floors and doors, cobwebs inside the shed in the yard and in the care home, urine containers not emptied, and tarp hanging from roof. Pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency was cited per 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 was not met based on observations, which determined that the care home did not ensure the premises was clean and in good repair regarding multiple observed items addressed during visit. A plan of correction (POC) was to include the care home creating a system for cleaning the care home, addressing biowaste, and addressing repairs. Care home was also to address all concerns observed during visit. LPA cleared deficiency during a follow-up inspection. Based on the information above, the allegation that staff are not ensuring facility is clean and in good repair is determined to be substantiated. Due to care home receiving a citation for 87303(a) Maintenance and Operation during visit conducted on June 16, 2026, no additional citations for allegation will be issued. Based on interviews conducted, observations, and records reviewed by the Department, as well as a medication count, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D pages. A civil penalty in the amount of $250 was assessed for today's date due to repeat violation. As a result of the investigation findings, an immediate civil penalty per Health and Safety Code §1569.49 in the amount of $500 for the date of July 15, 2026 is assessed for a violation that the department determines resulted in the injury or illness of a person in care. An additional civil penalty assessment is under review and a determination is pending. LPA will return on a future date to assess an additional civil penalty if warranted. Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents. On December 13, 2025, R1 was discharged from the hospital. Medical staff recommended that R1 receive hospice services at Legacy Lane Senior Living II after discharge. Based on interviews conducted by the Department, R1’s family denied hospice services but agreed to have R1 placed on oxygen. According to R1’s family, R1 had been declining medically since around October 2025, was losing weight, and needed to be spoon fed their meals. Sacramento County Sheriff’s Office detective interviewed R1’s primary care physician, who reported that R1’s family did not report any medical concerns related to R1’s decline but knew that R1 needed to be spoon fed. R1’s primary care physician noted that R1 was diagnosed with dementia and was admitted to the care home for acute renal failure. R1 did not require a special diet. Based on the findings written above, the allegation that R1 died due to staff neglect is unsubstantiated. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 59-AS-20251212164744

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jul 16, 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. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the care home did not ensure to observe changes in R1 and provide appropriate assistance for unmet needs, which poses an immediate health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: Care home will complete training for all staff regarding observing residents for changes in condition and providing assistance for unmet needs. Care home will provide an estimated date for completion of training to LPA by POC due date of July 16, 2026. Care home will also provide LPA materials involved with staff training by POC due date. An immediate civil penalty in the amount of $500 is assessed for today's date due to a violation that resulted in the injury or illness of a resident in care.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 16, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews conducted, observations, medication count, and records reviewed, the care home did not ensure to assist residents with self-administered medications as needed, which poses an immediate health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: Care home will complete training for all staff regarding medication administration. Care home will provide an estimated date for completion of training to LPA by POC due date of July 16, 2026. Care home will also provide LPA materials involved with staff training by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87486.1(a)(1) · Plan of correction due date: Jul 16, 2026

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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews conducted, the care home did not ensure that residents were accorded dignity in their personal relationships with staff, which poses an immediate health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: Care home will complete training for all staff regarding how to treat residents with dignity. Care home will provide an estimated date for completion of training to LPA by POC due date of July 16, 2026. Care home will also provide LPA materials involved with staff training by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 16, 2026

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 conducted and records reviewed, the care home did not ensure to provide care, supervision, and services to meet the needs of the residents in care, which poses an immediate health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: Care home will complete training for all staff regarding how to provide care and supervision to the residents. Care home will provide an estimated date for completion of training to LPA by POC due date of July 16, 2026. Care home will also provide LPA materials involved with staff training by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 16, 2026

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. (...) This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the care home did not ensure personnel were competent to provide services necessary to meet the residents' needs, which poses an immediate health, safety, and personal rights violation to the residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: Care home will complete training for all staff regarding personnel expectations when providing care. Care home will provide an estimated date for completion of training to LPA by POC due date of July 16, 2026. Care home will also provide LPA materials involved with staff training by POC due date. A civil penalty in the amount of $250 was assessed for today's date due to repeat violation.

Type of visit: POC

Licensing Program Analyst (LPA) arrived at the care home and met with Overseer, Christina Allen, to follow-up regarding citations previously issued at the care home. During visit, LPA reviewed plan of corrections and cleared deficiencies. Facility has yet to clear deficiency issued on June 25, 2026. Facility agrees to rescind 30-Day Notice of Termination of Residency issued to resident (R1) and provide proof of 30-Day Notice of Termination of Residency issued to R1 being rescinded to LPA. No deficiencies are being cited as a result of today's visit. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jul 1, 2026

Allegation investigated: Unlawful eviction notice was issued to resident

Licensing Program Analyst (LPA) Michael Hood arrived at the care home and met with caregiver, Deaja Malcolm, to open a complaint investigation into the allegation listed above. During visit, LPA spoke with resident (R1) and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Unlawful eviction notice was issued to resident LPA observed a "30-Day Notice of Termination of Residency" in R1's possession during today's inspection. LPA observed eviction notice as issued to R1 at the care home address. ** Report continued on 9099-C ** Substantiated 30-Day Notice of Termination of Residency issued to R1 states the following: "The reason(s) for this Notice are as follows: 1. Repeated and/or serious violations of facility house rules and policies pursuant to Title 22 Section 87224. 2. Failure to comply with the terms of the Admission Agreement despite prior discussions and interventions by facility staff. 3. Conduct and behaviors that interfere with the orderly operation of the facility and the well-being, safety, and comfort of staff and other residents." LPA did not observe any other reasons listed regarding the justification of the eviction on the notice issued to R1 beyond the statement written above. LPA observed that the reasons listed regarding justification of the eviction on the notice issued to R1 did not include specific facts to permit determination of the date, place, witnesses, and circumstances concerning the reasons for eviction. LPA also observed the wrong mailing address used for R1's right to file a complaint with the nearest office of Community Care Licensing. Based on observations and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jun 25, 2026 · control 59-AS-20260624193028

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: Jul 1, 2026

87224 Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. (1) The notice to quit shall include the following information: (...) (C) A statement informing residents of their right to file a complaint with the licensing agency, as specified in Section 87468, subsection (a)(4), including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office. (...) This requirement is not met as evidenced by: Based on observations and records reviewed, the facility did not ensure to comply with Title 22 eviction procedures when drafting 30-Day Notice of Termination of Residency that was issued to R1, which poses a potential health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jun 25, 2026

Plan of correction: Facility will ensure to comply with Title 22 regulations and the Health and Safety code when drafting eviction notices in the future. Facility will rescind 30-Day Notice of Termination of Residency issued to R1. Facility will provide proof of 30-Day Notice of Termination of Residency issued to R1 being rescinded to LPA by POC due date of July 1, 2026.

Type of visit: POC

Licensing Program Analyst (LPA) and Licensing Program Manager (LPM) Lauren Crocker arrived at the care home and met with Administrator, Shanice Downer, to follow-up regarding citations previously issued at the care home. During visit, LPA and LPM toured the premises and reviewed documents. LPA and LPM observed concerns regarding cleanliness and repair of the care home, including cleanliness of floors and doors, cobwebs inside the shed in the yard and in the care home, urine containers not emptied, and tarp hanging from roof. LPA and LPM observed a vial of Xylocaine in a resident's room readily accessible for a resident who should not have access to medications according to their most updated medical assessment. LPA and LPM also observed accessible medications stored in the staff bedroom. As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. A civil penalty in the amount of $250 was assessed for today's date due to repeat violation. Deficiencies are listed on 809-D pages. Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jun 16, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jun 17, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observations, the care home did not ensure to keep medications inaccessible to the residents in care when resident had a vial of Xylocaine accessible in their bedroom and medications were accessible in staff bedroom, which poses an immediate health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jun 16, 2026

Plan of correction: Facility will ensure that all centrally stored medications are kept in a safe and locked place. LPA will conduct a future visit to clear deficiency. A civil penalty in the amount of $250 was assessed for today's date due to repeat violation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Jun 29, 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 observations, the care home did not ensure the premises was clean and in good repair regarding multiple observed items addressed in report, which poses a potential health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jun 16, 2026

Plan of correction: Facility will create a system for cleaning the care home, addressing biowaste, and addressing repairs. Facility will address all concerns observed during visit. LPA will conduct a future visit to clear deficiency.

Allegation investigated: Staff do not provide the foods necessary for resident's special diet.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to condluede an investigation and deliver findings to a complaint received on May 21, 2026. LPA met with Deaja Malcolm, caregiver, and stated the reason for the inspection. LPA was advised care staff, Christina Allen, had just finished her shift, and there were (6) residents were present in their resident rooms. LPA observed (2) residents in the common area during part of the inspection. During the investigation, LPA interviewed the Administrator, (2) care staff, (4) residents, including resident, (R1), who is the subject of the investigation. LPA also reviewed pertinent documenation for (R1). The results of the investigation are as follows: (R1) moved to the facility on/around February 2025. The Pre-Appraisal and physician's report notes (R1) has some auditory and visual impairment, and requires a gluten free, dairy free, and low sugar diet. *cont on 9099C-1.. Unsubstantiated 9099C-1.Allegation: Staff do not provide the foods necessary for resident's special diet. The allegation states staff has not purchased resident (R1) almond milk and are not serving foods (R1) can eat. The Administrator and another care staff stated to LPA, on May 22, 2026, that (R1) follows a special diet that does not include dairy or gluten/wheat. Both of these staff stated the facility orders specific food for (R1), who also shops on their own, with one staff confirming she drives (R1) to the store. LPA observed (2) half gallons of dairy free unsweetened almond milk in the refrigerator on May 22, 2026. One of the half gallons was almost empty and was dated May 7, 2026. The second half gallon had not been opened. Staff showed LPA where (R1) keeps her food in the refrigerator/freezer, and on the shelf. LPA observed a frozen loaf of Gluten Free bread (100% whole grain) that was marked "Dairy, soy and nut free" on the packaging. Additionally, staff showed LPA where fruit and meat on hand for (R1) were located. LPA observed (2) types of dry cereal (Chex and Cheerios). Both cereal boxes were marked "gluten free". LPA observed each resident's "Special Diet" to be posted on the outside of the refrigerator. A third staff stated on June 4, 2026 that staff has consistently followed (R1's) special diet and the "diet sheet" for all residents is posted on the refrigerator. This staff stated (R1) will typically eat fruit and cereal for breakfast, fruit, vegetables and smoked turkey for lunch, and often has fruit, chips, potato bread and burgers (without cheese) for dinner. This staff confirmed that the facility "always has" Almond Milk on hand. LPA interviewed (3) residents. Two residents stated they will tell staff what they can't eat prior to the meal, and staff will follow that. A third resident stated there haven't been too many times when staff served something he couldn't eat, but when they did, staff will offer an alternative food. This resident stated he does not have any allergies and staff will document what they serve. Resident (R1) stated on June 1, 2026 that staff are "now" giving them the correct foods. On June 4, 2026, the staff showed LPA food on site for (R1), including cereal, fresh fruit (bananas, cantaloupe, berries), (1) unopened half gallon of Almond Milk, (2) kinds of deli meals, spinach/lettuce, and frozen bread and frozen vegetables. The facility was previously cited on April 22, 2026 for not following (R1's) special diet. Based on observations made, documentation reviewed, and interviews conducted, the allegation is found to be UNSUBSTANTIATED- A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided. 9099A-C-1.. The Ombudsman who was present at the facility on May 22, 2026, at the same time LPA was, stated that (R1) has been sitting on the large couch in the living room when he visited the facility previously. (3) residents stated that they have never been denied access to the living room and have never heard staff tell any other residents they cannot go in the living room. These residents stated they have regularly observed resident (R1) sit and watch television from the large couch in the living room. These residents stated they generally don't use the couch in the office, but they have never been told they cannot since the office area is a walk way from the kitchen to a resident room. Resident (R1) stated on June 1, 2026, that the "Ombudsman made it clear to me that that the couch is an office couch, and I have no business going into the office". (R1) explained they like to sit on the couch in the office and talk to the staff while they are cooking. (R1) added that they only sit on the Ottoman in the main living room area because the couch is made for tall people. One staff stated that (R1) likes to lay down on the ottoman. This same staff stated that residents will sit at the dining room table and on the main couch, near the front entrance. This staff stated she wasn't present on the day (R1) wanted to sit on the couch in the office and was asked to wait for a short period. (R1) stated that no residents sit on the big sofa, but if they got a "different sofa", (R1) would sit there. (R1) confirmed that it was "just one time" that staff wouldn't allow them to sit on the couch in the office. Based on interviews conducted, the allegation is found to be UNFOUNDED-meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 59-AS-20260521081320

Type of visit: POC

Licensing Program Analyst (LPA) arrived at the care home and met with Administrator, Shanice Downer, to follow-up regarding citations previously issued at the care home. During visit, LPA reviewed plan of corrections and cleared deficiencies. No deficiencies are being cited as a result of today's visit. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, May 13, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Michael Hood arrived at the care home and met with Christina Allen, Overseer, to conduct a case management visit in relation to a separate inspection conducted on May 7, 2026. During visit, LPA observed centrally stored medication unlocked and accessible to the residents in care. LPA reviewed resident records and observed three (3) of six (6) residents were assessed to be unable to have access to centrally stored medications. LPA reviewed staff records for caregiver on site. LPA observed that staff on site did not have sufficient training documented in accordance with the Health and Safety Code. As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8 and the Health and Safety Code. A civil penalty in the amount of $250 was assessed for today's date due to repeat violation. Deficiencies are listed on 809-D pages. Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, May 7, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 8, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on LPA's observations and records reviewed, the facility did not ensure that residents' medications were kept in a safe and locked place, which poses an immediate health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, May 7, 2026

Plan of correction: Facility will ensure that all centrally stored medications are kept in a safe and locked place. LPA will conduct a future visit to clear deficiency. A civil penalty in the amount of $250 was assessed for today's date due to repeat violation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR1569.625(b)(1) · Plan of correction due date: Jun 6, 2026

§1569.625 Staff training; legislative findings; contents (b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Based on LPA's observations and records reviewed, the facility did not ensure that staff on site received training in accordance with the Health and Safety code, which poses a potential health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, May 7, 2026

Plan of correction: Facility will complete required training for all staff in accordance with Health and Safety code and ensure documentation of training is maintained at the care home at all times. LPA will conduct a future visit to clear deficiency.

Type of visit: Office

An informal conference was conducted at 9:15am on April 28, 2026, with Sacramento North Regional Office via Microsoft Teams. The purpose of this informal conference meeting is to address and discuss concerns regarding the most recent inspections conducted. Licensee was told that this Informal conference is a part of the Administrative Action process and that further noncompliance may result in an elevation to a formal noncompliance conference, which could lead to a referral to the Department's legal division for possible revocation of license. The following Licensing staff were present: Licensing Program Managers (LPMs) Lauren Crocker and Licensing Program Analyst (LPA) Michael Hood The following facility representatives were present: Licensee Cleopatra Gardiner The following topics were covered during today's meeting: · An overview regarding citations recently issued · Pending POCs Facility was notified that the Department may increase monitoring at the facility. Technical support was offered to facility representative during meeting and the facility will be referred. An exit interview was conducted and a copy of this report will be provided to the facility via email.the state’s words, verbatim · CDSS document, Apr 28, 2026

Type of visit: POC

Licensing Program Analyst (LPA) Michael Hood arrived at the care home and met with Administrator, Shanice Downer, to conduct a POC visit following citations issued during inspections conducted the previous week. LPA verified the facility has a certified Administrator assigned and associated to the facility. LPA reviewed records at the facility to be complete. LPA cleared deficiencies during inspection. During visit, LPA reviewed Admissions Agreement Addendum placed in resident records. LPA observed under "Refund Conditions (...) No refunds are given for those that are admitted under 'Hospice Services.'" Per Health and Safety Code §1569.652(c), “A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.” Per Title 22, Division 6, Chapter 8, Section 87507(h)(4), “The admission agreement shall not contain the following: Any provision that violates the rights of any residents including but not limited to those specified in Section 87468 and in Health and Safety Code section 1569 et seq.” As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiency is listed on 809-D pages. Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Apr 28, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(h)(4) · Plan of correction due date: May 11, 2026

87507 Admission Agreements (h) The admission agreement shall not contain the following: (4) Any provision that violates the rights of any residents including but not limited to those specified in Section 87468 and in Health and Safety Code section 1569 et seq. This requirement is not met as evidenced by: Based on records reviewed, the facility did not ensure that admission agreements for the residents did not violate rights indicated in Health and Safety Code section §1569.652(c), which poses a potential health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Apr 28, 2026

Plan of correction: Facility will update Admissions Agreement Addendums for all residents and ensure that there is nothing included that violates any rights specified in Section 87468 and in Health and Safety Code section 1569 et seq. Facility will submit updated Admissions Agreement Addendums to LPA by POC due date of May 11, 2026.

Allegation investigated: Staff stole a resident's personal belongings.

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Overseer, Christina Allen, to deliver findings regarding the complaint allegation listed above. During the investigation, LPA conducted interviews and toured the premises. The results of the investigation are as follows: Relevant party reported that staff member (S1) stole resident (R1's) cell phone charger and their appointment book while they were away from the facility. ** Report continued on 9099-C ** Unsubstantiated Interview with S1 indicated that they have never taken anything from R1. Interview with residents (R2, R3, and R4) indicated that they have never had their property stolen and never witnessed anyone else's property being stolen from staff. Interview with resident (R5) indicated that they have never had staff take their property. Interview with staff members (S2 & S3) indicated that they never witnessed staff take a resident's personal belongings. LPA observed that R1's appointment book was found in R1's belongings in their room during investigation. Interview with S2 indicated that the facility will replace R1's phone charger. Based on interviews conducted and observations, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 59-AS-20260417132352

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Christina Allen, Overseer, to conduct a case management visit to address observations made during a separate inspection conducted on April 23, 2026. During today's visit, LPA provided technical assistance regarding resident supervision. LPA observed staff roster only included one (1) caregiver and staff who were either not present at the facility or no longer working at the facility. LPA requested an updated staff roster during inspection. Facility could not provide requested record during visit. As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiency is listed on 809-D pages. Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Apr 23, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: May 7, 2026

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. (...) The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on observations, interviews conducted, and records reviewed, the facility did not ensure to provide sufficient staffing to meet the needs of the residents in care, which poses a potential health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Facility will update the staff roster and provide updated staff roster to LPA by POC due date of May 7, 2026. Facility will maintain a staff schedule as a comprehensive record of personnel on-site. Facility will ensure that staff present reflect both the roster and staff schedule at all times.

Allegation investigated: Staff do not keep facility free from pests. Staff not following resident’s dietary needs.

Licensing Program Analyst (LPA) Michael Hood arrived at the care home and met with Overseer, Christina Allen, to deliver complaint investigation findings regarding the allegations listed above. During investigation, LPA conducted interviews and toured the premises. The results of the investigation are as follows: Allegation: Staff do not keep facility free from pests. Relevant party reported to the Department that resident rooms have cockroaches. ** Report continued on 9099-C ** Substantiated LPA conducted an inspection of the care home on April 21, 2026. LPA observed a cockroach in resident (R1's) bedroom during visit. Interviews conducted with residents R1, R2, R3, and R4 indicated that they have observed cockroaches in their bedrooms and on the premises. Interviews with residents R1, R2, R3, and R4 indicated that they haven't witnessed pest control at the facility to address current issue with cockroach infestation. Interviews with staff indicated that that they could not recall when pest control last provided treatment at the facility. During visit conducted on April 22, 2026, LPA observed a black widow in the living room of the care home, as well as R4's bedroom. LPA was not provided any current documented proof of pest control services completed at the facility by the conclusion of this investigation. Allegation: Staff not following resident’s dietary needs. Relevant party reported that facility staff are not providing meals to R1 that abide by their special diet. Relevant party reported that R1 is allergic to milk and wheat. Interview with R1 indicated that they want to eat food that is a part of their special diet and staff are not providing food that belongs with their special diet. R1's Physician's Report (LIC 602A) dated January 29, 2025 states R1 has a special diet which includes "gluten free, dairy free." R1's Resident Appraisal (LIC 603A) dated February 1, 2025 indicates "yes" for special diet/observation of food intake as "gluten & dairy free." R1's Admission Agreement dated February 1, 2025 states "Basic services at a minimum include: (5) Food Services: 2. Special diets if prescribed by a doctor." During visit conducted on April 22, 2026, LPA observed staff member (S1) serve a sandwich to R1 for lunch. R1 inquired if it was bread she could eat, and S1 stated that the bread was healthy. LPA observed bread bag of bread used in R1's sandwich and observed bread contained wheat gluten and may contain traces of milk. Based on observations, interviews conducted, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 59-AS-20260420092822

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 5, 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 observations, interviews conducted, and records reviewed, the facility did not ensure that premises was free from pests, including multiple bedrooms for residents, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Facility will contract for regular pest control services to address pest infestation, including, but not limited to, spiders and roaches . Facility will provide a copy of the contract for pest control services to LPA by POC due date of May 5 , 2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: May 5, 2026

87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by: Based on observations, interviews conducted, and records reviewed, the facility did not ensure that R1 was provided food belonging to their medically prescribed modified diet, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Facility will immediately post all residents special diets for staff and begin providing meals to residents that abide by their modified diets. Facility will provide a training to staff regarding special diets and provide proof of training to LPA by POC due date of May 5, 2026.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Christina Allen, Overseer, to conduct a case management visit to follow-up regarding observations made during separate inspections conducted on April 21, 2026 and April 22, 2026. During visit conducted on April 21, 2026, LPA observed medications accessible to the residents located in resident R1 and R2's bedrooms. LPA observed R1's nighttime medications pre-poured in R1's bedroom. LPA observed multiple prescription bottles stored in R2's bedroom. Interview with R2 indicated that they had a week's worth of medications pre-poured for them. LPA observed a week's worth of medications pre-poured stored in R2's bedroom. During today's visit, LPA reviewed records, including four (4) resident records. Per Physician's Report (LIC 602A) dated January 29, 2025, R1 is not "able to store own medications." Per LIC 602A dated December 11, 2025, R2 is not "able to administer own prescription medications," not "able to administer own PRN medications," and not "able to store own medications." Per interview and observation, R1 self-manages their own glucose testing. Per LIC 602A dated January 29, 2025, R1 is not "able to perform own glucose testing." Per regulation 87628(a) Diabetes, "The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional." ** Report continued on 809-C ** LPA requested Centrally Stored Medication Forms for current residents. Facility was unable to provide requested forms to LPA by the conclusion of their visit. As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are listed on 809-D pages. Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Apr 22, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Apr 23, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on interviews conducted and observations, the facility did not ensure that residents' medications were kept in a safe and locked place, which poses an immediate health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Facility will ensure that all centrally stored medications are kept in a safe and locked place. LPA will conduct a future visit to clear deficiency.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(5) · Plan of correction due date: Apr 23, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Based on interviews conducted and observations, the facility did not ensure that residents' medications were kept in a safe and locked place, which poses an immediate health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Facility will ensure that all centrally stored medications are kept in their originally received container. Facility will complete a statement of understanding regarding regulation 87465 and submit statement to LPA by POC due date of April 23, 2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(6) · Plan of correction due date: Apr 23, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year (...). This requirement is not met as evidenced by: Based on LPA's observations and records reviewed, the facility did not ensure to maintain a record of centrally stored medications for each resident for at least one (1) year, which poses an immediate health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Facility will create a record of all residents' current medications in accordance with Title 22 and maintain documentation of records for at least one (1) year. Facility will provide a copy of all residents' centrally stored medication records to LPA by POC due date of April 23, 2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87628(a) · Plan of correction due date: May 22, 2026

87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Based on LPA's observations, interviews conducted, and records reviewed, the facility did not ensure resident admitted was assessed to be able to perform their own glucose testing, which poses a potential health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Facility will either obtain an updated medical assessment to determine resident's capability to perform their own glucose testing or acquire services from skilled professional to provide assistance to resident by POC due date. LPA will conduct a future visit to clear deficiency.

Type of visit: POC

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Overseer, Christina Allen, to conduct a POC visit following citations issued during Required-1 Year Inspection conducted on December 17, 2025. During visit, LPA measured hot water temperature and observed hot water to be 113 degrees F. LPA also observed a complete first aid kit on the premises. LPA observed a Disaster Drill Log for the year of 2025 and obtained a copy. LPA cleared deficiencies during visit. LPA observed that the facility does not have an assigned certified administrator during inspection. LPA observed that staff member (S1) was handling medications without medication training at the facility. LPA requested records during today's inspection that the facility was unable to provide to LPA at the conclusion of this visit, including records for all residents. As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are listed on 809-D pages. Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Apr 21, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87506(a) · Plan of correction due date: Apr 22, 2026

87506 Resident Records (a) 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 LPA's observations and records reviewed, the facility did not ensure to make complete and current records available to licensing agency staff to review, which poses an immediate health, safety, and/or personal rights violation to the residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2026

Plan of correction: Facility will ensure that a separate, complete, and current record is maintained for each resident in the facility at all times and ensure records are readily available to licensing agency staff. LPA will return at a later date to clear POC.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(d) · Plan of correction due date: Apr 22, 2026

87411 Personnel Requirements - General (d) 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, as appropriate for the job assigned and as evidenced by safe and effective job performance: (4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement is not met as evidenced by: Based on LPA's observations, interviews conducted, and records reviewed, the facility did not ensure that staff assisting residents with self-administered medication had medication training at the facility, which poses an immediate health, safety, and/or personal rights violation to the residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2026

Plan of correction: Facility will ensure that staff assisting residents with self-administered medications receive medication training and documentation for training is maintained at the facility at all times. Facility will provide proof of medication training for staff assisting residents with self-administered medications to LPA by POC due date of April 22, 2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: May 4, 2026

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by: Based on LPA's observations and records reviewed, the facility did not ensure to have an assigned certified administrator at the facility, which poses a potential health, safety, and/or personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2026

Plan of correction: Facility will hire a certified administrator and send proof of employment to LPA by POC due date of May 4, 2026.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Marisa Chiarelli and Michael Hood arrived at the facility unannounced on December 17, 2025 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are five (5) bedrooms and four (4) bathrooms for resident use. LPAs observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 155 degrees F. LPAs checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPAs observed knives, cleaning products, and other toxins to be locked away and inaccessible to residents. LPAs observed the backyard and perimeter of the care home to be free of clutter and debris. LPAs observed smoke detectors and carbon monoxide detectors to be operational in the care home. Emergency exits were unobstructed during visit. Fire extinguishers are maintained and ready for emergency use. LPAs reviewed one (1) residents' medications and observed medication storage to be locked away and inaccessible to the residents. LPAs reviewed five (5) resident files and two (2) staff files. Facility has a current copy of certificate of liability insurance and LPAs obtained a copy. As a result of this visit, deficiencies were cited per California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are attached on 809-D pages. Exit interview conducted. A copy of report and appeal rights given.the state’s words, verbatim · CDSS document, Dec 17, 2025

Allegation investigated: Facility staff are not ensuring that residents are treated with dignity and respect

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Moria Gaunavou, to deliver findings regarding the complaint allegation listed above. During the investigation, LPA conducted interviews, toured the premises, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Facility staff are not ensuring that residents are treated with dignity and respect ** Report continued on 9099-C ** Substantiated Interview conducted with R1 indicated that they are being disrespected by residents and care staff at the care home. R1 stated that they have been called names, such as an "old hag," by resident (R2). Resident stated that they were grabbed by R2 on the arm along with care staff (S1). R1 stated that R2 and S1 tried to force R1 into their room. R1 stated that R2 and S1 were unsuccessful in forcing them back into their room after resisting. R1 stated that they contacted local law enforcement regarding the incident. R2 denied physically assaulting R1 during incident on June 6, 2025. R2 denied anyone, resident or staff, assaulting R1 on June 6, 2025. R2 stated that they did have a verbal altercation with R1 on June 6, 2025, including getting in R1's face and telling R1 to go to their room. R2 claimed that R1 has violated their personal rights on multiple occasions. Interview with resident (R3) and Administrator confirmed that there have been verbal altercations between R1 and R2 at the facility. R3 stated that R1 and R2 have yelled at each other, but have never physically assaulted each other. R3 stated that they witnessed incident on June 6, 2025, and stated that neither R2, nor S1, physically assaulted R1. R3 confirmed that R1 tends to violate other residents' personal rights. Administrator stated that they did not witness incident on June 6, 2025. Administrator stated that R1 tends to start conflict with the other residents. Administrator will redirect residents when they initiate verbal altercations between each other. LPA contacted local law enforcement for records and information regarding incident on June 6, 2025. LPA spoke with local law enforcement representative via telephone call, who stated that no police report was completed regarding incident. Local law enforcement representative stated that there was a "disturbance" at the facility on June 6, 2025, but no crime was found to be committed. Local law enforcement representative stated that caregiver on site did not witness any physical altercation between residents on June 6, 2025. LPA reviewed R1's Admission Agreement, including house policies. LPA did not observe any house policies established in admission agreement regarding personal rights and residents treating others with dignity and respect. Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Oct 24, 2025 · control 59-AS-20250709144213

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Nov 21, 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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure that residents were treated with dignity and respect in their relationships with other residents, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: Facility will update house policies for all residents to include personal rights violations. Facility will have all residents sign house policies to include in their admission agreements. Facility will submit updated and signed house policies to LPA by POC due date.

Type of visit: POC

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Moria Gaunavou, to follow-up on a plan of correction made to the facility on July 9. 2025 to be corrected on July 31, 2025. During today's visit, LPA received a copy of the POC, which involved proof of service regarding first treatment for flies and roaches after contracting with a pest control service. LPA cleared deficiencies during inspection. No deficiencies are being cited as a result of today's visit. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Aug 7, 2025

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Michael Hood arrived at the care home unannounced on 7/9/25 to conduct a post licensing visit. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are five (5) bedrooms and four (4) bathrooms for resident use and one (1) bedroom for staff. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 120 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPA observed knives, cleaning products, and other toxins to be locked away and inaccessible to residents. LPA observed the backyard and perimeter of the care home to be free of clutter and debris. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home. LPA reviewed two (2) residents' medications and observed medication storage to be locked away and inaccessible to the residents. LPA reviewed six (6) resident files and one (1) staff file. Facility has a current copy of certificate of liability insurance and LPA requested a copy. As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. A civil penalty in the amount of $250 was assessed for today's date due to repeat violation. Deficiency is listed on 809-D page. Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jul 9, 2025

Allegation investigated: Licensee is not addressing pest infestation.

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Moria Gaunavou, to open a complaint investigation into the allegation listed above. LPA also spoke to Administrator, Cleopatra Gardiner, via telephone call during visit. During the investigation, LPA conducted interviews, toured the premises, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Licensee is not addressing pest infestation. ** Report continued on 9099-C ** Substantiated During visit conducted on June 6, 2025, LPA toured the premises, including kitchen/living room area, resident bedrooms, staff bedroom, and perimeter of the care home. LPA observed at least a dozen live flies in the kitchen/living room area and multiple dead flies in the kitchen/living room area. LPA also observed dead flies in two (2) resident bedrooms. Interviews with staff members S1 and S2 acknowledged the large amount of flies inside the facility. S1 stated that one (1) resident will leave their outside bedroom door open and cause flies to enter the home. LPA observed roach traps in one (1) resident bedroom. Interview with S1 indicated that roach traps were purchased and placed by resident. Interview with S1 and residents (R1 & R2) indicated that they have witnessed roaches inside the facility. Interview with R2 also indicated witnessing spiders inside the facility. Interview with Administrator Gardiner indicated that the last time they have had pest control conduct treatment at the facility was prior to the license being issued. Administrator Gaunavou provided LPA with an invoice dated May 21, 2025 indicating that pesticide treatment for roaches, flies, and lizards was conducted. S1 and R1 indicated observing roaches after treatment conducted on May 21, 2025. Licensing is requesting facility contract with a pest control service for regular treatment to address ongoing infestation. Based on LPA's observations, interviews conducted, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jun 6, 2025 · control 59-AS-20250530084909

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(27) · Plan of correction due date: Jun 13, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on observations and interviews conducted, the facility did not ensure that the kitchen area was free from insects, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 6, 2025

Plan of correction: Facility will contract for regular pest control services to address pest infestation, including, but not limited to, roaches and flies. Facility will provide proof of service regarding first treatment for flies and roaches by POC due date of 6/13/2025.

Type of visit: Prelicensing

On January 2, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a Pre-Licensing inspection. LPA met with Applicant, Cleopatra Gardiner and explained the purpose of the visit. During today's inspection, LPA and Applicant conducted a tour of five residents room, staff room, bathrooms, kitchen, and the common areas. Applicant is designated to be Administrator, LPA observed Administrator Certificate #6069023740 to be active with expiration date of 04/15/2026. LPA observed a designated lock area for files, medications, sharps and toxins. LPA observed a fire extinguisher present with service date of February 28, 2024. LPA and Applicant discussed ensuring fire extinguishers are serviced annually. LPA observed auditory devices present on all exit doors, LPA observed the alerts to be working. LPA observed facility to have preparation of seven days of nonperishable food present at the facility with a pantry of cereal, oatmeal, canned vegetables and grains. LPA observed facility having the presence of books and board games for activities. LPA observed the facility to have the required compliance posters posted in a conspicuous space. LPA observed the exterior of the facility to be free from obstruction in pathway. LPA observed First Aid kit to be recently purchased, filled with the requires items listed in 87465 Incidental Medical and Dental Care (a)(8)(A-F). LPA and Applicant discussed that facility is to have night lights maintained in hallways and passages to non private bathrooms. LPA observed nonskid mats presence in bathroom. File review conducted for template resident files, and observed the required documents. Inspection tool completed and facility is in compliance to Title 22. Comp III waived. Applicant has passed the Pre-Licensing component of the application process. LPA will notify the Centralized Application Bureau of completion. Facility is not licensed until notify by Centralized Application Bureau Analyst along with a copy of license. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 2, 2025

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Interview Method: Telephone interview On 12/16/2024, applicant/administrator participated in COMP II. Identification of the applicant / administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant / administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Dec 16, 2024