Lotus Villa and Memory Care

Allegation investigated: Facility is not reporting resident incidents to resident responsible party.

Licensing Program Analysts (LPAs) Paola Guerrero and Matthew Aguilar arrived at the facility to deliver investigative findings. LPAs met with Facility MedTech Desiree Martinez and explained the purpose of the visit regarding the allegation stated above. First allegation: Facility is not reporting resident incidents to resident responsible party. Regarding the allegation stated above, LPAs conducted interviews with Staff #1 and Staff #1 regarding the alleged allegation. Staff #1 informed LPAs that on 6/6/2026 and 6/7/2026 Resident #1 had sustained two falls, one in which was witnessed and the second was unwitnessed. Staff #1 further explained that both falls were not reported to resident’s responsible party. Staff #1 further informed LPAs that Resident #1 responsible party was informed by Staff #1 about the concerns of not reporting Resident #1 incidents. Based on the evidence gathered during the investigation, the above allegations are Substantiated. Substantiated A finding that the complaint is Substantiated means that the findings are valid because the preponderance of the evidence standard has been met. Title 22 Regulations Reporting Requirements 87211 (a)(1)(2), from division 6, chapter, article 6, is, cited on the attached LIC 9099 D. An exit interview was conducted where this report, appeal rights, and LIC9099-D was discussed, and a copy of the report was provided to Facility MedTech Desiree Martinez at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 7, 2026 · control 56-AS-20260706152847

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(2) · Plan of correction due date: Jul 17, 2026

Reporting Requirements ...(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case....(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidence by: Based on record review, interviews, the licensee did not adhere to the regulation stated above by not reporting R#1 incidents to resident’s responsible party, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: The Licensee has agreed to read over regulation: Reporting Requirements(a)(1)(2) and provide training to all staff. Licensee will provide LPA with proof of training by emailing the copy of the training signed and dated by all staff by POC date 7/17/2026.

Allegation investigated: Staff neglect resulted in resident being hospitalized. Facility staff did not meet the residents’ care needs.

Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Mayra Alfaro and explained the purpose of the visit regarding the allegations stated above. First allegation: Staff neglect resulted in R1 being hospitalized. Investigation was conducted by department staff which included review of records and witness interviews. Based on the investigation, it was discovered that facility staff observed a significant decline in Resident #1 (R1)’s condition but staff continued to let critical time pass while R1’s condition continued to decline throughout August 2025. An appraisal dated March 28, 2024, and a preplacement appraisal dated April 15, 2024, show R1’s overall health as being good. In addition, a physician’s report dated May 2, 2025 indicated R1’s health as fair. In addition, a Needs and Service plan dated August 6, 2025, indicates that R1 was able to make their needs known and needing assistance with Activities of Daily Living (ADLs). Substantiated Documentation dated July 26, 2025, shows R1 had a decrease in eating and drinking over the last two days and needing extra encouragement to eat. On July 28, documentation shows that R1 health was declining, eating and drinking had diminished and R1 sometimes refused eating with increased weakness and fatigue. Records show that on July 31, 2025, R1 was determined to be appropriate to receive hospice services. However, hospice was not initiated. The Operations Manager acknowledged that R1 was not eating or drinking for some time in August so Boost shakes were ordered. However, there was no documentation to confirm fluid intake or when Boost shakes were provided. In addition, there was no documentation showing that staff assisted R1 with eating or drinking or assistance with spoon-feeding due to weakness. R1 was hospitalized on September 1, 2025, and medical records show R1 had a gradual decline and failure to thrive since August 28, 2025. A nutrition assessment dated September 3, 2025, charts significant unintentional weight loss of 27% over the last three months. R1 was determined to be severely malnourished. Her weight was 150lbs on April 19, 2025, and 110 on September 2, 2025. R1 was hospitalized on September 1 and diagnosed with severe sepsis, pneumonia, dehydration and malnutrition. R1 died in the hospital on September 8, 2025. Second allegation: Facility staff did not meet the residents’ care needs. Regarding the second allegation, it was Investigated through department staff that throughout R#1 stay at Lotus Villa R#1 was hospitalized three (3) times, March 2025, April 19, 25, and June 9, 2025. None of the hospitalizations were reported to resident responsible party by staff. It was reported that resident responsible party learned about the hospitalizations when called directly by Kaiser Permanente. Report indicates that prior to R#1 hospitalization on September 1, 2025, R1 lost a significate amount of weight. In addition, staff did not assist R#1 with Activities of Daily Living (ADL’s), but rather left R1 in bed, not being assisted with feeding or grooming. Report also indicated that staff did not administer oxygen to R#1 for over a month. Records indicate that upon R#1 hospitalization to Kaiser Permanente on September 1, R#1 was found to be severely septic with pneumonia, dehydrated, and malnourished. Based on the evidence gathered during the investigation the allegation of neglect and facility did not meet the residents care needs are substantiated. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence standard has been met. In addition, an immediate civil penalty of $500.00 was assessed, per Health and Safety Code 1548 (c). Furthermore, an additional civil penalty may be imposed, per Health and Safety Code 1569.49 (f). An exit interview was conducted where this report, appeal rights, and LIC9099-D was discussed, and a copy of the report was provided to Facility Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jun 12, 2026 · control 56-AS-20250911105509

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jun 15, 2026

87466 Observation of the Residents: 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 evidence by: Based on, interviews and record review, the licensee did not adhere or follow protocol based on the regulation listed above which resulted in R#1 being hospitalized on 9/1/2025, and diagnosed with severe sepsis, pneumonia, dehydration and malnutrition. This posed an immediate Health, Safety, or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 12, 2026

Plan of correction: The Licensee has agreed to read over regulation 87466 Observation of the Residents: and provide training to all staff who provide care to residents. The licensee will also provide LPA with proof of the training signed by all participating staff acknowledging and understanding the regulation by POC date: 6/15/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jun 15, 2026

Personnel Requirements – General 87411 (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. This requirement is not met as evidence by: Based on, interviews and record review, the licensee did not adhere to the regulation stated above by not properly reporting R#1 change of condition and not adhering to R#1 care needs which resulted in R#1 to be hospitalized on 9/1/2025, and diagnosed with severe sepsis, pneumonia, dehydration and malnutrition. This posed an immediate Health, Safety, or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 12, 2026

Plan of correction: The Licensee has agreed to read over regulation 87411 (a) Personnel Requirements – General: and provide training to all staff who provide care to residents. The licensee will also provide LPA with proof the of the training signed by all participating staff acknowledging and understanding the regulation by POC date: 6/15/2026.

Allegation investigated: Staff does not prevent the spread of scabies.

Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Mayra Alfaro and explained the purpose of the visit regarding the allegations stated above. First allegation: Staff does not prevent the spread of scabies. Regarding the allegation stated above, LPA conducted an interview with Staff #1 regarding the alleged allegation pertaining to Resident #1. Staff #1 informed LPA that the facility has not had any reports concerning scabies. Staff #1 informed LPA that R#1 has been receiving on going treatment for an unknown skin condition since April 2026. Staff #1 provided LPA with documentation indicating that Resident #1 has been receiving continuous treatment for an unknown skin rash. LPA conducted an over the phone interview with NP Keysha Royster who informed LPA that Resident #1 has been under their care and receiving treatment for skin rash. NP Keysha Royster further indicated that a skin test was performed on Resident#1 by infectious disease at Kaiser and was informed on 5/21/2026 that Resident #1 tested negative for scabies. Unsubstantiated Based on corroborating evidence LPA has determined that the above allegation is Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Mayra Alfaro.the state’s words, verbatim · CDSS document, May 29, 2026 · control 56-AS-20260520083454

Allegation investigated: Unqualified staff provide medical care to residents.

Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Mayra Alfaro and explained the purpose of the visit regarding the allegations stated above. First allegation: Unqualified staff provide medical care to residents. Regarding the allegation stated above, LPAs conducted interviews with Resident #1, Resident #2, Resident #3, and Resident #4, pertaining to the alleged allegation and three out of the four residents informed LPAs that they independently administer their own insulin as well as checking their own blood sugar. During further interview Resident #4 informed LPA that facility staff assists with the administration of insulin. Resident #4 further explained that the assistance is not hand over hand assistance but full injectable administration of insulin. Resident #4 also stated that the last administration done by staff was about a week ago. Based on the evidence gathered during the investigation, the above allegation is Substantiated. Substantiated A finding that the complaint is Substantiated means that the findings are valid because the preponderance of the evidence standard has been met. Title 22 regulations Injections 87629 (a)(b)(1), from division 6, chapter, article 6, is, cited on the attached LIC 9099 D. An exit interview was conducted where this report, appeal rights, and LIC9099-D was discussed, and a copy of the report was provided to Facility Administrator at the conclusion of the visit. LPAs conducted interviews with staff who reported that in the past the facility was treated for bedbugs, however, currently there has not been any reports regarding bedbugs. Second allegation: Facility staff are not allowing activities for residents in care. Regarding the allegation stated above, LPAs conducted interviews with Staff #1, Staff #2, Staff #3, and Staff #4, regarding the alleged allegation Staff #1 informed LPAs that Memory Care Unit located on the second floor take qualified residents out for walks three times a day. In addition, Staff #1-4 informed LPAs that activities in memory care are always completed and all activities are also witnessed as residents in memory care must be escorted and accompanied by one or two staff members. Based on corroborating evidence LPA has determined that the above allegations are Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. In addition, during the inspection LPAs observed that on 3/4/2026 the facility had a census of 92 and was on compliance and not exceeding the capacity of 99. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Mayra Alfaro.the state’s words, verbatim · CDSS document, Apr 13, 2026 · control 56-AS-20260304110227

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87629(a)(b)(1) · Plan of correction due date: Apr 14, 2026

87629 Injections ....(a) The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional.....(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensees who admit or retain residents who require injections shall be responsible for the following: ....(1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement is not met as evidence by: Based on interviews, the licensee did not adhere by regulation 87629, by permitting a non-skilled professional to administer insulin through injection to resident #4, which poses an immediate health, safety, or personal rights, risk to residents in care.the state’s words, verbatim · CDSS document, Apr 13, 2026

Plan of correction: The Licensee has agreed to read over: 87629 Injections (a)(b)(1), regulation and provide training to all staff who assist with the administration of medication. The licensee will ensure that all Medtech’s, Caregivers, have a clear understanding that ONLY appropriately skilled professionals are to administer injections to residents in care. The licensee will email LPA a copy of the signed training and acknowledged by all Med-Support by POC 4/14/2026.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Administrator Melisa Sevilla and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (99) current census (94). LPA was accompanied by Facility Administrator, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside 2nd floor Med-Room inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed five (5) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Melisa Sevilla.the state’s words, verbatim · CDSS document, Nov 6, 2025

Allegation investigated: Staff unlawfully evicted a resident

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Melisa Sevilla and explained the purpose of the visit. The investigation consisted of interviews, review of records, and observations. First allegation: Staff unlawfully evicted a resident. Regarding the allegation LPA conducted interviews with Staff #1, Staff #2, and Staff #3, LPA went over the allegation with staff and S#1-3 informed LPA that the facility has not evicted or refuse to accept any resident back the facility. Based on records LPA observed that no name of the victim was listed or provided for the unlawful eviction. Staff #3 informed LPA that one resident, Resident #1 was transported to a local hospital on 10/22/2023 and discharged on 10/23/2025 Staff #3 informed LPA that facility was having arrangement issues pertaining to R#1 however, Staff #3 informed LPA that R#1 was later transported to back the facility by Kaiser transport. Staff #3 informed LPA that R#1 is still a resident at the facility. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated. Unsubstantiated Unsubstantiated: meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Melisa Sevilla at the end of the visit.the state’s words, verbatim · CDSS document, Oct 27, 2025 · control 56-AS-20251023100251

Allegation investigated: Facility staff are not properly addressing bed bugs in the facility

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Melisa Sevilla and explained the purpose of the visit. The investigation consisted of interviews, review of records, and observations. First allegation: Facility staff are not properly addressing bed bugs in the facility. Regarding the allegation, LPA conducted interviews with Staff #1, Staff #2, and Staff #3, who informed LPA that the facility received a report from a resident on 10/7/2025 regarding bedbugs. Based on treatment contract LPA observed that a two-day treatment was completed on 10/13 and on 10/24/2025, staff informed LPA that treatment has been completed, and the indication of bedbugs was no longer present. In addition, Staff informed LPA that a total of four (4) residents will be moving back into their rooms in the next couple of days. LPA conducted interviews with R#2, R#3, and R#4, who informed LPA that they have no bedbug bites, and that they are aware of the treatment that is being done in their rooms. Unsubstantiated R#2, R#3, and R#4, informed LPA that they have no concerns and that they are waiting to receive the clearance to return back to their rooms. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated. Unsubstantiated: meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Melisa Sevilla at the end of the visit.the state’s words, verbatim · CDSS document, Oct 27, 2025 · control 56-AS-20251020101251

Allegation investigated: Staff do not provide adequate supervision to the residents in care.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Business Office Manager Reyna Figueroa and explained the purpose of the visit. The investigation consisted of interviews, and review of records. First allegation: Staff do not provide adequate supervision to the residents in care. Regarding the allegation LPA conducted interviews with staff #1 and staff #2 who informed LPA that on 9/19/2025, it was reported by staff that R#1 had not been seen and was possibly missing. S#1 and S#2 informed LPA that family and local police department were notified of the incident pertaining to R#1. S#1 informed LPA that R#1 was found three in a half hours later (3.5 hrs.) and was found to be inside a storage room located on the second-floor same floor where R#1 room is located. S#1 informed LPA that storage room was accidently left opened which R#1 gained access and was locked in the storage room for 3.5 hrs. Based on the evidence gathered during the investigation, the above allegation is Substantiated. Substantiated Substantiated; A finding that the complaint is Substantiated means that the residents’ is valid because the preponderance of the evidence standard has been met. Title 22 regulations 87468.1 (a)(2), Personal Rights of Residents in All Facilities General from division 6, chapter, article 6, is being cited on the attached LIC 9099 D. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights to Facility Business Office Manager Reyna Figueroa.the state’s words, verbatim · CDSS document, Sep 22, 2025 · control 56-AS-20250915144012

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

Personal Rights of Residents in All Facilities General....(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:....(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on interviews, and record review, the licensee did not ensure R#1 to be accorded safe, based on title 22 regulation, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 22, 2025

Plan of correction: Licensee has agreed to read over the "Personal Rights General" and provide training to all staff regarding care and supervision. The licensee will email a copy of the training on POC date 10/3/2025.

Allegation investigated: Staff did not follow up on resident's change of condition Staff left resident in filthy clothes Staff did not ensure resident in care was hydrated Staff did not ensure resident in care was properly fed Staff did not provide proper medication assistance to resident in care

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Heather O’Neel and explained the purpose of the visit. The investigation consisted of interviews, observation, and review of records. First allegation: Staff did not follow up on resident's change of condition. Regarding the allegation stated above LPA conducted interviews with S#1, S#2, and S#3, who informed LPA that on 11/19/2023, facility informed InnoVage clinic that Resident #1 was being transported to local hospital because R#1 was weak and was not eating. LPA collected documentation pertaining to R#1 and LPA discovered that on 11/19/2023, R#1 was seen at a local hospital and diagnosed with UTI R#1, was discharged on the same day. LPA observed that medication was set to be delivered to the facility per InnoVage orders. LPA observed that R#1 completed antibiotics as indicated in addition, based on R#1 follow-up information documentation indicated that R#1 is to return within 1-2 days if any problems or concerns. Based on documentation no problems or concerns were listed after R#1 discharge. Unsubstantiated Second allegation: Staff left resident in filthy clothes. Regarding the allegation listed above LPA conducted interviews with Resident #2, Resident #3, R#4, and Resident #5, who informed LPA that facility provides laundry services as part of their agreement. In addition, R#2-5 informed LPA of not having any issues or concerns regarding laundry services. R#2-5 informed LPA that caregivers change and dress residents twice a day (morning & night), and as needed in case resident might need a diaper change or during an accident. LPA conducted a file review and observed that the facility provides laundry services to residents as part of their basic services listed on their admission agreement. LPA conducted interviews with Staff #1, S#2, and Staff #3, who informed LPA that facility provides laundry services twice a week for all residents or as needed. Third allegation: Staff did not ensure resident in care was hydrated. Regarding the allegation LPA conducted interviews with Resident #2, Resident #3, Resident #4, and Resident #5 regarding the allegation stated above and all residents informed LPA that facility provides and has water available to all residents in care. In addition, resident #2-5, informed LPA that the facility has water dispensers available throughout the facility. In addition, water is also provided to resident[s] upon residents’ request. LPA conducted interviews with Staff #1-3, regarding the allegation stated above, and staff #1-5 informed LPA that there is a total of three (3), water stations available to residents and that water is also available upon residents’ request. Furthermore, Staff #1, S#2, and Staff #3, also informed LPA that pitchers of water are provided, to assist residents when taking medication. Fourth allegation: Staff did not ensure resident in care was properly fed. Regarding the allegation LPA conducted interviews with Resident #2, Resident #3, Resident #4, and Resident #5 who informed LPA that facility provides residents with breakfast, lunch, dinner, and in between snacks, R#2-5 also informed LPA that the facility provide options from their optional menu incase the resident does not want to eat what is being served. In addition, R#2-5 informed LPA that facility has a dining area where residents eat however, caregivers will usually take residents food into resident’s room incase resident is not in the dining area. LPA conducted interviews with S#1, S#2, and S#3, LPA went over the allegation with staff and S#1-3 informed LPA that all residents are provided three meals a day and food is typically provided in the dining area or delivered to the resident depending on residents needs. Fifth allegation: Staff did not provide proper medication assistance to resident in care: Regarding the allegation stated above LPA conducted interviews with Staff #1, S#2, and Staff #3, who informed LPA that on 11/19/2023 Resident #1 was transported to local hospital for further evaluation regarding R#1 being weak and not eating. LPA requested for documentation pertaining to Resident #1 during review of record LPA discovered that after R#1 discharge R#1 was prescribed Cephalexin (Keflex 500 Mg) to take twice a day for five (5), days for UTI. Based on R#1 medication list R#1 completed treatment. In addition, during further record review LPA observed that resident was diagnosed with urinary tract infection, and weakness, no indication of dehydration was listed as a diagnosis for Resident #1. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated. Unsubstantiated: meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Heather O’Neel at the end of the visit.the state’s words, verbatim · CDSS document, Aug 26, 2025 · control 56-AS-20231215091035

Allegation investigated: Facility staff are not administering residents’ insulin as prescribed.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Heather O’Neel and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records. First allegation: Facility staff are not administering residents’ insulin as prescribed. Regarding the allegation LPA conducted interviews with Staff #1 and Staff #2, provided LPA with a verbal admission, that R#1 did not receive insulin medication because R#1 insulin could not be located. S#1 and S#2 informed LPA that R#1 insulin medication was later located and found to be inside Med-room refrigerator. Because R#1 insulin was not located and found several days later R#1 was not able to receive their medication as prescribed. Based on the evidence gathered during the investigation, the above allegation is Substantiated. Substantiated Second allegation: Resident did not have access to phone while in care. Regarding the allegation LPA conducted interviews with Staff#1-3 who informed LPA that resident #1 was in room #105 however, was transferred to 2nd floor Room#208 because R#1 phone/call light was not in working condition and because of that matter R#1 was relocated. LPA conducted a room inspection and observed that R#1 had access to a phone in addition, LPA inspected R#1 phone/call-light and discovered that R#1 phone was in working condition during the time of the inspection. Third allegation: Facility staff did not adequately clean resident’s bathroom. Regarding the allegation LPA conducted interviews with S#1-3 who informed LPA that on different occasions housekeeping has attempted to clean R#1 room however, R#1 refused for housekeeping to clean R#1 room. S#1-3 informed LPA that conversations with R#1 regarding safety precautions were held however, staff indicated that R#1 refused. LPA conducted a walkthrough in R#1 room LPA observed room to be in standard LPA inspected R#1 bathroom and observed bathroom to be in standard in addition, LPA observed that all bathroom fixtures were in working condition. LPA conducted interviews with Staff #1-3 who informed LPA that residents rooms along with bathrooms get cleaned daily. LPA conduced interviews with Resident #2-4 regarding housekeeping and all residents informed LPA that they have no issues pertaining to their bathrooms or rooms. R#2-4 informed LPA that their bathrooms get cleaned daily by housekeeping. Fourth allegation: Facility is in disrepair. Regarding the allegation stated above LPA conducted a walkthrough of the facility first and second floor, during the walkthrough LPA observed facility to be clean and free of clutter. During the walkthrough LPA observed that the inside of the facility was in good repair LPA observed that all safety features in the facility were in working condition. LPA conducted a walkthrough of the outer perimeter of the facility and observed that the outer perimeter was in good repair. Fifth allegation: Facility staff did not follow resident's diabetic diet. Regarding the allegation LPA conducted interviews with S#1-3 who informed LPA that R#1 was on a diet order based on resident diabetic diet. S#1-3 informed LPA that InnoVage would send the facility a new diet order if any changes will occur. S#1-3 informed LPA that meal orders are provided to kitchen who then follow all resident’s meal plans based on each resident[s] requirements. During review of records LPA observed that R#1 was on a regular texture with a diabetic plan. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated. Unsubstantiated: meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Heather O’Neel at the end of the visit. Substantiated; A finding that the complaint is Substantiated means that the residents’ is valid because the preponderance of the evidence standard has been met. Title 22 regulations 87465(a)(2), incidental medical and dental care from division 6, chapter, article 6, is being cited on the attached LIC 9099 D. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights to Facility Administrator Heather O’Neel.the state’s words, verbatim · CDSS document, Aug 20, 2025 · control 56-AS-20240416172928

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Aug 21, 2025

Incidental Medical and Dental Care (a) ....A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:.....(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 evidence by: Based on observation, interviews, and record review, the licensee did not ensure to follow "Incidental Medical and Dental Care" for R#1 who did not receive medication on time, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: Licensee has agreed to read over the Incidental Medical and Dental Care(a)(2) and provide training on medication management along with the storing of medication. Training will be emailed and provided to LPA Guerrero by POC date 8/29/2025.

Allegation investigated: Staff allowed resident to become dehydrated while in care. Staff did not prevent outbreak of covid. Staff did not report a change in resident's condition to resident's responsible party. Staff did not provide adequate care to resident while in care.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Heather O’Neel and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records. First allegation: Staff allowed resident to become dehydrated while in care. Regarding the allegation LPA conducted interviews with Resident #2-5 regarding the allegation listed above all residents informed LPA that facility has water available to all residents. In addition, resident #2-5, informed LPA that facility has water dispensers available throughout the facility, and that water is also provided upon residents’ request. LPA conducted interviews with Staff #1-5, regarding the allegation stated above, and staff #1-5 informed LPA that there is a total of three (3), water stations available to residents and that water is also available upon residents’ request. Furthermore, staff #1-5 also informed LPA that pitchers of water are provided, to assist residents when taking medication. Unsubstantiated Second allegation: Staff did not prevent outbreak of covid. Regarding the allegation LPA conducted interviews with Resident #2-5 regarding the allegation “Staff did not prevent outbreak of covid.” And Resident #2-5 informed LPA that staff conduct COVID testing on residents that are exhibiting COVID symptom’s residents informed LPA that residents are quarantined during positive readings. Resident #2-5 further explained that staff are wearing masks and housekeepers disinfect all COVID areas. Resident #1 informed LPA that although facility cleans and disinfects that it is difficult to prevent COVID because residents attend their PACE Program “InnoVage” and go out and visit their families, and later come back sick or test positive due to outside exposure. LPA conducted interviews with Staff #1-5 regarding the allegation, and all staff informed LPA that during a COVID-19 positive reading that all staff are informed and wear the Proper Protective Equipment (PPE), to help minimize the spread. In addition, Staff #1-5 informed LPA that all common areas are disinfected by housekeepers and residents are quarantined. In addition, staff also informed LPA that during exposures or outbreaks facility will conduct COVID rapid testing every two days to help detect new COVID cases. In addition, staff informed that all cases would be reported to CCL Regional Office and Department of Public Health. Third allegation: Staff did not report a change in resident's condition to resident's responsible party. Regarding the allegation stated above LPA conducted an interview with Staff #6 regarding Resident #1 LPA requested documentation pertaining to R#1 upon the review of documentation LPA observed Doctor’s communication notes pertaining to Resident #1 and resident change of condition. In addition, during further review of Resident #1 records LPA observed that special incident reports (SIR), were documented and reported to Resident #1 Responsible Party. Fourth allegation: Staff did not provide adequate care to resident while in care. Regarding the allegation LPA conducted interviews with Resident #2-5 regarding the allegation listed above and R#2-5 informed LPA that facility staff provide the necessary care that meets their needs. In addition, R#2-5 informed LPA that they have no concerns to report regarding to their care. LPA conducted interviews with Staff #1-3 regarding the allegation and staff #1-3 informed LPA that staff ensures that residents care needs are always provided. In addition, Staff #1-5 informed LPA that they have not witness staff deny or retain care to any resident in care. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated. Unsubstantiated: meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Heather O’Neel at the end of the visit.the state’s words, verbatim · CDSS document, Aug 11, 2025 · control 56-AS-20240830134517

Allegation investigated: Staff did not safeguard resident's personal item. Staff did not prevent a resident from sustaining falls while in care. Staff did not prevent residents from engaging in an altercation. Staff did not respond to resident's call light.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Business Office Manager Reyna Figueroa and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records. First allegation: Staff did not safeguard resident's personal item. Regarding the allegation LPA conducted an interview with Resident#1 pertaining to the allegation R#1 informed LPA that resident does not know if resident’s cellphone was misplaced, lost, or stolen. Resident #1 informed LPA that resident shares a room, however, resident#1 does not know if roommate or staff might have taken R#1 cellphone as R#1 has not witnessed any theft. Resident #1 informed LPA that resident has a designated area where resident stores their personal items. LPA conducted a review of R#1 records during the review of records LPA observed an inventory sheet that lists all valuable items pertaining to R#1. In addition, LPA observed that the facility has a Loss/and theft program to be in place. Unsubstantiated Second allegation: Staff did not prevent a resident from sustaining falls while in care. Regarding the allegation LPA conducted a review of records pertaining to Resident #1 during the review of records LPA discovered that R#1 was considered a fall risk. LPA observed that R#1 had a fall risk sign in resident room to keep staff informed. Based on documentation LPA discovered that 15-30minute round checks are implemented for residents who are listed as fall risk. addition, LPA discovered that R#1 utilizes a walker to ambulate. Furthermore, during the review of record LPA discovered that resident sustained a few falls on different occasions. LPA observed that last fall occurred on 6/11/2025 while resident was out with family. LPA conducted interviews with staff and staff informed LPA that resident does not call for help when needed, in addition, staff informed LPA that Resident #1 does not comply with directions when it comes to asking for assistance. Third allegation: Staff did not prevent residents from engaging in an altercation. Regarding the allegation LPA conducted interview with Resident #1 regarding the allegation listed R#1 informed LPA that Resident #1 was upset and smacked her hand which caused residents phone to shatter. In addition, Resident #1 informed LPA that resident does not get along with R#2 and both residents argue constantly. LPA conducted an interview with Resident #2 who informed LPA that R#1 was bothering R#2 and had enough and smacked R#1 hand. R#1 and R#2 informed LPA that management has offered residents to be relocated to another room and both R#1 and R#2 declined and stated that they liked their room and don’t want to be relocated. LPA conducted interviews with staff#1 and Staff #2 who informed LPA that conversations were held with both residents who were made aware that aggressive behavior will not be tolerated, and a 30-day notice will be issued if such behaviors continued. Fourth allegation: Staff did not respond to resident's call light. Regarding the allegation listed above LPA conducted an interview with R#1 who informed LPA that staff take over 30 minutes to respond to residents call light. LPA conducted interviews with R#3 R#4, and R#5 who informed LPA that they have no issues regarding staff not responding to their calls R#4 informed LPA that the longest resident has waited was 40-minutes. R#4 informed LPA that resident feels safe and has no issues to report at the time. LPA conducted Interviews with Staff #3 and Staff #4 who informed LPA that staff always respond to resident’s calls. Staff#2 also informed LPA that during busy times or during certain incidents staff will take a little longer but will respond within 35-minutes. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated. Unsubstantiated: meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Business Office Manager Reyna Figueroa at the end of the visit.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 56-AS-20250418130652

Allegation investigated: Staff neglect resulted in resident falling. Staff did not ensure resident’s room was adequately cleaned. Staff did not ensure resident’s room was free from odors. Staff did not safeguard resident's personal belongings. Staff did not assist resident with personal hygiene care.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Business Office Manager Reyna Figueroa and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records. First allegation: Staff neglect resulted in resident falling. Regarding the allegation listed above LPA conducted a review of records pertaining to Resident #1 during the review of records LPA discovered that R#1 sustained an unwitnessed fall on 9/25/2024, based on report R#1 was later transported to local hospital for treatment. During further investigation LPA observed that R#1 has not sustained no falls since initial fall that occurred on 9/24/2024. LPA conducted an interview with Resident#1 pertaining the allegation stated above R#1 informed LPA that during the fall resident was attempting to lean to the side and went a little to far and that is when resident sustained the fall. Resident #1 informed LPA that staff neglect was not the reason R#1 sustained the fall but rather an accidental fall. Unsubstantiated Second allegation: Staff did not ensure resident’s room was adequately cleaned. Regarding the allegation “Staff did not ensure resident’s room was adequately cleaned” Prior to the start of LPA’s interview LPA observed two housekeepers cleaning R#1 room. LPA conducted interviews with both housekeepers who informed LPA that R#1 room gets cleaned daily. During the time of the visit LPA observed that R#1 room was clean and organized. LPA conducted an interview with Resident #1 who informed LPA that housekeeping services are done daily and has no concerns pertaining to housekeeping services at the facility. Third allegation: Staff did not ensure resident’s room was free from odors. Regarding the allegation “Staff did not ensure resident’s room was free from odors” Prior to the start of LPA’s interview LPA observed two housekeepers cleaning R#1 room. LPA conducted interviews with both housekeepers who informed LPA that R#1 room gets cleaned daily and as needed. LPA conducted an interview with Resident #1 who informed LPA that housekeeping services are done daily and has no concerns pertaining to housekeeping services. However, R#1 informed LPA that resident’s roommate is not clean and at times refuses to be changed and at times the room can hold a strong urine odor. During the time of the visit LPA observed that R#1 room was clean, organized, and free of odors. Fourth allegation: Staff did not safeguard resident's personal belongings. Regarding the allegation “Staff did not safeguard resident’s personal belongings” LPA conducted an interview with Resident #1 pertaining to the allegation stated above Resident #1 informed LPA resident is not aware of the items that might have been misplaced R#1 informed LPA that resident has not witnessed anyone take residents personal belongings. Resident #1 informed LPA that resident had misplaced TV remote however, resident informed LPA that the remote was replaced and has not been misplaced since. Resident informed LPA that resident has no issues or concerns regarding resident’s belongings. Fifth allegation: Staff did not assist resident with personal hygiene care. Regarding the allegation stated LPA conducted an interview with Resident #1 pertaining to the allegation stated above during the investigation R#1 informed LPA that resident has no concerns regarding facility not meeting residents’ personal hygiene. Prior to LPA conducting her interview LPA was waiting outside residents’ room because resident was being dressed and change by care staff. During the interview with R#1 resident informed LPA that care staff change residents briefs daily and as needed. Resident informed LPA that during the day resident can utilize the restroom but require supervision due to resident’s vision impairment. During review of record LPA observed that Resident #1 is under SCAN Health Plan and receives in-house care by SCAN. LPA obtained a copy of Resident#1 shower schedule and observed that R#1 receives showers twice a week (Wed and Sat). Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated. Unsubstantiated: meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Business Office Manager Reyna Figueroa at the end of the visit.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 56-AS-20250210141739

Allegation investigated: Licensee is financially abusing resident(s) in care. Staff do not respond to residents' requests for assistance as necessary. Staff do not accord dignity to resident(s) in care.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Business Office Manager Reyna Figueroa and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records. First allegation: Licensee is financially abusing resident(s) in care. Regarding the allegation stated above LPA conducted an interview with Business Office Manager who informed LPA all rent payments are received and processed by facility Business Office Manager (BOM). Business Office Manager informed LPA that all residents receive a proof of payment and upon request. In addition, BOM explained to LPA that all residents receiving SSI at the end of the year receive a 2.5-percent cost of living increase deemed by social security. BOM further explained that due to the cost-of-living increase residents rents get impacted (increased). LPA conducted interviews with four residents and four out of four residents informed LPA that they have not witnessed residents getting financially abused. Unsubstantiated In addition, four out of four residents informed LPA that they have not had any issues with facility increasing rent charges without residents’ knowledge. Four out of four residents informed LPA that they provide checks, cash, debit, or credit as a form of payment and all residents informed LPA that they receive a receipt upon completion of payment. Resident #2 informed LPA that residents often deny a copy of payment receipt. Second allegation: Staff do not respond to residents' requests for assistance as necessary. Regarding the allegation LPA conducted interviews with residents and four out of four residents informed LPA that Business Office Manger provides assistance when needed and available. Residents denied staff refusing to help residents when needing to pay rent in addition, four out of four residents also denied witnessing staff tell residents that they are being too busy. Four out of four residents informed LPA that the person who handles all rent transactions is friendly and that they or have not had any issues. LPA conducted interviews with staff and three out of three staff denied the allegation and informed LPA that assistance is provided to all residents when needed. Third allegation: Staff do not accord dignity to resident(s) in care. Regarding the allegation LPA conducted interviews with four residents pertaining to the allegation “staff does not accord residents with dignity” four out of four residents denied witnessing staff being rude to residents. In addition, four out of four residents also denied witnessing staff to deny residents with assistance when needed. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated. Unsubstantiated: meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Business Office Manager Reyna Figueroa at the end of the visitthe state’s words, verbatim · CDSS document, Jun 6, 2025 · control 56-AS-20250213100958

Allegation investigated: Resident sustained multiple falls due to lack of supervision.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Heather O’Neel and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records. First allegation: Resident sustained multiple falls due to lack of supervision. Regarding the allegation listed above LPA collected documentation pertaining to R#1. During the review or R#1 documentation LPA discovered that R#1 was able to ambulate via walker, and facility caregivers will assist as needed. On 7/12/2024, and 7/13/2024, R#1 sustained two unwitnessed falls in which paramedics were notified and transferred R#1 to be treated. Based on R#1 needs, and service plan R#1 was receiving escorting as needed as well as observation checks every two hours. LPA conducted interview with R#2 who denied pushing R#1 or being aggressive towards any other residents. R#2 reported not witnessing R#1 being pushed or mistreated by any other residents in care. Unsubstantiated LPA collected incident reports pertaining to R#2 and observed that no incidents involving physical aggression towards other residents have been reported for R#2. LPA collected facility personnel report and observed that facility has sufficient care staff to meet resident care needs. LPA interviewed R#3, R#4, and R#5, and all indicated not witnessing R#1 being pushed or mistreated by any residents. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated. Unsubstantiated: meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Heather O’Neel at the end of the visit.the state’s words, verbatim · CDSS document, Feb 7, 2025 · control 56-AS-20240716144230

Allegation investigated: Facility is not meeting resident care needs

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Heather O’Neel and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records. First allegation: Facility is not meeting resident care needs. Regarding the allegation “Facility is not meeting resident care needs” LPA conducted an interview with Resident #1 Responsible Party who informed LPA that R#1 had developed a bad diaper rash on 9/14/2024. Resident #1 Responsible Party stated to LPA that R#1 had developed a diaper rash because R#1 was left on a soiled diaper for a long period of time. LPA received photograph pictures of R#1 during review of photos LPA observed that R#1 appeared to have a rash and redness around R#1 groin area. Based on the interviews and evidence gathered the above allegation is Substantiated. Substantiated Substantiated: A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, 87411 (a) Personnel Requirements – General, from division 6, chapter, article 6, is being cited on the attached LIC 9099 D. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights. to Facility Administrator Heather O’Neel. Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed, and appeal rights were provided to Facility Administrator Heater O'Neel.the state’s words, verbatim · CDSS document, Jan 22, 2025 · control 56-AS-20240916135423

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jan 29, 2025

Personnel Requirements – General 87411 (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. 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 evidence by: Based on observation, interviews, and record review, Licensee did not ensure R#1 basic needs to be met, which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 22, 2025

Plan of correction: Administrator has agreed to conduct a training and review Personnel Requirements – General 87411 (a) regulation with all Care Staff. Administrator will provide a copy of completed training signed by all staff and emailed to LPA by POC date 1/29/25.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Paola Guerrero and Beena Singh made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs met with Facility Administrator Heather O'neel and was granted entry to the facility. At the time of the visit there was The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (99) current census (93). LPAs was accompanied by Facility Administrator, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPAs inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside 2nd floor Med-Room inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPAs reviewed six (6) resident files for admission agreements, updated physician reports, and needs and services plans. LPAs also reviewed six (6) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Heather O'neel.the state’s words, verbatim · CDSS document, Nov 6, 2024

Allegation investigated: Staff do not ensure resident records are properly maintained. Facility does not ensure staff follow infection control requirements. Staff do not ensure residents medications are properly stored and secured .

Licensing Program Analysts (LPAs) Paola Guerrero and Beena Singh conducted an unannounced visit to deliver findings on the allegations listed above. LPAs met with Administrative Assistant Reyna Figueroa and explained the purpose of the visit. The investigation consisted of interviews and review of records. First allegation, Staff do not ensure resident records are properly maintained. Regarding the allegation “Staff do not ensure residents records are properly maintained” LPA Guerrero conducted a record inspection in facilities Med-room LPA observed med-room to be locked. Med-room was opened by Staff #1. LPA observed that all Residents records were filed in a secured and designated area. LPA inspected MAR record along with residents’ medication card and observed medication to be dispensed and recorded properly by staff. Unsubstantiated Second allegation, Facility does not ensure staff follow infection control requirements. Regarding the allegation “Facility does not ensure staff follow infection control requirements” LPA conducted interviews and review of records based on review of records LPA discovered that facility does not have any current incident reports regarding scabies. LPA observed facility to have an infection control plan in place on how to properly asses’ contagious outbreaks or cases such as scabies. Facility Administrator informed LPA that facility currently does not have anyone being treated or exposed to scabies. Third allegation, Staff do not ensure residents medications are properly stored and secured. Regarding the allegation “Staff do not ensure residents medications are properly stored and secured” LPA conducted a medication inspection in facilities Med-room office LPA observed med-room to be locked and opened by Staff #1. During med inspection LPA asked Staff #1 to unlock med cart, LPA observed residents’ medication to be locked and secured in med cart. In addition, LPA observed PRN medication to be locked and secured in med cart. LPA inspected MAR record along with residents’ medication cards and observed medication to be dispensed and recorded properly by staff. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated. Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Administrative Assistant Reyna Figueroa at the end of the visit.the state’s words, verbatim · CDSS document, Sep 20, 2024 · control 56-AS-20240610140357

Allegation investigated: Staff did not treat resident with respect. Staff slapped resident.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Rebecca Parra and explained the purpose of the visit. The investigation consisted of interviews and review of records. First allegation, Staff did not treat resident with respect. During the course of the investigation, interviews were conducted, a review of resident (R1) records was completed and copy of pertinent documents were obtained. Regarding the alleged allegation, staff did not treat resident with respect. interviews with staff were conducted and all staff denied mistreating resident[s] or violating resident[s] rights in addition, staff also denied witnessing staff mistreat or violate resident[s] rights. Interviews with residents were conducted where 4 out five residents denied being mistreated or their personal rights to be violated by staff. In addition, four residents denied witnessing staff mistreating or violating resident (R1) rights. Unsubstantiated Second allegation, Staff slapped resident. During the course of the investigation, interviews were conducted, regarding the alleged allegation, staff slapped resident. interviews with staff were conducted and all staff denied mistreating resident[s] or physically assaulting resident[s] in care, in addition, staff also denied witnessing other staff mistreat or physically assault resident[s] in care. Interviews with residents were conducted where 4 out five residents denied being mistreated or physically assaulted by staff. In addition, four residents denied witnessing staff mistreat or physically assault (R1). Based on the corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated. Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Rebecca Parra.the state’s words, verbatim · CDSS document, Jun 20, 2024 · control 56-AS-20240416115905

Allegation investigated: Staff did not properly address resident's multiple falls resulting in injuries.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Administrator Rebecca Parra and explained the purpose of the visit. The investigation consisted of interviews and review of records. First allegation, Staff did not properly address resident's multiple falls resulting in injuries. During facility record review LPA found that Resident #1 sustained two falls on 1/16/2024 and on 4/1/2024. Both falls in which Resident #1 received medical treatment. Records also revealed that after Resident #1 last fall the facility updated Resident #1 Needs and Service along with resident’s care plan that addressed the preventative measures that the facility has in place for Resident #1 to prevent continuation of falls. LPA obtained a copy of the facilities current roster and observed that facility has sufficient staffing support to meet resident’s needs. Unsubstantiated Based on the evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated. Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Rebecca Parra.the state’s words, verbatim · CDSS document, Apr 19, 2024 · control 56-AS-20240405124933

Allegation investigated: Staff serve food that is of poor quality.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Administrator Rebecca Parra and explained the purpose of the visit. The investigation consisted of interviews and review of records. First allegation, Staff serve food that is of poor quality. LPA observed and inspected the quantity and quality of food on (2) separate facility visits. LPA conducted interviews with kitchen staff. LPA conducted a review of food service of meals served. LPA collected a copy of the current menu, along with the alternative menu. LPA collected a copy of the internal food temperature logs and food handlers training certificates. LPA toured the facility and observed the meals that are being served reflected on what was on the menu for the week. LPA observed food to be of adequate quality. Meals appeared to be fresh and balanced. Unsubstantiated Based on the evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated. Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Rebecca Parra.the state’s words, verbatim · CDSS document, Apr 19, 2024 · control 56-AS-20240325145341

Type of visit: Prelicensing

Licensing Program Analysts (LPA) Paola Guerrero conducted an announced pre-licensing visit to facility. LPA met with Operations Manager Eli Goldman. The pending application is for a Residential Care Facility for Elderly (RCFE) capacity (99) current census (80). Operations Manager accompanied LPA on a tour of the inside and outside of the facility. The physical plant, in general, was in good repair. The buildings and grounds are free from hazards. The indoor and outdoor passageways are free of obstruction. There are no pools, bodies of water, firearms, or ammunition. All residents bedrooms are furnished with a bed, nightstand, dresser, and chair. All bedrooms have adequate lighting for resident use. Bathroom's toilet, shower and tubs are in good repair and have non-skid mats. LPA measured and observed the water temperatures in the bathrooms to be at 105.3 degrees F. All appliances are clean and operating properly. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present. Facility yard is completely enclosed with functioning gate with alarm system to exit to front yard. The outdoor space is suitable for client use. LPA observed fully charged fire extinguisher present in the facility. Smoke alarms and carbon monoxide are present and functional. Facility has a designated area (Med-Room) where medications are stored and locked. The facility had a designated area where staff and resident records are stored. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There is adequate seating in the common areas. Facility had a supply of activities for the clients. Pre-licensing inspection is complete, and no corrections are needed to be made. The Comp III presentation was completed during today's visit. An exit interview was conducted, and a copy of this report was provided to Operations Manager Eli Goldman.the state’s words, verbatim · CDSS document, Nov 15, 2023