Melrose Gardens

Allegation investigated: Staff did not administer resident's medication. Staff are rude to residents.

On 8/25/26, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a subsequent visit regarding the allegation listed above. LPA conducted the initial complaint visit on 10/28/25. LPA met with facility Administrator, presented official CDSS badge identification, and reason for the visit was disclosed. At 10:50 am, LPA conducted a physical plant tour; no health and safety issues were observed. Allegation: Staff did not administer residents's medication. It was alleged that on 10/17/25, Staff #1 (S1) withheld Resident #1's (R1) insulin. To investigate the allegation, LPA interviewed two (2) staff, and eight (8) residents; both staffers refute the allegation and stated they do not refuse residents their medications. [LIC 9099C] Continued- Unsubstantiated Based on records review and staff interviews, R1 was provided their medications as prescribed. S1 stated to LPA that they did not work at the facility on 10/17/25; a review of the facility staff schedule shows S1 was not scheduled to work on the date of the alleged incident. LPA documents reviewed revealed the following: R1 is able to perform their own glucose testing, and administer their own medication injections with some assistance by staff. Based on interviews and records review, the allegation is unsubstantiated at this time. Allegation: Staff are rude to residents. It was alleged that Staff#1 (S1) treats Resident#1 (R1) and other residents rudely. To investigate this allegation, LPA interviewed eight (8) out of a total fifty-four (54) residents. Seven (7) out of eight (8) residents interviewed stated to LPA that they have no issues with staff temperament and are treated respectfully by staff. Based on interviews and record review, the allegation is unsubstantiated at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 25, 2026 · control 31-AS-20251021083505

Allegation investigated: Staff sexually abused a resident

At 3:00 p.m. on 08/13/26, Licensing Program Analyst (LPA) Nicholas Reed conducted a subsequent visit to complete the investigation of the above allegation. LPA met with the facility Administrator, and the reason for the visit was disclosed. At 3:10 p.m., LPA inspected the facility; no health and safety hazard were noted. On 01/20/26, LPA Ray Comer, conducted an initial visit to investigate the allegation, at which time, LPA interviewed facility Administrator, and Staff #1 (S1). Additionally, LPA obtained and reviewed R1's Physician's report (602A), appraisal, needs and service plan, and other documents relevant to the investigation. This complaint was referred to the Investigations Branch, (IB) of the Community Care Licensing Department (CCLD) [LIC9099C] Continued- Unsubstantiated The Department's investigation consisted of an interview with Resident #1 (R1) and Staff #1 (S1). The following is a summary of The Department's investigation, in conjunction with LPA Comer's interviews with Administrator, staff, and records review. On 01/22/26, The Department interviewed R1 which revealed the following: R1 stated she had lived as a resident of the facility for "possibly over one (1) year" and that over the course of that year, R1 stated they had been harassed by a male staff member at least two times. However, it is noted that R1's file shows they have only been a resident of the community for less than two months. R1 confirmed to The Department having challenges with their memory. R1 recalls telling their social worker about alleged incident, but was unable to provide a description of the alleged assailant other than them being a "tall male" standing in R1's room naked when R1 got out of the shower. R1 stated to The Department that the alleged incident occurred on 1/13/26. R1 stated to The Department they reported the incident to a staff at the facility's front desk. However, R1 could not recall the front desk staff with which they reported the incident to, nor provide a description of front desk staff. R1 states that the police came to take a report but was unable to provide any further details and denied being taken to a hospital or clinic as a result of the alleged incident. On 1/22/2026, The Department interviewed Staff #1 (S1) which revealed the following: Per S1, on 1/16/26, the facility was notified by Welbe Adult Day Health Care Program, that R1 reported a sexual abuse allegation possibly involving a staff member at the facility, but did not provide any further details. Per S1, on the afternoon of 1/16/26, S1 asked R1 if everything was ok, and if they were having any issues with anyone at the facility, which R1 denied. S1 confirmed to The Department that R1 had only resided at the facility for approximately one month, and that R1 tends to be confused, believing everyday that they are moving out of the facility to go and live with their daughter. The Department and S1 observed security camera footage, from the hallway camera that faces R1's room (Room 222), to witness anyone going in R1's room from January 12, 2026 to January 13, 2026. During that period, it was observed that no staff members, nor any other males, entered R1's room. S1 confirmed that there is only one way in/out of R1's room, so if anyone entered or exited R1's room, such persons would have been identified on the facility's security footage. [LIC9099C] Continued- LPA Comer's interviews with the Administrator and staff revealed the following: Both Administrator and Staff#1 (S1) refute the allegation stating that staff respect the rights of all residents in care. Both Administrator and S1 stated to LPA that R1 is challenged with dementia, and at time expresses episodes of confusion, disorientation, and lack of impulse control. R1 converses with staff and occasionally mentioning unsolicited graphic and salacious stories of a sexual nature. Based on inspection, interviews and record review, there is not sufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit Interview conducted, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Aug 13, 2026 · control 31-AS-20260116141610

Allegation investigated: Staff do not ensure resident's showering needs are being met. Staff do not ensure resident is being assisted with dressing.

Today, 6/09/26, Licensing Program Analyst (LPA) Raymond Comer conducted unannounced subsequent visit to investigate the above allegation(s). LPA Antonia Alvizar-Ettima conducted the initial complaint visit on 12/16/25. At which time, at 8:30 am, LPA obtained Resident #1 (R1’s) Identification Emergency Information, Appraisal, Needs and Services Plan, Physician Report, Shower Schedule and other pertinent information. During today’s visit, Between 8:25am and 9:45am, LPA Comer obtained and reviewed Facility's resident roster, personal roster, R1's Physician's report, appraisal, Needs/Service plan, Shower schedule and other records relevant to the investigation. At 10:00am, LPA Comer conducted a tour of the facility. Between 10:15am and 11:00am LPA Comer conducted interviews with the Administrator, and two (2) staff. Between 11:15am and 12:40pm, LPA Comer conducted interviews with R1's Responsible Family Member, and six (6) residents out a total of fifty-one (51) facility residents. [LIC9099C] Continued- Unsubstantiated Allegation: Staff do not ensure resident's showering needs are being met. It was alleged that Resident#1 (R1) was emanating foul body odor for several days due to staff neglect. LPA Comer's review of documents revealed the following: R1's needs/service appraisal shows that R1 "needs cueing/reminders to complete bathing tasks". LPA Comer's interview with the Administrator and two (2) staff indicated that staff provide cueing, reminders, and offer direct assistance to R1, and other residents with showering, and all other ADL',as needed. LPA Comer spoke with R1 and observed them as clean, hair groomed, and not exhibiting any foul odor. While touring the facility, LPA observed residents as clean, well-groomed and did not experience any malodor in the facility. LPA Comer's interviews with R1's Responsible family member, and six (6) out of fifty-one (51) total residents revealed the following: Staff provide adequate assistance to residents requiring staff cueing/reminders or direct assistance with their bathing/hygiene needs. Therefore, based on LPA's observations, records review, and interviews, this allegation is Unsubstantiated at this time. Allegation: Staff do not ensure resident is being assisted with dressing. It was alleged that Resident#1 (R1) was observed wearing the same clothes for several days at a time due to staff neglecting to assist R1. LPA Comer's review of documents revealed the following: Both R1's Physician's Report and Appraisal show that R1 does not need assistance with dressing. LPA Comer's interview with the Administrator and two (2) staff indicated that R1 is largely independent, does not need assistance to dress themselves and ensure R1 is dressed in clean clothing. LPA Comer's interview with R1 revealed the following: R1 was observed as clean, dressed in clean clothes, and did not exhibit any foul odor. While touring the facility, LPA observed residents as wearing clean clothing, and did not experience any malodor in the facility. LPA Comer's interviews with R1's Responsible family member, and six (6) out of fifty-one (51) total residents revealed the following: Staff provide adequate assistance to residents requiring staff cueing/reminders or direct assistance with their changing/dressing needs. Therefore, based on LPA's observations, records review, and interviews, this allegation is Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Jun 9, 2026 · control 31-AS-20251209081116

Allegation investigated: Licensee does not ensure that facility has adequate staffing to meet the needs of residents in care.

On Monday, 4/13/26, Licensing Program Analyst (LPA) Raymond Comer conducted unannounced subsequent visit to complete an investigation of the above noted allegation. It was reported on 11/17/25 that staffing levels were insufficent to ensure adequate care and supervision to residents. To deal with staff shortages, existing staff were compelled to work overtime hours and were exhausted, due to working overtime hours for an extended period. To investigate the allegation, on 11/24/25, LPA conducted an initial complaint visit. During initial visit, at 1:25 pm, LPA spoke with the Administrator and discussed the allegations, and at 1:35 pm, conducted a tour of the facilty. At 1:45 pm, LPA recieved and reviewed residents roster and personnel roster. Between 1:50 pm, and 2:30 pm, LPA conducted interview with Administrator, and two (2) staff. During today’s visit, at 9:45 am, LPA conducted and physical plant tour to inspect overall levels of staff coverage. LPA observed various staff assisting residents in the activities room, dining room, housekeeping services, and med tech staff assiting residents; staffing levels appeared to provide aquequate resident care and supervion. [LIC9099C] Continued- Unsubstantiated Between 10:20 am and 12:15 pm, LPA interviewed additional staff. Between 12:45 pm, and 1:30 pm, LPA interviewed six (6) out of fifty-six total (56) residents. LPA's interview with the Administrator revealed the following: Administrator refutes the allegation, stating to LPA that elevated levels of sick and vacation call outs are anticipated, especially during the holiday months of November and December. Per Administrator, adequate staff coverage is maintained by offering overtime to staff on a voluntary basis. (Overtime is never "required"; staff are always able accept or refuse to overtime hours) Additionally, Administrator stated to LPA that licensee is contracted with temp caregiver agency, Exemplary Care LLC., which provides additional caregiver staffers, if necessary. LPA interviews with staff revealed the following: Five (5) out of five (5) staff stated to LPA that facility maintains adequate levels of staffing ensuring satisfactory resident care and supervision. All staff interviewed confirmed never being either compelled nor "required" to work overtime hours and chose to work overtime on a strictly volunteer basis. All staff interviewed confirmed to LPA that hours worked at the facility are neither egregious, nor did staff state feeling unable to get adequate rest/address personal concerns during their off-days due to working persistent overtime hours. LPA interviews with six (6) out of fifty-six (56) residents revealed the following. All six (6) residents stated to LPA their satisfaction with facility staffing levels, and the quality of care and supervision provided to residents. Based on LPA observations, and interviews of staff and residents, there isn't enough evidence to prove that there was inadequate supervision at the facility. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, and copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Apr 13, 2026 · control 31-AS-20251118114554

Allegation investigated: Staff do not ensure resident's hygiene needs are met.

On Friday, 03/27/26, Licensing Program Analyst, (LPA) Raymond Comer, conducted an initial 10-day complaint visit to investigate the above allegation. LPA presented official CDSS identification badge, met with the Administrator, and reason for the visit was disclosed. At 9:45 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation, Between 10:45 am and 11:50 am, LPA received and reviewed Facility Resident roster, Personnel roster, Resident#1 (R1) Physician Report, Appraisal/Needs & Services Plan, and other pertinent documentation. Between 12:30 pm, and 2:15 pm, LPA interviewed the Administrator, R1's Responsible family member (F1) and Six (6) Residents. [LIC 9099C] Continued- Unsubstantiated Allegation: Staff do not ensure resident's hygiene needs are met. Reporting Party (RP) alleges that resident#1 (R1) had not been bathed, nor teeth brushed for several days to weeks. RP states that when R1's responsible family member inquired about this issues to staff, they claimed that the R1 was completing these tasks independently, and not being provided required assistance as per R1's care plan. LPA's interview with Administrator revealed the following: R1 is largely independent and does not require bathing, nor tooth brushing hygiene assistance by staff; they are only instructed to provide "reminder cues" to R1 to encourage bathing and tooth brushing tasks are completed. In addition, Administrator has instructed staff to assist R1 with hygiene assistance to ensure satisfactory health outcomes for R1. LPA's records review of R1's file revealed the following: R1's physician's report (LIC 602) shows that R1 is able to bathe, groom, and care for their own toileting needs. Preplacement appraisal documentation shows that R1 does not require assistance with bathing, hair care, toileting, or personal hygiene; only "reminders" from staff. Resident appraisal show same instruction for staff to provide R1 "reminders" only. R1's needs and service plan shows R1 is "independent in all her ADL's and is encouraged by staff to do so". LPA interview with R1's responsible family member (F1) revealed the following: F1 is satisfied with the level of staff assistance, care and supervision provided by staff and has no concerns regarding R1. LPA interviewed (6) out of fifty-five (55) residents, which revealed the following: Five (5) out of six (6) residents interviewed stated they are satisfied with staff's assistance and service provision and had no health/safety concerns. Overall, LPA's investigation concludes there was not sufficient evidence to verify staff are neglecting R1's hygiene needs. Therefore, based on interviews, records review, and LPA observation, the allegation is UNSUBSTANTIATED at this time. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Mar 27, 2026 · control 31-AS-20260319124118

Allegation investigated: Staff do not ensure the safety of residents from other residents.

On Friday, 03/27/26, Licensing Program Analyst, (LPA) Raymond Comer, conducted an initial 10-day complaint visit to investigate the above allegation. LPA presented official CDSS identification badge, met with the Administrator, and reason for the visit was disclosed. At 9:45 am, LPA conducted a physical plant tour; no health and safety issues were observed. During LPA's tour of the facility, LPA observed California RCFE Complaint Poster (PUB 475) prominently displayed in common area of the facility. To investigate the allegation, Between 10:05 am and 10:35 am, LPA received and reviewed Facility Resident roster, Personnel roster, Resident#1 (R1) Physician Report, Appraisal/Needs & Services Plan, and other pertinent documentation. Between 11:00 am, and 12:30 pm, LPA interviewed the Administrator, Three (3) Staff, and Six (6) Residents. [LIC9099C] Continued Unsubstantiated Allegation: Staff do not ensure the safety of residents from other residents. It was alleged that on 03/20/2026, Resident #1 (R1) was verbally and physically aggressive towards Resident#2. (R2) Reporting Party alleges that staff did not intervene to address R1's alleged aggression. LPA's interview with Administrator, and three (3) staff revealed the following: There was no physical altercation between R1 and R2. Administrator and staff stated to LPA that although R1 is known for using "cursing and strong language" on occasion when frustrated, R1 is not physically combative towards neither residents, nor staff. On 3/20/26, while R1 was eating in the facility dining room, R1 was asked by staff to move his chair closer to the table. R1 became frustrated and responded to staff by cursing, and telling staff "don't talk to me while I am eating". Staff stated to LPA that they were able to calm R1 and that R1 complied with staff's request. LPA interviewed (6) out of fifty-five (55) residents, which revealed the following: Five (5) out of six (6) residents interviewed stated feeling comfortable eating in the dining room, and are satisfied with staff's level of supervision in ensuring resident safety; residents interviewed had no health/safety concerns. Overall, LPA's investigation concludes that although there was an incident in the dining room involving R1 and a staff, there was not sufficient evidence to verify any physical altercation between residents. Therefore, based on interviews with staff and residents, the allegation is UNSUBSTANTIATED at this time. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Mar 27, 2026 · control 31-AS-20260323090813

Allegation investigated: Staff does not safeguard resident's personal belongings. Staff do not allow resident to have visitors.

On Thurday, 1/15/26, Licensing Program Analyst (LPA) Raymon Comer conducted an unannounced subsequent visit to the facility to conduct additional investigations and render findings for the above noted allegations. LPA met with the Administrator, and informed them about the purpose of this visit. The investigation of the allegations was initiated on 11/04/2024 at which time LPA Comer requested residents and staff rosters. At 11:30 am, LPA requested and received copies of Residents files, including but not limited to Physician report, need and service plan, inventory records of resident(s) personal belongings and other documents relevant to investigation. In addition, on 12/04/2025, between 12:10 pm and 12:30 pm, LPA inspected R1’s room and observed and assessed R1. At 12:45pm, other residents and staff were interviewed. [LIC9099C] Continued Unsubstantiated Allegation: Staff does not safeguard resident's personal belongings. It was alleged that Resident #1’s (R1’s) friend purchased comforters and sheets for R1, but they were lost or stolen before being used. Staff revealed that R1’s linens and comforters are being changed as frequently as needed and no one ever reported them lost or stolen. Other residents interviewed during investigation did not reveal any concerns regarding their personal belongings. A review of R1’s inventory record of personal belongings did not verify that R1 had linens and comforters. Per LPAs inspection and observation of R1’s bedroom, R1 had fresh linens on their bed, and they appeared to be clean and dry. Based on inspection, observation, interviews and record reviews, there is not sufficient information to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Allegation: Staff do not allow resident to have visitors. Concerns were addressed that about two weeks prior to October 29, 2024, based on the request by R1’s family member, the Administrator informed one of the visitors (V1) that they would no longer be allowed to visit R1 as contact with the visitor could affect R1’s health and safety. The Executive Director (ED) and other staff revealed that V1 was coming to the facility and hanging around in R1’s room until visitation hours were over. V1 was coming to the facility under the influence of alcohol and exhibiting aggressive behavior towards R1, making them upset and agitated. R1 was in shared room and while V1 was present, he was not allowing staff to assist R1, and their roommate. The ED made attempts to allow supervised visitation to V1. However, it angered V1 causing them to make verbal threats to facility staff. ED was in contact with R1’s responsible party/family member (F1), who also noted V1’s negative impact towards R1’s health and safety. Based on F1’s written request, as well as complaints and concerns addressed by the facility staff and other residents, ED had no choice but to prohibit R1 from visiting the facility. V1’s presence was posing a hazard not only to R1 but also R1’s roommate, other residents and staff. Interview with F1 verified the information received from ED and other staff. [LIC9099C] Continued A review of e-mail communications between ED and family member, supported the information received from interviews. Based on interviews, and record review, the allegation did occur and V1 was prohibited to come to the facility. However, the decision was made to protect health and safety of R1, other residents and staff. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety hazards were noted. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 31-AS-20241029123550

Allegation investigated: Staff withheld medication from a resident in care.

Licensing Program Analyst, Abeye Duguma (LPA) conducted a subsequent complaint visit to investigate the above allegations. LPA met with Joseph Weider and explained the reason for the visit. ---Staff failed to ensure proper medication administration. It was alleged that Staff #1 (S1) withheld Resident #1's (R1) insulin at 4:30p.m on 12/29/2025. when requested. To investigate the allegation, on 12/29/2025 at around 10:00a.m, LPA requested documents and interviewed three (03) staff and six (06) residents 10:30a.m. to 12:00p.m. A review of physician's orders states R1 is to take insulin at 8:00a.m., 12:00p.m. and 4:00p.m. A review of facility staff records shows R1 received all medications as prescibed on the date of the alleged incident. A review of the facility staff schedule shows S1 was not working on the date of the alleged incident. During interviews with staff, all staff stated they do not refuse resident medications and R1 was given their medications as prescribed. (CONT. on LIC9099-C) Unsubstantiated During interviews with residents, R1 stated S1 did not give insulin when requested and did not offer a reason why R1 was not going to get insulin. All other residents stated staff give medications as prescribed and are not refused medications. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 31-AS-20251223092143

Allegation investigated: Staff does not ensure resident receives adequate food service. Facility is not kept clean and sanitary. Staff do not ensure that resident has clean linen.

At 10:05 am, Thursday, 12/04/25, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a subsequent complaint investigation regarding the allegation(s) listed above. Inital 10-day visit conducted on 11/04/24. LPA met with Administrator, presented official CDSS badge identification, and reason for the visit was disclosed. At 10:20 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation, LPA received Facility resident roster, and staff roster. Between10:40 am and 11:25 am, LPA reviewed Resident 1's (R1) file, and documents relevant to the investigation. Between 12:10 pm and 1:45 pm, LPA observed R1, their bedroom, interviewed staff and residents. [LIC 9099C]-Continued Unsubstantiated Allegation: Staff does not ensure resident receives adequate food service. Reporting Party (RP) alleges that Resident#1 (R1) is not adequately provided meals by staff and, as a result, R1 is losing weight. During today's visit, LPA observations revealed the following: Today's menu consisted of chicken dumpling soup, orange chicken with rice, vegetable egg roll, and coconut cake. LPA observed R1 eating in the facility dining room; R1 appeared in good spirits, smiling and conversing with other residents and staff. LPA conducted interviews with four (4) out of a total thirty (30) residents. All four (4) residents interviewed stated enjoying the meals provided by staff. Based on the information LPA obtained through observation, and interviews, It cannot be proven that R1 is not provided meals by staff. Therefore, the allegation is deemed unsubstantiated at this time. Allegation: Facility is not kept clean and sanitary. Reporting Party (RP) alleges that Resident#1 (R1's) room and restroom are not properly cleaned and sanitized, and that restroom often contains feces and urine stains. During today's visit, LPA observations revealed the following: Both the facility in general, and R1's bedroom/restroom were found to be clean, without feces/urine stains, and having no odor. LPA conducted interviews with four (4) out of a total of thirty (30) residents. All four (4) residents interviewed stated being satisfied with the consistency and level of cleanliness provided by staff. Based on the information LPA obtained through observation, and interviews, It cannot be proven that R1's room and bedroom are not properly cleaned and sanitized by staff. Therefore, the allegation is deemed unsubstantiated at this time. Allegation: Staff do not ensure that resident has clean linen. Reporting Party (RP) alleges that staff do not change Resident#1 (R1's) linens frequently. During today's visit, LPA observations revealed the following: R1's bedsheets, pillowcases, and incontinence mattress pads were found to be clean, dry and free of odor. Facility's linen closet was examined and found to contain clean and odor free linens and towels provided to residents. Based on the information LPA obtained through observation, and interviews, It cannot be proven that staff neglect provision of clean linen and towels to residents. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 31-AS-20241029123550

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff are not ensuring residents are provided with a safe environment. Staff speak inappropriately to residents in care.

At 12:15 p.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced subsequent complaint visit at this facility to continue the investigation on the above allegations. LPA met with the Executive Director, Joseph "Yossi" Wieder and LPA explained the reason for the visit. An entrance interview was conducted. To investigative the allegations LPA Rios conducted an initial visit on 07/22/2025 and requested a copy of the resident roster and personnel report. On 7/22/2025 at approximately 12:50 p.m., LPA initiated a physical plant tour. Between 1:10 p.m. and 2:00 p.m., LPA conducted interviews with two (02) residents, Resident #1 (R1) and Resident #2 (R2). Between 3:00 pm and 4:00 pm, LPA interviewed two (02) staff of which one was the Wellness Director, Nancy Adam and the Administrator, Marco Villegas. At 4:00 pm, LPA requested copies of pertinent information relevant to the investigation which include, but is not limited to residents' physician’s reports, appraisal/needs and services plans and progress notes. (Continue to LIC9099-C) Unsubstantiated (Continued from LIC9099)During today's visit from 12:24 p.m. to 2:00 p.m., LPA Rios interviewed two (2) staff and four (4) residents, Resident #3 through Resident #6 (R3-R6). LPA obtained copies of the facility's resident roster, Personnel Report (LIC500) and R1's hospital discharge paperwork from 08/28/2025 and skilled nursing discharge paperwork from 10/23/2025. Allegation: Staff are not ensuring residents are provided with a safe environment. It was reported that Resident #2 (R2) verbally attacked and later physical confronted, Resident #1 (R1) and when the abuse was reported to the administrator no action was taken. LPA's interview with R1, confirms the allegation stating R2 would say derogatory statements towards them about their appearance. R1 reports that R2 had knocked off R1's personal property from their dresser and slammed a door on R1's foot. According to R1 they reported the incidents to management and nothing was done. Interview with R1 and R2 each indicated the other as the perpetrator and instigator. However R2 admits they were experiencing mental health concerns that were addressed and are aware they could have been difficult to live with. R2 denies becoming physically confrontational with R2 except for knocking things off of R1's dresser. Interview with the administrator at the time Marco Villegas and Wellness Director Nancy Adams denied physical confrontation had been reported but they were aware that R1 and R2 were both not getting along. According to the Wellness Director, had they known a physical confrontation had happened they would have acted immediately and moved residents to different rooms. The administrator stated both residents were asked separately if they would move to a different room but they both declined. R1 and R2 corroborate management had asked if they would like to move to another shared room and they declined. Interview with staff on 07/22/2025 and 11/19/2025 corroborate R1 and R2 were having issues. Staff interviews indicated R1 was being argumentative with R2 and had not witnessed it the other way around. Staff also deny witnessing physical confrontations. LPA's interview with four (4) residents on 11/19/2025 indicated they feel staff is ensuring a safe environment. R1 left the facility on 08/27/2025 and returned on 10/24/2025 and agreed to move to a different room. Based on LPAs interview, there is corroborating evidence that R1 and R2 were having issues, however the facility offered resident's to move rooms and they declined at the time. Therefore the allegation staff are not ensuring residents are provided with a safe environment is Unsubstantiated at this time. Page 2 of 3 Allegation: Staff speak inappropriately to residents in care. Regarding the allegation is was reported the Administrator and the Wellness Director at the time threatened to "kick out" Resident #1 (R1) if they reported the abuse. Interview with R1 confirmed the allegation stating after no action was taken regarding R2 being verbally and physically abusive towards them they stated they would report it to Adult Protective Services (APS). According to R1, management stated they would evict them for causing problems. Interviews with the administrator and staff deny the allegation. Interview with the Wellness Director indicated R1 let them know she sent a report after she had already made it to APS and not before. LPA's Interview with staff indicated they felt management act on issues concerning residents and they had not witnessed management make threats. Staff also indicated residents had not made complaints regarding staff making inappropriate statements. LPA's interview with Resident #2 (R2) on 07/22/2025 and four (4) residents on 11/19/2025 indicated they feel they could report to to staff and management if they had a serious concern. Residents also denied staff speak inappropriately to them. Based on LPA interviews, there is not enough information to verify the allegation. Therefore, the allegation is Unsubstantiated at this time. No immediate health or safety issues observed. Exit interview conducted. Copy of report provided. Page 3 of 3the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 31-AS-20250718135547

Type of visit: Case Management - Annual Continuation

Today, Thursday, 11/06/25, at 10:15 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a continuation of the required annual facility Inspection initiated on Monday,11/03/2025. LPA met with Administrator, Joseph Wieder, and the purpose of visit was disclosed. The following remaining inspection domains were observed, reviewed and inspected: FIRE SAFETY: Fire safety system is present in the facility. Multiple dual smoke/carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. Fire alarm was tested and works properly. Fire extinguishers were observed throughout the facility on all floors; last serviced on December 23, 2024. Evacuation chair was observed atop the second floor stairwell. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. Fire drill last conducted September 30, 2025. MEDICATIONS: Medication room is located on second floor. LPA observed room as secured and inaccessible to residents. Inside the room, medications are properly labeled and stored in secured cabinets. Medication documentation and distribution records appear to be complete. First aid kits were observed on carts stored in the medication room. LAUNDRY: LPA observed the laundry rooms located on sub floor level. Laundry area is clean. Detergents, cleaning supplies, and other toxins, are inaccessible to residents. [LIC 809C] Continued- STAFF RECORDS: Records are stored in the Administrator’s office, which was observed as locked and inaccessible to residents. A total of five (5) staff files were reviewed for current IPP and/or Needs and Services plans, physician report, admission agreements, and all relevant documentation. Staff records appeared to be complete and current. There were no health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Nov 6, 2025

Allegation investigated: Staff failed to ensure proper medication administration. Staff violated resident rights to privacy and property security.

Licensing Program Analyst, Abeye Duguma (LPA) conducted a subsequent complaint visit to investigate the above allegations. LPA met with Joseph Weider and explained the reason for the visit. ---Staff failed to ensure proper medication administration. It was alleged that staff are leaving Resident #1’s (R1) medications in their rooms in a cup and then walking away without ensuring R1 took their medications once dispensed. To investigate the allegation, on 08/15/2025 at around 10:30a.m. LPA conducted a physical plant tour and requested documents. LPA also interviewed four (04) staff from 11:30a.m. to 2:00p.m. On 10/21/2025, LPA interviewed six (06) residents from around 11:30a.m. to 1:00p.m. A review of facility staff records shows that all MedTechs have completed all required training. (CONT. on LIC9099-C) Unsubstantiated During the physical plant tour, LPA did not observe medication left unattended or accessible to residents. During interviews with staff, all staff stated they do not leave medication unattended. During interviews with residents, R1 stated staff are leaving Resident #1’s (R1) medications in their rooms in a cup and then walking away without ensuring R1 took their medications once dispensed. All other residents stated staff ensure residents take their medications before walking away. Based on record reviews, interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. ---Staff violated resident rights to privacy and property security. It was alleged that staff do not knock on the door before entering. To investigate the allegation, on 08/15/2025 LPA interviewed four (04) staff from 11:30a.m. to 2:00p.m. On 10/21/2025, LPA interviewed six (06) residents from around 11:30a.m. to 1:00p.m. During interviews with staff, all staff stated they respect the residents’ right to privacy and knock on the door and announce their presence before entering. During interviews with residents, R1 stated staff do not knock on the door before entering. All other residents stated they feel staff do respect their privacy and knock before entering. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 4, 2025 · control 31-AS-20250812142625

Type of visit: Required - 1 Year

On Monday, 11/03/25, 10:15 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct an unannounced annual inspection of the Facility. LPA met with Executive Director; Joseph "Yossi" Wieder, and reason for the visit was disclosed. Facility is licensed as a two story building. Fire clearance approved for seventy-two (72) non-ambulatory, and twenty-eight (28) ambulatory; total capacity, one hundred (100) residents. Bedridden cleared for bedrooms #101-#107, #109, #111, #113, #115, #117, #119, #120, and #122. Hospice waiver approved for twenty (20). Currently, five (5) residents receive hospice care services; no bedridden at this time. At 10:30 am, LPA conducted a tour of the physical plant and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Facility provides dementia care; LPA observed delayed egress system working properly throughout all access points of the facility. Visitor Sign-in sheet, sanitizer, gloves and masks are available. Hand washing, coughing etiquette, and other necessary signage posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 76.0°F. within the required range. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted: 9/30/25. [LIC 809C] Continued KITCHEN: At 10:45 am, LPA observed kitchen as clean, commercial refrigerators and freezers observed to maintain required temperatures. Appliances and fixtures appeared as functioning properly. Sufficient amount of perishable and non-perishable food observed as properly stored and labeled. Residents do not have access to the kitchen. Facility menu appears to meet the daily dietary needs of the residents. No pesticides, nor poisons, were observed near any food area. BEDROOMS: LPA observed resident bedrooms and bathrooms for safety, privacy, and comfort. Random resident rooms (Room# 101, 103, 105, 211, 212, 213) were inspected and observed to maintain required furnishings, sufficient lighting, bed linens, and blankets. All bedrooms were observed to be clean and clear from obstruction. BATHROOMS: LPA observed bathrooms to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip flooring). Hot water temperature measured between 108°F. and 115.5°F.; within the required range. COMMONS: Activity rooms, dining area, and library observed to be clean and well lit and free of foul odor. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed. OUTDOOR: Outdoor (courtyard) area observed to have a shaded patio, with table with sufficient seating for the residents. Outdoor furniture was observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility. RESIDENT RECORDS: Records are stored in the Administrator’s office, which was observed as locked and inaccessible to residents. A total of five (5) Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, admission agreements, and all relevant documentation. Resident records appeared to be complete and current. Due to time constraints, LPA was unable to complete the required Annual inspection visit. LPA will complete at a later date. Exit interview conducted/copy of report given to Executive Administrator.the state’s words, verbatim · CDSS document, Nov 3, 2025

Allegation investigated: Staff failed to provide adequate food service and meal accommodation. Licensee failed to ensure staff can communicate with residents in care.

Licensing Program Analyst, Abeye Duguma (LPA) conducted a subsequent complaint visit to investigate the above allegations. LPA met with Joseph Weider and explained the reason for the visit. --- Staff failed to provide adequate food service and meal accommodation. --- Licensee failed to ensure staff can communicate with residents in care. It was alleged that the food is inedible, that facility does not offer alternatives and kitchen staff don't speak any English, finding difficult to communicate their needs. To investigate the allegation, on 08/15/2025 at around 10:30a.m. LPA conducted a physical plant tour, and requested documents. LPA also interviewed four (04) staff from 11:30a.m. to 2:00p.m. On 10/21/2025, LPA interviewed six (06) residents from around 11:30a.m. to 1:00p.m. During the physical plant tour, LPA observed a variety of well-balanced foods being offered and served. (CONT. on LIC9099-C) Unsubstantiated A review of the facility’s menu shows that there is an assortment of well-balanced meals for breakfast, lunch and dinner. During interviews with staff, all staff stated they offer a variety of meals with alternatives. Staff added they get feedback from residents and are able to communicate effectively to meet their needs. During interviews, LPA did not experience any communication issues with staff. During interviews with residents, Resident #1 (R1) and Resident #2 (R2) stated the food is inedible, they do not offer options but that they are able to communicate effectively with staff. All other residents stated they are satisfied with the food options and are able to communicate their needs. Based on record reviews, interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 21, 2025 · control 31-AS-20250812142625

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff do not prevent resident from entering other residents rooms-

At 10:00 am, Thursday, 5/01/25, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a subsequent visit regarding the allegation listed above. LPA conducted the initial complaint visit on 12/12/24. LPA met with facility Administrator, Marco Villegas, presented official CDSS badge identification, and reason for the visit was disclosed. At 10:10 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation, LPA received Facility resident roster, and staff roster. LPA conducted a review of Resident 1's (R1) file, and documents relevant to the investigation. Between 11:15 am and 1:30 pm, LPA interviewed the Executive Director, Residents and Staff. [LIC 9099C]- Continued Unsubstantiated Allegation: Staff do not prevent resident from entering other residents rooms- The Reporting Party (RP) alleges that staff are aware of a resident that entered Resident#1 (R1's) room on multiple occasions. However, staff neglected to address this issue. LPA conducted interviews with Staff which revealed the following: Both the facility's Executive Director, (ED) and S1 refute the claim, stating that all residents have locks to secure their rooms are secured. Per the ED, all visitors are required to sign-in at the front desk prior to roaming the facility's premises. Per the ED, he had spoken at resident council meetings of the needs for residents to secure their rooms when unoccupied in order to better secure their personal property. R1 has a private room with no roommates. However, per the ED, R1 had a habit of leaving her room unoccupied with the door left open wide. At the time of this subsequent visit by LPA, Resident#2, (R2) whom the RP accused of wandering into others bedrooms, no longer resides at the facility. Per Staff#1, (S1) facility staff were aware that R2 liked to wander facility hallways, and that staff were vigilant to redirect R2 to common areas of the facility away from resident bedrooms. Per S1, R2 was actively sought for by staff to ensure he was not entering other resident bedrooms. LPA conducted interviews with six (6) residents, or 10% of the current census. Six (6) out of six (6) residents interviewed state having no issues with anyone entering their rooms without their consent. Further, all residents interviewed state feeling safe, and that their personal belongings are secure. Based on the information obtained through LPA observation, records review, and interviews, it cannot be proven that staff is failing to prevent residents from entering other resident's rooms. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, May 1, 2025 · control 31-AS-20241206091537

Allegation investigated: Staff do not answer the facility telephone-

On Friday, 03/21/25, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced, initial 10-day complaint visit to investigate the above allegation. LPA presented official CDSS identification badge, met with Executive Director, Marco Villegas, and reason for the visit was disclosed. At 9:35 am, LPA conducted a physical plant tour; no health and safety issues were observed. During LPA's tour of the facility, LPA observed the telephone to be in working condition. LPA also contacted that facility out of view; the ringtone was present, and and Staff #1 (S1) answered the phone. Additionally, LPA witnessed consistant front desk coverage by staff. To investigate the allegation(s), LPA received Facility Resident roster, and Staff roster. Between 10:00 am, and 1:30pm, LPA interviewed the Executive Director, Staff, and Residents. [LIC 9099C]- Continued Unsubstantiated Allegation: Staff do not answer the facility telephone - Reporting Party (RP) alleges during the morning and afternoon hours, staff do not answer telephone calls. Also, due to the lack of staff front desk/concierge coverage, visitors are unable to either enter or leave the facility. To investigate this allegation, LPA conducted interviews with staff and residents. LPA interviews with Executive Director and S1 revealed the following: Both refute the alleged claim, stating that staff provides consistent coverage of the front desk area, ensuring that telephone calls to the facility are answered, and that door access is available on a consistent basis. Additionally, Executive Director and S1 state that the facility's telephone system is in working order, and the system has not experience significant service disruptions within the last year. LPA interviews with six (6) residents revealed the following: Six (6) out of six (6) residents state that staff provides them with access to telephone service, that callers have no issues with staff responding to calls made to the facility, and that neither residents, nor visitors have had issues entering/leaving the facility due to lack of staff front desk coverage. Based on LPA observations, and interviews, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time.the state’s words, verbatim · CDSS document, Mar 21, 2025 · control 31-AS-20250311153509

Allegation investigated: Staff did not distribute residents' medications as prescribed- Staff did not safeguard residents' personal belongings-

On Thursday, 11/14/24, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced, initial 10-day complaint visit at the facility to investigate the above allegation(s). LPA met with Executive Director, Marco Villegas, and the reason for the visit was disclosed. At 10:15 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation(s), LPA received Facility Resident roster, and Staff roster. At 10:30 am, LPA conducted a review of Resident files. Between 11:15 am and 12:35 pm, LPA interviewed the Executive Director, Staff, and Conservator. At 1:00 pm, LPA conducted an observation and review of MAR documents in the facility medication room. Between 1:20 pm and 2:00 pm, LPA interviewed Residents. [LIC 9099C]- Continued Unsubstantiated Allegation: Staff did not distribute residents' medications as prescribed- It was reported that, sometime between August 2024 and September 2024, Resident#1 (R1's) medication was missing/not distributed. Reporting Party (RP) states that staff instead gave R1 medication for another resident. LPA's review of R1's Medical Administration Records (MAR's) refutes the claim that staff did not provide R1 their medication as prescribed. LPA interviews suggest that R1 has a history of accusing staff of not having their medication available, and instead, giving R1 medication meant for other residents. Five (5) out of five (5) residents interviewed by the LPA state Staff distributing their medications as prescribed by their physician. Based on the information obtained through LPA observation, records review, and interviews, it cannot be proven that staff is failing to distribute residents their medications as prescribed. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Staff did not safeguard residents' personal belongings- It was reported that clothing belonging to Resident#3 (R3) and Resident#4 (R4) were missing, due to staff not providing proper safeguarding. LPA observations and interviews with Staff, Residents, and Conservator revealed the following: Staff members state that no one has reported missing items for R3 and R4. The conservator for R4 states to LPA that none of R4's clothing items are missing, and witnessed the items in R4's bedroom during a recent visit. During LPA interview, R3 confirmed that all clothing items are in their room, and that they sometimes share some of their clothing items with their roommate. During LPA observation of R3's bedroom, the items listed on R3's inventory of personal property were found in their bedroom. Five (5) out of five (5) residents interviewed by the LPA state having no concerns with staff safeguarding of their personal belongings. Based on the information obtained through LPA observations, and interviews, it cannot be proven that staff is failing to safeguard residents' personal belongings. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 31-AS-20241104095811

Allegation investigated: Facility staff do not provide adequate incontinent care- Staff do not ensure resident's hygiene needs are being met-

On Monday, 11/04/24, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced/initial 10-day complaint visit at the facility to investigate the above allegation(s). LPA met with Executive Director, Marco Villegas, and the reason for the visit was disclosed. At 08:35 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation(s), LPA received Facility resident roster, and staff roster. At 9:05 am, LPA conducted a review of Resident 1's (R1) file, and documents relevant to the investigation. Between 9:40 am and 11:45 am, LPA interviewed the Executive Director, and R1's Responsible Family Member (F1), via cellphone. At 12:10 pm, LPA made multiple attemps, via cellphone, to contact the Reporting Party. (RP) However, the RP did not respond. [LIC 9099C]- Continued Unsubstantiated Between 12:15 pm, and 2:00 pm, LPA interviewed two (2) Medical Technician Staff, and conducted an observation of R1's bedroom. Allegation: Facility staff do not provide adequate incontinent care- It was reported, for an extended period of time, R1 had been left in soiled diapers. . LPA's review of R1's Physician's report, and Appraisal/Needs Assessment reveals that R1 does not require assistance with bathing, dressing, toileting, and personal hygiene: Per R1's Primary Care Physician, (PCP) R1 is able to complete most Activities of Daily Living (ADL's) with minimal assistance. LPA observed R1 wearing clothes which were clean and dry. LPA observed R1's room finding it clean, and with no urine smell. R1's clothes hamper contained some worn clothing items, however no urine stains, nor smell present. Interviews with staff, and F1 reveal that R1 is consistent with accomplishing toileting needs on their own, with occasional assistance from staff. Based on the information obtained through LPA observation, records review, and interviews, it cannot be proven that staff is failing to meet the resident's incontinent needs. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Staff do not ensure resident's hygiene needs are being met- It was reported that R1 was not assisted with showing, and tooth brushing tasks. LPA's review of R1's Physician's report, and Appraisal/Needs Assessment state that R1 does not require assistance with bathing, and personal hygiene as R1 is able to complete these tasks with minimal assistance. LPA interview with responsible family member (F1) revealed the following: F1 visits R1 at least once per week. F1 says R1 sometimes refuses assistance with showering and tooth brushing. However, staff contact F1 when R1 refuses to staff assistance. Interviews with staff reveal that R1 will sometimes refuse their assistance. However, R1 will accept staff assistance with F1's encouragement when contacted. Based on the information obtained through LPA records review, and interviews, it cannot be proven that staff is failing to ensure R1's hygiene needs are being met. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Nov 4, 2024 · control 31-AS-20241029123550

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

Today, Tuesday, 10/22/24, at 10:15 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a continuation of the required annual facility Inspection initiated on Monday,10/21/2024. LPA met with Administrator Designee, Nancy Adams, and the purpose of visit was disclosed. The following remaining inspection domains were observed, reviewed and inspected: Fire Detection/Protection system is present in the facility. Multiple dual smoke/carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. Fire alarm system was tested and works properly. Fire extinguishers were observed throughout the facility on all floors; last serviced on December 24, 2023. Evacuation chair was observed atop the second floor stairwell. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. Fire drill last conducted September 25, 2024. Medications: Medication room is located on second floor. LPA observed room as secured and inaccessible to residents. Inside the room, medications are properly labeled and stored in secured cabinets. Medication documentation and distribution records appear to be complete. First aid kits were observed on carts stored in the medication room. Laundry: LPA observed the laundry rooms located on the first and second floor. Laundry area is clean. Detergents, cleaning supplies, and other toxins, are securely stored and inaccessible to residents. Commons: Activity rooms, dining area, and library observed to be clean. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed. [Continued on LIC 809-C] Bedrooms: LPA observed accommodations in resident bedrooms and bathrooms for safety, privacy, and comfort. Random resident rooms were inspected and observed to maintain required furnishings and sufficient lighting, bed linens, and blankets. All bedrooms were observed to be clean and clear from obstruction. Bathrooms were observed to be clean and sanitary, with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 111°F., within the required range. Outdoor (courtyard) area observed to have a shaded patio, with table with sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility. Resident records: A total of six (6) Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current. Staff records: A total of six (6) Staff files were reviewed. Criminal record clearances were present and Staff are associated to this facility. Staff records appear to be complete and current. There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to facility representative, Administrator Designee, Nancy Adams.the state’s words, verbatim · CDSS document, Oct 22, 2024

Type of visit: Required - 1 Year

On 10/21/24, 10:15 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct an unannounced annual inspection of the Facility. LPA met with Administrator Designee; Wellness Director, Nancy Adams, and reason for the visit was disclosed. Facility is licensed as a two story building. Fire clearance approved for seventy-two (72) non-ambulatory, and twenty-eight (28) ambulatory, for total capacity of one hundred (100) residents. Bedridden cleared for bedrooms #101-#107, #109, #111, #113, #115, #117, #119, #120, and #122. Hospice waiver approved for twenty (20). Currently, five (5) residents receiving hospice care services and no bedridden. At 10:30 am, LPA conducted a tour of the physical plant with the Administrator and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Facility provides dementia care; LPA observed delayed egress system working properly throughout all access points of the facility. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, and other necessary signage posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 77.0°F. within the required range. Facility maintains an approved Mitigation and Infection Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted: September 25, 2024. [LIC 809C] Continued Kitchen: At 11:15AM, LPA observed kitchen as clean, commercial refrigerators and freezers observed to maintain required temperatures, appliances and fixtures functional, and a sufficient amount of perishable and non-perishable food observed as properly stored and labeled. Residents do not have access to the kitchen; knives and sharps are secured, and inaccessible to residents. Facility menu appears to meet the daily dietary needs of the residents. No pesticides, nor poisons, were observed near any food areas. Resident records: A total of six (6) Resident files were reviewed for current IPP and/or needs and services plans, physician report, admission agreements, pre-admission appraisals\reappraisals, centrally stored medication logs, and resident identification. Resident records appeared to be complete and current. Due to time constraints, LPA was unable to complete the required Annual inspection visit. LPA will complete at a later date. Exit interview conducted/Copy of report given to Administrator Designee, Nancy Adams.the state’s words, verbatim · CDSS document, Oct 21, 2024

Allegation investigated: Staff does not ensure facility serves food of good quality and quantity to residents Staff does not ensure residents are spoken to in an appropriate manner Staff do not ensure medications are properly managed for residents

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with Executive Director Marco Villegas and explained the reason for the visit. LPA conducted physical plant tour at 9:33 AM, requested copies of facility documents relevant to the investigation at 10:05 AM and interviewed staff and residents between 11:00 AM to 1:00 PM. Regarding the allegation that Staff does not ensure facility serves food of good quality and quantity to residents, it was alleged that the food quality is not very good, quantity of food portions is also very small and the facility runs out of food. LPA's observation during today's visit at about 10:30 AM revealed that the facility has more than enough stock of food in their walk in refrigerator including but not limited to eggs, milk, vegetables and lots of meat. LPA's interview with kitchen staff today at 11:30 AM revealed that they have food deliveries every Tuesday and Wednesday of every week. Further interview also revealed that kitchen staff allot about 10% for second servings or more, depending on the requests of the residents. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) LPA's interview with six (6) random residents today or 10% of the current census between 11:00 AM to 1:00 PM and two (2) residents on 05/08/24 revealed that eight (8) out of eight (8) residents interviewed revealed that the food being served is of good quality and sufficient. Regarding the allegation Staff does not ensure residents are spoken to in an appropriate manner, it was alleged that Staff #1 (S1) was very rude when S1 speaks and yells at residents. LPA's interview with three (3) staff who were present during the incident with Resident #1 (R1) and Resident #2 (R2) revealed that R1 and R2 were the ones yelling at S1 on those incidents and not the other way around. LPA's interview with eight (8) residents during this and prior visit also revealed that eight (8) out of (8) residents did not witness S1 being rude and/or yelled at any resident but witnessed R1 and R2 yelling at the reception area. Regarding the allegation that Staff do not ensure medications are properly managed for residents, it was alleged that R1's medication are not getting refilled and did not ensure that R1's prescription is getting re-ordered. LPA's record on 05/08/24 at around 1:30 PM revealed that R1 has a PRN (As needed) medication that was not covered by R1's insurance that caused the delay of R1's medication. LPA's interview with staff on 05/08/24 at about 12:00 PM revealed that R1's medication was ordered by the pharmacy for ninety (90) days’ supply and was not approved by the insurance due to volume and that the staff made a call to the pharmacy and ordered a one week or (7) days’ supply of this medication instead and R1's insurance approved it. Further interview with staff also revealed that it was a Narcotic drug and R1's doctor did not allow R1 to take it the way R1 wanted as it will conflict with R1's other medication. Based on the information gathered during this and prior visit, these allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Sep 24, 2024 · control 31-AS-20240507132704

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Raymond Comer delivered, in person, an amended LIC 9099 Complaint Investigation Report in association with complaint report# 31-AS-20240425102904, and the initial complaint investigation visit conducted on 4/30/24. The Amended LIC 9099 Complaint Investigation Report was hand delivered to Assistant Administrator, Jennifer Riverathe state’s words, verbatim · CDSS document, May 29, 2024

Allegation investigated: Staff do not allow resident to have visitors

This is an amendment of the original complaint report (LIC 9099) issued on 04/30/24. Report was amended to correct verbiage and maintain the confidentiality of Complaintant. Licensing Program Analysts (LPAs), Raymond Comer and Micheal Cava, conducted Health and Safety Inspection of the Facility at 1:20 PM; no issues observed. LPAs spoke with Wellness Director. (S1) They state the Facility does not prohibit residents visitation rights. LPAs spoke with the Reporting Party (RP) who says the Facility Administrator, Marco Villegas, specifically is prohibiting Resident #1's (R-1) family member from visiting at the facility. Additional information obtained from the RP during the investigation indicates that the family member in question lives in a different Adult Care Facility (West Los Angeles VA Home for Heroes) and the medical team at that Facility is temporarily not allowing them to leave their campus at this time. LPAs conducted an interview with Staff at West Los Angeles VA Home for Heroes and were advised that their Resident was currently unable to visit R-1 pending a complete medical evaluation by the Primary Care Physician. LPAs interviewed the Administrator, Marco Villegas, who states that he has spoken with R1, however, he did not tell R1 that their family member was prohibited from visiting the Facility, Based on interviews, there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time.” Unsubstantiated LPAs' spoke with Staff for the family member of R#1. Staff communicated that the Family Member in question is currently not able to visit R#1 until their Primary Care Physician has completed a medical evaluation. Based on interviews, there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Apr 30, 2024 · control 31-AS-20240425102904

Allegation investigated: Staff did not order resident’s medication refills in a timely manner

At 10:45 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent complaint visit. LPA was joined by Licensing Program Manager(LPM) Naira Margaryan and LPA Leizl De La Cerra. Team met with the Marco Villegas, Administrator and disclosed the reason for the visit. An initial visit was conducted on 01/22/24. Between 11:00 AM to 1:00 PM, LPA conducted an interview with the Administrator, Business Office Manager, Wellness Coordinator, one staff (1), one (1) MedTech, and eight (8) out of nine (9) residents. Additionally, LPA requested copies of pertinent information which include, but not limited to Medication Policy, MAR(medication administration record), Centrally Stored Medication and Destruction Records (CSMDR) for Resident #1 (R1) and R2, R3, and R4, Staff training etc., Moreover, on 02/12/2024, additional interviews with the wellness coordinator, and medical technician were conducted. Continue on LIC 9099 Substantiated During the investigation, LPA was able to review the medication delivery document, and MAR for Resident # 1 (R1). The CSMDR was partially complete. Upon review it was determined that R1’s medication was not refilled in a timely manner back in 01/02/2024, due to the late submission of the refill request from the facility to the pharmacy. Based on the interviews and record review, R1’s medication ran out on 01/03/2024, and the facility sent the refill request on 01/02/2024. Records review during this visit also confirmed that medication was refilled and delivered to the facility on 01/08/2024. Additionally, during the review of R1’s (MAR/CSMDR) LPA observed an additional discrepancy. On 01/08/24 R1 was relocated to a different facility, review of MAR indicated that the staff continued to initial R1’s medications as given even after R1 no longer resided at the facility. The MAR was initialed every day until 01/14/24. Wellness Coordinator and Medical Technician were unable to provide an explanation to the LPA as to how this discrepancy occurred. Based on the information and records review obtained this allegation is deemed Substantiated. Deficiency issued on LIC 9099 D. Exit interview conducted and appeal rights explained. Copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Feb 29, 2024 · control 31-AS-20240112101811

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a) · Plan of correction due date: Mar 1, 2024

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical care shall be developed by each facility... This requirement is not met as evidenced by Based on interviews and medical records review the facility did not refill medication on timely manner for R1. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: The Administrator has agreed to the following: 1. The Administrator shall take state approved vendor training on Incidental Medical and Dental Care. 2. Submit the training certificate to CCL.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.50(a)(3) · Plan of correction due date: Mar 1, 2024

Conduct inimical- Denial, suspension, or revocation of license; grounds… (3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement is not evidenced by: Based on medication record review and interview, the facility staff were marking the MAR days in advance of actually giving the medication, which is conduct inimical. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: Formal medications training by a vendor. All staff responsible for assisting with meds including the Administrator. Training shall include the training material, facility medications policy, and staff sign in sheet with the day, training and time spent.

Allegation investigated: Staff did not prevent resident from handling another resident in a rough manner Staff did not prevent resident from making threatening comments towards another resident Staff are not providing a comfortable environment for resident

At 10:45 AM, Licensing Program Analysts (LPAs) Huma Rahimi, DeLaCerra, Leizl, and LPM Naira Margaryan conducted an unannounced initial complaint visit. Team met with the Marco Villegas, Administrator and disclosed the reason for the visit. During course of the investigation, at 10:50 am, LPAs requested resident and staff roster. At 10:55 am, LPAs requested and reviwed copies of pertinent records which include, but not limited to Admission Agreement, Identification Emergency Sheet, Physician Report, Pre-placement Appraisal, Subsequent Appraisal, Incident Report, and Facility Notes, relevant to the investigation. At approximately 11:30 am, LPA conducted a physical plant tour. Between 12:00 PM – 1:00pm, LPA conducted an interview with the Administrator, four (04) staff; two (2) caregivers and two (2) med techs and seven (7) residents. Continue on LIC 9099C Unsubstantiated Staff did not prevent resident from handling another resident in a rough manner Staff did not prevent resident from making threatening comments towards another resident Regarding the above allegations: It was alleged that the facility resident #2 (R2) verbally and physically abused Resident #1 (R1). Staff revealed they always try to prevent residents form being verbally abusive and/or being rough to other resident(s. They try to intervene as soon as possible to prevent inappropriate interactions. R1 and R2 residing in the same room (please note R1 and R2 are married couple) Staff revealed that on 02/17/24, there was an incident of verbal and physical abuse between R1 and R2. Staff was alerted by R1 and they immediately intervene to assist residents. R2 was removed from the room and placed to another room. Staff intervention prevent the situation from escalating. Interview with R1 verified the information received from staff. Furthermore, R1 stated that they feel safe in the facility and staff is assisting them all the time. In addition, interviews with seven (7) residents confirmed that the staff are always available to prevent any kind of incident from happening. Based on information obtained through interviews and observation, it was concluded that although the incident between 2 residents occur, the staff intervene and took all required steps to assist as needed. Therefore, this allegation is unsubstantiated at this time. Staff are not providing a comfortable environment for resident It was alleged that the R1 was scared from R2 and does not want to be in the same room with R2 and staff is not moving R2. Staff revealed that they were not able to remove R2 to different room permanency, because R1 and R2 are married couple and wanted to be in the same room. However, on 02/17.24, when R2 was aggressive toward R1, they took an immediate action by removing R2 from the room and transferring them to a different room. R1 verified the information revealed from staff. A Review of resident records revealed that R2 has health conditions triggering aggressive behavior which may require close supervision by facility staff. The information revealed from records supported the information received from staff. Based on inspection, observation, and record review there is no sufficient information to support the allegation. Therefore, this allegation is deemed Unsubstantiated. No immediate health and safety issues were noted during this visit. Exit interview was conducted and copy of report was issued.the state’s words, verbatim · CDSS document, Feb 29, 2024 · control 31-AS-20240221085535

Type of visit: Case Management - Deficiencies

This case management visit was conducted in conjunction with complaint investigation to address the deficiencies unrelated to the complaint. While conducting complaint investigation at 10:45am LPAs DelaCerra, and Rahimi and LPM Margaryan observed deficiencies unrelated to the complaint. 1.While entering to the parking lot the buzzer was not working. LPM had to call the Administrator to have staff to open the gate. 1, LPAs and LPM observed the trash containers blocking the exit door next to the gate. 2.There were cigarette buts everywhere. 3.The parking lot that was also used as an outside recreational/smoking area for the residents, was obstructed with the old and broken furniture and some of the pieces had sharp corners that could pose hazard to the residents’ health, safety and wellbeing. 4.The whole parking lot including recreational areas for the residents was not mantined as required. At the time of this visit the Licensee Representative arrived at the facility and LPM Margaryan discussed all noted issues. The Licensee representative arranged to remove all broken furniture and clean up the whole parking lot today 02/29/2021. Based on inspection and observation, the following deficiency will be cited and recorded on LIC809D. No other issues noted at the time of this visit. Exit interview is concuted, appeal rights were discussed and a copy of report was issued.the state’s words, verbatim · CDSS document, Feb 29, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 29, 2024

87303 Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors. . This requirement is not met as evidenced by. Licensee did not ensure that facility parking lot and outside recreational area are clean and free of obstructions. This possess potential health and safety hazard to residents in care.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: The Licensee contacted appropriate agencies to remove broken furniture and clean up the backyard. Therefore, this citation is cleared during this visit.