Manzanita Village at Rancho Belago

Allegation investigated: Facility staff neglected the needs of residents in care.

**On February 10, 2026, the Department conducted a subsequent visit to facility. The purpose of the visit is to include additional information in the report dated 1/29/26 required to justify the finding which will remain the same. The department met with and Anna Martinez, Assistant Executive Director and explained purpose of visit. Investigation consisted of the following: On January 29, 2026, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegations and to deliver findings. The Department was met by Christina Miller and Anna Martinez, Executive Director and Assistant Executive Director and the purpose of the visit was explained. On April 2, 2025, the Department conducted an unannounced initial visit to the facility to investigate the complaint allegation mentioned above. During the visit, 3 staff interviews and 3 resident interviews were conducted. It was determined that the complaint required further investigation. On 4/25/25 and 9/11/25, subsequent visits were made and during those visits, 5 resident and 3 witness interviews were conducted. However, no findings were rendered. Page 1 of 3 Unsubstantiated On January 28, 2026, the Department requested and obtain the following documents via email: Resident rights training (dated 3/27/25), Incontinent care training (dated 3/6/25), Service plan, physician’s report, and pre-placement appraisals for Residents (R1-R5), Incident/death report for R3 (dated 3/25/25). On January 29, 2026, The Department conducted interviews with Assistant Administrator (A2), and 4 staff (S1-S4) The investigation revealed the following: Allegation: Facility Staff neglected the needs of residents in care. The detail of the complaint alleges R1-R5 has been neglected by staff: Dinner was allegedly withheld from R2 and served 2 hours later, decline in R3’s health and sudden death allegedly was a result of neglect. R4 reportedly was left soiled for an extended period without being changed. R5 allegedly was denied cake repeatedly when R5 asked for it. On April 2, 2025, the Department interviewed 3 residents regarding the allegation, and on April 25, 2025, 5 additional residents were interviewed. 8 out of 8 residents denied the allegation, stating that staff provide appropriate care and they have not experienced neglect. Each resident confirmed that dinner is always served on time, snacks are never withheld, and 8 out of 8 residents indicated that they have never been left soiled for an extended period. On January 29, 2026, at 11:15am the Department interviewed Assistant Administrator (A2) who denied the allegation stating that no resident is ever denied food, residents are changed regularly and/or as needed. Additionally, A2 states that all staff have had Resident Rights training, and training on caring for incontinent residents. Lastly, A2 states that R3 was on hospice care at the time of her passing so A2 denies that there was neglect related to R3’s death. Page 2 of 3 On January 29,2026, between 11:30 am and 1:00pm, the Department interviewed 4 staff (S1-S4) regarding the allegation. Of those interviewed, 4 out of 4 denied the allegation stating that meals are served at the designated time, and no residents are denied food. 4 out of 4 state that residents are changed regularly and as needed therefore, no resident is left soiled for extended periods of time. On January 29, 2026, the Department observed the facility during mealtimes and can confirm that the meal was served on time at time of visit. Additionally, the Department noted that there was sufficient staff present to provide adequate care and supervision to the residents. On January 29, 2026, the Department reviewed and evaluated the following documents: Staff in-service training on caring for incontinent residents (dated 3/6/25), Resident rights training (dated 3/27/25), R1-R5’s Service plans (dated 9/30/25, 4/30/25, 1/3/25, 1/20/26, physician’s reports (dated 4/22/25, 2/5/24, 1/8/25, 6/8/25, pre-placement appraisals (dated 2/24/24, 6/7/18), Incident/death report for R3 (dated 3/25/25), and meal schedule/menu (dated 1/25-1/31/25). During review of the documents, the Department found that the facility maintains that all staff are trained in incontinent care of the residents and have received resident rights training. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today’s visit. Exit interview conducted with Executive Director, Cristina Miller and a copy of report provided.the state’s words, verbatim · CDSS document, Feb 10, 2026 · control 18-AS-20250327112938

Allegation investigated: Staff did not prevent an inappropriate sexual interaction between the residents while in care

On January 30, 2026, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegations and to deliver findings. The Department was met by Cristina Miller and Anna Martinez Executive Director and Assistant Director and the purpose of the visit was explained. Investigation consisted of the following: On 5/20/25, the Department conducted an unannounced initial visit to the facility to investigate the complaint allegations mentioned above. During the initial visit, 3 staff interviews, 4 Resident interviews and 2 interviews were conducted. It was determined that the complaint required further investigation. On January 28, 2026, the Department requested and obtain the following documents via email: Resident rights training (dated 3/27/25), R1’s Service plan, physician’s report, and pre-placement appraisals, R1 Incident Report (dated: 5/12/25). On January 30, 2026, the Department obtained copy of staff training Understanding Wandering and Elopement and Abuse Neglect, and Exploitation in the Elder Care setting. Additionally, the Department obtained a copy of facility internal investigation including witness statements of R1’s alleged incident. Page 1 of 2 Unsubstantiated The investigation revealed the following: Allegation: Staff did not prevent inappropriate sexual interaction between the residents while in care The detail of the complaint alleges that on 5/12/25 at 8:00 PM “R1 was allegedly sexually assaulted by another resident.” On 5/20/2025, during the initial interviews with Executive Director, staff and residents, the following was revealed: 3 out of 3 staff denied allegation stating that there is no evidence that incident happened. 4 out of 4 residents interviewed denied the allegation including R1. Lastly, 2 out of 2 witnesses stated that they did not see the incident and can’t say with certainty that the incident happened as they heard from another party. On January 30, 2026, the Department reviewed and evaluated the following documents: Facility’s internal investigation with witness statements (dated 5/12/2025) During review of the documents, the Department found that there is no credible evidence to support the allegation. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today’s visit. Exit interview conducted with Cristina Miller, Executive Director and copy of report provided.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 18-AS-20250514105046

Allegation investigated: Staff did not prevent resident from entering resident's room Lack of supervision resulted in resident pushing another resident

On January 30, 2026, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegations and to deliver findings. The Department was met by Cristina Miller, Executive Director and the purpose of the visit was explained. Investigation consisted of the following: On 4/16/25, the Department conducted an unannounced initial visit to the facility to investigate the complaint allegations mentioned above. During the initial visit, 2 staff interviews were conducted. It was determined that the complaint required further investigation. On 4/25/25 and 11/21/25, subsequent visits were made and during those visit, 5 residents and 2 additional staff and Executive Director at the time Brooke Abrego-Huerta interviews were conducted. However, no findings were rendered. On January 28, 2026, the Department requested and obtain the following documents via email: Resident rights training (dated 3/27/25), R1’s Service plan, physician’s report, and pre-placement appraisals. On January 30, 2026, the Department met with Executive Director (A1) and obtained the following documents: staff roster and resident roster (dated:1/27/26). Page 1 of 3 Unsubstantiated The investigation revealed the following: Allegation: Staff did not prevent resident from entering resident's room The detail of the complaint alleges staff did not prevent another resident from entering R1’s room. During the initial and subsequent visits, interviews with Executive Director and staff was conducted on 4/16/25, 4/25/25 and 11/21/25. It was revealed that incident did not occur, as there had been no such incident reported to them. 4 out of 4 staff interviewed denied the allegation stating if a resident entered another resident's room staff would notice and/or it would be captured by hallway cameras. It was also revealed that some residents wander but they are redirected by staff. Of the 5 residents interviewed, 4 out of 5 residents stated they had no issues with anyone coming into their room, nor had they witnessed another resident going into another resident’s room. 1 out of 5 residents was unavailable for interview. On January 30, 2026, the Department reviewed and the following documents: staff roster/schedule, resident roster, staff training: Understanding Wandering and Elopement and Abuse, Neglect, and Exploitation in the Elder Care setting. During review of the documents, the Department found that the facility maintains adequate staffing to meet residents’ needs, and the staff are trained in resident behaviors including wandering behaviors. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Page 2 of 3 Allegation: Lack of supervision resulted in resident pushing another resident The detail of the complaint alleges that a lack of supervision resulted in R1 being pushed out of bed. During the initial and subsequent interviews with Executive Director and staff on 4/16/25, 4/25/25 and 11/21/25, it was revealed that the incident did not occur, as there had been no reports of a resident being pushed out of bed. 4 out of 4 staff interviewed during that time stated that there was no indication that R1 was pushed out of bed. Of the 5 residents interviewed, 4 out of 5 residents stated they had no not heard of a resident being pushed out of bed. 1 out of 5 residents was unavailable for interview. On January 30, 2026, the Department reviewed and the following documents: staff roster/schedule, resident roster, staff training: Understanding Wandering and Elopement and Abuse, Neglect, and Exploitation in the Elder Care setting. During review of the documents, the Department found that the facility maintains adequate staffing to meet residents’ needs, and the staff are trained in resident behaviors including wandering and other behaviors. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today’s visit. Exit interview conducted with Cristina Miller, Executive Director and copy of report provided. Page 3 of 3the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 18-AS-20250411144423

Allegation investigated: Facility Staff neglected the needs of residents in care.

On January 29, 2026, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegations and to deliver findings. The Department was met by Christina Miller and Anna Martinez, Executive Director and Assistant Executive Director and the purpose of the visit was explained. Investigation consisted of the following: On 4/2/25, the Department conducted an unannounced initial visit to the facility to investigate the complaint allegation mentioned above. During the visit, 3 staff interviews and 3 resident interviews were conducted. It was determined that the complaint required further investigation. On 4/25/25 and 9/11/24, subsequent visits were made and during that visit, 5 resident and 3 witness interviews were conducted. However, no findings were rendered. On January 28, 2026, the Department requested and obtain the following documents via email: Resident rights training (dated 3/27/25), Incontinent care training (dated 3/6/25), Service plan, physician’s report, and pre-placement appraisals for Residents (R1-R5), Incident/death report for R3 (dated 3/25/25) The department conducted interviews with Assistant Administrator (A2), and 4 staff (S1-S4). Page 1 of 3 Unsubstantiated The investigation revealed the following: Allegation: Facility Staff neglected the needs of residents in care. The detail of the complaint alleges R1-R5 has been neglected by staff: Dinner was allegedly withheld from R2 and served 2 hours later, decline in R3’s health and sudden death allegedly was a result of neglect. R4 reportedly was left soiled for an extended period without being changed. R5 allegedly was denied cake repeatedly when R5 asked for it. On January 29, 2026, at 11:15am the Department interviewed Assistant Administrator (A2) who denied the allegation stating that no resident is ever denied food, residents are changed regularly and/or as needed. Additionally, A2 states that all staff have had Resident Rights training, and training on caring for incontinent residents. Lastly, A2 states that R3 was on hospice care at the time of her passing so A2 denies that there was neglect related to R3’s death. On January 29,2026, between 11:30 am and 1:00pm, the Department interviewed 4 staff (S1-S4) regarding the allegation. Of those interviewed, 4 out of 4 denied the allegation stating that meals are served at the designated time and no residents are denied food. 4 out of 4 state that residents are changed regularly and as needed therefore, no resident is left soiled for extended periods of time. On January 29, 2025, the Department observed the facility during mealtime and can confirm that the meal was served on time at time of visit. Additionally, the Department noted that there was sufficient staff present to provide adequate care and supervision to the residents. Page 2 of 3 On January 29, 2025, the Department reviewed and evaluated the following documents: Staff in-service training on caring for incontinent residents (dated 3/6/25), Resident rights training (dated 3/27/25), R1-R5’s Service plans (dated 9/30/25, 4/30/25, 1/3/25, 1/20/26, physician’s reports (dated 4/22/25, 2/5/24, 1/8/25, 6/8/25, pre-placement appraisals (dated 2/24/24, 6/7/18), Incident/death report for R3 (dated 3/25/25), and meal schedule/menu (dated 1/25-1/31). During review of the documents, the Department found that the facility maintains that all staff are trained in incontinent care of the residents and have received resident rights training. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today’s visit. Exit interview conducted with Executive Director, Cristina Miller and a copy of report provided. Page 3 of 3the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 18-AS-20250327112938

Type of visit: Case Management - Health Checks

On January 05, 2026, Licensing Program Analyst (LPA) Venus Mixson arrived unannounced to look into a matter that was brought to the attention of Community Licensing. On December 22, 2025, the Regional office received information that a husband and wife had a physical altercation. LPA observed there were enough staff present to assist with the care and supervision of resident in care. There were working utilities, the facility was clean and free of clutter and debrief. LPA saw the required postings throughout the facility, and the maintenance and housekeeper teams were present and attending to their duties at the time of this visit. Facility was found to have the required amount of food and a variety of food types available. LPA Mixson saw caregivers assisting resident who required assistance with walkers, caregivers were observed walking by the residents side and offering assistance as needed. LPA's todays unannounced visit the LPA observed the facility was clean and free of debris and unpleasant odors. LPA was able to see and hear how the facility staff attended to the other residents in care due to the resident in question no longer residing at the facility. There were sufficient staff to attend to the care and supervision of the residents in care. The Med-techs were busy making their rounds, and assisting with the resident's medication management. An exit interview was conducted and a copy of this report discussed and provided to the Administrator, Brooke Huerta.the state’s words, verbatim · CDSS document, Jan 9, 2026

Type of visit: Case Management - Other

On December 30, 2025, LPAs Venus Mixson and Yolanda Delgado arrived unannounced to complete the previously started annual visit and met with the Administrator Anne Martinez. Additionally, LPAs conducted a case management visit to approve the facility capacity increase. LPAs conducted a tour of the facility and requested and received a copy of the most current LIC 9020. Client/ Resident roster. There were no observable health and safety concerns observed at the time of this visit. LPAs conducted a review of the six of the residents files and completed the annual visit. There were issues observed at the time of this visit. No further information was obtained at this time.the state’s words, verbatim · CDSS document, Dec 30, 2025

Type of visit: Case Management - Annual Continuation

On December 22, 2025, LPAs Venus Mixson and Mia Lankford arrived at the facility unannounced in order to continue the Required Annual Inspection and met with the Licensee, Brooke Huerta. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for 125 Elderly Adults and is currently operating at a capacity of 123 for a RCFE facility type (740). The LPAs conducted a review of the facility staff files following is a summary of the file reviews. The LPAs requested and received 10 percent of the facility staff files and 10 percent of the facility resident files. The LPAs utilized the "Inspection Tool" Care-Tools to review the files and reviewed and documented the following items. There were no visible deficiencies observed or cited during today's visit. An exit interview was conducted, and a copy of this report was discussed and provided to the Administrator, Brooke Huerta.the state’s words, verbatim · CDSS document, Dec 22, 2025

Allegation investigated: Facility is not staffed to meet residents needs Staff are not adhering to hygiene measures with resident's food Facility does not have a menu

On December 17, 2025, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegations and to deliver findings. The Department was met by Brook Abrego-Huerta Administrator and the purpose of the visit was explained. Investigation consisted of the following: On May 1, 2024, the Department conducted an unannounced initial visit to the facility to investigate the complaint allegations mentioned above. During the visit, it was determined that the complaint required further investigation. On December 16, 2025, the Department requested and obtain the following documents: Staff schedule (dated: December 2025, May 2024), client roster (dated 12/16/25) Riverside County food handlers certificates for staff with the following expiration dates: 12/3/27, 11/18/27, 11/26/27, 11/6/27), Facility Menu (dated 12/14-12/20/2025). The Department conduct interviews with Administrator (A1), 5 staff (S1-S5), 4 residents (R1-R4). On December 16, 2025, the Department determined that the complaint needs further investigation to render a finding. On December 17, 2025 the Department conducted 1 resident interviews (R5) and review relevent documents. Page 1 of 4 Unsubstantiated Allegation: Facility is not staffed to meet residents’ needs The detail of complaint alleges that care givers and Medtech staff working in kitchen and performing cleaning tasks in addition to their duties On December 16, 2025, at 1:30pm, the Department interviewed Brooke Abrego-Huerta (A1) who denied the allegation stating that the facility is meeting the needs of the residents. A1 further stated that all employees are considered caregivers, so if there is a need, then they will step in and help. On December 16, 2025, between 2:00pm and 3:30pm, the Department interviewed 5 staff (S1-S5) regarding the allegation. Of those interviewed, 5 out of 5 denied the allegation stating they have enough staff to meet the needs of the residents and when there is a need everyone works together to help. On December 16, 2025, and December 17, 2025, the Department observed that there was adequate staff at time of the visits. On December 16, 2025, between 3:30pm and 4:30pm, the Department interviewed 4 Residents (R1-R4). Of those interviewed, 4 out of 4 stated that they are treated well and stated that there is adequate staffing to meet their needs. On December 17, 2025, the Department interviewed 1 additional resident (R5) who also stated that they are treated well and there is adequate staff to meet their needs. On December 17, 2025, the Department reviewed and evaluated the following documents: Staff schedule (dated: December 2025, May 2024), client roster (dated 12/16/25), During review of the documents the Department found that the facility maintains adequate staffing. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Page 2 of 4 Allegation: Staff are not adhering to hygiene measures with resident's food The detail of the complaint alleges that due to the caregivers doing kitchen work, there is a concern for adherence to hygiene measures. On December 16, 2025, at 1:30pm, the Department interviewed Brooke Abrego-Huerta (A1) who denied the allegation stated that the facility makes sure every staff has Riverside County Food Handler’s certification which includes instruction of proper hygiene measures. On December 16, 2025, between 2:00pm and 3:30pm, the Department interviewed 5 staff (S1-S5) regarding the allegation. Of those interviewed, 5 out of 5 denied the allegation stating they have a current food handler’s certificate. Additionally, 5 out of 5 state that they use proper hand hygiene measures while working at the facility. On December 17, 2025, the Department reviewed and evaluated the following documents: Riverside County food handler’s certificates for staff with the following expiration dates: 12/3/27, 11/18/27, 11/26/27, 11/6/27) Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Page 3 of 4 Allegation: Facility does not have a menu The detail of complaint alleges that the facility does not have a menu On December 16, 2025, the Department requested and obtained a copy of facility menu (dated 12/14-12/20/2025). On December 17, 2025, the Department reviewed past menus. The department observed that the facility has always had menus available. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today’s visit. Exit interview conducted with Administrator and copy of report provided. Page 4 of 4the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 18-AS-20240422101017

Allegation investigated: Staff are not properly supervising a resident who is a fall risk

On December 17, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced at the facility and met with the Licensee, Brooke Huerta. LPA explained the reason for the visit was to provide findings for the complaint investigation. During the investigation, LPA conducted interviews, record reviews, and made observations pertaining to the listed allegation. On July 22, 2025, Community Care Licensing received a complaint alleging staff are not properly supervising a resident who is fall risk. It was reported that Resident #1 (R1) is not being properly supervised because on July 21, 2025, the First Responders/ Emergency Services were called out twice within three hours on the same day. R1 had an unwitnessed fall, but there were no observable injuries and they did not complain of any pain. Information obtained from interview with Administrator; Brooke Huerta, indicated the facility staff are providing adequate supervision. Furthermore, Administrator specified that staff followed the emergency policy and procedures in place of an unwitnessed fall. Administrator stated that R1 is a fall risk and there is a plan in place to mitigate the number of falls. Administrator indicated that R1 requires assistance to transfer, but will try to transfer from their chair to their bed, without pressing their pendant for assistance. Information obtained from interviews with the staff indicated staff followed medical emergencies procedures for when a resident falls, which includes properly reporting and documenting the incident. Unsubstantiated Additionally, staff stated that they followed R1’s plan to reduce falls, but R1 did not call for assistance. Additional information received from interviews indicated that staff did remain with R1 until first responders arrived. Information obtained from an interview with R1 described that they attempted to get out of bed without notifying staff that they need assistance. R1 corroborated that they refused medical care as they were not experiencing pain. R1 stated they have not experienced staff delaying assistance for unreasonable amounts of time. R1 indicated there are no concerns with how the facility staff attend to their daily needs or supervision. Information obtained from interviews with additional residents indicated they feel safe while at the facility and have no concerns about how staff attend to their daily needs. Information obtained from interviews with Additional Witness indicated R1 had an unwitnessed fall and that R1 refused to be transported for further medical evaluation. On several unannounced visits, LPA observed R1 attempting to get up out of their wheelchair, prior to calling staff for assistance. A review of the records, including the facility’s policy and procedure regarding reporting, corroborated the information obtained. An additional review of the records, including R1’s needs and service plan, confirmed R1 is a fall risk and R1 is to call for assistance prior to transferring from their wheelchair. Based on information obtained from interviews, record reviews, and observations, the evidence received pertaining to the allegation that staff are not properly supervising a resident who is a fall risk has been deemed unsubstantiated. An unsubstantiated allegation means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted. A copy of this report was discussed and given to the Administrator, Brooke Huerta.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 18-AS-20250722121432

Allegation investigated: Staff are not able to meet the needs of residents in care due to staff shortage.

On December 16, 2025, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegations and to deliver findings. The Department was met by Brook Abrego-Huerta Administrator and the purpose of the visit was explained. Investigation consisted of the following: On August 26, 2025, the Department conducted an unannounced initial visit to the facility to investigate the complaint allegations mentioned above. During the visit, it was determined that the complaint required further investigation. On December 16, 2025, the Department requested and obtain the following documents: Staff schedule (dated: December 2025, May 2024), client roster (dated 12/16/25) Riverside county food handlers certificates for staff with the following expiration dates: 12/3/27, 11/18/27, 11/26/27, 11/6/27), Facility Menu (dated 12/14-12/20/2025). the Department conduct interviews with Administrator (A1), 5 staff (S1-S5) 4 residents (R1-R4) Page 1 of 3 Unsubstantiated The investigation revealed the following: Allegation: Staff are not able to meet the needs of residents in care due to staff shortage. The detail of complaint alleges that on 5/5/24, only one staff member assisting all 20 residents. On December 16, 2025, at 1:30pm, the Department interviewed Brooke Abrego-Huerta (A1) who denied the allegation stating that the facility is not understaffed now and was not understaffed in May of 2024 as complaint indicated. A1 further stated that there is enough staff to meet the residents’ needs. On December 16, 2025, between 2:00pm and 3:30pm, the Department interviewed 5 staff (S1-S5) regarding the allegation. Of those interviewed, 5 out of 5 denied the allegation stating the facility has enough staff to meet the needs of the residents and has never been understaffed since they have been there. On December 16, 2025, at time of visit, the Department made observation during tour of the facility and observed adequate staff. On December 16, 2025, between 3:30pm and 4:30pm the Department interviewed 4 Residents (R1-R4). Of those interviewed, 4 out of 4 stated that they are treated well and stated that there is adequate staffing to meet their needs. Page 2 of 3 On December 16, 2025, the Department reviewed and evaluated the following documents: Staff schedule (dated: December 2025, May 2024), client roster (dated 12/16/25) Riverside county food handler’s certificates for staff with the following expiration dates: 12/3/27, 11/18/27, 11/26/27, 11/6/27), Facility Menu (dated 12/14-12/20). During review of the documents the Department found that the facility maintains adequate staffing. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today’s visit. Exit interview conducted with Administrator and copy of report provided. Page 3 of 3the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 18-AS-20240507160515

Type of visit: Required - 1 Year

On December 11, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Licensee, Brooke Huerta. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for 125 Elderly Adults and is currently operating at a capacity of 123 for a RCFE facility type (740). LPA Mixson toured the facility along with the Licensee, Brooke Huerta and made observations pertaining to the annual visit. LPA inspected the facility inside and outside there were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. Additionally, there were no bodies of water on the premises. The facility is comprised of three buildings and is gated. Physical Plant: The facility phone number is (951) 379-0100 and it is operable. LPA Mixson observed a sampling of the residents’ living units, and each was furnished with required fixtures as per Title 22. Units observed included (8, 22, 27, and 109). LPA Mixson inspected a sample of the facility restrooms, and the hot water temperature tested within regulations on those restrooms sampled. The bathrooms were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something,” the "Personal Rights," and the LTCO poster. The cleaning supplies and sharp items were locked and inaccessible to the residents in care presently. There were designated storage spaces for the residents’ and staff’s files, and this office was locked and inaccessible to residents in care at the time of this annual visit. Medications: The medications were locked and inaccessible to residents in care. The nurses’ station was locked the medication records were maintained and there was a sufficient supply of medication for each resident. There were no documented errors observed on the centrally stored medication forms that were reviewed at the time of the annual visit. Additionally, the medications were stored in their original containers during this visit. The facility has several Med-techs and nurses available currently and a number of caregivers are present. Additionally, LPA observed the housekeeping team and the maintenance team arrived shortly after. Food Service& furniture: The kitchen was clean and free or clutter and unsightly debris. The non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for the residents at this time. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. The overall facility is clean; the furniture is in good condition and arranged in a manner which provides space for the residents to move safely. The facility cooling system and other appliances were operable at present. The Licensee informed the LPA there were safety lights for night throughout the facility. Care & Supervision/Administration: There are adequate staff present for the care and supervision of the resident in care. The floor plans, telephone numbers and personal rights were found posted in the facility. The listed Administrator possesses a current administrator’s certificate. Records Reviewed and Resident/Staff Files: LPA reviewed staff files and reviewed the facility's staff schedule. The staff files reviewed have criminal clearance, updated training, along with current First Aid certification. Resident files reviewed possessed the required paperwork as per Regulations at the present. Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill met the Department standards and was conducted as required per standards. Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found required infection control measures met the Department requirements. An exit interview was conducted. A copy of this report was reviewed and given to the Licensee, Brooke Huerta.the state’s words, verbatim · CDSS document, Dec 11, 2025

Type of visit: Case Management - Other

On November 24, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a Health and Safety case management visit, and met with the Administrator, Brook Huerta. LPA Mixson toured the facility, along with the Administrator, Brook Huerta, and made observations. There were sufficient staff present to attend to the care and supervision of residents at the time of this case management visit. Residents were occupied with noon meal, medication management, and afternoon activities. There were no imminent health and/or safety concerns observed at present. LPA Mixson did not observe any obstructions or debris inside or outside of the facility. LPA observed the facility utilities to be operating without issue. LPA assessed the availability of food and observed there was a variety of food types available for the residents in care. Food supply meets the requirement of a two-day supply of perishable foods and a seven-day supply of non-perishable food items. Medications were found to be in sufficient supply, locked, and inaccessible to residents in care. Housekeeping team was present and making their rounds. Facility is clean, neatly organized, and has a supply of activities available for the residents in care. Activities Coordinator was present and facilitating scheduled activities. No unattended residents were observed currently. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and/or welfare of the residents in care. There were no visible deficiencies observed or cited during today's visit. An exit interview was conducted, and a copy of this report was provided to Administrator, Brook Huerta.the state’s words, verbatim · CDSS document, Nov 24, 2025

Allegation investigated: Resident billing statement does not clearly state charges. Staff are not providing services agreed upon in the resident's Admission Agreement.

On 10/28/2025, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent visit to gather information and deliver findings regarding the above allegations. LPA met with Anna Martinez, Assistant Executive Director, and the purpose of the visit was explained. LPA was granted entry to the facility. The investigation included the following: On 10/27/2025, LPA Richard reviewed and obtained the Residents' Roster (dated 07/11/2025), the Staff Roster (dated 06/25/2025), the Admission Agreement for Resident #1 (R1), the billing statement for R1 (dated 05/28/2024), the Medication Administration Record (MAR) (dated October 2025) for residents #2-6, and the Physician Report for residents #2-6. LPA interviewed the Assistant Executive Director (AED), Med Tech (MT), the Dining Services Manager (DSM), two staff members (S1-S2), and five residents (R2-R6). The facility's weekly menu and the optional menu (dated October 26 through November 1, 2025) were also reviewed. A copy of the beautician schedule and services was obtained (2024). Unsubstantiated Allegation #2: The Resident's billing statement does not clearly state charges. The complaint alleged that the financial statements provided to the residents' responsible party were inaccurate. On October 27, 2025, from approximately 10:00 AM to 12:30 PM, LPA Richard interviewed the Assistant Executive Director (AED). The AED denied the allegations and explained that when the administration increased a resident's care level, the facility was required to conduct a new pre-appraisal to assess the resident's care needs. The AED also noted that the issue with the R1 billing statement was related to the previous administration and that the facility had corrected the problem. Additionally, the AED pointed out that the facility's admission agreement stated that rates would increase annually and that the responsible party would be notified in writing of any increase two months prior. During the same time period, LPA interviewed four staff members (S1-S4), all of whom denied the allegations. Later on, on October 27, 2025, from approximately 1:30 PM to 2:30 PM, LPA interviewed five residents (R2-R6). Three out of the five residents denied the allegations, stating that their representative would receive a letter regarding the matter. On October 23, 2025, LPA interviewed R1's responsible party, who confirmed that, following the new administration's takeover, they had refunded all charges. LPA's review of the R1 billing statement, dated January 31, 2023, indicated that the responsible party received a credit for the discrepancy. Unfortunately, LPA was unable to interview R1, as R1 passed away in December 2023. Report Continued on LIC9099C Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated. Allegation #3: Staff are not providing services as agreed upon in the resident’s admission agreement. The complaint alleged that the resident relied on the services of a beauty shop on the premises, which was listed as a service in the admission agreement. The new administration terminated the beauty shop's services. On 10/27/2025, between approximately 10:00 AM and 12:30 PM, the LPA Richard interviewed the AED, who denied the allegations and stated that the facility has a beautician who comes every Wednesday to provide beauty services to residents. Furthermore, the LPA interviewed four staff members (S1-S4), who denied the allegation and said that the facility has a beautician who visits to assist residents with haircuts, nails, Shampoo, and other needs. On 10/27/2025, between approximately 1:30 PM and 2:30 PM, the LPA interviewed five residents. All five residents (R2-R6) denied the allegations and stated that a beautician visits them and helps them with their beauty needs. They also felt it was a good idea for the beauticians to come to their rooms to meet their needs. On 10/27/2025, the LPA reviewed the beautician's schedule, including services provided to residents upon request, and documented the dates and times of these services since 2024. Unfortunately, LPA was unable to interview R1, as R1 passed away in December 2023. Report Continued on LIC9099C Based on the LPA observations, interviews, and record reviews, the Preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. No deficiency cited. An exit interview was conducted. A copy of the report was provided to the Assistant Executive Director Anna Martinez.the state’s words, verbatim · CDSS document, Oct 28, 2025 · control 18-AS-20230411113844

Allegation investigated: Staff are not providing medications as prescribed to resident (s) in care. Facility staff are dispensing medications in care without a prescription. Facility did not provide proper notification to authorized representative for fee increase.

On 10/28/2025, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent visit to gather information and deliver findings regarding the above allegations. LPA met with Anna Martinez, Assistant Executive Director, and the purpose of the visit was explained. LPA was granted entry to the facility. The investigation included the following: On 10/27/2025, LPA Richard reviewed and obtained the Residents' Roster (dated 07/11/2025), the Staff Roster (dated 06/25/2025), the Admission Agreement for Resident #1 (R1), the billing statement for R1 (dated 05/28/2024), the Medication Administration Record (MAR) (dated October 2025) for residents #1-5, and the Physician Report for residents #1-5. LPA interviewed the Assistant Executive Director (AED), Med Tech (MT), the Dining Services Manager (DSM), two staff members (S1-S2), and five residents (R1-R5). The facility's weekly menu and the optional menu (dated October 26 through November 1, 2025) were also reviewed. A copy of the beautician's schedule and services was obtained. A copy of the facility's new Admission Agreement dated 2025. Unsubstantiated Allegation #1: Staff are not providing medications as prescribed to residents in care. The complaint alleged that staff members were not providing medication on time, with residents often receiving it hours after the scheduled times. On October 27, 2025, from approximately 10:00 AM to 12:30 PM, LPA Richard interviewed the Assistant Executive Director (AED), who denied the allegations. During the same time frame, LPA also interviewed a Medication Technician (MT), who also denied the allegations. The MT explained that medications should be administered 1 hour before or after the scheduled time. However, MT consistently tries to deliver residents' medicines on time. In emergencies, a delay may occur, but it should not exceed 1 hour from the scheduled time. Additionally, during this period, LPA interviewed a staff member (S1/MT), who also denied the allegations, stating that the staff are familiar with the residents and ensure that medications are administered in a timely manner. Later that day, between approximately 1:30 PM and 2:30 PM, the LPA interviewed five residents (R1-R5). Four of the five residents denied the allegations, stating that the facility provided their medications on time and that they had never encountered any problems. They also mentioned that the MTs were very helpful with their medication needs. Furthermore, the LPA reviewed the Medication Administration Records (MARs) for all five residents (dated October 1, 2025) and found no discrepancies concerning any of the residents' medications. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated. Report Continued on LIC9099C Allegation #2: Facility staff are dispensing medications to residents in care without a prescription. The complaint alleged that the facility provided the residents with non-prescribed medications, such as supplements and Tylenol/Aspirin. On 10/27/2025, between approximately 10:00 AM and 12:30 PM, the LPA Richard interviewed the AED, who denied the allegations. On 10/27/2025, from approximately 10:00 AM to 12:30 PM, LPA Richard interviewed the MT, who denied the allegations and emphasized that they are very thorough in administering residents' medications. There is no way they would give a resident PRN medications without a doctor's orders. Even over-the-counter medications require a doctor’s order. MT also stated that we do have some residents who are prescribed PRN medications as needed by their doctor. Furthermore, the LPA interviewed one staff member (S1/MT), who denied the allegation and stated that S1/MT continuously checks a doctor’s orders for any medications received from the pharmacy; without a doctor’s orders, we would not give the resident the medicines. On 10/27/2025, between approximately 1:30 PM and 2:30 PM, the LPA interviewed five residents. All five residents (R1-R5) denied the allegations and stated that their doctor did prescribe them pain medications. Furthermore, the LPA examined the 1-month Medication Administration Records for five residents (dated October 1, 2025) and found that four residents are currently taking PRN medications. Report Continued on LIC9099C Based on the LPA observations, interviews, and record reviews, the Preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. Allegation #3: The Facility did not provide proper notification to the authorized representative for the fee increase. The complaint alleged that the facility's family member fees increased from $400 to $ 1,600 after management took over without notifying them. On October 27, 2025, from approximately 10:00 AM to 12:30 PM, LPA Richard interviewed the Assistant Executive Director (AED). During the interview, the AED denied the allegations and explained that when the administration raises a resident's care level, the facility must conduct a new pre-appraisal to assess the resident's care needs. If a resident's level of care changes, they will receive a different care rate, which will be communicated in writing. Additionally, the AED pointed out that the facility's admission agreement states that fees will increase annually. The responsible party will be notified in writing of any fee increase at least 2 months in advance, including the reason for the increase and a general description of the additional costs involved. The AED also mentioned that the facility would send a certified letter to the responsible party for these changes. On 10/27/2025, between approximately 1:30 PM and 2:30 PM, the LPA interviewed five residents. All five residents (R1-R5) stated that their responsible party would know all about it, because they are not the ones writing the checks. Report Continued on LIC9099C Since the complaint didn’t specify a particular resident, LPA reviewed the facility's current Admission. It states on page 6, descriptions of Fee Increase, Level of Care Change, and Services. Based on the LPA observations, interviews, and record reviews, the Preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated No deficiency cited. An exit interview was conducted. A copy of the report was provided to the Assistant Executive Director Anna Martinez.the state’s words, verbatim · CDSS document, Oct 28, 2025 · control 18-AS-20230306145647

Allegation investigated: Facility has insufficient staffing to meet residents' needs. Staff failed to provide adequate food service.

On 10/27/2025, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent visit to gather information and deliver findings regarding the above allegations. LPA met with Anna Martinez, Assistant Executive Director, and the purpose of the visit was explained. LPA was granted entry to the facility. The Investigation consisted of the following: On 10/27/2025, LPA Richard reviewed and obtained the Residents' Roster (dated 07/11/2025), the Staff Roster (dated 06/25/2025), Medication Administration Record (MAR) (dated October 2025) for residents #1-5, and the Physician Report for Residents #1-5. LPA interviewed the Assistant Executive Director (AED), Med Tech (MT), the Dining Services Manager (DSM), two staff members (S1-S2), and five residents (R1-R5). The facility's weekly menu and the optional menu (dated October 26th through November 1st, 2025). Report Continued on LIC9099C Unsubstantiated Allegation #1: Facility has insufficient staff to meet residents’ needs. The complaint alleged that residents are paying a significant amount of money, but their needs are not being met. On 10/27/2025, from approximately 10:00 AM to 12:30 PM, LPA Richard interviewed the AED, who denied the allegations and stated that we have enough staff to care for and meet the residents' needs. The AED also noted that the facility has staff on call in case of an emergency. LPA interviewed the (MT), who disagreed and said that the facility has more than enough staff to meet the residents' needs. At the same time, LPA interviewed (DSM), who denied the allegation and stated that we offer various dining services for breakfast, lunch, and dinner to serve residents. LPA also interviewed two staff members (S1 and S2), who denied the allegation and stated that the facility has on-call staff who can help if they are short-staffed. On 10/27/2025, from approximately 1:30 PM to 2:30 PM, LPA interviewed five residents (R1-R5). All five denied the allegation and said the facility served their food on time and met their needs. The caregivers are excellent at caring for them. During the same period, LPA's review of the facility personnel roster showed four on-call caregivers and two on-call Med Techs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated. Report Continued on LIC9099C Allegation #2: Staff failed to provide adequate food service. The complaint alleged that the facility doesn’t serve snacks to the residents in memory care. On 10/27/2025, between approximately 10:00 AM and 12:30 PM, LPA Richard interviewed the AED, who denied the allegations and stated that the facility serves three meals a day and provides snacks between breakfast, lunch, and dinner. At the same time, the LPA also interviewed the (MT), who denied the allegation. Additionally, the LPA interviewed with the (DSM), who denied the allegation and explained that they provide a great weekly menu and an options menu in case a resident does not like what is on the regular menu that day. They also offer snacks between meals for all residents. Furthermore, the LPA interviewed two staff members (S1-S2), who denied the allegation and stated that the residents have many food options. On 10/27/2025, between approximately 1:30 PM and 2:30 PM, the LPA interviewed five residents. All five residents denied the allegation and stated that the facility provides them with adequate food and snacks between meals. They also said that if they don’t like what food they are served, they can order something else. Report continued on LIC9099C On 10/27/2025, LPA reviewed the facility's weekly menu, and the optional menu (dated Oct 26th - Nov 1st, 2025) showed a variety of food choices for the residents. LPA Richard observed the facility serving lunch at 12:00 pm; the residents had a large portion of food with side dishes, fruit, salad, dessert, and different types of beverages. Based on the LPA observations, interviews, and record reviews, the Preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. No deficiency cited. An exit interview was conducted. A copy of the report was provided to the Assistant Executive Director Anna Martinez.the state’s words, verbatim · CDSS document, Oct 27, 2025 · control 18-AS-20230306151448

Allegation investigated: Staff did not respond to the resident’s calls for assistance in a timely manner

On 10/21/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering an investigative finding into the allegation listed above. LPA met with Executive Director, Brooke Huerta, and explained to Anna the purpose of the visit. The investigation consisted of interviews and records review. Information received alleged that facility staff did not respond to residents calls for assistance in a timely manner. Records review conducted of the facility’s signaling system logged from April 11, 2023 to April 18, 2023 detailed numerous incidents of residents waiting approximately 20 minutes to 65 minutes until care staff arrived to assist the resident. Interviews conducted with residents divulged that the facility was experiencing a shortage of staff resulting in a delay of when residents would receive assistance. (Continue to LIC9099C...) Substantiated (Continuation from LIC9099) During an interview conducted with Resident #1 (R1), R1 reported waiting an hour until staff arrived to assist R1. A record review conducted for the signal system revealed that on 4/18/2023, R1 waited 65 minutes for care staff to arrive for assistance. Interviews conducted with (5) residents corroborated waiting long periods of time to receive assistance once a pendant was activated. Based on records review and interviews, the preponderance of evidence standard has been met. Therefore, the allegation of staff did not respond to residents call for assistance in a timely manner is deemed substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. California Code of Regulations Title 22 is being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of the LIC9099, LIC 9099D, and appeal rights were reviewed and provided to Executive Director, Brooke Huerta. (Continuation from LIC9099) Interviews conducted with (4) four out of (6) six staff reported there being an alternative main course menu for residents with dietary restrictions which allowed residents to choose what they wanted to eat if the resident could not eat something that was served in the scheduled main course meal. Interviews with staff further reported that kitchen staff had a list of resident names and their dietary restrictions to ensure the residents needs were met. Interview with Staff #1 (S1) reports their being alternatives available to residents but not being of nutritional value. LPA attempted to conduct an interview with Staff #2 (S2) who declined LPA’s interview request. Records review conducted of the facility’s weekly menu documents main course meals to have pork products multiple times a week for every mealtime (i.e. breakfast, lunch, and dinner) but offered alternatives to substitute a main course item. Therefore, the allegation of staff do not meet the needs of the resident’s religious dietary preferences is deemed unsubstantiated. A finding that is deemed unsubstantiated means that although the allegation may have occurred, there is not enough evidence to prove the violation did or did not take place. Exit interview conducted and copy of report provided Executive Director, Brooke Huerta.the state’s words, verbatim · CDSS document, Oct 21, 2025 · control 18-AS-20230412124717

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 4, 2025

(a) In addition to the rights listed in Section 87468.1... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights (4) To care, supervision, and services that meet individual needs... This requirement was not met with evidence by: Through interviews and records review staff did not respond to (5) five out of (5) five residents within a timely manner resulting to residents waiting between an average of 30 minutes to a hour for staff assistance which is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Executive Director (ED) Brooke Huerta agreed to do an in-service training with care staff on how to answer pendant system and cover what is a "timely manner" with care staff. ED agreed to conduct unannounced random pendant activations with staff to ensure calls are being cleared within a timely manner. Plan of Correction will be emailed to LPA by Closed of Business on 11/04/2025.

Allegation investigated: Facility did not administer medication as prescribed

THIS DOCUMENT WAS AMENDED On September 11, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced at the facility and met with the Licensee, Brooke Huerta. LPA explained the reason for the visit was to provide findings for the complaint investigation. During the investigation, LPA conducted interviews, record reviews, and made observations pertaining to the listed allegation. On April 02, 2025, Community Care Licensing received a complaint alleging facility staff did not administer medication as prescribed. It was reported that once Resident #1 relocated from the facility, R1 was given 13 unopen boxes of eye drops, causing concern that the medication was not being distributed as described. Information obtained from interview with Licensee, Brooke Huerta, denied the allegation that R1 was not being prescribed their medication. It was reported that the medication was provided in singular doses. Licensee indicated that R1 did not miss any prescriptions, which would be revealed on the logs. Information obtained from additional staff members indicated that the medicine was provided individually and that is why it appeared that R1 had a surplus of medication. Information received from interviews with additional residents indicated there were no concerns about how the staff administer their prescribed medications. Information obtained from interviews with additional witness confirmed R1’s prescription was provided in a larger quantity and the medication for each eye was in a separate box. Unfounded LPA’s review of the records, including R1’s centrally stored medication record, medication record at the time of discharge, and discontinued medications list, verified the information provided through interviews. LPA’s review of the records confirmed there was no documentation recording that R1 missed their medication. LPA conducted a subsequent interview with additional witness and they advised that they were unaware that the medication was provided in single doses and is now confident that R1 did not miss any medication. Additional witness indicated there were no further concerns or issues. Although LPA was unable to speak with R1 to obtain additional information, there is sufficient evidence to provide that the allegation did not occur. Based on information obtained from interviews, record reviews, observations, the evidence received pertaining to the allegation, facility did not administer medication as prescribed, the allegation is unfounded. A finding of unfounded indicates that the allegation is false, could not have happened, or is without a reasonable basis. The agency has dismissed the complaint. An exit interview was conducted. A copy of this report was discussed and given to the Licensee, Brooke Huerta.the state’s words, verbatim · CDSS document, Sep 5, 2025 · control 18-AS-20250402160033

Allegation investigated: Facility staff was negligent in resident's death

On 8/19/2025, Licensing Program Analyst (LPA) Valerie Flores arrived at the facility unannounced for the purpose of delivering findings of the listed allegations. LPA Flores met with Assistant Director, Anna Martinez, and a tour of the facility was conducted. On 4/12/2023, Community Care Licensing (CCL) received a complaint alleging facility staff was negligent in resident's death. Information obtained through interviews revealed staff attempted to assist Resident #1 (R1) with showering, while doing so R1 became agitated, R1’s agitation is related to R1s cognitive impairment which became noticeable after a change in R1s medication. This is consistent with Needs/Service Plan-File Review. According to information obtained R1 did not want to shower. Staff would assist R1’s showering needs during the evening for R1 to be presentable at church services, at the request of R1’s Responsible party. R1’s shower schedule would vary depending on R1’s mood. R1’s agitation increased, and staff attempted to mitigate the situation by using a “change of face” technique. Unsubstantiated The change of face technique is a non-confrontational behavior intervention used when a resident becomes agitated during an interaction with a particular staff. The approach involves substituting the current staff with a different staff member, often leading to a reset in the residents emotional state. Through interviews, it was alleged that while showering R1, R1 took a step backwards, lost their balance, fell, and struck their head on the wall. The facility staff attempted to catch R1 prior to the fall but their attempt was unsuccessful. The facility’s protocol does not allow staff to move the residents after an injury as it may harm the residents. The ambulance was immediately called, however, a valid signed, Do Not Resuscitate (DNR) was located in R1’s file. Through observations, the facility’s bathrooms complied with Title 22, regulation 87303, as showers were equipped with non-skid mats and grab bars. In addition, information obtained through interviews revealed that the facility’s protocol after any client falls, the service plan will be updated based on any specific need. This is to prevent any further falls and address safety measures. Residents will also participate in a re-evaluation provided by a medical professional after so many fall incidents. No reassessment was completed due to R1 passing. Furthermore, the facility complied with all protocols pertaining to R1’s needs and service plan, such as conducting checks on R1 and assisting R1 with their medications. Staffs training records were current, Staff implemented de-escalation techniques pertaining to R1’s agitated state at the time of the incident. According to the autopsy received by the Coroner’s Office, the reported cause of death was accidental and due to blunt force trauma. Based on observations, interviews and records reviewed, the allegation of staff was negligent in resident's death is unsubstantiated. A finding that is unsubstantiated means although the allegation may have happened and/or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where a copy of this report was reviewed and provided to Assistant Director, Anna Martinez.the state’s words, verbatim · CDSS document, Aug 19, 2025 · control 18-AS-20241016142418

Type of visit: Case Management - Deficiencies

On May 27, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a Case Management with Deficiencies and met with Anna Martinez, Memory Care Director. LPA made introductions and stated the purpose of the visit. LPA Mixson made observations, along with record reviews. There were sufficient staff present to attend to the care and supervision of residents at the time of this case management visit. Residents were occupied with medication management, and scheduled activities. There were no imminent health and/or safety concerns observed at present. LPA Mixson did not observe any obstructions or debris inside or outside of the facility. LPA observed the facility utilities to be operating without issue. LPA assessed the availability of food and observed there was a variety of food types available for the residents in care. Food supply meets the requirement of a two-day supply of perishable foods and a seven-day supply of non-perishable food items. Medications were found to be in sufficient supply, locked, and inaccessible to residents in care. The housekeeping team was present making their rounds. The facility is clean, neatly organized, and has a supply of activities available for the residents in care. The Activities Assistants there were two present and facilitated scheduled activities. No unattended residents were observed currently. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and/or welfare of the residents in care. However, on May 14, 2025, Community Care Licensing received information stating that a resident wandered into another resident’s room, deficiencies will be cited for "Facility Failed” to prevent a Resident from wandering into another resident’s room. 80078(a). An exit interview was conducted, and a copy of this report was discussed provided to Anna Martinez.the state’s words, verbatim · CDSS document, May 27, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80078(a) · Plan of correction due date: Jun 2, 2025

Responsibility for providing care & supervision: The licensee shall provide care and supervision as necessary to meet the clients needs. Licensee/Administrators failed to provide appropriate and adequate supervision to residents in care when behavior of wandering into another residents room was observed by caregivers and staff. Based on (interviews) and (record review)], the Licensee did not comply with the section cited above in one of one incidents which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 27, 2025

Plan of correction: Licensee shared training shall be conducted to include, but not be limited to, all of the following: Dementia care, including the interaction of drugs commonly used by the elderly, and the adverse behavior of persons with dementia, and Elopment Drill.

Type of visit: Case Management - Health Checks

On May 20, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a Health and Safety case management visit, and met with the Administrator, Brook Huerta. LPA made introductions and stated the purpose of the visit. LPA Mixson toured the facility, along with the Administrator, Brook Huerta and made observations. There were sufficient staff present to attend to the care and supervision of residents at the time of this case management visit. Residents were occupied with noon meal, medication management, and afternoon activities. There were no imminent health and/or safety concerns observed presently. LPA Mixson did not observe any obstructions or debris inside or outside of the facility. LPA observed the facility utilities to be operating without issue. LPA assessed the availability of food and observed there was a variety of food types available for the residents in care. Food supply meets the requirement of a two-day supply of perishable foods and a seven-day supply of non-perishable food items. Medications were found to be in sufficient supply, locked, and inaccessible to residents in care. Housekeeping team was present and making their rounds. Facility is clean, neatly organized, and has a supply of activities available for the residents in care. Activities Coordinator was present and facilitating scheduled activities. No unattended residents were observed currently. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and/or welfare of the residents in care. There were no visible deficiencies observed or cited during today's visit. An exit interview was conducted, and a copy of this report was provided to Administrator, Brook Huerta.the state’s words, verbatim · CDSS document, May 20, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA), Stephanie Martinez, conducted a continuation of an unannounced required annual inspection at the facility. The LPA met with Executive Director (ED), Brooke Abrego-Huerta, and informed her of the purpose for the visit. Physical Plant / Environmental Safety: The LPA conducted a tour of the facility, accompanied by the facility maintenance director, Sammy Ortiz. The LPA observed the alarm system in all three (3) buildings to show, "system normal". Two (2) carbon monoxide devices were inspected in the two hundred and four hundred halls and observed to be operable. The LPA inspected three (3) bedrooms in both memory care buildings and four bedrooms in the assisted living building. The LPA observed a chair(s) to be missing in room 8 and 27, and 109; a night stand to be missing in room 27; and a drawer to be missing from the chest of drawers in room 22. These violations were addressed at the time of the LPA's visit. Therefore, an advisory notice will be issued. Bedrooms had sufficient lighting for resident needs. Resident bathrooms were observed to have grab bars available and slip resistant material present in the showers. The toilet, handwashing, and bathing facilities were all in working condition. The hot water temperature was tested and observed to be within regulatory requirements. The call system was tested and observed to be in working order. The LPA inspected and observed sufficient space for storage of supplies and equipment. Storage areas were observed to be appropriately secured for the safety of the residents in care. There are no pools or other bodies of water located at the facility. According to ED, Abrego-Huerta, there are no known firearms being stored at the facility. The facility does have a working telephone available for resident use. Staffing: Staff have current First Aid/CPR training on file. Separate staffing is available to perform independent tasks for the operation of the facility. According to ED, Abrego-Huerta, all personnel working in the facility are at least 18 years of age. Emergency training is provided to staff members who work the night shift. ED, Abrego-Huerta, is present at the facility during normal working hours and a manager has been observed to be responsible for the operation of the facility when the ED is temporarily absent. Planned Activities: The facility does have activities for residents in care, which include socialization, group discussion, crafts, games, other recreation activities, and outings. The facility does have a staff member who has full responsibility to organize, conduct, and evaluate planned activities. There is sufficient space for activities at the facility. Food Service: The LPA inspected the facility's kitchen areas in all three (3) buildings and the food supply. The LPA observed all food to be of good quality. All readily perishable foods and beverages capable of supporting rapid and progressive growth of micro-organisms were stored in covered containers at appropriate temperatures. Soaps, detergents, cleaning compounds and similar substances were stored in areas separate from food supplies. All kitchen areas were kept clean and free of litter, rodents, vermin, and insects. Modified diets appear to be provided to residents in care as special diet needs were observed to be posted in the kitchen. There appeared to be at least 7 days worth of non-perishable food items and 2 days worth of perishable food items. Incidental Medical and Dental: The facility is arranging, or assisting in the arrangement of medical and dental care for residents. Staff are assisting residents with the administration of medication. Medication rooms were inspected in all three (3) buildings. Centrally stored medications were observed to be organized and inaccessible to unauthorized individuals. Medications were observed to be appropriately labeled. Centrally stored medication and destruction records were observed on file. Resident Records- Incidental Reports: The facility does maintain a continuing record of any illnesses, injury, or medical or dental care, when it impacts the resident's ability to function or the services needed. Resident records showed pre-admission appraisals, admission agreements, and medical assessments on file. Admission agreements appeared to meet regulatory requirements. Medical assessments appeared to have all the required medical information. The facility does conduct re-appraisals on residents, and updates are made to resident's written record of care. The facility currently has an approved hospice waiver for twenty (20) residents. There are currently ten (10) residents receiving hospice services. Residents with Special Health Needs: Resident hospice records were observed to have the required records. No smoking - Oxygen in use, signs were observed to be posted throughout the facility. Staff training in oxygen administration was observed to be completed. The facility does have secured perimeters available for residents diagnosed with dementia that wonder. No deficiencies were cited at the time of the visit. This report was reviewed with Executive Director, Brooke Abrego Huerta, and a copy was provided.the state’s words, verbatim · CDSS document, Jan 24, 2025

Allegation investigated: Staff are not properly supervising residents who may be a fall risk

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegation. The LPA met with Executive Director, Brooke Abrego-Huerta, and informed her of the purpose for the visit. A report was received by the Department alleging multiple calls were being made to emergency services (911) for Resident One (R1) relating to falls, where the resident was found in common areas of the building, indicative of the facility staff not meeting the resident's level of care needs. The investigation, which was started on 01/07/2025, involved staff and resident interviews, review of records, and collection of relevant documentation. Three (3) of five (5) resident interviews revealed facility staff are meeting their care needs. Four (4) of five (5) interviews with care staff reported the facility was meeting R1's care needs. Of those interviews, four (4) staff reported there have been at least two (2) and up to seven (7) calls made to 911 in response to an incident or concerning observation involving R1. Medical records were obtained and revealed only four (4) calls were made to emergency services for R1, resulting in the resident being transported to a local hospital. Unsubstantiated Of the four (4) calls for service, one (1) call was made relating to a fall the resident sustained. Two (2) of four (4) calls for service resulted in R1 being admitted to the hospital for additional medical treatment. An AMR (American Medical Response) Patient Care Report, dated 10/21/2024, revealed AMR responded to the facility for R1 who experienced a witnessed ground level mechanical fall. The report revealed the resident presented alert and oriented times two (X2) with no medical complaints. According to the report, facility staff explained how R1 fell forward while walking outside, losing their footing on a curb. The report revealed R1 denied hitting their head, did not lose consciousness, and did not want to go to the hospital. The report revealed facility staff expressed their desire to have R1 transported due to the mechanism of the fall and R1's recent behavior challenges with staff. R1 was later transported to a local hospital. An Unusual Incident/Injury Report (UIR) from the facility was available for review for the 10/21/2024 incident. The report revealed R1 was exit seeking, exited the memory care building into the secured courtyard, started swinging at staff, and fell onto their knees after tripping over a flower bed. The report revealed R1 complained of pain to their knees after their fall. Staff #1 (S1) was identified to be present during the incident in both the AMR Patient Care Report and the UIR. An interview was attempted with S1; however, no response was received prior to the closure of the investigation. R1 also could not be reached for an interview prior to the closure of the investigation. No additional information was obtained that could either refute or corroborate the validity of the allegation. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint 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. This report was reviewed with Executive Director Abrego-Huerta and a copy was provided.the state’s words, verbatim · CDSS document, Jan 22, 2025 · control 18-AS-20250102161349

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Stephanie Martinez, conducted a required annual inspection at the facility. The LPA was allowed entrance into the facility and met with Executive Director (ED), Brooke Abrego-Huerta, and informed her of the purpose for the visit. The inspection included the following: Infection Control Plan: The facility has an Infection Control Plan in place. The plan does not appear to be reviewed annually, as documentation shows it was last reviewed on 05/04/2022. According to the ED, the facility is following the policies listed in the plan whenever there are infectious outbreaks within the facility. Operational Requirements: The facility does have a Plan of Operation available at the facility, which includes a Dementia Plan of Care and Bedridden Plan of Care. Proof of liability insurance was observed on file and expires on 06/01/2025. Personnel Records-Training: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Training on dementia care, postural supports, restricted health conditions, hospice and medication administration was observed on file; though incomplete. Postural support training, which is a required 4 hours, was not completed for four (4) care staff members. An advisory notice will be issued. Resident Rights-Information: The facility has internet accessible devices available for resident use. The LPA did not observe the complaint poster (PUB 475), non-discrimination notice, Personal Rights (87468.1) or Personal Rights of Residents in All Facilities (87468.2) to be posted. An advisory notice will be issued. Disaster Preparedness: The facility does have an emergency and disaster plan in place, which included contact information for appropriate agencies. Proof of staff training on emergency procedures was observed on file. Proof of emergency drills were observed on file; a Fire Drill was completed with staff and residents on 01/17/25. Due to insufficient time a follow up visit will have to be conducted to complete the inspection. This report was reviewed with ED Abrego-Huerta and a copy was provided.the state’s words, verbatim · CDSS document, Jan 22, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit at the facility to follow up on alleged thefts involving residents in care. The LPA met with Memory Care Director, Anna Martinez, and informed her of the purpose for the visit. Several reports were received by the Department, from the facility, regarding thefts of resident's property and valuables. One alleged theft involved Resident One (R1), who had a withdrawal of funds from their bank account in the amount of $1,000.00. According to a Report of Suspected Dependent Adult/Elder Abuse, R2's family member called the facility to report the resident loaned a staff member $100.00; however, after a review of bank records it was later found the check, dated 09/27/2024, was in the amount of $1,000.00. It was further alleged in the report that, R1 reported they deliberately placed $200 in a chest in their bedroom in front of the same staff member and later found the money was gone. According to the report, the staff member involved was Staff One (S1). A second report of alleged theft involved Resident Two (R2), whose bank card went missing and numerous unauthorized transactions totaling up to $8,000 being discovered. According to a Report of Suspected Dependent Adult/Elder Abuse, one purchase was made on 10/11/2024 at a beauty supply business. The business confirmed the identity of the individual who made the transaction, later identified as S1. According to a Notice to Employee as to Change in Relationship report, S1 was laid off/discharged on 10/14/2024. LPA made attempts at reaching S1 to obtain the staff member's statement; however, the attempts were unsuccessful. As of this date, R1 and R2 were not available for an interview. According to one staff interview, the incidences have been reported to law enforcement. Incident report numbers were obtained from the facility. The staff interview also revealed, as of two (2) weeks ago, that staff names have been assigned to their key fobs in order to show who last entered a resident's bedroom. It was further reported that staff, residents, and family members were notified in writing, that gifts and/or loans are not to be given to staff members of the facility. Additional time is required, prior to the closure of the investigation, in order to obtain further information. This report was reviewed with the Memory Care Director and a copy was provided. (NOTE: LPA was off the premises from 12:00 PM - 12:30 PM. Administrator, Brooke Abrego-Huerta, was unavailable for the LPA's visit.)the state’s words, verbatim · CDSS document, Nov 5, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Yolanda Delgado conducted an unannounced Case Management Death Report visit. LPA was greeted by Brooke Abrego-Huerta, Executive Director. LPA explained the purpose of the visit. The visit is in response to the death of Resident #1 (R1), that was reported on 09/09/2024 to have died of unknown cause on 09/07/2024. During LPA's visit, LPA reviewed R1's file and obtained copies of the following: ID/emergency Information, admission agreement, Physician's report, Appraisal/Needs and Services Plan, physician's orders, POLST, Medication list, three (3) statements and email notifications to CCLD. LPA also requested a copy of R1s death certificate when it is made available, and staff schedule for 9/6/2024 and 9/7/2024. During today's visit no deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to Brooke Abrego-Huerta along with a copy of the LIC811.the state’s words, verbatim · CDSS document, Sep 10, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to follow up on two incident reports received from the facility relating to alleged theft. The Department received two reports relating to the theft of personal items belonging to Resident One (R1). During the visit the LPA reviewed and collected relevant records. Additional time is required, prior to the conclusion of the investigation, in order to obtain further information. This report was reviewed with the Executive Director and a copy provided.the state’s words, verbatim · CDSS document, Jul 11, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to continue the required annual inspection which was started on 03/08/2024. The LPA was allowed entrance into the facility and met with Administrator, Brooke Abrego Huerta. Abrego Huerta was notified of the purpose for the visit. The facility currently has an approved Hospice Waiver for twenty (20) residents. The inspection included the following: Physical Plant: A tour of the facility's interior and exterior areas was completed; resident bedrooms were clean, had the required furniture and had sufficient lighting. There are no bodies of water located on the property. According to Administrator, Abrego Huerta, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet and shower used by residents. Bathroom faucets, showers, and toilets were observed to be in working order. Resident showers have non-skid material present. The LPA inspected the fire alarm panel and observed the system to show "normal". According to facility staff, the carbon monoxide and smoke detectors are combined on one device. The LPA observed a sprinkler system to be available in the bedrooms where bedridden residents were residing. The facility was observed to be clean and free of odors. Food Service: There is a minimum of 2 days of perishable foods and 1 week's supply of non-perishable foods available. The facility kitchen was toured and observed to be clean. Supplies were observed to be available. No presence of insects or rodents was observed in the kitchen areas. Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Dementia care training, Restricted Health Conditions training, and Hospice training was observed to be available and complete. Staff training records revealed the facility has also provided staff with additional training, such as personal rights training. The LPA was informed by Administrator Abrego Huerta that there are currently thirteen (13) residents in care who are receiving hospice services. Hospice Care Plans were observed on file at the facility. There is a disaster and mass casualty plan in place. Proof of emergency drills were observed on file. All services requiring specialized skill are being performed by residents or personnel qualified as appropriately skilled professionals. The facility was observed to not be operating beyond the conditions specified on the license. Medication Review: The LPA reviewed resident medications. Medications were observed to have the required prescriptions on file. The facility's medication room was inspected and found to be clean and inaccessible to unauthorized individuals. An exit interview was conducted with Administrator Abrego Huerta; this report was reviewed, and a copy was provided. No citations were issued during this visit.the state’s words, verbatim · CDSS document, Apr 5, 2024

The state marks this report as 15 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility to conduct a required annual inspection. The LPA met with Administrator, Brooke Abrego Huerta, and informed her of the purpose for the visit. Staff Interviews: Interviews were conducted with facility care staff. Staff displayed sufficient knowledge and awareness in providing appropriate care and supervision to residents. Emergency Disaster Plan: The Emergency Disaster Plan was reviewed. The plan was observed to require updates, as the plan indicates an emergency generator is available for use; however, according to one staff interview the facility has no generator on the premises. According to the Maintenance Director, contact information is available for a company who can provide an emergency generator. According to Administrator Huerta, the plan was last reviewed January 2024. Due to insufficient time a return visit will be conducted in order to complete the inspection. This report was reviewed with Administrator, Brooke Abrego Huerta, and a copy was provided.the state’s words, verbatim · CDSS document, Mar 8, 2024

The state marks this report as 15 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.