Lilos Tender Senior Care

Allegation investigated: Lack of supervision resulting in resident being touched inappropriately

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director, Wes Hebner. On 7/1/25, it was alleged that lack of supervision resulted in a resident being touched inappropriately. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. During the visit, the LPA observed staff coverage in common areas and residential corridors. Staff were present and engaged with residents, providing assistance and maintaining line-of-sight supervision consistent with Title 22 requirements. No unsafe supervision gaps or high-risk situations were observed. The environment appeared calm and organized, and staff demonstrated awareness of resident boundaries and safety. Unsubstantiated Staff 1 (S1) denied witnessing or being informed of any inappropriate touching and described standard supervision practices, including routine rounding and immediate intervention when residents require redirection. S1 confirmed understanding of mandated reporting requirements and facility protocols for responding to allegations of abuse. Two (2) residents were interviewed; both denied experiencing or witnessing inappropriate touching and reported that staff are generally present and responsive in common areas. Outside source 1 (OS1), reported no concerns regarding supervision and stated they had not been informed of any incidents of inappropriate contact. OS1 described staff interactions as professional and consistent with resident rights. A review of facility records, including incident logs, communication notes, and staffing schedules, revealed no documented incidents confirming that a resident was touched inappropriately due to lack of supervision. Staffing schedules matched observed coverage and indicated adequate ratios with qualified personnel on duty. Training records showed staff had completed in-service training on abuse prevention, professional boundaries, and mandated reporting requirements. Facility policies addressing supervision, abuse prevention, and reporting were current and consistent with regulatory standards. Based on observations, interviews, and records reviewed, there is insufficient evidence to support the allegation that lack of supervision resulted in a resident being touched inappropriately. Therefore, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Eric Mendoza, caregiver to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 08-AS-20250701114347

Allegation investigated: Staff gave resident medication without a physicians order

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to initiate a complaint investigation regarding the above-mentioned allegation and deliver the finding. LPA introduced themselves and disclosed the purpose of the visit to Caregiver Paola Castillo. It was alleged Staff gave resident medication without a physician's order. CCLD’s investigation involved an unannounced facility visit, review of facility records, interviews with facility staff, residents, outside sources, and LPA direct observations. Regarding the allegation, staff interviews revealed that as a policy, the facility staff do not administer injections. Staff 1 (S1) stated Resident 1 (R1) does not do their own injections. When asked about R1's medication management, S1 stated R1 cannot manage their own medications and they travel to an outside medication management agency for insulin injections. (continued on Page 2, LIC9099C) Unfounded (continued from Page 1, LIC9099) Resident interviews revealed that when R1 was asked about insulin injections, they confirmed they have neither administered their own insulin at the facility, nor have they had any staff members administer it for them. R1 stated they've received their insulin injections from outside medication management agency. R1 was able to corroborate staff interviews. Outside Source interviews revealed that Outside Source 1 (OS1) was not aware of R1 injecting themselves with insulin as part of their routine in the facility. OS1 confirmed R1's memory is not reliable. OS1 stated that in regards to the reporting party's incident report, it is very possible R1 could have misremembered the events when retelling the reporting party. Records Review revealed that R1 takes oral medication to manage their diabetes. The medical administration record (MAR) has no indication of injectable insulin medications. The Physician's report indicated that while there is no direct mention of a diagnosed cognitive disorder, it is stated that there is "forgetfulness" and "other specified mental disorders due to known physiological condition" which corroborated outside source accounts of R1's memory impairment. LPA observations revealed that inspection of the medications at the facility, R1 had no injectable insulin medications. All medications were prepackaged and provided by outside medication management agency and LPA was able to corroborate staff accounts of medication management. Based on records and interviews, the allegation that Staff gave resident medication without a physician's order is unfounded, meaning it was false, could not have happened, and/or is without a reasonable basis. The allegation has therefore been dismissed. An exit interview was conducted with the Caregiver Paola Castillo, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Sep 5, 2025 · control 08-AS-20250829135252

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Domingo was welcomed by, identified herself to, and discussed the purpose of the visit with Pa0la Castillo Lead Direct Support Staff. The facility is licensed to serve six (6) residents; of which all can be non-ambulatory, two (2) can be under Hospice Care, and one (1) resident may be bedridden. During today's visit all six (6) Residents were present. LPA Domingo, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 72 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 112 F, Bathroom #1 sink was 112 F. Refrigerator temperature was 33 F and freezer temperature was 0 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and resident. LPA Domingo reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance and surety bond. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Paola Castillo, Lead Direct Support Staff to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Apr 11, 2025

Allegation investigated: Staff were administering injections to resident

Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced complaint investigation visit to gather additional records and deliver findings. The LPA introduced herself and disclosed the purpose of the visit to Care Giver Wendy Gomez Estrada and a spoke on the phone with Licensee Annie Nazaian. It was reported to Community Care Licensing Division (CCLD) on August 16, 20204 staff were administrating medication injections to a resident. The licensees and their designated facility staff are limited to “assistance with self-administration” and are prohibited from “administering” medications, unless done so by an appropriately skilled professional acting within their scope of practice. Records reviews indicate that staff members were not authorized to administered medication injections and did not have proper medical authorization or training to administer medication injections. (continued on 9099-c) Substantiated (Continued from 9099) Throughout the investigation, the department inspected the facility, secured pertinent records and conducted interviews with staff, residents, and outside sources. Interviews with outside sources, staff, and resident confirm staff were administering medication injections to their resident. Based on interviews and records reviewed, a preponderance of evidence exists to show the Licensee did administer injections to their resident. The allegation is therefore substantiated. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A joint plan of corrections was developed with Licensee Annie Nazaian over the phone. An exit interview was conducted in person with Care Giver Wendy Gomez Estrada and Care Giver Carolina Fuentes and over the phone with Licensee Annie Nazaian to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 08-AS-20240816153126

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Oct 4, 2024

87465 Incidental Medical and Dental Care (a )A plan.. be developed by each facility. (5)Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited.. Based on records review and staff interviews, 1 of 6 clients (C1) used an injection pen device, but Licensee did not ensure that direct care staff were trained on the use of “assistance with self-administration” medications.the state’s words, verbatim · CDSS document, Sep 19, 2024

Plan of correction: Licensee agreed to provide in service training by an outside vendor to all staff regarding asisstance with self administered medication. LPA confirmed medicaiton injections were no longer being administered. Licensee will provide a training date to the LPA by 9/20/24. Once training is complete, administrator will send the LPA proof of completion.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Amy Domingo conducted an announced Pre-Licensing visit. LPA Domingo was joined by Applicant Nvard Bebekyan and granted entry into the facility. The purpose of the visit was to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. The fire inspection was completed on 01/23/24, and the facility was approved for 5 non ambulatory residents and 1 bedridden resident. During today's visit, LPA, accompanied by applicant, toured the facility inside and outside and inspected every room. The facility was found to be in good repair with no pathway obstructions. Clients' bedrooms were observed to be clean and resident accommodations included furnishings, linens and personal hygiene items; resident bathrooms were equipped with grab bars, bath mats; staff and administrative records are located in a locked office; food service including dishes, utensils, food storage and a seven day supply of non perishables and a two day supply of fresh perishables are present; toxic substances are stored locked in the garage or the office; medication storage and administration logs are located in a locked cabinet in the kitchen; first aid kit and current first aid manual are located in the office; activities, supplies and sufficient space to conduct are present; fire extinguishers are affixed with a current tag; smoke and carbon monoxide detectors are present and operable; facility posting requirements are present in a common area and the facility administrators certification is current; no pools or other body of water is present on the facility; per the applicant there are no guns, weapons or ammunition located on the property. Discussed with the applicant were continuing operation requirements, record keeping and physical plant compliance. The applicant shall contact the Centralized Application Unit (CAU) for completion of this pending facility application. An exit interview was conducted with Nvard Bebekyan , and a copy of this report and Licensee Appeal Rights (LIC 9058) were were printed and given to Nvard Bebekyan at the facility.the state’s words, verbatim · CDSS document, Apr 18, 2024