Mainplace Senior Living

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr made an unannounced case management visit in conjunction with Unusual Incident/Injury Report (UIIR) dated August 24, 2026. LPA was greeted and granted entry by Executive Director (ED) Rhonwinn Hipolito. LPA explained the reason for the visit. Per UIIR, on August 23, 2026, Resident 1 (R1) exited the Memory Care through the doors adjacent to the Medication Technician (MT) station. Per UIIR, it appeared that R1 exited the secure area while a visitor was entering the unit. Per UIIR, Police located R1 on the La Veta bridge, located behind the community. During today's visit LPA reviewed the Physician Report (LIC602A) dated May 26, 2026, for R1. Per Physician Report, R1 is unable to leave facility unsupervised. A Health and Safety inspection was conducted, and LPA Ramirez observed no Health and Safety concerns during today's visit. An immediately $1000 Civil Penalty for Repeat Violation was issued today. Based on observations and records reviewed during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with ED Hipolito and a copy of this report and Appeal Rights were provided at the time of exit.the state’s words, verbatim · CDSS document, Aug 28, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 31, 2026

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not as evidence by: Per UIIR, on August 23, 2026, Resident 1 (R1) exited the Memory Care through the doors adjacent to the Medication Technician (MT) station. Per UIIR, Police located R1 on the La Veta bridge, located behind the community. Per Physician Report, R1 is unable to leave facility unsupervised. This poses an immediately health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2026

Plan of correction: Licensee to submit a written Plan of Action on how to prevent future Memory Care elopements. Licensee to submit POC by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr made an unannounced case management visit in conjunction with Unusual Incident/Injury Report (UIIR) dated August 17, 2026. LPA was greeted and granted entry by Executive Director (ED) Rhonwinn Hipolito. LPA explained the reason for the visit. Per UIIR, on August 17, 2026, Resident 1 (R1) was discovered missing from Memory Care at approximately 10:30 a.m. Per UIIR, R1 was located at approximately 11:00 a.m. near Fairview Ave and 5th St. During today's visit LPA reviewed the Physician Report (LIC602A) dated June 3, 2026, for R1. Per Physician Report, R1 is unable to leave the facility unassisted. A Health and Safety inspection was conducted, and LPA Ramirez observed no Health and Safety concerns during today's visit. Based on observations and records reviewed during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with ED Hipolito and a copy of this report and Appeal Rights were provided at the time of exit.the state’s words, verbatim · CDSS document, Aug 21, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 24, 2026

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Per UIIR, on August 17, 2026, Resident 1 (R1) was discovered missing from Memory Care at approximately 10:30 a.m. Per Physician Report, R1 is unable to leave the facility unassisted. This poses an immediately health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 21, 2026

Plan of correction: Licensee to submit a written plan to ensure basic services including care and supervision are provided to residents in care at all times. Licensee to submit POC by POC due date.

Allegation investigated: Facility staff mismanaged residents medication Facility staff are not preventing residents from disturbing other residents sleep schedules Facility staff did not safe guarding residents’ belongings

**This 9099 page supercedes previous 9099 page dated 08/10/2026 due to update of original allegations. On 08/13/2026, Licensing Program Analyst (LPA) contacted the licensee via email to deliver final findings regarding a complaint that was received on 09/24/2024. **Continued on 9099-C page Unsubstantiated Facility staff mismanaged residents medication Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Facility staff are not preventing residents from disturbing other residents sleep schedules Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Facility staff did not safe guarding residents’ belongings Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Facility staff did not ensure a residents was treated with dignity Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are 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. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Aug 10, 2026 · control 22-AS-20240924085800

Allegation investigated: Facility did not safeguard resident’s personal belongings Facility failed to provide care and supervision, resulting in resident developing pressure injuries Facility did not ensure daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents Facility did not provide medication as prescribed

On 08/10/2026, Licensing Program Analyst (LPA) contacted the licensee via email to deliver final findings regarding a complaint that was received on 04/30/2024. **Continued on 9099-C page Unsubstantiated Facility did not safeguard resident’s personal belongings Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Facility failed to provide care and supervision, resulting in resident developing pressure injuries Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Facility did not ensure daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Facility did not provide medication as prescribed Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is 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. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Aug 10, 2026 · control 22-AS-20240430141619

Allegation investigated: Facility did not provide personal rights which interfere with the resident’s sleep Facility staff is not responding in a timely manner Facility is understaffed

On 08/10/2026, Licensing Program Analyst (LPA) contacted the licensee via email to deliver final findings regarding a complaint that was received on 04/25/2024. **Continued on 9099-C page Unsubstantiated Facility did not provide personal rights which interfere with the resident’s sleep Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Facility staff is not responding in a timely manner Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Facility is understaffed Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is 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. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Aug 10, 2026 · control 22-AS-20240425140238

Allegation investigated: Staff did not administer medication as prescribed. Staff did not safeguard resident's medication.

On 08/10/2026, Licensing Program Analyst (LPA) contacted the licensee via email to deliver final findings regarding a complaint that was received on 12/21/2023. **Continued on 9099-C page Unsubstantiated Staff did not administer medication as prescribed. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff did not safeguard resident's medication. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is 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. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Aug 10, 2026 · control 22-AS-20231221162352

Allegation investigated: Facility did not issue a refund. Resident's furniture was in disrepair. Resident's responsible person was not informed about the change of condition.

On 08/10/2026, Licensing Program Analyst (LPA) contacted the licensee via email to deliver final findings regarding a complaint that was received on 05/08/2024. **Continued on 9099-C page Unsubstantiated Facility did not issue a refund. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Resident's furniture was in disrepair. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Resident's responsible person was not informed about the change of condition. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is 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. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Aug 10, 2026 · control 22-AS-20240508173111

Allegation investigated: Staff are not dispensing medication to resident as prescribed.

On 08/10/2026, Licensing Program Analyst (LPA) contacted the licensee via email to deliver final findings regarding a complaint that was received on 09/05/2023. Staff are not dispensing medication to resident as prescribed. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is 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. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 10, 2026 · control 22-AS-20230905215602

Allegation investigated: Resident fell and sustained an injury due to lack of supervision. Facility failed to get resident medical attention after previous fall incident.

On 08/10/2026, Licensing Program Analyst (LPA) contacted the licensee via email to deliver final findings regarding a complaint that was received on 12/11/2023. ** Continued on 9099- C page Unsubstantiated Resident fell and sustained an injury due to lack of supervision. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Facility failed to get resident medical attention after previous fall incident. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are 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. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Aug 10, 2026 · control 22-AS-20231211124535

Allegation investigated: Facility staff did not meet the personal rights of the residents.

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez. LPA met with Executive Director (ED) and Clinical Director (ED) Ruby Racca-Magao and explained the purpose of the inspection. Complaint alleges Staff 1 (S1) and Staff 2 (S2) did not meet the personal rights of the residents by discussing Resident 1's (R1’s) personal information with other residents. During the course of the investigation, interviews were conducted with three facility residents and three staff. During their interview, R1 stated S1 and S2 had informed Resident 2 (R2) and Resident 3 (R3) that they had sustained a fall due to being "drunk" or overdosing. Per R1, Staff 3 (S3) also had knowledge of the incident and had witnessed S2 and S3 informing R2 and R3 of their fall. During their interview, R2 denied the allegation and stated facility staff “are the nicest and most professional.” (Cont. LIC9099-C) Unsubstantiated Per R2, R1 personally told them they had taken “too much medicine" and forgot to set the breaks on their wheelchair leading to the fall. R2 stated that after R1 informed them of what had occurred, they told "everybody" and R1 “was upset.” R2 denied S1 or S2 ever discussing R1’s fall with them personally and denied having any knowledge of S1 or S2 ever discussing R1 or R1’s fall with other residents. During their interview, R3 denied S1 or S2 ever discussing R1’s fall with them personally and denied having any knowledge of S1 or S2 ever discussing R1 or their fall with other residents. Per R3, it had been R2 who had informed other residents that R1 had sustained a fall because of their drinking. R3 stated they have overheard staff discussing other residents and the care being provided on more than one occasion, however, R3 unable to identify the staff alleged to have been discussing residents or identify residents alleged to have been discussed. During their interview, Staff 1 (S1) denied ever discussing R1 or R1’s fall with R2 or R3 and denied ever informing R2 or R3 that R1 had been drinking or overdosed. S1 denied having any knowledge of S2 or any other staff discussing R1's or any other resident's personal information with other residents. During their interview, Staff 2 (S2) denied ever discussing R1 or R1’s fall with R2 or R3 and denied ever informing R2 or R3 that R1 had been drinking or overdosed. S2 denied having any knowledge of S1 or any other staff discussing R1's or any other resident's personal information with other residents. During their interview, S3 denied having any knowledge of S1 or S2 discussing R1 or R1's fall amongst themselves or with other residents. S3 denied witnessing or having any knowledge of S1 or S2 discussing R1's drinking with R2 or R3. Per S3, residents gossip amongst each other and that is how information about other residents spreads. Due to allegation being uncorroborated during interviews conducted, the Department is unable to determine if Facility staff did not meet the personal rights of the residents. Although the above allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore at this time the above allegation is unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, May 6, 2026 · control 22-AS-20260428141727

Allegation investigated: Staff are refusing to transport resident to pick up prescriptions. Staff did not ensure resident was transported to doctor's appointment. Staff did not ensure residents room wasn't in disrepair. Staff yell at resident. Staff did not safeguard residents food.

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of delivering findings. LPA met with Executive Director (ED) Rhon Hipolito and explained the purpose of the inspection. Regarding allegation, Staff are refusing to transport resident to pick up prescriptions, the following was revealed: It is alleged facility staff were refusing to transport Resident 1 (R1) to pick up their prescriptions. Interviews were conducted with two facility staff and six residents, including R1. During their interview, R1 stated they had requested to go to the pharmacy to pick up medication about a month ago, however, facility staff refused. Four of five additional residents interviewed denied the allegation and stated their medication is delivered from the pharmacy to the facility and per Resident 2 (R2), staff responsible for the medication “are really good” at ensuring they receive their medication. One of five residents stated they do not take any medication and were unsure how medication is transported to the facility. (Cont. LIC9099-C) Unsubstantiated During their interview, two of two staff stated the pharmacy delivers medication to the facility and in the event a resident needs a ride, they can notify staff and rides are offered on Tuesdays and Thursdays. Regarding allegation, Staff did not ensure resident was transported to doctor's appointment, the following was revealed: It is alleged R1 missed a doctor’s appointment due to a mix up in scheduling transportation. During their interview, R1 denied missing a doctor’s appointment and stated staff take them to necessary doctor’s appointments. Five of five additional residents interviewed denied the allegation and stated the doctor comes to visit them at the facility or facility staff will make arrangements. Per R2, the facility also offers rides on Tuesdays and Thursdays. During their interview, two of two staff stated there was an isolated event in which R1 did not notify staff of their appointment. Per both staff, had staff been aware of R1’s appointment, they would have been able to transport them to their appointment and stated rides are also offered on Tuesdays and Thursdays. Regarding allegation, Staff did not ensure residents room wasn't in disrepair, the following was revealed: It is alleged that upon move-in, R1’s room was not ready and still in the process of being remodeled and R1 did not have water or a sink for a few days. During their interview, R1 stated that upon moving into the facility, there were boxes all over the room because it was still being painted, and their television did not work. Resident 4 (R4) and R1 moved into the facility on the same date and were placed in rooms directly next to one another. During their interview, R4 denied anything in their room being in disrepair upon moving in, including their television. Four of four additional residents interviewed denied their room being in disrepair upon moving in and stated their television has been and continues to be operable. During their interview, two of two staff denied having any knowledge of anything in R1’s room or any other resident’s room being in disrepair upon moving in. Regarding allegation, Staff yell at resident, the following was revealed: It is alleged an unknown staff member yelled at R1. During their interview, R1 stated that after staff refused to transport them to the pharmacy, “one lady” looked at them and stated they could “walk over there.” R1, however, was unable to identify the individual or any other staff alleged to have yelled. Five of five additional residents interviewed denied personally being yelled at by staff and denied witnessing or having any knowledge of any other resident being yelled at by staff. Per R3, “on the contrary. They are very friendly and very helpful.” During their interview, two of two staff denied personally yelling or having any knowledge of any other staff yelling at a resident. (Cont. LIC9099-C) Regarding allegation, Staff did not safeguard resident’s food, the following was revealed: It is alleged an unknown staff member threw R1’s food away, which was placed in a facility fridge. During their interview, R1 was unable to confirm or deny the allegation and stated the only food they eat is what is provided by the facility. During their interview, R3 stated that at mealtimes they “eat everything on [their] plate” and have never had leftovers or food that needs to be safeguarded. Four of five additional residents interviewed stated they are provided with meals by the facility and if they have leftovers, the facility provides leftover containers, and they are able to bring them to their bedroom and eat them at their own discretion. Two of two staff denied having any knowledge of staff not safeguarding any resident’s food. Due to allegations being uncorroborated during interviews conducted, the Department is unable to determine if Staff were refusing to transport resident to pick up prescriptions, if Staff did not ensure resident was transported to doctor's appointment, if Staff did not ensure residents room wasn't in disrepair, if Staff yell at resident, or if Staff did not safeguard residents food. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore at this time the above allegations are unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Mar 13, 2026 · control 22-AS-20221129145306

Allegation investigated: Staff refused to administer medication to resident

On December 16, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Wellness Coordinator (WC) Ervin Nario later arrived to assist with the visit. During the course of the investigation, the Department inspected the facility, interviewed residents and staff, reviewed and obtained pertinent documents to the complaint such as current staff roster, current resident roster, and resident records. Regarding the allegation that, staff refused to administer medication to resident, the following has been concluded: It was alleged that a facility staff, Person #1 (P1) refused to administer medication to Resident #1 (R1). However, the Department observed that P1 was not an employee at the facility and the facility did not have any record of P1 ever being a staff at the facility. The Department conducted an interview with R1 who denied the allegation and stated that staff never refused to administer her medication. CONTINUED ON LIC9099-C Unfounded R1 stated that there was an incident where she became upset with a facility staff because they ran out of one of her medications, however, they were able to do an emergency refill with the Pharmacy and she has not had any issues since. The Department additionally conducted five resident interviews. Five out of the five residents interviewed denied any issues with their medication and denied staff ever refusing to administer their medication. All five residents interviewed stated that they receive their medication on time and that they do not have any concerns about the staff administering the medication. The Department also conducted four staff interviews. Four out of the four staff interviewed denied ever observing or witnessing a staff refusing to administer medication to a resident. The Department observed that there was an Unusual Incident/Injury Report (UIIR) received by the Orange County Regional Office on June 6, 2023. The UIIR contradicts the complaint allegation and describes R1 being verbally and physically to staff due to her Primary Care Physician (PCP) being unable to order her medications. Based on the evidence gathered during this investigation, the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis. An exit interview was conducted with Wellness Coordinator Ervin Nario and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 22-AS-20230630114211

Allegation investigated: Staff did not ensure resident's toileting equipment was emptied in a timely manner. Staff did not safeguard resident's personal belongings. Staff did not ensure resident’s assistive equipment needs were met. Staff did not properly transfer resident. Staff did not assist resident with wound care in a timely manner.

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above for the purpose of delivering findings. LPA met withExecutive Director (ED) Rhon Hipolito and Clinical Director (CD) Ruby Racca-Magao, and Business Office Manager Briana Garcia and explained the purpose of the inspection. Interviews were conducted with eleven facility residents and three facility staff regarding the allegation, Staff did not ensure resident's toileting equipment was emptied in a timely manner. During their interview, R1 stated they use a "urinal for men", which is essentially a plastic 32oz bottle. Per R1, when using the facility signal system, it would take staff 15 minutes to 30 minutes to respond and if R1 did not call, the urinal would sit in their room without being emptied all day. Two of ten additional facility residents interviewed were unable to confirm or deny the allegation and eight of ten residents stated staff is responsive to their toileting needs and assist them as needed in a timely manner. During their interview, three of three staff denied the allegation and stated residents are assisted with toileting needs in a timely manner. (Cont. LIC9099-C) Unsubstantiated Per three of three staff, it is facility protocol to empty all toileting equipment, whether it is full or not, two to three times per shift. Regarding the allegation, Staff did not safeguard resident's personal belongings, the following was revealed: It is alleged staff did not safeguard R1’s wheelchair leg supports. Interviews were conducted with eleven facility residents and three facility staff. During their interview, R1 stated that on August 17, 2025, they were wheeled to breakfast by Staff 2 (S2). Per R1, they requested that S2 take their wheelchair leg supports off. S2 complied and the leg supports were placed in R1’s room. Per R1, upon returning to their room, the leg supports were still there, however went missing later the same day. Per R1, after reporting their leg supports were missing, the facility replaced them with "almost identical" ones. Two of ten additional facility residents interviewed were unable to confirm or deny the allegation and eight of ten facility residents denied having anything missing or having any stolen items, including wheelchair leg supports, or any other ambulating assistive device. During their interview, S2 denied the allegation and stated they were not aware R1 had been missing their wheelchair leg supports. During their interview, S3 stated R1’s wheelchair leg supports were immediately replaced upon R1 reporting them missing, however, were later found to have been in R1’s bedroom all along. Regarding the allegation, Staff did not ensure resident’s assistive equipment needs were met, the following was revealed: It is alleged R1’s did not receive a hospital bed with half bed railing, and air mattress. During their interview, R1 stated Kaiser provided them with a hospital bed with bed railings and an air mattress, however these items were never provided to R1 at the facility. During the course of the investigation, Kaiser was contacted, and a Kaiser Representative (KR) confirmed a hospital bed with half side rails and mattress had been ordered for R1 on August 20, 2025. Per KR, these items would have been delivered by third-party vender, Apria. During their interview, Apria Representative (AR) confirmed a hospital bed with half side rails and mattress had been ordered for R1, however stated the order had been received on September 20, 2024, and stated a delivery order for R1 had not been placed by Kaiser in the year 2025. AR confirmed delivery address as that of the facility, however, R1 was not admitted to the facility until August 13, 2025. During their interview, three of three facility staff denied any knowledge of Kaiser providing R1 with a hospital bed with railings and/or an air mattress. Interviews were conducted with eleven facility residents and three facility staff regarding the allegation, Staff did not properly transfer resident. (Cont. LIC9099-C) During their interview, R1 stated that during transfers they were able help themselves sit up in bed and facility staff would then pull them up by their undergarment and shorts. Per R1, upon staff doing this the thread on their clothing would start to audibly tear and the undergarment cut into the skin on their inner thighs. R1 stated that this did not cause an injury to them but could easily have. Two of ten additional facility residents interviewed were unable to confirm or deny the allegation, five of ten residents denied the allegation and stated staff assist them with transfers in a gentle manner, and two of ten residents stated they are not assisted with transfers and denied witnessing staff assisting other residents with transfers. During their interview, three of three staff stated pulling a resident by their undergarment or shorts is not part of a typical transfer, however, does occur in emergency instances, such as preventing a resident from falling during a transfer. Regarding the allegation, Staff did not assist resident with wound care in a timely manner, the following was revealed: It is alleged R1 was not assisted with wound care in a timely manner leading to wound developing maggots.During their interview, R1 stated they have wounds on their legs due to their medical condition and their wounds are treated and bandaged by Home Health. R1 was unable to provide specifics regarding the dates and times they were seen by Home Health. Per R1, about a week went by and they had not seen anyone from Home Health nor had the facility staff treated or re-bandaged their legs, when they observed a fly on their bandage. Per R1, S3 saw the fly and instructed S1 to open the bandages and maggots came out. R1 stated S3 dressed and cleaned their wounds and made sure there were no more. Per R1, on August 28, 2025, they decided to go to the hospital and was provided with wound care and given anti-biotics. During the course of the investigation, Excell Home Health was contacted, and Excell Representative (ER) stated R1 had been seen by a Home Health Nurses on August 21, 2025 and on August 26, 2025 for wound care. Per ER, R1 had also been seen on August 28, 2025, however, their notes did not specify if wound care had been provided at that time. LPA attempted to contact Home Health Nurse, Witness 1 (W1), who provided wound care for R1 on August 21, 2025 on three separate occasions, however, W1 could not be reached to confirm or deny allegation. LPA attempted to contact Home Health Nurse, Witness 2 (W2), who provided wound care for R1 on August 26, 2025 on three separate occasions, however, W2 could not be reached to confirm or deny allegation. During their interview, S1 stated that on August 28, 2025, they had observed a fly on R1’s leg wound bandage and upon removing it, maggots were observed. Per S1, R1 spent most of their time outside and they believe a fly flew into R1’s bandage sometime on August 27, 2025, which led to the rapid development of maggots. (Cont. LIC9099-C) During their interview, S3 stated R1 was seen by a Home Health Nurse on August 26, 2025 and was provided with wound care. Per S3, on the morning of August 28, 2025, R1 reported discomfort to the wound on their leg and upon S1 removing the bandage, maggots were observed. R1 was immediately transferred to the hospital. S3 stated a Home Health Nurse had been present at the time, however had not provided wound care due to R1 being transported to the hospital. Per facility progress notes, on the morning of August 28, 2025, R1 was provided with wound care and transferred to a local area hospital for further evaluation. Based on record review of R1’s facility progress notes and due to allegations being uncorroborated during interviews conducted, the Department is unable to determine if Staff did not ensure resident's toileting equipment was emptied in a timely manner, if Staff did not safeguard resident's personal belongings, if Staff did not ensure resident’s assistive equipment needs were met, if Staff did not properly transfer resident or if Staff did not assist resident with wound care in a timely manner. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore at this time the above allegations are unsubstantiated. An exit interview was conducted and copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 22-AS-20250826142151

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Executive Director (ED) Rhon Hipolito and Clinical Director (CD) Ruby Racca-Magao, and Business Office Manager Briana Garcia and explained the purpose of the inspection. During the inspection, LPA and Staff Abenzer Zeleke conducted a tour of the inside and outside of the facility common areas and resident rooms, and observed the following: The facility consists of a single-story building used for memory care and assisted living and an additional attached two-story building used solely for assisted living. An evacuation chair was observed at the top of every stair way. Select resident rooms were inspected and all were observed to have the required furnishings. LPA observed all resident beds had linens and blankets. Signal system was tested and observed to be operable. There are three courtyards with multiple shaded sitting areas. LPA observed residents socializing in common areas and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 103.4-118.5 degrees Fahrenheit. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. There is a fire extinguisher located at the end of every facility hallway. Fire extinguishers were observed to be fully charged with service tags dated September 5, 2025. Facility kitchen appliances were inspected and observed to be operable. Laundry washer and dryer were also observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication was observed to be centrally stored and locked in medication carts. LPA reviewed select resident files and staff files. LPA interviewed eleven residents and four staff. (Cont. LIC809-C) Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 6, 2025

Type of visit: Office

At this Informal Conference present were Clinical Director Ruby Racca Magao, California Market Leader Ann Zavela, and California Clinical Market Leader Roanne Delos Reyes. Representing the Department were Regional Manager (RM) Marina Stanic and Licensing Program Analysts (LPAs) Claudia Gutierrez and Rose Ruppert. The following was discussed: • Administrative Organization • The Department’s consultation role The following was agreed upon: • Facility will provide the Department updated Administrative Organization (LIC309), Board Minutes, By laws and Articles of Incorporation by Monday, October 20, 2025 An exit interview was conducted and a copy of this report was provided to the end of the Informal Conference.the state’s words, verbatim · CDSS document, Oct 15, 2025

Allegation investigated: Facility staff did not provide adequate supervision resulting in a physical altercation between residents in care.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegation received on March 21, 2025. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Rhonwinn Hipolito. LPA explained the reason for the visit. This Department has investigated the complaint alleging that facility staff did not provide adequate supervision resulting in a physical altercation between residents in care. Regarding the allegation the following was revealed: During the course of the interviews with individuals one of eight individuals confirmed the allegation. During the course of the investigation LPA reviewed documents including the Unusual Incident/Injury Report (UIIR) dated March 25, 2025, for Resident 1 (R1). Per UIIR on March 21, 2025, R1 was involved in an unwitnessed incident. Per UIIR, R1 reported having an altercation with R2. During the course of the interviews with residents, R2 reported that he did not argue with R1 and stated that he never punched R1. CONTINUED ON LIC9099-C... Unsubstantiated Per R3, she is not aware of an altercation between R1 and R2. R3 reported that if there is an altercation between residents it is not due to staff not supervising the residents and stated that some residents are difficult. During the course of the interviews with staff, Staff 1 (S1) reported that the altercation was not due to inadequate staff supervision. Per S2, she disagrees with the statement that staff did not provide adequate supervision resulting in a physical altercation between residents in care. During the course of the interviews AD reported that the altercation was not due to lack of staff supervision. Per AD, staff reported that R2 was in bed sleeping or resting when staff walked in. During the course of the interviews with witnesses, Witness 1 (W1) reported that the facility staff provided adequate supervision and stated that he does not expect staff to be checking on R1 24 hours per day. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with ED Hipolito, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 3, 2025 · control 22-AS-20250321131529

Allegation investigated: Facility management staff is never available Food service is inadequate Facility failed to safeguard resident’s property

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on May 31, 2024. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Rhonwinn Hipolito. LPA explained the reason for the visit. This Department has investigated the complaint alleging that facility management staff is never available. Regarding the allegation the following was revealed: During the course of the interviews with individuals one of seven individuals confirmed the allegation. During the initial visit on June 7, 2024, and subsequent visits on September 26, 2025, and October 3, 2025, LPA observed that the Administrator (AD), Business Office Manager and Wellness Director were on duty. During the course of the interviews with residents, Resident 1 (R1) reported that the AD is rarely at the facility and reported that there is no backup manager. Per R2, facility staff are always available and stated that she can always get a hold of staff. R3 reported that management is available when needed and stated that management helps her when needed. CONTINUED ON LIC9099-C... Unsubstantiated Per R4, facility management is always available and reported that he has no problems. R5 stated that management staff are available and reported that he can always get a manager to help him. Per R5, he gets helped within one hour. During the course of the interviews with staff, Staff 1 (S1) reported that facility management is always available to the residents and stated that the Medication Technician (MT) is backup when management is in their all-staff meeting. During the interviews AD reported that if he is not available it is usually after hours or at night. AD reported that the management backup is the Business Office Manager and Wellness Director. Per AD, if management is in a meeting the MT will help the residents. Regarding the allegation that food service is inadequate, the following was revealed: During the course of the investigation LPA reviewed documents including the Mainplace Senior Living Menu dated June 3-9, 2024, and September 22-28, 2025. Per menu options the residents are offered a different meal for breakfast, lunch and dinner. During the course of the interviews with residents, R1 reported that the food is terrible. Per R2, the food is good and reported that she is able to get seconds. R4 reported that he has not experienced stomach issues or vomiting. Per R4, the food is great and reported that the food is nutritional. R5 stated that the food service is adequate and reported that he has not had food poisoning or vomiting due to bad food. During the course of the interviews with staff, S1 reported that the food service is adequate and stated that the meals are nutritional and include vegetables and fruit. Per S1, the food is not causing the residents to be ill. During the interviews AD reported that all meals include protein, vegetables and fruit. Per AD, no residents have complained about food poisoning or feeling ill because of the food. AD stated that the residents can order from the alternative menu. Regarding the allegation that facility failed to safeguard resident’s property, the following was revealed: During the course of the interviews with individuals one of seven individuals confirmed the allegation. It was alleged that R1 had several break ins into their bedroom, and their Blood Pressure medication was stolen. During the course of the investigation LPA reviewed documents including the Physician Report (LIC602A) dated February 13, 2020, for R1. Per Physician Report R1 is able to administer and able to store own prescription medications. During the course of the interviews with residents, R1 reported that staff entered her bedroom and stole her personal property; however, R1 could not identify the perpetrator. Per R2, she has never had anything stolen and stated that the facility safeguards the residents' property properly. R3 stated that staff always safeguard the residents' property and reported that staff do a good job by not touching the residents' property valuables. Per R4, no staff member has entered his bedroom without his consent and reported that staff have not steal from him. R5 reported that staff have not entered his bedroom to steal and stated that staff are respectful, courteous and attentive. CONTINUED ON LIC9099-C... During the course of the interviews with staff, S1 reported that she has not heard that staff have been entering the residents' bedrooms and stealing. Per S1, each resident has a key to lock their bedroom and stated that staff carry a master key in case of an emergency and/or to do Wellness checks. During the interviews AD reported no staff have stolen property or valuables from the residents. Per AD, R1 manages her own medications and stated that staff are respectful and hard working. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with ED Hipolito, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 3, 2025 · control 22-AS-20240531162520

Allegation investigated: Lack of care and supervision resulted in resident sustaining a fracture.

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility for the purpose of investigating the above mentioned complaint allegation. LPA was greeted and granted entry by staff. LPA met with Executive Director (ED) Rhon Hipolito and discussed the purpose of the visit. The investigation into the allegation of Lack of care and supervision resulted in resident sustaining a fracture revealed the following: On April 13, 2024, at approximately 6:30PM Resident #1 (R1) had an unwitnessed fall in the Memory Care unit resulting in the need of a hip replacement. R1 was admitted to the facility on December 14, 2022. Per physician report on file, R1 had no motor impairment, was non-ambulatory due to their mental condition only and was able to independently transfer. The physicians report stated that R1 was diagnosed with Dementia and that R1 is checked as yes for confused/disoriented. The physician report was not dated; however, was signed by a physician. Continue on 9099-C Unsubstantiated Facility pre-placement appraisal for R1 dated December 6, 2022, documented that R1 ambulated independently, can walk without physical assistance, are active with no physical assistance required and are able to go up and down stairs easily. R1s appraisal also stated that R1 did not need help with moving about the facility. The appraisal was signed by R1s authorized representative on December 6, 2022. LPA observed R1s service plan with an initiation date of December 28, 2022, stating that R1s mobility is marked as assistance as needed, ambulates independently, transfers independently and is ambulatory. The service plan also states that R1 is occasionally forgetful with reminders. Progress notes done by facility staff covered the dates of March 4, 2024, to April 4, 2024. The progress notes stated that there have been no changes to R1s activities of daily living or care needs in the past month. LPA observed an incident report dated April 18, 2024, stating that staff was inside the memory care dining room when they heard R1 scream. Staff immediately checked on R1 and observed a bump on R1s forehead and R1 complained of pain on their right arm. R1 stated they lost balance and fell due to someone bumping into them. The incident report stated that paramedics were called and R1 was transported to the hospital for further medical assessment and treatment. During interviews it was revealed that six of six staff stating R1 was independently ambulatory and was able to move around the facility with no assistance. Six of six staff stated that R1 did not use assisted devices when walking, such as a cane or walker. Three of six staff stated that R1 did not have a history of falls. Three of six staff stated that the memory care unit always has staff in one of the common areas of the unit. It was reported to two of six staff that on April 13, 2024, via phone call that R1 fell in the tv room outside of the dining room as the incident occurred over the weekend on their days off. It was reported to two of six staff that the closest staff was in the dining room overseeing dinner service next to the tv room when the incident occurred. It was reported to staff #1 (S1) that the resident had left the dining room during dinner service and was seen walking towards the tv room before the incident occurred. Two of six staff informed LPA that facility staff called 911 and R1 was sent to the hospital for further evaluation due to R1 hitting their head. R1 was admitted to the hospital and was diagnosed with a hip fracture. LPA attempted to contact R1s responsible party but was unsuccessful. Continue on 9099-C Although R1 sustained a fall at the facility, it remains unclear if the fall occurred due to a lack of care and supervision. Based on information gathered during the investigation the department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with ED Rhon Hipolito And a copy of this report was provided at the time of the investigation.the state’s words, verbatim · CDSS document, Sep 26, 2025 · control 22-AS-20240418131913

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit for the purpose of following up regarding Death Report received by Community Care Licensing (CCL) for Resident 1 (R1) on August 28, 2025, and to conduct a Health and Safety inspection. LPA met with Business Office Manager (BOM) Briana Garcia and explained the purpose of the visit. During the inspection LPA and BOM conducted a tour of the facility and observed the following: Resident bedrooms were observed to have the required furnishings. LPA observed resident beds had linens and blankets. LPA observed the facility has electricity, gas, water, internet and phone service. Medication was observed to be centrally stored in locked medication carts. Fire extinguishers are located in every facility hallway and were observed to be fully charged with service tags dated October 14, 2024. LPA tested signal system in select resident bedrooms and observed signal system to be operable. There are three courtyards, each containing a shaded sitting area, and no obstacles or hazards were observed. LPA observed residents resting in their respective bedrooms and engaging in leisure activities, such as board games and socializing amongst each other. LPA did not observe any immediate threats to the health or safety of residents in care. Based on observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 3, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit for the purpose of following-up regarding an incident report received by Community Care Licensing (CCL) on June 18, 2025 and to conduct a Health and Safety inspection. LPA met with Administrator in Training (AT) Monica Guardian, Business Office Manager Briana Garcia, and Clinical Director Ruby Racca-Magao and explained the purpose of the visit. During the inspection LPA and AT conducted a tour of the facility and observed the following: Resident bedrooms were observed to have the required furnishings. LPA observed resident beds had linens and blankets. LPA observed the facility has electricity, gas, water, internet and phone service. Water temperature tested at 113.9 degrees Fahrenheit, and faucets and toilets were operational. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Fire extinguishers are located in every facility hallway, and were observed to be fully charged with service tags dated October 14, 2024. There are three courtyards, each containing a shaded sitting area, and no obstacles or hazards were observed. LPA observed residents resting in their respective bedrooms and engaging in leisure activities, such as watching a movie, coloring, and listening to music. LPA did not observe any immediate threats to the health or safety of residents in care. Based on observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 19, 2025

Allegation investigated: Insufficient staff to meet residents needs. Bathrooms are being made inaccessible to residents.

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced visit to the facility to continue the investigation and to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted by Wellness Director Ruby Racca-Magao and Business Office Manager- Briana Garcia. It was alleged that there is insufficient staff to meet resident’s needs. LPA Rodriguez conducted a total of 6 resident interviews, all of which did not corroborate with the allegation. 3 out of the 6 resident interviews stated that there has been improvement with staffing and confirmed that there was never a time where only one staff member was present. LPA Rodriguez conducted an interview with 2 staff members, of which both interviews did not corroborate with the allegation by stating that if the facility was in need of additional staffing, the wellness coordinator would assist. For this visit, LPA Rodriguez observed that there was a total of 5 direct care staff members on the assisted living side, and 4 direct care staff members on the memory care unit. Unsubstantiated Per record review, in the month of February 2023 and March 2023, LPA Rodriguez observed the clock in times for staff in February 2023 and March 2023 and observed that there were multiple staff members present, and verified that there was never just one staff member present. It was alleged that bathrooms are being made inaccessible to residents. LPA Rodriguez conducted a total of 6 resident interviews, all of which did not corroborate with the allegation. LPA Rodriguez conducted a total of 2 staff interviews, of which both did not corroborate with the allegation. LPA Rodriguez observed that on the assisted living side, there are two bathrooms designated for staff, which remained unlocked, and one bathroom designated for the public, which also was unlocked. LPA Rodriguez observed that each resident room had their own bathroom and was made accessible to the resident(s) living in that room. LPA Rodriguez observed that on the memory care unit, there are bathrooms in each resident’s room, and one extra shared bathroom located in the hallway, that is designated only for residents. LPA Rodriguez observed that the memory care bathroom in the hallway was locked, however it is due to safety concerns, to prevent the residents from entering the bathroom on their own since per physician reports, the memory care residents are unable to use the bathroom independently and require assistance. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. For this visit, there were no citations were issued. An exit interview was conducted with Wellness Director Ruby Racca-Magao and Business Office Manager- Briana Garcia. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Jun 16, 2025 · control 22-AS-20230301101840

Allegation investigated: Lack of facility supervision resulted in resident sustaining serious injuries Lack of facility care and supervision resulted in resident sustaining multiple falls Facility staff failed to provide timely medical attention to the resident who was injured

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by Ervin Nario, Health and Wellness Cooridnator, and explained the purpose of the visit. During the course of the investigation, the Department interviewed staff and witnesses; and subpoenaed and reviewed medical records from Quality Hospice and University of California Irvine (UCI) Medical Center. The investigation revealed the following: Resident #1 (R1) was admitted to the facility on February 18, 2021. Per Physician report dated December 05, 2024, R1 had a diagnosis of Dementia and Osteoporosis. Physician report further assessed R1 was confused and disoriented; unable to communicate needs and was non-ambulatory. (Continued on LIC 9099-C) Substantiated (Continued from LIC 9099) On October 1, 2024, at 4:30am Resident #1 (R1) was found on the floor, unresponsive by facility staff. Resident sustained a laceration on their left eye and 911 transported R1 to UCI for evaluation and admitted to the hospital for further observation. Two days later on October 3, 2024, Resident had a second unwitnessed fall at 12:27pm. Per facility med tech, R1 was evaluated to have no injuries noted. R1’s Power of Attorney (POA) was contacted and POA requested R1 not be sent out to hospital. The facility did not seek immediate medical attention. Resident was assisted into wheelchair and was monitored every two to three hours. Two weeks later, on October 17, 2024, at 10:15am, R1 was in the hallway near room #307 and stepped on a weigh scale; used to measure residents. Per Medical Technician (MT), R1 was observed to have fallen backwards onto the floor. MT denied observing R1 hit their head. R1 was assessed by MT who observed no injuries noted. Following the third fall that month, the facility implemented increased monitoring of R1. R1 was frequently checked and monitored every two to three hours and staff were instructed to clear trip hazards as reported on Unusual Incident Report on October 18, 2024. On November 3, 2024, at 9:50am R1 was observed on the ground in the Memory Care patio. R1 had a laceration to the left eyebrow and lower lip and complained of neck pain. 911 was called and R1 was transported to UCI Medical Center for further evaluation. Upon return to the facility on November 4, 2024, a Care Plan meeting was held with R1’s POA and facility Administrator and Wellness Director. During the meeting the facility recommended for R1 to receive hospice services. Quality Hospice was initiated on November 5, 2024. Quality Hospice noted R1 had an unsteady gait and documented fall precautions, such as unobstructed pathways and that frequent checks should be implemented. On December 16, 2024, Resident had another unwitnessed fall at 12:57pm and was found by facility staff. R1 sustained a hematoma on left eyebrow area and left nostril per MT assessment. Quality Hospice and POA were notified and hospice nurse assessed; stating R1 hit their head and was bleeding from nose. At the time of incident, the facility did not call 911 to seek medical attention. Hospice nurse applied ice pack to affected area and R1 was checked every two to three hours. Four days later on December 20, 2024, at 4:10pm, R1 was found lying on their back on Memory Care patio from an unwitnessed fall. Wellness Director (WD) noted R1 was bleeding from the back of their head. WD (Continued on LIC 9099-C) (Continued from LIC 9099C) and MedTech cleaned head wound and contacted hospice. Hospice did not arrive to assess until 7:00 pm and recommended R1 be sent out to Emergency Room (ER). Hospice contacted R1’s POA, who requested to take R1 themselves via their private vehicle. R1 was not picked up by POA until 9:30pm, resulting in a 5 hour and 20 minute delay in medical services. Per the facility’s policy, non-emergency transport is only to be used when the resident needs urgent but non-emergency medical care. R1 being transported to the hospital by their POA violated the facility’s own policy. Per UCI Medical Records, R1 was admitted due to trauma and was evaluated by hospital staff. Findings include the following: left nondisplaced orbital floor fracture; maxillary sinus fracture; chronic dens fracture; C2 arch fracture; and laceration on right occipital area. R1 was discharged on December 25, 2024 back to the facility. Quality Hospice records noted on December 20, 2024, that R1 sustained bruises on the left side of their face, a skin tear on left eyelid/eyebrow and an open wound on the occipital area. Notes reiterated fall precautions and staff monitoring while R1 ambulates. Prior to the falls, R1 was able to ambulate independently as R1’s care plan dated March 24, 2021, under Activities and Socialization, notes to “Encourage resident to participate in activities. Resident likes walking in courtyard, watching TV, or listening to music.” Based on evidence obtained, the facility failed to re-assess R1’s needs upon having a change in condition of their ambulatory abilities. As a result, R1 sustained ongoing falls with the last fall resulting in serious bodily injury requiring hospitalization. Based on interviews conducted and records reviewed, the preponderance of evidence has been met. The allegations that: Lack of facility supervision resulted in resident sustaining serious injuries, Lack of facility care and supervision resulted in resident sustaining multiple falls and Facility staff failed to provide timely medical attention to the resident who was injured were substantiated. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f) An exit interview was conducted with Ervin Nario, Health and Wellness Coordinator, and a copy of this report, 9099-D, LIC421IM and Appeal Rights were left at the facility.the state’s words, verbatim · CDSS document, Apr 29, 2025 · control 22-AS-20241223154032

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 24, 2025

87464(f)(1) Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: R1 suffered a total of six falls in the time span of approximately three months without documented re-evaluation of re-evaluation of care needs resulting in R1 being hospitalized 12/20/24 and diagnosed with left orbital floor fracture, maxillary sinus fracture and chronic dens C1 arch fracture.the state’s words, verbatim · CDSS document, Apr 29, 2025

Plan of correction: Licensee to provide staff in-services so all staff understand the regulation for Basic Services. Licensee to include date of inservice(s), topics covered and participant signature and email proof to LPA by POC due date. (continued) This poses an immediate health and safety risk to resident in care. A civil penalty will be assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Apr 24, 2025

87465(g) Incidental Medical and Dental Care: (g) The licensee shall immediately telephone 9-1-1 if an injury... has resulted in an imminent threat to a resident’s health... including, but not limited to, an apparent life-threatening medical crisis... This requirement was not met as evidenced by: On 12/20/2024 at 4:10pm, R1 was found on their back on Memory Care patio from an unwitnessed fall. Hospice was called but did not arrive to assess R1 until 7pm. Hospice recommended facility call 911 at this time but were asked by the POA to allow POA to transport resident.the state’s words, verbatim · CDSS document, Apr 29, 2025

Plan of correction: Licensee to provide staff in-services so all staff understand the regulation for Incidental Medical and Dental Care. Licensee to include date of inservice(s), topics covered and participant signature and email proof to LPA by POC due date. (continued) POA did not arrive at facility until 9:30pm which resulted in a 5 hour and 20 minute delay for medical attention for the resident who was injured. This poses an immediate health and safety risk to resident in care. A civil penalty will be assessed.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Executive Director (ED) Rhon Hipolito and discussed the purpose of the inspection. During the inspection, LPA and ED conducted a tour of the inside and outside of the facility, common areas, resident rooms, and observed the following: The facility consists of a single-story building used for memory care and assisted living and an additional attached two-story building used solely for assisted living. Select resident rooms were inspected and all were observed to have the required furnishings. LPA observed all resident beds had linens and blankets. Signal system was tested and observed to be operable. There are three courtyards with multiple shaded sitting areas. LPA observed residents socializing in common areas and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 105.9-116.4 degrees Fahrenheit. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. There are two fire extinguishers located in every hallway of the facility. Fire extinguishers were observed to be fully charged with service tags dated October 14, 2024. Facility appliances were inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication was observed to be centrally stored and locked in medication carts. LPA reviewed centrally stored medication for select residents and did not observe any discrepancies. LPA reviewed ten resident files and five staff files. LPA interviewed ten residents and five staff. (Cont. LIC809-C) Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jan 15, 2025

Allegation investigated: Facility staff are not ensuring air conditioning is maintained in good repair Facility staff are not preventing physical altercations between residents

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analysts (LPAs) Claudia Gutierrez and Samer Haddadin regarding the allegations mentioned above. LPAs met with Wellness Director (WD) Ruby Racca-Magao and explained the purpose of the inspection. Interviews were conducted with four facility staff, and seven residents regarding allegation, facility staff are not ensuring air conditioning is maintained in good repair. Two of four staff interviewed stated the air conditioning did not appear to be working in areas of the facility last week, however, the issue has since been repaired by maintenance staff. Two of four staff stated the air conditioning was operational last week and continues to be operational this week. One of seven residents interviewed stated they were unsure if the air conditioning was operational last week but stated the air conditioning is currently operational. One of seven residents stated the air conditioning was operational last week and continues to be operational. Five of seven residents stated the air conditioning had not been operational last week, however, it was repaired within a week and is currently operationing. (LIC9099-C) Unsubstantiated Interviews were conducted with four facility staff, and seven residents regarding allegation, facility staff are not preventing physical altercations between residents. Four of four staff interviewed denied witnessing or having any knowledge of any physical altercations between residents. Six of seven residents denied witnessing or having any knowledge of physical altercations between residents taking place. One of seven residents denied personally having a physical altercation with another resident, however, indicated they were involved in a verbal altercation with another resident at an unknown time in the past. During the complaint investigation, LPAs and WD conducted a tour of the facility and observed the air conditioning to be operating as designed and room temperature tested between 76- and 82- degrees Fahrenheit. LPAs observed residents in common areas and resting in their respective bedrooms without disturbance, and no physical altercations between residents were observed. Based on observations and due to conflicting information received during interviews conducted, LPA is unable to determine if facility staff are not ensuring air conditioning is maintained in good repair or if facility staff are not preventing physical altercations between residents. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore at this time the above allegations are unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Sep 18, 2024 · control 22-AS-20240909104554

Allegation investigated: Resident did not receive medication correspondence sent to the facility in a timely manner

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the initial investigation into the allegation listed above. LPA was greeted and granted entry by front desk staff after introducing himself and stating the purpose of the visit. Executive Director Rhonwinn Hipolito was present and able to assist later during the visit. LPA requested and obtained the current facility census. An interview was conducted with Wellness Director Ruby Raccamagao. Resident records for five individual currently in care at the facility were requested, obtained and reviewed during the visit. Front desk staff present was also interviewed. Four resident interviews were attempted or conducted during the visit. LPA additionally reviewed and obtained copies of the facility's grievance log and package delivery log. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 Regarding the allegation that Resident did not receive medication correspondence sent to the facility in a timely manner, the following has been concluded: Based on records reviewed, residents R1, R2, R3 and R4 have been confirmed to have been assessed to be capable of managing their own medication by their respective primary care physicians. During interviews conducted, one out of four residents indicated that their medication was delivered directly to their unit by the pharmacy upon request from their physician. Another one of four residents stated that she had medication delivered by postal service on or around July 10, 2024 but never received it. The same resident stated that facility management had reported that no postal deliveries had been documented by front desk staff on that day. Another package was noted to have been brought by USPS on July 7, 2024 and stated by staff to have been brought to the resident's unit as the resident does not come down to the lobby. No active grievances regarding interference with personal correspondence appear to have been formally filed with facility management in the period from January 23, 2024 to the present visit. Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jul 23, 2024 · control 22-AS-20240718134344

Allegation investigated: Licensee does not ensure that staff are adequately trained.

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above. LPA met with Administrator in Training (ADT) Charlie Marinko and discussed the purpose of the inspection. During the visit, LPA interviewed six staff and conducted record review of eight direct care staff training files. Upon direct care staff file review, LPA observed eight of eight direct care staff training records did not contain 40 hours of training; consisting of 20 hours, including six hours specific to dementia care, and four hours specific to postural supports, restricted health conditions, and hospice care before working independently with residents, and the remaining 20 hours, including six hours specific to dementia care completed within the first four weeks of employment, as required by regulation. During interviews, six out of six staff confirmed they have conducted training online, as well as hands-on and shadowing training pertaining to providing direct care and supervision to residents. (Cont. LIC9099-C) Substantiated Three of six staff confirmed they conducted first aid training and training was conducted on-site at the facility. One of six staff stated they had completed first aid training at their previous employment and personally provided LPA with a digital certificate of training completed. Two of six staff denied they have received first aid training. Facility was unable to provide LPA with a copy of first aid training cards for five of eight staff. Based on staff record review and interviews conducted, LPA determined that Licensee does not ensure that staff are adequately trained. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of regulations. (See LIC9099-D). An exit interview was conducted with Wellness Director (WD) Ruby Racca-Magao and Community Liaison Elizabeth Mendoza. A copy of this report, and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jun 21, 2024 · control 22-AS-20240618101708

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: Jul 19, 2024

Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidence by: The licensee did not comply with the section cited above in five of eight care staff files which poses a potenital safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 21, 2024

Plan of correction: WD stated direct care staff would immediately be provided with first aid training and proof provided to LPA via email by POC.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(1) · Plan of correction due date: Jul 19, 2024

...20 hours, including six hours specific to dementia care... and four hours specific to postural supports, restricted health conditions, and hospice care.. before working... with residents.. remaining 20 hours... include six hours specific to dementia care and shall be completed within the first four weeks of employment... This requirement is not be as evidence by: Based on record review, the licensee did not comply with the section cited above in eight out of eight care staff files, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 21, 2024

Plan of correction: WD stated required staff training will begin to be conducted immediately. WD stated they will submit proof to LPA via email by POC date.

Allegation investigated: Resident sustained multiple falls while in care.

Regarding the complaint allegation: Resident sustained multiple falls while in care. 7 of 7 individuals either denied the allegation or were unable to support the allegation. During an interview, Resident 1 (R1) admitted to falling about once every two months and the resident claims to use a walker which was present during the interview. Staff 1 (S1) denied R1 is a fall risk and claims R1 walks to the dining room to eat. Staff 5 (S5) stated R1 has had falls in the past but has improved recently. Based on the information gathered during the investigation through interviews, document review, and observations, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed Unsubstantiated. An exit interview was conducted, and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 8, 2024 · control 22-AS-20230208162544

Allegation investigated: Resident in care sustained multiple bruises. Residents in care engage in unsafe interactions

Licensing Program Analyst (LPA) Jerome Haley made an unannounced follow up visit to the facility to complete additional interviews and deliver the findings on the complaint allegations above. LPA Haley was greeted by staff and explained the reason for the visit. The complaint investigation consisted of interviews with facility staff and residents, and included document and photo review. A total of 7 interviews were conducted. Regarding the complaint allegation: Resident in care sustained multiple bruises. 3 of 7 individuals confirmed the allegation above. During interviews and document review, it was discovered Resident 1 (R1) sustained bruises to different areas of the upper body. According to Staff 1 (S1) after a February 7, 2023 incident, when staff went to assess R1, bruising was noted on R1 and the bruises did not look like they were from a fall. Staff 2 (S2) responded to the incident on February 7, 2023 and went to R1’s room to assist the resident and observed bruising to R1 and stated, bruising was all over R1’s body including the nose.” Continued on LIC9099C Substantiated Regarding the complaint allegation: Residents in care engage in unsafe interactions. 7 of 7 individuals confirmed the allegation above. During interviews, Staff 1 (S1) revealed Resident 2 (R2) was given an eviction notice for yelling behavior and making the community unsafe. According to S1, facility staff reached out to the family of R1 regarding the concerning behavior of R2. Staff 3 (S3) mentioned that other residents always report to staff that R2 is always yelling. Staff 2 (S2) stated, we (staff) thought it was all verbal, R2’s always yelling and screaming. Staff 5 (S5) stated, other residents would tell staff that R2 yells at R1 and calls R1 names. During an interview, R2 admitted to biting R1 on the fingers so R1 would let the resident go. According to R2, R1 was holding on to R2 after slipping and falling of the potty. Based on the evidence gathered through interviews and document review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6. An exit interview was conducted, and a copy of this report, and appeal rights were provided.the state’s words, verbatim · CDSS document, May 8, 2024 · control 22-AS-20230208162544

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 15, 2024

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. The above requirement is not being met as evidenced by interview confirmation, document, and photo review that revealed Resident 1 (R1) sustained multiple bruises to upper body while in care. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Wellness Director agrees to conduct an in-service training for all staff on Personal Rights of residents in all facilities. Wellness Director will email LPA Haley an outline of the topics covered in the in-service training and a copy of the sign in sheet of the staff in attendance by the POC due date: Wednesday, May 15, 2024 at 1PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: May 15, 2024

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. The above requirement is not being met as evidenced by interview confirmation and document review that reveal Resident 1 (R1) was being abused by Resident 2 (R2) while in care. This poses a health and safety risk to resident in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Wellness Director agrees to conduct an in-service training for all staff on Personal Rights of residents in all facilities, and a detailed plan that outlines what steps will be taken when residents engage in abusive behavior towards each other. Wellness Director will email LPA Haley an outline of the topics covered in the in-service training, a copy of the sign in sheet of the staff in attendance, and the detailed plan regarding resident on resident abuse by the POC due date: Wednesday, May 15, 2024 at 1PM.

Type of visit: Case Management - Deficiencies

During the investigation into complaint control number 22-AS-20230208162544 it was discovered the facility failed to report an attack that resulted in an injury to the Regional Office. All serious incidents should be reported to the Regional Office within 7 days. Mainplace Senior Living failed to report a resident was attacked by another resident which resulted in injuries to the resident and the Orange County Sheriff being called. LPA Haley received in-house notes that documented the incident and received details about the incident from Staff 1 (S1) during staff interviews. As a result of today’s Case Management visit, a violation will be cited per California Code of Regulations Title 22. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: May 15, 2024

Reporting Requirements (a) Each licensee shall furnish...reports as the Department may require, including, but not limited to... (1) A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events specified... below. This report shall include the resident’s name, age...disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not being met as evidenced by the facilities failure to report the incident involving Resident 1 (R1) and Resident 2 (R2) which resulted in the police being called. This poses a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Wellness Director agrees to conduct an in-service training for all staff on Reporting Requirements. A sign in sheet and outline of the topics covered and duration of the in-service training will be emailed to LPA Haley by the POC due date. Wellness Director agrees to send a detailed plan that outlines the steps that will be taken to ensure all serious incidents are reported. The detailed plan will include the following: • Who will be responsible for sending incident reports • A backup staff member responsible for reporting serious incidents. The in-service training sign-in sheet, in-service training outline, and detailed plan on reporting serious incidents will be emailed to LPA Haley by Wednesday, May 15, 2024 at 1PM.

Allegation investigated: Facility staff did not safeguard resident's belongings Facility staff are not answering communications from resident's responsible person

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA interviewed staff and witness as well as reviewed and obtained pertinent documentation such as skilled nursing discharge paperwork and inventory list. Regarding the allegations that facility staff did not safeguard resident's belongings and facility staff are not answering communications from resident's responsible person, the investigation revealed the following: Resident 1 (R1) admitted into the facility on 02/22/2024 after hospitalization at a skilled nursing facility (SNF). Discharge paperwork indicated resident's needs included a wheelchair but inventory list at discharge stated resident had no belongings. Staff 1 (S1) stated assisting the resident out of bed at the SNF and assisting the resident into van. The SNF took the wheelchair back the resident was in and resident boarded the van. Three out of three staff indicate resident did not have a wheelchair when the resident arrived to the facility and facility's wheelchair was used by the resident. CONTINUED ON LIC 9099C DATED 04/23/2024 Unsubstantiated S1 states resident did not have shoes on when the staff picked up the resident and states the resident had on grippy socks only. Two out of two staff deny seeing the resident with shoes. Facility progress notes dated 02/23/2024 indicated 911 was called twice for resident with resident being sent out to the hospital in the early morning hours. Facility documentation shows facility left a message for the resident's family on two different occasions that night. Staff 2 states having a conversation with family on the telephone and in-person regarding the alleged missing wheelchair and shoes. Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, all allegations are deemed Unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 23, 2024 · control 22-AS-20240415111317

Allegation investigated: Facility did not safeguard residents’ belongings in room. Facility did not report theft.

Licensing Program Analyst (LPA) Jerome Haley made an unannounced follow up visit to the facility to complete additional interviews and deliver the findings on the complaint allegations above. LPA Haley was greeted by staff and explained the reason for the visit. The complaint investigation consisted of interviews with facility staff, residents, a resident family member, a witness, and document review. Two additional witnesses were contacted but could not be reached. Regarding the complaint allegation: Facility did not safeguard residents’ belongings in room. During the investigation interviews were conducted with facility staff, residents, and witnesses for a total of nine interviews. Continued on LIC9099C Unsubstantiated Two additional interviews were attempted, but witnesses could not be reached. Regarding the allegation above, 8 of 9 individuals were unable to corroborate the complaint allegation. Three of four residents interviewed denied any problems with anyone entering their room unauthorized and all residents reported they fell safe in the community. Resident 2 (R2) denied any personal items being stolen and said staff only enter the room to pick up dirty laundry. Resident 4 (R4) denied anyone entering the room unauthorized, and denied anything being stolen from the room. When asked if anything has been stolen, R4 said, “Thank God… nothing valuable here.” R3 denied anything has been stolen form as well. All staff interviewed denied items being stolen form residents, but all did mention that some residents claim things have been stolen form them. Staff 1 (S1) mentioned a resident who claimed items were stolen from them and then a couple days later claimed whoever stole the items, brought them back. Staff 3 (S3) mentioned the same resident, and claimed the resident has reported items are missing and really the items are misplaced by the resident. S3 said once after the resident claimed items were missing, S3 located the missing item in the resident’s room. Regarding the complaint allegation: Facility did not report theft During the interviews it was discovered the Resident 1 (R1) reported medications were stolen from the resident’s room. Document review revealed the resident’s son was informed of the reported theft and was informed R1 contacted the Police. The incident number and detective's name in the facility progress notes matched the incident report number and detective’s name provided by R1. During interviews with Staff 2 (S2) and Staff 3 (S3) both were unaware of any reported theft from R1 being reported to the facility. Based on the information gathered during the investigation through interviews, document review, and observations, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, all allegations are deemed Unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 10, 2024 · control 22-AS-20240112162107

Allegation investigated: Facility did not have appropriate staffing to meet residents needs. Facility does not have required postings

Licensing Program Analyst (LPA) Jerome Haley made an unannounced follow up visit to the facility to complete additional interviews and deliver the findings on the complaint allegations above. LPA Haley was greeted by staff and explained the reason for the visit. The complaint investigation consisted of interviews with facility staff, residents, a resident family member, a witness, and document review. Two additional witnesses were contacted but could not be reached. Regarding the complaint allegation: Facility did not have appropriate staffing to meet residents needs. During the investigation interviews were conducted with facility staff, residents, and witnesses for a total of nine interviews. Continued on LIC9099C Unfounded Two additional interviews were attempted, but witnesses could not be reached. Regarding the allegation above, 7 of 9 individual’s interviewed denied the complaint allegation. According to Staff 2 (S2) there is enough staff and 2 new staff members were just hired. During the interview, S2 stated two interviews were scheduled for later in the afternoon (April 10, 2024). S2 says the census is growing so new employees have been hired. S3 says, there is enough staff, but it doesn’t hurt to have more, as people call off sometime. All residents interviewed said there is enough staff in the facility. Regarding the complaint allegation: Facility does not have required postings. During the investigation LPA Haley observed the required PUB 475 See Something Say Something poster hanging on the wall as soon as you enter the Assisted living portion of the facility as well as one in the Memory Care Unit. The Ombudsman’s posters were observed near the elevator in the Assisted Living Unit, and in the Memory Care Unit. Photos were taken of the postings. Based on the information gathered through interviews and observations, the following allegations: Facility did not have appropriate staffing to meet residents needs, and Facility does not have required postings, are UNFOUNDED, meaning the allegations are false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 10, 2024 · control 22-AS-20240112162107

Type of visit: POC

On this day Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced Plan of Correction (POC) visit in conjunction with complaint control #22-AS-20230629084645 and citation issued on 01/10/2024. LPA was greeted and granted entry into the facility by Business Office Manager (BOM) Brianna Garcia and explained the reason for the visit. On 01/31/2024, Licensee failed to correct the following: Deficiency cited under Title 22 Regulation 87412 (c)(1)(A)(B) pertaining to Personnel Records (Training and Orientation...in-service training). Deficiency cited under Title 22 Regulation 87412 (c)(1)(A)(B) pertaining to Personnel Records (Training and Orientation...in-service training) has NOT been cleared. Per California Code of Regulation under 87707 (a)(2) under Training Requirements If Advertising Dementia: Direct care staff shall complete at least eight hours of in-service training on the subject of serving residents with dementia within 12 months of working in the facility and in each succeeding 12-month period. Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with BOM Garcia and a copy of this report along with the LIC809D and Appeal Rights were provided at the time of this visit.the state’s words, verbatim · CDSS document, Mar 14, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c)(1)(A)(B) · Plan of correction due date: Mar 15, 2024

Personnel Records (1) training and orientation shall be documented: (A)...at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter...(B)For staff who provide direct care to residents with dementia...the licensee shall document ...orientation received as specified in Section 87707(a)(1)...in-service training received as specified in Section 87707(a)(2).This requirement is not met as evidence by: Based on LPA's observations and file reviews S1, S2 and S3 do not meet Tittle 22 training requirements.the state’s words, verbatim · CDSS document, Mar 14, 2024

Plan of correction: Licensee to provide up to date trainings transcripts for S1, S2 and S3 by POC due date.

Allegation investigated: Staff did not ensure resident is administered eye drops as prescribed. Staff did not ensure resident was provided a comfortable temperature. Facility does not have adequate staffing to respond to resident's call in a timely manner. Staff did not provide resident's authorized representative a copy of admissions agreement. Staff do not communicate with authorized representative changes of resident's health.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegations listed above. LPA was greeted and granted entry by facility staff after explaining the purpose of the visit. Facility administrator was present to assist with the visit. The initial investigation visit was conducted at the facility on November 22, 2023. LPA requested and obtained partial resident records for resident R1, conducted a tour of the physical plant and interviewed multiple staff members. A follow-up visit took place on February 2, 2024. One staff interview with the facility's Executive Director was conducted. Additional records requested and obtained. A tour of R1's former unit was also conducted. Additional witness interviews conducted in person or via telephone on February 9, 2024. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099-A Regarding the allegation that Staff did not have adequate record keeping for resident, the following has been concluded: When a copy of the initial agreement concluded in November 2021 was requested by R1's authorized representative, no copy could be provided per a written staff statement indicaing the document had been misplaced. Following a change of ownership, an updated document was drafted and provided to the authorized representative. The statement corroborates that the facility had incomplete records for R1 that did not meet the requirements of Title 22 regulations. Regarding the allegation that Staff did not provide authorized representative with resident's records, the following has been concluded: Based on email exchanges with the facility including timestamps, it was confirmed that the required maximum of two business days to obtain access to a resident's records upon request was not met after R1's authorized representative requested documents upon R1's discharge from the facility. Two type B deficiencies were cited for failure to meet the requirements of the California Code of Regulations' Title 22 Division 6 on the attached form LIC9099-D. An exit interview was provided and a copy of this report along with appeal rights were provided to a facility representative. CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff did not ensure resident is administered eye drops as prescribed, the following has been concluded: During an interview with R1, R1 stated she often did not receive her medication as prescribed. It is however unclear whether R1 has the ability to make accurate recollection due the primary diagnosis on file. Additional interviews were unable to corroborate that R1's condition had worsened due to a failure to receive treatment. A review of the facility's Medication Administration Records provided for the full period of admission did not evidence instances of missed administration. Regarding the allegation that Staff did not ensure resident was provided a comfortable temperature, the following has been concluded: During a tour of the physical plant, the former resident's shared bedroom was measured to be at an adequate temperature and the thermostat as well as heating operations were shown to be operational. Regarding the allegation that Facility does not have adequate staffing to respond to resident's call in a timely manner, the following has been concluded: An interview with R1 did not evidence issues with staff response time. The facility call system was witnessed to be operational during two tours of the physical plant. Additionally, staff posted schedules and clock punches were reviewed and did not evidence insufficient staffing levels. Regarding the allegation that Staff did not provide resident's authorized representative a copy of admissions agreement, the following has been concluded: When a copy of the initial agreement concluded in November 2021 was requested no copy could be provided per a written staff statement indicated the document had been misplaced. Following a change of ownership, an updated document was drafted and provided to the authorized representative. Regarding the allegation that Staff do not communicate with authorized representative changes of resident's health, the following has been concluded: Based on a review of scheduling documents, staff notes and interviews, it was determined that facility staff reached out to R1's authorized representative after a change in behavior patterns and exit seeking became apparent and a recommendation of a placement in memory care was formulated. Based on these conclusions gathered after review of records, site observation and staff, resident and witness interviews, the five allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid there is no preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Feb 14, 2024 · control 22-AS-20231120213146

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Mar 14, 2024

Per the California Code of Regulations: "A separate, complete, and current record shall be maintained for each resident in the facility" This requirement was not met as evidenced by: Based on a review of written exchanges of facility staff with a resident's authorized representative, it was determined that at least one resident's admission agreement had been misplaced, hence rendering the resident's records incomplete at the time. This constitutes a potential risk to the health, safety and welfare of residents in care.the state’s words, verbatim · CDSS document, Feb 14, 2024

Plan of correction: Licensee will audit current records for accuracy and completeness and finish the process of updating admission agreements to the current ownership of the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Mar 14, 2024

Per CCR Section 87468.2(a)(19) on Additional Personal Rights of Residents in Privately Operated Facilities, residents shall (...)"have prompt access to review all of their records (...). (...) records shall be provided within two (2) business days (...)." This requirement was not met as evidenced by: Based on records reviewed, facility records were not provided until more than two business days after a resident's authorized representative had requested them. This constitutes a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Feb 14, 2024

Plan of correction: Licensee will provide a statement indicating that all office staff have been informed of the regulatory requirement for providing records and will adhere to it for future requests.

Allegation investigated: Facility windows are not secured. Facility gate is not secured.

Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced Complaint Investigation for the purpose of delivering findings regarding the allegations mentioned above. LPA met with Business Office Manager, Chasidy Washington and Community Liason, Elizabeth Mendoza. Interviews were conducted with staff and Resident 1 (R1) regarding facility windows not being secured. Two out of three staff stated that facility windows are secure, have a latch, and a screen. One out of three staff stated the window in the resident room where R1 was thought to have exited, was not screened on at least one occasion. All three staff, however, confirmed R1 did not exit through their own bedroom window. R1 entered room 306, which was a different resident’s room, and exited through that window. On 8/16/22, LPA conducted initial complaint investigation inspection at the facility. At 3:50 p.m. LPA conducted a tour of the inside and outside of the facility. LPA observed facility windows within the memory care unit to be latching and had an audible alarm. (Cont. LIC9099-C) Unsubstantiated LPA tested the alarm on window identified as R1’s possible exit point, the window was observed to be three to four feet off the ground and alarm was found to be operable. LPA determined R1 would have entered a bedroom not assigned to them, approached the window, and climbed the three to four feet off the ground to exit through the window. During their interview, R1 was unable to confirm or deny if the window was secure. Interviews were conducted with Staff and Resident 1 regarding allegation facility gate is not secure. Two out of three staff stated that the gate is secure, and it would be difficult for a resident to exit that way. One out of three staff stated the gate is not secure and does not lock. During a tour of the facility, LPA observed gate to be self-latching with an operable lock; the gate has a doorknob that locks from the inside and requires a key to be opened from the outside. The gate is designed to keep people out and is not meant to lock residents or others in. LPA noted that there are no patios or doors that lead to that gate. The only way to access the gate from inside the facility would be to exit through a window. During their interview, R1 could not corroborate the allegation and was unable to confirm or deny is facility gate is secure. Due to conflicting information received during interviews conducted and after a review of facility grounds, LPA is unable to determine if facility windows were not secured or if facility gate was not secured. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore at this time the above allegation is unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Jan 31, 2024 · control 22-AS-20220809112719

Allegation investigated: Staff did not adequately supervise resident in care resulting in multiple wanderings from the facility.

Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced Complaint Investigation for the purpose of delivering findings regarding the allegation mentioned above. LPA met with Business Office Manager, Chasidy Washington and Community Liason, Elizabeth Mendoza. On 8/10/22, the Department received an Unusual Incident Report (LIC624) stating that on 8/09/22 at approximately 3:25 p.m. staff noted Resident 1 (R1) missing. Staff notified Wellness Director (WD) Kimberly Mims and Executive Director (ED) Phat Nguyen. A search of the unit including bathroom areas, bedrooms, and closets was conducted. Window in resident room 306 identified as possible exit point. Search of facility and surrounding area was initiated and expanded to surrounding neighborhoods. Per Case Management visit dated 8/10/22, R1 was found on 8/10/22 at approximately 1:15 p.m. by a good Samaritan standing outside a home miles away from the facility. Per Physician Reported dated 7/29/2022, R1 is not able to leave facility unassisted and needs special observation and night supervision due to confusion and forgetfulness. (Cont. LIC9099-C) Substantiated On 8/04/22 the Department had previously received an Unusual Incident Report (LIC24) regarding R1 stating that on 8/03/22, staff had noticed that R1 was not in the common area and immediately began looking for them. At the same time R1’s family drove into the facility parking lot and saw R1 coming around the corner of the building and began walking down the street. R1’s family member got out of the car and followed R1. The family member and facility staff were able to assist R1 return to the facility. Based on the facility’s own disclosure of events, LPA determined that Staff did not adequately supervise resident in care resulting in multiple wanderings from the facility. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. A deficiency is being cited per Title 22 Division 6 of the California Code of regulations. (See LIC9099-D). An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jan 31, 2024 · control 22-AS-20220809112719

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.2(c) · Plan of correction due date: Feb 1, 2024

“Care and supervision” means the facility assumes responsibility for, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidence by: Based on the facility’s own disclosure of events, they did not assume responsibility for Resident’s wandering behavior, resulting in multiple wanderings from the facility, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 31, 2024

Plan of correction: Community Liason stated auditory alarms on windows are maintained in operable condition and staff training has been conducted to address auditory alarms immediately after being activated, and training regarding resident wandering behavior. Additional activites are also being provided to deter wandering behavior. Community Liason will provide LPA with proof of training conducted regarding resident wandering behavior and elopement and activity calendar by POC date.

Allegation investigated: Facility does not staff appropriately to meet residents' needs. Residents are left unattended.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on 06/29/23. LPA was greeted and granted entry into the facility by Receptionist Noemi Otero. LPA explained the reason for the visit. Business Office Director Chasidy Washington arrived shortly after. This agency has investigated the complaint alleging that facility does not staff appropriately to meet residents' needs. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Six of ten individuals interviewed denied the allegation. During the investigation LPA reviewed documents including the July, November and December 2023 staff schedule. On average there are four caregivers and two medication technicians for the morning shift, two to four caregivers and two medication technicians for the evening shift and two caregivers and one medication technician for the night shift. During interviews with the residents, CONTINUED ON LIC9099-C... Unsubstantiated Resident 1 (R1) reported that the facility has enough staff and that staff do not take long to assist her. Regarding the allegation that residents are left unattended, the investigation revealed the following: Nine of ten individuals interviewed denied the allegation. During interviews conducted with the residents, R2 reported that staff are good overall. Per R2 residents are not left unattended. During interviews conducted with staff, Staff 1 (S1) reported that she has not witnessed residents being left unattended and stated that caregivers always try their best. Based on LPA's observation and information gathered during the investigation, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, the allegations are deemed UNSUBSTANTIATED. LPA Ramirez conducted an exit interview with Business Office Director Washington, and a copy of this report was provided to the facility. date of employment. Training transcript for S2 shows Not Applicable (N/A) under Initial/Direct Care Staff Training dated 08/29/20. S2 date of employment is listed as 08/03/20. Training transcript for S3 does not show dementia care training. S3 date of employment is listed as 06/09/23. Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: untrained staff are providing care and supervision to residents is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. A deficiency is being cited under Personnel Records 87412(c)(1)(A)(B)(1)(2). An exit interview was conducted with Business Office Director Washington, and a copy of this report, 9099-D Page, and Appeal Rights was left at the facility.the state’s words, verbatim · CDSS document, Jan 10, 2024 · control 22-AS-20230629084645

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c)(1)(A)(B) · Plan of correction due date: Jan 31, 2024

Personnel Records (1) training and orientation shall be documented: (A)...at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter...(B)For staff who provide direct care to residents with dementia...the licensee shall document ...orientation received as specified in Section 87707(a)(1)...in-service training received as specified in Section 87707(a)(2).This requirement is not met as evidence by: Based on LPA's observations and file reviews S1, S2 and S3 do not meet Tittle 22 training requirements.the state’s words, verbatim · CDSS document, Jan 10, 2024

Plan of correction: Facility to provide up to date trainings transcripts for S1, S2 and S3 by POC due date.

Allegation investigated: Staff are not addressing resident's fall risk.

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility and to deliver the findings. LPA De Perio explained the purpose of today's visit, and was greeted by executive director (ED) Rhon Hipolito. During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that staff are not addressing resident's fall risk. LPA De Perio conducted 7 resident interviews, of which 7 out of the 7 interviews did not corroborate with the allegation. LPA De Perio conducted a total of 2 staff interviews, of which also did not corroborate with the allegation by stating that staff are trained on the protocol for when a resident falls and is also advised to contact medical assistance immediately for the resident to obtain an evaluation. Unsubstantiated Per documentation review, resident (R1) is diagnosed with Dementia and has a history of falls. On December 25, 2023, R1 sustained an unwitnessed fall in the facility common area, and staff contacted 911, to which then R1 was transported to the hospital. LPA De Perio conducted an interview with R1's responsible party (RP) and confirmed that the facility notified RP immediately of the incident. RP also verified that R1 has had a history of falls, but stated that the fall sustained at the facility is not due to staff neglect, but because R1 likes to walk around and would take off their eyeglasses. R1 is also ambulatory and receives assistance with dressing and bathing. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with ED Hipolito. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Jan 4, 2024 · control 22-AS-20231226144300

Allegation investigated: Facility did not report theft of resident's personal belongings

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegation received on 06/27/23. LPA was greeted and granted entry into the facility by Receptionist Noemi Otero. LPA explained the reason for the visit. Director of Sales and Marketing Elizabeth Bran Mendoza arrived shortly after. This agency has investigated the complaint alleging that the facility did not report theft of resident's personal belongings. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: One of ten individuals interviewed corroborated the allegation. Records reviewed by LPA Ramirez included the Mainplace Senior Living Theft and Loss Policy. Per Theft and Loss Policy “Lost or stolen property with a value of $100.00 or more will be reported to law enforcement within thirty-six (36) hours of the discovery of the loss or theft.” Records reviewed by LPA Ramirez included the Orange Police Department (OPD) Incident dated 06/30/23 CONTINUED ON LIC9099-C... Substantiated for Resident 1 (R1). Per OPD Incident report R1 reported that they discovered that $400 was missing from their room. Per OPD Incident report the date/time item was discovered missing is listed as 06/12/23 at 4:00 PM. During the course of the interviews ED stated that a Police report was filed with the OPD on 06/30/23. The facility filed a Police report 18 days after the discovery of R1’s stolen property. During the interviews with residents, R1 reported that they notified management, but that management did not file a Police report. Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: facility did not report theft of resident's personal belongings is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with Wellness Director (WD) Ruby Raccamagao and a copy of this report along with the Appeal Rights were provided at the time of this visit. money from the resident bedrooms and stated that staff are good people. Per S2 staff never take resident’s personal belongings because it is a job policy and because it is not correct. During the course of the interviews ED stated that staff do not go through the residents’ personal belongings and reported that residents lock their bedroom when they go out. Based on LPA's observations and information gathered during the investigation, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. LPA Ramirez conducted an exit interview with Wellness Director (WD) Ruby Raccamagao, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 22, 2023 · control 22-AS-20230627074740

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a)(3)(i) · Plan of correction due date: Dec 27, 2023

Theft and Loss (a) The licensee shall ensure… (i) Reports to the local law enforcement agency within 36 hours when… property with a then current value of one hundred dollars ($100) or more has been stolen. This requirement is not met as evidenced by: Based on interviews and LPA observations the facility did not report R1’s stolen property with a value of $400.00 to Law Enforcement within 36 hours as documented per facility’s Plan of Operation. This poses a potential risk to resident’s health and safety while in care.the state’s words, verbatim · CDSS document, Dec 22, 2023

Plan of correction: Licensee/Administrator agrees to read regulation and sign a statement of understanding and forward proof to LPA by POC due date.

Allegation investigated: -Facility staff did not answer resident's calls for assistance.

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz and (LPA) Jenifer Tirre conducted a joint unannounced visit for the purpose to deliver findings for complaint allegation listed above. LPA Quiroz and LPA Tirre were greeted and granted entry by Front desk receptionist and met with Executive Director (ED) Rhonwinn Hipolito and discussed purpose of today's visit. The ten day inspection visit was conducted on 10/3/2023 and a complaint follow up inspection visit was conducted on 10/17/2023. During the course of the investigation, LPA Quiroz conducted interviews with interviewees consisting of staff, residents and other witnesses and documentation review but not limited to physician reports, needs and services plans and facility call log report. Regarding the allegation "Facility staff did not answer resident's calls for assistance" the investigation revealed the following: Interviews conducted with interviewees consisting of staff and residents concluded that there is enough staff working at the facility and staff are responding to call lights in a timely manner. CONTINUED ON LIC 9099-C PAGE... Unfounded CONTINUED... During the course of the investigation, Eleven of eleven interviewees indicated staff respond to call lights and assistance requests timely. (ED) Hipolito indicated staff conduct routinely checks on residents every 2 hours or depending on their needs but do not keep a record of routinely checks. During inspection visit conducted on 10/17/2023 on or about 3:23pm , LPA Quiroz conducted tour of Resident 1 (R1) and Resident 2 (R2) bedroom area. During inspection visit, LPA Quiroz observed call light button covered in duct tape and observed furniture obstructing call light access. Five of five staff interviewed indicated frequent routine checks attempts on (R1) and (R2) during their work shift stating "But they never open the door. We hear they're in there, but (R2) refuses all help and assistance for (R1)." During facility inspection visits, LPA Quiroz observed a table located outside of (R1) and (R2)s bedroom area, interviews conducted with eleven of eleven interviewees concluded that the table outside of (R1) and (R2)s bedroom area was identified as a place where staff is requested by (R2) to drop off any items such as mail, packages, trash bags or door dash food services. Documentation review of the facility call log report for (R1) and (R2) indicate no call request activity during the time period of 1/01/2023 - 10/17/2023. The Department has investigated the complaint alleging that staff did not answer resident's calls for assistance. Therefore based on the preponderance of evidence gathered through interviews, documentation review and observations conducted by LPA Quiroz, the allegation that the "Facility staff did not answer resident's calls for assistance," is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies cited during today's visit. An exit interview was conducted with (ED) Hipolito and a copy of today's report and LIC 811- Confidential Names were provided.the state’s words, verbatim · CDSS document, Nov 20, 2023 · control 22-AS-20230929113543

Allegation investigated: Staff did not provide medications to resident as prescribed.

Licensing Program Analyst’s (LPA’s) Jenifer Tirre and Rosie Quiroz made an unannounced joint visit to conduct follow up into complaint Investigation. LPA's was greeted and granted entry by staff. LPA's identified themselves and discussed the purpose of the visit with Executive Director Rhonwinn Hipolito. During the visit, LPA Tirre conducted interviews and requested pertinent documents such as Physician’s Report and Personnel Report. During the investigation, Interviews were conducted with staff and residents, Pertinent documents were reviewed and requested. On 1/20/23 the department received allegations that facility staff did not provide medications to resident as prescribed. Per interviews conducted with staff five out of five staff confirmed there was no issues with prescribed medications provided to residents. Interviews with residents confirm that five out of five residents had no issues with receiving medications and that prescribed medications were administered. Interviews with four of five staff also confirmed that Resident 1 managed their own medications. Resident Physcian's Report dated 6/28/22 confirms resident 1 is able to administer own CONTINUED ON 9099 C Unfounded prescription medications, able to administer own PRN medications and able to store own medications. Based off interviews conducted and documents received Resident 1 was able to self administer medications at time initial complaint received therefore the above allegation Staff did not provide medications to resident as prescribed is deemed UNFOUNDED meaning , that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies cited during today's visit. An exit interview was conducted with (ED) Hipolito and a copy of today's report and LIC 811- Confidential Names were provided.the state’s words, verbatim · CDSS document, Nov 20, 2023 · control 22-AS-20230120095133

Allegation investigated: Resident sustained injuries from a fall while in care. Resident has fallen multiple times while in care.

An unannounced complaint investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez, regarding the allegations mentioned above. LPA met with Administrator (AD) Rhon Hipolito and explained the purpose of the visit. Interviews were conducted with two staff and Resident 1 (R1). Two out of two staff corroborated both allegations, and stated they did not recall the exact dates and times but stated R1 fell numerous times and at least one of those times required hospitalization. Per both staff, a re-appraisal of R1 due to falls was not done to their knowledge. R1 also corroborated both allegations and stated they fell multiple times, but did not recall exact dates and times. R1 stated that as a result of these falls they are no longer ambulatory. LPA reviewed facility progress notes for R1, which stated R1 sustained a fall on 6/10/22 at 6:30 a.m., 6/19/22 at 10:00 a.m., 6/20/22 at 12:10 p.m., 6/23/22 at 4:30 p.m., and on 6/28/22 R1 was sent to the hospital for another fall. (Cont. LIC9099-C) Substantiated Appraisal for R1 dated 4/14/2022, states R1 is alert, oriented, with no impairment, and able to walk without any physical assistance. After sustaining falls in June of 2022, R1’s appraisal was not updated and R1 was not re-assessed. On 7/06/22, R1 returned from the hospital under Haven Hospice with a diagnosis of brain hemorrhage. Per disclosures made during interviews, and records obtained, LPA determined resident had fallen multiple times and sustained injuries from a fall while in care. The preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Nov 15, 2023 · control 22-AS-20220629113139

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a) · Plan of correction due date: Nov 16, 2023

...appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate.. reappraisals shall document changes in the resident's physical, medical, mental, and social condition... This requirement is not met as evidence by; R1 sustained a fall on 6/10/23 at 6:30 a.m., 6/19/22 at 10:00 a.m., 6/20/22 at 12:10 p.m., 6/23/22 at 4:30 p.m., and on 6/28/22. R1 was not re-assesed and appraisal was not updated to reflect resident's change in condition, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 15, 2023

Plan of correction: AD stated a monthy in-service is held regarding any changes in condition for residents and procedures have now been implemented for a new care plan to be assessed once this is a change in condition. AD will provide LPA with proof of in-service held and new care plan assessments via email by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(c) · Plan of correction due date: Dec 15, 2023

...licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff... when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first... This requirement is not met as evidence by: R1 sustained a fall on 6/28/22 that required hospitalization, resulting in a significant change in R1's condition. A meeting was not arranged with R1, RP, or facility staff in regards to change of condition, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 15, 2023

Plan of correction: AD stated Health Care Coordinator arranges meetings for residents, RPs, and facility staff to discuss significant changes in residents' condition and will continue to implent this procedural policy. AD will provide LPA with proof of meetings being held via email by POC date.

Allegation investigated: -Facility does not meet resident’s needs. -Floor in resident room is not cleaned properly.

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose to conduct additional interviews and deliver findings for complaint allegations listed above. LPA Quiroz was greeted and met with Executive Director (ED) Rhonwinn "Rhon" Hipolito and discussed purpose of today's visit. The 10 day visit was conducted on 6/12/2023 by LPA Quiroz. During the course of the investigation, LPA Quiroz conducted interviews with interviewees consisting of staff, residents and other witnesses. Regarding the allegation "Facility does not meet resident’s needs," the investigation revealed the following: Nine of ten interviewees denied the allegation. Six of six residents denied the allegation indicating staff respond timely when called for assistance. Resident 2 (R2) indicated "My room mate just wants to get rid of me and wants his own private room." CONTINUED ON NEXT PAGE... Unfounded Regarding the allegation "Floor in resident room is not cleaned properly," the investigation revealed the following: Nine of ten interviewees denied the allegation indicating Maintenance Director conducts carpet cleaning when requested. Health and Wellness Director Mims indicated "There's a carpet cleaning request list in the front lobby, so residents can call and request carpet cleaning and it'll get done by the Maintenance Director timely." (R2) indicated "My room mate wants to get rid of me, so he keeps saying I'm having accidents and not being cleaned." Five of six residents indicated "Staff disinfect the carpet immediately when needed due to sanitary reasons." Health and Wellness Director Mims indicated "(R1) has requested laminate floor in bedroom area and he's on our list for floor already." Executive Director (ED) Rhon Hipolito indicated laminated floor was installed in (R1) and (R2)s bedroom area on July 19, 2023. Therefore based on the preponderance of evidence gathered through interviews and observations conducted by LPA Quiroz, the allegation that the "Facility does not meet resident’s needs" and "Floor in resident room is not cleaned properly" are deemed UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. This agency has investigated this complaint. No deficiencies cited during today's visit. An exit interview was conducted with (ED) Rhon Hipolito and a copy of report was provided at exit.the state’s words, verbatim · CDSS document, Oct 3, 2023 · control 22-AS-20230606092904