Melrose Villas

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Resident sustained injuries due to neglect Staff mismanaged Resident’s medication Staff did not provide care in a timely manner

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced subsequent complaint visit for the above allegations. LPA arrived and was greeted by the receptionist and met with the Administrator Designee Darkis Giron. Regarding the Allegation: Resident Sustained Injuries Due to Neglect It is alleged that on or around March 16, 2025, Resident 1 (R1) sustained injuries as a result of a fall. Interview with the Administrator, Candis Allen, revealed that she was hired as the Administrator after the alleged incident and was not aware of any incidents involving R1. LPA interviewed five (5) staff members and seven (7) residents; however, none of the individuals interviewed were able to verify the allegation. LPA also reviewed all Special Incident Reports (SIRs) for March 2025 and was unable to confirm that the alleged incident occurred. Based on the information obtained through interviews and record review, there is insufficient evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. (Continue on 9099C) Unsubstantiated Regarding the Allegation: Staff Mismanaged Resident's Medication It is alleged that R1 developed liver damage that may have been caused by medication administered by facility staff. It is also alleged that R1 may have received an incorrect medication or dosage. Interview with the Administrator revealed that medications are administered as prescribed and at the correct dosage. Interviews with seven (7) residents confirmed that medications are administered as prescribed by their physicians. Interview with Staff 2 (S2) revealed that staff are not permitted to change medication dosages or administer medications without a physician's order. LPA reviewed R1's medication records and found that R1's medications were administered as prescribed and documented accordingly. Based on the information obtained through interviews and record review, there is insufficient evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the Allegation: Staff Did Not Provide Care in a Timely Manner It is alleged that R1 fell and called for staff assistance; however, staff did not respond to R1's room. Interviews with the Administrator and five (5) staff members revealed that the facility's protocol is to check on residents every two (2) hours. Staff also reported that some residents receive checks every one (1) hour based on their individual needs. Additionally, LPA conducted a random test of the emergency call button at 12:08 p.m. A caregiver responded to the call at 12:09 p.m. Interviews with six (6) residents confirmed that staff provide care and assistance in a timely manner. Based on the information obtained through interviews, there is insufficient evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted, copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Aug 19, 2026 · control 31-AS-20250324142530

Allegation investigated: Staff did not prevent a resident from having access to a sharp object.

Licensing Program Analyst (LPA) Michael Cava conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with the administrator, Candis Allen and explained the reason for the visit. During today’s visit LPA conducted a tour of the facility between 9:40am to 10:30:am, interviewed the administrator, three (3) staff, and ten (10) residents between 10:30am to 11:30am, reviewed and requested copies of the following documents, between 11:30am to 12:00am: Resident roster, staff roster, and an invoice from the pest control company. Regarding allegation: Staff did not prevent a resident from having access to a sharp object, it was reported that Resident 1 (R1), who resides in room 214 has a knife with them in their room. There were no direct witnesses identified to corroborate that R1 has a knife in their possesion. Moreover, R1 did not threaten anyone with the knife. It is also unknown where R1 got the knife. Reporting party also indicated that a staff was informed but was unable to find a knife in R1's room. Unsubstantiated Interviews with the administrator and staff deny the allegation, stating there are no male residents in this facility identified by R1's name. The administrator adds that there were no residents occupying room 214 for approximately two months as it was being treated for pest control services. Interviews held with the ten residents also do not confirm the allegation, as residents were unable to identify R1, or if R1 had ever lived at this facility. Review of the facility's resident roster confirm there is no resident on the list identified as R1. Also obtained for record and review were invoices from the pest control company confirming that room 14 was being serviced for insects and pests from about May 4, 2026 to about July 10, 2026. Based on the department’s observations, interviews, and record review which were conducted, there was insufficient evidence to confirm the allegation of staff not preventing a resident from having access to a sharp object. Therefore, the allegation is deemed Unsubstantiated at this time. administrator advised and a copy of this report issued.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 31-AS-20260706130041

Allegation investigated: Staff do not ensure that residents' rooms and bathrooms are clean. Staff do not ensure that facility is free of pests.

On 7/03/26, Licensing Program Analyst, (LPA) Raymond Comer, arrived at the facility to conduct an initial, 10 day visit to investigate the allegation(s) listed above. LPA Comer spoke with the facility Administrator, presented official CDSS badge and reason for the visit was explained. During today's visit, at 2:45 pm, LPA Comer conducted a tour to the facility; no health/safety issues were observed. Between 3:00 pm, and 3:30 pm, LPA spoke with the Administrator and a staff. Between 3:35pm and 4:15pm LPA Comer spoke with five (5) out of a total of fifty-one (51) residents. Between 4:20 pm, and 4:40 pm, LPA Comer recieved and reviewed facility resident roster, staff roster, pest control documentation from licensee's contracted vendor, (Ecolab) and other documents relevant to the investigation. [LIC 9099C] Continued- Unsubstantiated Allegation: Staff do not ensure that residents' rooms and bathrooms are clean. It was alleged that staff have not cleaned the resident rooms over a three week period, and that residents have been compelled to empty their own trash. LPA tour of the facility revealed the following: LPA observed facility common areas (i.e., dining room, television\activities room, hallways, and patio area) as clean and clear of clutter. LPA conducted observations of random resident bedrooms and found them as clean, free of dirt, dust and clutter. LPA interviews with staff revealed the following: Both the Administrator, and a Staff#1 (S1) refute the allegation, stating that housekeeping staff clean common areas and resident bedrooms/bathrooms on a daily basis. LPA interviews with residents revealed the following: Out of a total of fifty-one (51) residents, five (5) out of five (5) residents interviewed confirm their satisfaction with level of cleanliness provided by housekeeping staff. Based on the information gathered during this visit, this allegation is UNSUBSTANTIATED at this time. Allegation: Staff do not ensure that facility is free of pests. It was alleged that roaches have been observed in the dining room and inside resident dresser drawers. LPA Comer conducted a tour of the physical plant; No evidence of an active pest infestation was observed. A review of documents revealed the following: Licensee's contracted pest control vendor (Ecolab) conducted monthly inspections, replaced pest traps, and performed routine interior/exterior pest service: Ecolab reports (Jan 2026 thru Jun 2026) show that pest monitoring, bait traps and insecticide applications are applied throughout the facility's interior and exterior. LPA Comer interviewed five (5) out of a total of fifty-one (51) residents which revealed the following: Five (5) out of five (5) residents interviewed stated they have not observed, nor have concerns regarding pest issues at the facility. Based on LPA Comer's observation, interviews, and records review, there is not sufficient information to verify that licensee is neglecting to keep facility free of pests. Therefore, the allegation is UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Jul 3, 2026 · control 31-AS-20260626094652

Allegation investigated: Staff consumed alcohol while working at the facility

This report supercedes the report issued January 28, 2026. The findings have not changed. Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegation. LPA met with the administrator, Candis Allen, and explained the reason for the visit. --- Staff consumed alcohol while working at the facility It was alleged that staff drink alcohol at the facility and yell racial slurs to people in the area. To investigate the allegation, on January 28, 2026, LPA interviewed four staff and six residents from around 11:00a.m. – 12:00p.m. During interviews with staff, all staff stated they and others do not drink alcohol or yell racial slurs at people in the area. During interviews with residents, all residents stated they have no witnessed staff drinking or yelling racial slurs at the facility. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 4, 2026 · control 31-AS-20260123081812

Allegation investigated: Staff neglect resulted in a resident being hospitalized.

On 5/11/26, Licensing Program Analyst (LPA) Ray Comer made an unannounced subsequent complaint visit to this facility at 10:15 am to deliver findings. LPA Comer met with the administrator, and disclosed the purpose of this visit. Allegation: Staff neglect resulted in a resident being hospitalized. It was alleged that Resident #1 (R1) developed osteomyelitis and foot ulcers due to suspected neglect of the facility. To investigate the allegation on 12/02/25, LPA Comer conducted a 10-day initial complaint visit. At 10:35 a.m., LPA Comer spoke with the administrator; at 11:00 a.m., facility records were requested and reviewed, and at 11:40 a.m., the facility was inspected; five (5) out of fifty three (53) residents were interviewed. As of 12/04/25, the investigation was continued by CCLD Investigators. LIC9099C] Continued- Unsubstantiated Between 12/17/25 and 02/26/26, additional interviews were conducted with the facility administrator, caregivers, other interested parties, and R1’s primary care physician (PCP). Staff denied neglecting R1’s care. Other residents residing at the facility were satisfied with the care provided at the facility. During the interviews with medical professionals, R1’s PCP stated that he did not observe any signs that the facility neglected R1’s care and nothing in R1’s hospitalization suggested facility wrongdoing. According to the doctor, R1’s chronic medical conditions were significant risk factors that contributed to the development of osteomyelitis. Per R1’s doctor, R1 was essentially predisposed to this disease due to other underlining conditions. A review of facility and hospital records conducted on 12/02/25 and 12/11/25, indicate that on 10/21/2025, R1 was noted to be failing to thrive, and the facility transferred R1 to the local hospital for evaluation. At that time, there was no indication, nor diagnosis of osteomyelitis. On 11/07/2025, staff observed an injury to R1’s foot, and R1 was again transferred to the local hospital for further assessment. Hospital documentation from that visit indicated that R1 had developed osteomyelitis. Staff denied neglecting R1’s care. Other residents residing at the facility were satisfied with the care provided at the facility. During the interviews with medical professionals, R1’s PCP stated that he did not observe any signs that the facility neglected R1’s care and nothing in R1’s hospitalization suggested facility wrongdoing. According to the doctor, R1’s chronic medical conditions were significant risk factors that contributed to the development of osteomyelitis. Per R1’s doctor, R1 was essentially predisposed to this disease due to other underlining conditions. Based on interviews, and record review, there is insufficient evidence to support that the facility failed to provide appropriate care or supervision. Therefore, the allegation of neglect, lack of care, and insufficient supervision is unsubstantiated. Exit interview conducted and a copy of report was proved to the Administrator.the state’s words, verbatim · CDSS document, May 11, 2026 · control 31-AS-20251130233914

Type of visit: Required - 1 Year

On 05/11/26, 10:30 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced annual visit. LPA met with the Administrator, and reason for the visit was disclosed. Facility is licensed as a two story residence, encompassing 34 shared resident bedrooms, each with bathroom; three (3) public bathrooms are located in hallway areas. Fire clearance approved for sixty-eight (68) non-ambulatory residents; of which, twenty (20) may be bedridden. Hospice waiver for twenty (20) residents. At the time of this inspection, no residents were receiving hospice care services. Facility’s main door is the primary access: Three (3) emergency exits are on the first floor, and two (2) emergency exits on the second floor. Exit routes are clear of obstruction. Screening area is located upon entrance. Delayed egress alarm sensors are present at all exit points and are working properly. Visitor sign-in sheet, hand sanitizer, gloves and masks are available. Room temperature is comfortable; wall thermostat displays a setting of 76 °F., within the required range. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on 4/29/2026. At 11:00 am, LPA conducted a tour of the physical plant with the Administrator, and observed the following: Kitchen: LPA observed kitchen to be clean, with an adequate supply of perishable and non-perishable foods located in the refrigerator, freezer, and pantry. LPA observed a variety of fresh fruits, vegetables, meats, dry cereals, and desserts. Foods are properly labeled and stored. Knives and sharps are stored in a designated area of the kitchen. Kitchen is secured and inaccessible to residents. [Continued on LIC 809C]- Fire Detection/Protection: LPA observed multiple smoke and carbon monoxide alarms installed, hardwired, and interconnected. Fire alarm system was tested and is working properly. Fire drill last conducted 4/29/2026. Fire extinguishers were observed on all floors of the Facility. All extinguishers were last serviced on 4/22/2026. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. Facility stairwells contain a required evacuation chair. Medications: Located on the second floor, medication room was observed as locked, and inaccessible to residents. Medications are listed on a centrally stored medication and destruction record log. LPA audit of resident medications, with corresponding Medications Administration Record, (MAR) found records as accurate. First Aid kits, located in cabinet storage, were observed as fully stocked. Bedrooms: LPA observed random bedrooms (Rooms #113, #110, #106, #202, #201, #211) finding them as clean, with sufficient lighting, bed linens, at least one chair, night stand, adequate closet space, and dressers. Signaling system was tested in random bedrooms and working properly. Average staff response time to activated signal was within five minutes. Bathrooms: LPA observed bathrooms to be clean and sanitary, with required safety fixtures. (grab bars, anti-slip floor stripping) Hot water temperature measured between 113.°F. and 116.°F; within the required range. Towels are not shared. Commons: LPA observed upstairs and downstairs hallways, activity room, and dining room, finding them clean and clear of obstruction; furnishings observed to be in good condition. No tripping hazards observed. Laundry: Is located on sub-floor level. Washer and Dryer machines were working properly. Laundry room, soaps, and other cleaning agents are stored and inaccessible to residents. Outdoor: Courtyard observed to have a shaded patio area, with a table, and sufficient seating for residents. Outdoor furniture observed to be in fair condition. Multiple sheds in the outdoor area contain tools, supplies, and PPE. All outdoor sheds were observed as locked and inaccessible to Residents. All trash cans were covered. There are no bodies of water in the facility. [Continued on LIC 809C]- Staff records: LPA observed records stored in a locked room on the first floor, inaccessible to residents. Criminal record clearances were present, and Staff are associated to this facility. Staff records appeared to be complete and current. Resident records: LPA observed records stored in a locked room on the first floor, inaccessible to residents. Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be current and complete. No deficiencies cited, exit interview conducted, and copy of this report provided to administrator.the state’s words, verbatim · CDSS document, May 11, 2026

Allegation investigated: Staff do not safeguard resident’s belongings. Staff do not provide an adequate quantity of food to residents in care. Staff are not addressing pests in the facility. Staff do not provide assistance to residents in a timely manner.

On 5/04/26, Licensing Program Analyst, (LPA) Raymond Comer, arrived at the facility to conduct a subsequent visit regarding the allegation(s) listed above. LPA Gary Tan conducted the initial complaint visit on 03/13/26, at which time LPA Tan spoke with the facility Administrator, and at 9:43 AM, requested copies of facility documents relevant to the investigation. During today's visit, at 11:00 am, LPA Comer conducted a tour to the facility; no health/safety issues were observed. Between 11:10 am and 11: 45 am, LPA spoke with Administrator and two (2) staff. Between 11:55 am and 12:40 pm, LPA Comer spoke with five (5) out of a total of forty-four (44) residents. Between 12:50 pm and 2:15 pm, LPA Comer recieved and reviewed facility roster, staff roster, staff in-service traning materials, pest control documentation from licensee's contracted vendor, (Ecolab) and other documents relevant to the investigation. [LIC 9099C] Continued- Unsubstantiated Allegation: Staff do not safeguard resident’s belongings. It was alleged that a resident took another residents toothbrush/toothpaste and that staff neglected to respond. It was also alleged that items (food and clothing) belonging to Resident#2 (R2) were taken by staff. To investigate the allegation, LPA interviews with Administrator and Staff revealed the following: The Administrator stated to LPA Comer that staff are trained and instructed to conduct regular inspections of residents rooms to ensure they are stocked with required hygiene products (soap, toothbrush, toothpaste, toilet paper, etc.) Both Administrator and Staff#1 (S1) stated to LPA Comer that they communicated with Resident#1 (R1) and replenished them with a new toothbrush and toothpaste. Per S1, "R1 comes to me personally and asks for additional soap and toothpaste; we provide those items without question to all residents". LPA conducted an observation of R1's room; toothbrush, toothpaste, toilet paper and fresh towels were present. Regarding the items alleged as taken from R2's room by staff, LPA Comer interviewed Administrator which revealed the following: Per Administrator, R2 was observed by staff to be hoarding items (bleach, toxics, spoiled food,excessive paper waste, etc.) in their room which were identified as health and safety hazards to themselves, and other residents within the community. Administrator informed R2 that such items are a violation of house rules and must be removed from R2's bedroom. R2 was given time to remove the items, however once the date to remove the items had elapsed, staff removed with those items with R2's knowledge. LPA Comer's review of documents revealed the following: R2's file contained "warning letters" informing R2 that the aforementioned items must be removed in order to comply with health/safety regulations. Five (5) out of a total of forty-four (44) residents stated to LPA Comer their satisfaction with staff efforts regarding safeguarding of resident's personal belongings. Based on LPA observation, interviews, and records reviewed during this investigation, there is not sufficient information to conclude that “Staff failed to safeguard residents’ belongings”. Therefore, the allegation is deemed as UNSUBSTANTIATED at this time. Allegation:Staff do not provide an adequate quantity of food to residents in care. It was alleged that not enough food is provided to residents and that residents regularly ask staff for more food. To investigate the allegation, LPA Comer inspected the facility kitchen pantry, refrigerator, and freezer, which was observed to contain a sufficient variety and quantity of canned goods, fresh vegetables, chicken, and meats. [LIC 9099C] Continued- LPA Comer interviewed five (5) out of a total of forty-four (44) residents which revealed the following: All five (5) residents interviewed stated their satisfaction regarding the quality, variety and food portions provided by staff. Based on the inspection and the interviews, there is no sufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time Allegation: Staff are not addressing pests in the facility. It was alleged that mice and roaches have been observed in the facility for several months. To investigate the allegation, LPA Comer conducted a tour of the physical plant; No evidence of an active pest infestation was observed. A review of documents revealed the following: Licensee's contracted pest control vendor (Ecolab) conducted monthly inspections, replaced pest traps, and performed routine interior/exterior rodent service: Ecolab reports (Jan thru May 2026) state "No rodent/No cockroach activity were noted". LPA Comer interviewed five (5) out of a total of forty-four (44) residents which revealed the following: Four (4) out of all five (5) residents interviewed stated they have not observed, nor have concerns regarding pest issues at the facility. Based on LPA Comer's observation, interviews, and records review, there is not sufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff do not provide assistance to residents in a timely manner. It was alleged that Resident#3 (R3) was walking through the facility hallways requesting staff assistance. To investigate the allegation, LPA Comer interviewed R3 who stated the following: R3 stated to LPA Comer that facility staff are "wonderful" and that he is provided hourly room well checks by staff. Per R3, he feels safe living at the facility, and has no issues regarding the quality, or response timeliness of staff. LPA Comer interviewed five (5) out of a total of forty-four (44) residents which revealed the following: All five (5) residents interviewed stated their satisfaction with quality and timeliness of staff's response. Based on LPA Comer's interviews with residents, there is not sufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, May 4, 2026 · control 31-AS-20260306163800

Allegation investigated: Staff do not safeguard resident's personal belongings. Staff is not providing residents with outings.

On 5/04/26, Licensing Program Analyst, (LPA) Raymond Comer, arrived at the facility to conduct a subsequent visit regarding the allegation(s) listed above. LPA conducted the initial complaint visit on 06/20/25, at which time LPA spoke with the facility Administrator, Staff, and Witnesses knowledgable of the allegations noted above. From 8:30 am to 10:00 am, LPA reviewed facility's resident and staff roster, and documents which included, but were not limited to, Resident#1's (R1's) file, conservator's documentation, personal property/valuables log, admissions Agreement, assessments, and other documents relevant to the investigation. Between 10:20 am and 11:05 am, LPA conducted a tour of facility commons, and an inspection of random resident bedrooms. From 11:15 am to 1:30 pm, LPA interviewed residents and staff. During today's visit, at 10:15 am, LPA Comer conducted a quick tour to the facility and inspect for any health and safety issues. At 10: 45 am, LPA spoke with two additional (2) staff members, and three (3) additional residents, making a total of nine (9) out of a total of forty-four (44) residents interviewed. [LIC 9099C] Continued- Unsubstantiated Allegation: Staff do not safeguard resident's personal belongings- It was alleged several items of R1's clothing (shirts, socks, and underwear) were missing and potentially stolen, due to staff neglect. Today, LPA's interview with the administrator revealed that during the meeting with R1 and their responsible family member, they had agreed to create an inventory of all the personal belongings of R1 and turn it over to the facility at a later date. However, submittal of said inventory never materialized. Finally, Both Administrator and R1’s conservator confirmed to LPA that although none of the items reported missing are listed on R1’s inventory log, licensee replenished R1 with new shirts, socks, and financially reimbursed R1’s conservator for clothing items. LPA interviews with nine (9) out at total of forty-four (44) residents revealed their satisfaction with staff safeguarding of resident's belongings. LPA's record review revealed that R1's client/personal property and valuables (LIC 621) signed by R1's conservator did not list any personal belongings. The information documented corroborated with staff statement. Based on interviews and records review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff is not providing residents with outings- It was alleged that staff suspended resident outings, which includes walks to the park, or going to local convenience stores. LPA observed that facility maintains a full time Activities Director, and that staff-supervised resident outings resumed on May 2025. Interviews with Administrator revealed that during the time the allegation was reported, Staff were unable to conduct resident outings to the park, as major sections of the park were sectioned off by the city in order to complete construction modifications. Most of the facility's residents, including R1, were authorized to leave the facility unattended, coming and going as they choose. LPA interviews with nine (9) out of forty-four (44) residents confirmed they are satisfied with both venturing to the community’s outdoor courtyard areas, and many of the facility's residents are authorized to leave to community unassisted by staff. Residents verified that they had knowledge about construction at the Park. LPA's record review revealed that facility has a posted activity calendar, and the dates were accurate. Outings to the park were not conducted due to issues outside of control of the facility . Based on interviews, and records review, it was concluded that residents’ activities were not suspended by facility staff. The participation was hindered by external factors beyond the facility’s control. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit interview conducted, and a copy of the report was issued to the administrator.the state’s words, verbatim · CDSS document, May 4, 2026 · control 31-AS-20250613093622

Allegation investigated: Staff did not ensure resident's room was free of bed bugs

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced subsquent complaint visit for the above allegation. LPA arrived and was greeted by the receptionist and met with the Adminisistrator Candis Allen and explained the reason for the visit Regarding the allegation Staff did not ensure resident's room was free of bed bugs: It is alleged that Resident #1’s (R1) room had bed bugs for several months. LPA conducted interviews with five staff members, all of whom confirmed the allegation. Additionally, interviews conducted on 04/02/25 with three out of seven residents also confirmed the presence of bed bugs in the facility.During the initial visit, the LPA conducted a physical plant tour and did not observe any bed bugs in resident rooms at the time of inspection. The LPA inspected Rooms #109, #211, #220, #102, #113, #103, and #206. (Continue on 9099C) Substantiated LPA also reviewed R1’s current medication list and did not observe any insulin injections prescribed. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report signed and delivered. Interviews with Staff #1 (S1) and Staff #2 (S2) indicated that the facility previously contracted with a pest control company; however, the services were ineffective, and the contract was subsequently terminated. Staff #3 (S3) reported that the facility currently receives bed bug treatment services at least once per month and on an as-needed basis. S3 provided copies of invoices and pest sighting/evidence logs to support ongoing pest control efforts. Based on interviews and documentation obtained, there is sufficient evidence to support the allegation. Therefore, the allegation is deemed Substantiated at this time. Exit interview was conducted. Citation was issued per Title 22 Division 6 of the CA Code of Regulations. Appeal rights were provided, and a copy of this report was reviewed with, signed by, and delivered to the facility Administrator.the state’s words, verbatim · CDSS document, Apr 27, 2026 · control 31-AS-20250326163124

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 27, 2026

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: Based on interviews and records reviews, the licensee did not comply with the section cited above. Staff did not ensure resident's room was free of bed bugs. This poses an a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 27, 2026

Plan of correction: Administrator provided copies of invoices and pest sighting/evidence logs to support ongoing pest control efforts. Bed bug treatment services is conducted at least once per month and on an as needed basis. POC is cleared.

Allegation investigated: Staff do not distribute resident's medication as prescribed. Staff do not provide a safe environment for resident.

On Monday, 04/20/26, Licensing Program Manager, Naira Margaryan, and Licensing Program Analyst, (LPA) Ray Comer, arrived to conduct an unannounced initial 10-day visit to investigate the allegation(s). LPM/LPA met with the Administrator, presented official CDSS badge identification, and reason for the visit was disclosed. During this investigation at 1:35pm LPM Margaryan conducted a quick tour to the facility and observed no health and safety issues. At 2:00pm LPM and LPA spoke with three (3) staff members, staff #1 (S1), staff #2 (S1), and staff #3 (S3), that had knowledge of R1’s care and supervision at the facility. At 2:40 pm, LPA spoke with five (5) facility residents, including Resident#1's (R1’s) roommate, and Resident #2 (R2). In addition, LPA Commer, requested and received facility records, including but not limited to R1’s physician report, medication administration and destruction records, incident reports involving R1, staffs testimonial about R1, and other documents pertinent to investigation. (Continued on LIC9099C) Unsubstantiated During this investigation at 1:40 pm, LPM Margaryan conducted a quick tour to the facility and observed no health and safety issues. At 2:00pm, LPM and LPA spoke with three (3) staff members staff #1 (S1), staff #2 (S1) and staff #3 (S3) that had knowledge about R1’s care and supervision at the facility. At 2:40 pm, LPA spoke with five (5) facility residents, including Residnent'#1' (R1's) roommate and Resident #2 (R2). In addition, LPA Comer, requested and reviewed facility records, including, but not limited to, R1’s physician report, medication administration and destruction records, incident reports involving R1, staff testimonials about R1, and other documents pertinent to investigation. Allegation: Staff do not distribute resident's medication as prescribed. It was alleged that R1’s medications, including patches, were not distributed to R1 as prescribed. Staff revealed that R1 does not follow facility medication administrator procedures and refuses to take their pills as prescribed. S1, who is a med tech assisting R1, revealed that R1 goes to the doctor, requests to change the dosage of medications, gets new orders from the pharmacy, and wants med techs to dispense a new order. When med tech explains that they need new prescription to change the order in the file, R1 gets upset, refuses the medication, yells at the staff and throws the med cup at them. Other residents interviewed during this visit, including R2, had no concerns regarding their medication assistance. R2 verified the information revealed by staff. A review of medication administration and destruction records corroborated the information received from the staff. Based on interviews, and records review, there is not sufficient information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. Allegation: Staff do not provide a safe environment for residents. It was alleged that R1 was verbally and physically abused by Resident #3 (R3). R3 was harassing R1 by calling him names, and talking badly about R1’s mother. On 04/16/26, R3 tried to fight R1, but did not touch them. S2, who witnessed both incidents, denies R3 fighting R1, or calling them names. S3 revealed that R1 always tried to fight and yell at other residents and staff. R3 denied fighting R1, or calling names. R3 stated that R1 yelled at him and called him names. R3 stated while R3 was trying to leave the dining room, R1 blocked the entrance so that R3 was unable to go out. (R3 uses wheelchair to ambulate.) LPA Comer attempted to speak with R1. However, they were not available. A review of collected records did not provide any information to support the allegation. Other residents verify that R1 was arguing with staff and residents. Based on interviews, and records review, there is not verifiable information to support the allegation. Therefore, the allegation is unsubstantiated at this time. Exit interview conducted and a copy of report was proved to the Administrator.the state’s words, verbatim · CDSS document, Apr 20, 2026 · control 31-AS-20260417090152

Allegation investigated: Improper eviction.

On Thursday, 04/02/26, Licensing Program Analyst, (LPA) Ray Comer, arrived to conduct an unannounced initial 10-day visit to investigate the allegation. LPA met with the Administrator, presented official CDSS badge identification, and reason for the visit was disclosed. LPA conducted a physical plant tour at 9:50 am; no health or safety issues were observed. Prior to this visit, on 03/20/26 LPA Comer received and reviewed a copy of the eviction notice submitted by the facility Administrator. During this investigation, At 10:15 am, LPA Comer requested and reviewed the facility resident roster, staff roster, Resident #1's (R1's) admission agreement, Physician's Report (LIC602), Appraisal Needs and Services, copy of 30 day eviction notice previously submitted to R1, and Unusual Incident Reports involving R1. Between 11:15 am and 12:30pm LPA conducted interviews with Administrator, R1, and R1's POA/Conservator. [LIC9099-C] Continued Substantiated Allegation: Improper Eviction- It was alleged that the eviction notice that was provided to resident #1 (R1), and their POA\Conservator was improperly executed as it was missing clear and specified reasons why R1 is being evicted. Prior to this visit on 03/20/26 LPA Comer received and reviewed a copy of the eviction notice submitted by the facility Administrator. The information provided on the notice was not clear and did not follow Title 22 requirements. LPA interviews with facility Administrator revealed the following: R1 had successfully attempted multiple elopements during R1's tenure as a facility resident. Per Administrator, R1 was provided with an eviction notice dated 3/20/2026, which explains that at this time the facility is not able to provide adequate care and supervision to R1 due to their behaviors posing hazard to themselves and others. R1, and their responsible party verified that R1 has no issues and concerns with the facility, and R1 could not recall any AWOL incident. A review of R1’s facility records and other pertinent documents revealed that R1 is a long-term resident of the facility and there are no previous records to identify changes in R1's physical, mental and psychological condition. Per physician report, R1 is able to leave facility unassisted. Information received revealed that R1 may have behavioral outbursts. However, there is no verification that R1's behavior poses hazard to themselves or others. Based on interview and record review, the facility may have reasonable ground for eviction. However, there is no measurable and verifiable information and evidence to support recent eviction notice issued to R1. License has not provided the documented due diligence to prove R1's change of mental/psychological condition that may cause harm to R1' s self, nor to the community. Therefore, the allegation is substantiated at this time. Under Title 22, Division 6, Chapter 8, the following citation was issued and recorded on LIC9099D. No immediate health and safety hazard is noted during this visit. Appeal rights discussed and provided. Exit interview conducted and copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Apr 2, 2026 · control 31-AS-20260323085304

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: Apr 2, 2026

Eviction Procedures (d)The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons...This requirement is not met by: Based on interviews and record reviews, the licensee did not ensure 30 day eviction was in compliance with Title 22, which poses in potential Health, Safety or Personal Rights risks to person in care.the state’s words, verbatim · CDSS document, Apr 2, 2026

Plan of correction: Licensee shall review eviction procedures and submit a statement of understanding to the department by POC due date 04/16/2026

Allegation investigated: Staff are not accepting resident back to facility.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegation. LPA met with the administrator, Candis Allen, and explained the reason for the visit. --- Staff are not accepting resident back to facility. It was alleged that administrator stated she will not accept patient back as patient has already been discharged from their facility. To investigate the allegation, on January 28, 2026, LPA requested documents at 11:00a.m. and interviewed Candis Allen from 11:15a.m. – 11:45a.m. During the interview, the Allen stated facility did not accept the resident as they have been in contact with the Department of Health who is finding placement for Resident #1's (R1). (CONT on LIC9099-C) Substantiated Allen also confirmed that a reassessment was not completed to determine if facility is able to meet R1's needs. Based on interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No other 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, Jan 28, 2026 · control 31-AS-20260125125414

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(b) · Plan of correction due date: Jan 29, 2026

(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement is not met as evidenced by; Based on interviews it was determined facility did not conduct an assessment prior to denying resident's return.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: Licensee will conduct an assessment to determine if they are able to meet the resident's needs by the POC due date and provide a written statement to the LPA.

Type of visit: Office

Case Management – Office Date: January 23, 2026 Time: 10:00 AM Location: Virtual An Office meeting was held virtually on January 23, 2026, at 10:00 AM to discuss a pending selling/change of ownership of Pasadena Villas (198603286), Melrose Villas (197609076), Melrose Chateau (197609724) and Cedars Assisted Living (197608267). Attendees: • Angela Whittaker – Regional Manager/South Woodland Hills • Troy Agard – Licensing Program Manager • Gina Saucedo – Licensing Program Analyst • David Sicarios- Licensing Program Manager • Tony Vasallo- Regional Manager/Monterey Park • Stephan Sarmazian-Vice President for Operations • Jai Chung-(Consultant) • Shawn Zhou – Chief Financial Officer (Consultant) 809-C continued Introductions were conducted at the beginning of the meeting. Regional Manager Angela Whittaker requested confirmation on whether the above facilities were being sold and/or if there would be a change of ownership in the near future. It was confirmed that there will be a future change of ownership for Cedars Assisted Living; however, because the facility is currently under revocation, the prospective owner is waiting for Legal to make a decision regarding the revocation action. The new owner is New Gen LLC, and the transaction will be a stock acquisition rather than a licensee change. The prospective owner plans to provide residents with a thirty (30) day notice and intends to submit a Community Care Licensing application on February 25, 2026. A copy of this meeting summary was emailed to all attendees listed above with signature on file.the state’s words, verbatim · CDSS document, Jan 23, 2026

Allegation investigated: Staff are not adhering to hand washing protocols.

Today, Thursday, 1/15/26, Licensing Program Analyst (LPA) Ray Comer, conducted an unannouced initial complaint visit, to obtain and gather information regarding the allegation mentioned above. LPA met with Administrator, and informed her of the reason for the visit. During today's visit, LPA toured the facility and interviewed staff and residents. Allegation: Staff are not adhering to hand washing protocols. The reporting party claims that there is no hand soap available for residents to wash their hands and that facility’s bathrooms do not have hand soap. LPA conducted a walk through and observed there was no soap in the first floor restroom. Interviews were conducted with residents and staff. Based on the information obtained, this allegation is deemed Substantiated.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 31-AS-20260114145051

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(D) · Plan of correction due date: Jan 15, 2026

Personal Accommodations & Services: Equipmen/supplies necessary for personal care...of adequate hygiene practice shall be readily available to each resident. Hygiene items,,,such as soap and toilet paper. This requirement was not met as evidenced by: During the physical plant inspection of the facility, LPA observed at first floor facilty bathroom not supplied with hand soap, which can pose a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: As POC, licensee will insure that all bathrooms, in use by the residents in care will be supplied with hand washing soap. Additionally, Admin will conduct staff training regarding required hygiene protocols, as per Title 22. Admin will complete POC and inform LPA by 1/27/26

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management, pertaining to information that was obtained during a complaint visit and incident report that was submitted to Licensing. LPA was informed by the Administrator Candis Allen, that a staff was placed on suspension, due to an internal investigation that is being conducted for staff allegedly violating resident # 1 (R1)'s personal rights. LPA obtained the incident report, and reviewed the document. The Administrator will follow-up with LPA regarding the outcome of the investigation. Further review by the office and LPA may follow after investigation by the Administrator. Exit interview and copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Dec 22, 2025

Allegation investigated: Staff did not keep facility free of bed bugs.

On Tuesday, 11/18/25, Licensing Program Analyst, (LPA) Ray Comer, arrived to conduct an unannounced initial 10-day visit to investigate the allegation. LPA met with the Administrator, presented official CDSS badge identification, and reason for the visit was disclosed. To investigate the allegation, LPA conducted a physical plant tour at 10:35 am, received facility resident roster, staff roster and requested facility documents relevant to the investigation. LPA interviewed staff and residents between 11:05 am and 12:30 pm, and reviewed records from 12:40 pm and 1:30 pm. Allegation: Staff did not keep facility free of bed bugs: The Reporting Party alleges that staff neglected to respond to the presence of pests (bed bugs) in the facility, and that staff refuse to treat the personal items of Resident#1, (R1) instead, staff have chosen to dispose of R1's items in the trash. (Continued on LIC9099C) Unsubstantiated LPAs' interview with the Administrator and staff revealed that on 10/03/25, the facility's pest control vendor (Ecolab) reported the presence on bed bugs in R1's room (#221). In the following weeks, Ecolab conducted further room inspections finding rooms #208, #207, #206, also having bed bugs; rooms #213, #106, #103 #205, and #203, were treated as a preventative measure. All residents in effected rooms were moved temporarily to unaffected rooms while Ecolab applied pesticide and heat treatments mattress and furnishings were immediately removed, clothing/linens were laundered at high temperature. Treated rooms were provided new new mattresses and furnishings, and residents returned to their rooms when cleared as "pest-free". The RP (Father of R1) complains that staff are violating R1's personal rights, as they were unwilling to store R1's personal items. (canvas paintings created by R1) However, it was revealed that pest control vendor, Ecolab, recommended the items to be disposed due to the presence of imbedded bed bug eggs, and potential health hazards from chemicals applied to treat the bed bug issue. The Administrator communicated multiple times to the RP that storing the aforementioned items would be a potential health and safety risk and attempted to coordinate the transport of the items in RP's possession. However, the RP refused, and demanded that the facility must store R1's items. . LPA interviews with residents revealed the following: Out of a today's census of fifty-eight (58) residents. Seven (6) out of six (6) residents confirmed to LPA that staff communicated to them of the bed bug issue, immediately responded by temporarily moving effected residents, providing pest control treatment, and replacing mattresses and furnishings to ensure the heath and safety of residents in care. All residents interviews stated to LPA that staff respect their personal rights and continue to feel safe living at the facility. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted and a copy of report was proved to the Administrator.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 31-AS-20251113113049

Allegation investigated: Staff did not ensure that resident received medical treatment. Staff do not ensure that client's mental health needs are met. Staff did not keep the facility free of cockroaches.

This is an Amendment to the original report issued 07/21/2025. Additional information was added to clarify the investigation. At 10:15 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent complaint visit and met with the front desk receptionist Cleef Dizon, and later with the Maintenance Director (MD) Saul Aranda. LPA explained the reason for the visit. An initial complaint visit was conducted on 04/14/2025. At 10:20 AM, LPA requested client and staff roster. At 10:25 AM, LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Admission Agreement, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 10:30 AM, LPA conducted a physical plant tour. Between 10:40 AM – 1:45 PM, LPA conducted an interview with the Administrator, two (2) staff, a MedTech and eight (8) residents. During today’s visit, LPA conducted additional interviews with MD, MedTech #2, R1's Primary Physician, Former Administrator Alexcis Peralta, and an Associate Director (AS) of Department of Health Services. Continue on LIC 9099C Substantiated Allegation: Staff did not ensure that resident received medical treatment. Regarding the allegation “Staff did not ensure that resident received medical treatment,” it was alleged that facility staff failed to secure medical care for Resident #1 (R1) after R1 sustained a burn injury to his/her feet. To investigate the allegation, during the initial complaint visit on 04/14/2025, LPA conducted interviews with the Administrator, MedTech #2, two (2) staff members, and eight (8) residents. During the subsequent visit on 07/21/2025, additional interviews were conducted with the Former Administrator, MD, Primary Physician, and MedTech #1. Interview with the Administrator revealed that on 03/07/2025, R1 spilled boiling water on his/her feet and staff offered medical assistance and hospital transport; however, R1 refused. LPA reviewed the Special Incident Report (SIR) and did not observe documentation of any 9-1-1 call or outside medical transport. Interviews with MedTech #1 confirmed the burn incident and that no 9-1-1 call was made. MedTech #1 stated R1 refused medical treatment and hospital transport. The MD confirmed that no formal outside medical assessment was arranged and documentation of refusal of care was incomplete. The Primary Physician informed LPA that he advised staff to transport R1 to the hospital for evaluation; however, the facility did not follow this recommendation. Interview with R1 at 12:15 PM confirmed the incident occurred; however, R1 stated he/she declined hospital transport. R1 further indicated receiving informal treatment with cream and home remedies but no outside medical evaluation. During the interview with R1, LPA observed the burnt present on R1’s feet and not being healed or covered. Based on interviews and record review, the facility failed to ensure appropriate medical follow-up after the burn injury and did not document refusal of care per policy. The facility also failed to follow the physician’s recommendation for outside medical evaluation. Therefore, the allegation is Substantiated. Allegation: Staff do not ensure that client's mental health needs are met. Regarding the allegation “Staff do not ensure that client’s mental health needs are met,” it was alleged that R1’s psychiatric and mental health needs were not addressed. To investigate the allegation, during the initial visit on 04/14/2025, LPA conducted record review and interviews with the Administrator, two (2) staff members, MedTech #2, and eight (8) residents. During the subsequent visit on 07/21/2025, additional interviews were conducted with the Former Administrator, the Associate Director of the Department of Health Services, and MedTech #1. Interview with the Administrator revealed that psychiatric appointments are scheduled but that R1 frequently refuses to attend. However, documentation of scheduled appointments and refusal forms was not provided. Record review did not reveal evidence of appointment scheduling or care plan updates addressing mental health services. Interview with the Former Administrator confirmed awareness of psychiatric services but stated that responsibility for scheduling appointments had been transferred to the Department of Health Services social worker. Continue on LIC 9099C The Associate Director of the Department of Health Services clarified that the facility remains responsible for arranging psychiatric services and transportation, though the department assists with coordination. No documentation of appointment scheduling was provided. Interviews with MedTech #1 indicated that R1 often refuses services but no formal documentation of refusals were made such as reappraisal and or incident reports. Moreover, LPA reviewed all incident reports on a system and did not observe an incident report regarding psychiatric appointment refusals. Based on interviews and documentation review, the facility failed to demonstrate efforts to arrange or document psychiatric services for R1. The lack of evidence supporting mental health follow-up supports the allegation. Therefore, the allegation is Substantiated. Allegation: Staff did not keep the facility free of cockroaches Regarding the allegation that staff did not keep the facility free of cockroaches, it was alleged that the facility had an infestation of cockroaches and bedbugs. To investigate the allegation, during the initial visit on 04/14/2025 at approximately 10:30 AM, LPA toured the facility and observed the general condition of the physical plant. Interviews were conducted with the Administrator, two (2) staff members, MedTech #2, and eight (8) residents. During a subsequent visit on 07/21/2025, additional interviews were conducted with the former Administrator, MD, and MedTech #1. During interviews, the Administrator, staff, MedTechs, and MD confirmed that the facility had experienced issues with cockroaches and bedbugs. MD reported that the facility is contracted with a pest control vendor, Ecolab, which is currently providing facility-wide pest control treatments to address the pest issues. Additionally, one (1) out of eight (8) residents interviewed reported witnessing bedbugs in their bedroom and cockroaches in the facility’s main elevator. Although LPA did not observe cockroaches or bedbugs during the facility tours, based on staff confirmations and the resident statement, there is sufficient evidence that pests were present in the facility. Therefore, the allegation is Substantiated. Deficiencies issued and appeal rights explained and given. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jul 21, 2025 · control 31-AS-20250409171120

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 28, 2025

87303 Maintenance and Operation (a)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: Based on interviews, staff failed to ensure that the facility is free from insects and pests, this poses a potential health and safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 21, 2025

Plan of correction: On 06/20/2025, LPA Raymond Comer issued a deficiency for complaint control # 31-AS-20250613093622 in which the Administrator has agreed to work with facility's pest control vendor to create a proposal for the enhanced treatment and eradication of pests in the facility. During today's visit, LPA received copy of the proposal and cleared the deficiency during today's visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jul 28, 2025

87468.1 Personal Rights of Residents in All Facilities- (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful..... . This requirement is not met as evidenced by: Based on interviews and record review medical treatment and Psychiatrist appointments were not given to R1 timely. This poses a potential health and safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 21, 2025

Plan of correction: The Licensee will develop a plan to ensure residents are receiving their medical and mental health treatments timely and correctly. The plan must be submitted to LPA by POC due day.

Allegation investigated: Staff are not ensuring that the facility is free of pests-

Today, Friday, 6/20/25, at 8:00 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannuouned, initial10- day visit to investigate the above allegation(s). LPA met with Administrator, Lori McKayl, presented official CDSS badge identification, and reason for the visit was disclosed. At 8:15 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate this allegation, LPA received facility resident roster, and staff roster. From 8:30 am to 10:00 am, LPA reviewed Resident#1's file. From 10:20 am to 11:05 am, LPA conducted a tour of facility common areas, and random inspection of resident bedroom. From 11:15 am, to 2:30pm, LPA interviewed residents and staff. [LIC9099C]-Continued Substantiated Allegation: Staff are not ensuring that the facility is free of pests - Reporting Party (RP) alleges that facility is experiencing pest control issues, stating that Resident#1 (R1) has seen cockroaches in the television/activities room. Additionally, the RP alleges that R1's bedroom has bed bugs and that the facility does not contract with a professional pest control service vendor. LPA interviews with staff revealed the following: The Administrator and Staff#1 (S1) confirm that the facility is contracted with pest control service vendor, Ecolab, who is currently providing eradication treatments, facility wide, to eliminate stated pest issues. Per staff, R1's room is scheduled for pest control treatment. LPA interviews with residents revealed the following: Out of a total of forty-six (46) residents, three (3) out of six (6) residents state observing cockroaches in facility common areas. Based on the information gathered during this visit, LPA determined that there was sufficient evidence to confirm the allegation of bedbugs and cockroach pest issues present in the facility. The allegation is substantiated. Deficiency cited on LIC9099-D Citation issued for CCR 87303(a) Maintenance and Operation on complaint control # 31-AS-20250326163124 and complaint control# 31-AS-20250409171120. Exit interview conducted, appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jun 20, 2025 · control 31-AS-20250613093622

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80087(a)(1) · Plan of correction due date: Jun 20, 2025

80087(a)(1) Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times…(1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement was not met as evidenced by: Based on interviews, staff failed to ensure that the facility is free from insects and pests, this poses a potential health and safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 20, 2025

Plan of correction: Administrator has agreed to work with facility's pest control vendor to create a proposal for the enhanced treatment and eradication of pests in the facility. Administrator will submit a proposa to LPA by 7/5/25.

Allegation investigated: Staff do not ensure that facility telephone is operable- Staff are not maintaining the facility clean- Staff provide inadequate food services to residents-

Today, Friday, 6/20/25, at 8:00 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannuouned, initial10- day visit to investigate the above allegation(s). LPA met with Administrator, Lori McKayl, presented official CDSS badge identification, and reason for the visit was disclosed. At 8:15 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate this allegation, LPA received facility resident roster, and staff roster. From 8:30 am to 10:00 am, LPA reviewed Resident#1's file. From 10:20 am to 11:05 am, LPA conducted a tour of facility common areas, and random inspection of resident bedroom. From 11:15 am, to 1:30pm, LPA interviewed residents and staff. [LIC9099C]-Continued Unsubstantiated Allegation:Staff do not ensure that facility telephone is operable- Reporting Party (RP) alleges that facility does not provide active telephone service for several weeks in month of June 2025. LPA observation of facility revealed the following: Facility's hardwire telephone system and resident-available cell phone are confirmed with active dial tone; phone and internet services are working properly. LPA interviews with staff revealed the following: Both the Administrator, and Staff#1 (S1) refute the allegation, stating that although there was a brief phone/internet service outage lasting a maximum of three (3) hours in the month of June, the facility continued to maintain active service access via cell phone. Staff state that all residents have access to either the facility's desk phone in the front lobby, or the facility provide cell phone. Staff state that resident#1 (R1) was offered access to facility provided cell phone service at the time of the brief service disruption. LPA interviews with residents revealed the following: Out of a total of forty-six (46) residents, Six (6) out of six (6) residents state there has been no significant phone/internet disruptions at the facility lasting more than a few hours, and confirm having ready access the telephone/internet service provided by the facility. Based on the information gathered during this visit, this allegation is unsubstantiated at this time. Allegation: Staff do not maintain a clean facility- Reporting Party (RP) alleges that facility does not keep the facility clean, stating that "...there is dust all over the furniture". LPA tour of the facility revealed the following: LPA observed facility common areas (i.e., dining room, television\activities room, hallways, and patio area) as clean and clear of clutter. LPA conducted observations of random resident bedrooms and found them as clean, free of dirt, dust and clutter. LPA interviews with staff revealed the following: Both the Administrator, and Staff#1 (S1) refute the allegation, stating that housekeeping staff clean common areas and resident bedrooms on a daily basis. LPA interviews with residents revealed the following: Out of a total of forty-six (46) residents, Six (6) out of six (6) residents confirm their satisfaction with level of cleanliness provided by housekeeping staff. Based on the information gathered during this visit, this allegation is unsubstantiated at this time. Allegation: Staff provide inadequate food services to residents- Reporting Party (RP) alleges that facility provide poor quality food and that staff "...primarily serve carbohydrates" which suggests a lack of vegetables, fruits, and meats nutrition. LPA observation of facility revealed the following: Facility's kitchen maintains a variety of fresh vegetables, fruits, meats, breads and other food items; no foods were observed as unhealthy or rotting. LPA observed refrigerators and walk in freezers working properly and all foods were wrapped and labeled accordingly. LPA observed a four-week calendar of food items which display a balanced variety of food options. LPA interviews with staff revealed the following: The Administrator refutes the allegation, stating that R1 is provided balanced, nutritious meals composed of a variety of vegetables, meats, fruits and carbohydrates. LPA interviews with residents revealed the following: Out of a total of forty-six (46) residents, five (5) out of six (6) residents state their satisfaction with the meals prepared and served by food service staff.. Based on the information gathered during this visit, this allegation is unsubstantiated at this time.the state’s words, verbatim · CDSS document, Jun 20, 2025 · control 31-AS-20250613093622

Type of visit: Case Management - Annual Continuation

Today, Friday 5/30/25, Licensing Program Analyst, (LPA) Raymond Comer, made an unannounced site visit to continue required 1 Year annual Inspection, initiated on 05/29/2024. LPA met with Administrator, Lori McKay, and the purpose of visit was disclosed. The remaining inspection domains were observed, reviewed and inspected: Medications: Located on the second floor, medication room is secured. locked, and inaccessible to residents. Medications are listed on a centrally stored medication and destruction record log. LPA audit of resident medications, with corresponding Medications Administration Record, (MAR) found records as accurate. First Aid kits, located in cabinet storage, were observed as fully stocked. Bedrooms: LPA observed random bedrooms (Rooms #104, #107, #109, #202, #203, #206, #209) finding them as clean, with sufficient lighting, bed linens, at least one chair, night stand, closet space, and dressers. Signaling system was tested in random bedrooms and working properly. Average staff response time to activated signal was within three minutes. Bathrooms: LPA observed bathrooms to be clean and sanitary, with required safety fixtures. (grab bars, anti-slip floor stripping) Hot water temperature measured between 115.°F. and 118.°F; within the required range. Hand towels are not shared. [LIC-809C]-continued Outdoor: Courtyard observed to have a shaded patio area, with a table, and sufficient seating for residents. Outdoor furniture observed to be in fair condition. Multiple sheds in the outdoor area contain tools, supplies, and PPE. All outdoor sheds were observed as locked and inaccessible to Residents. All trash cans were covered. There are no bodies of water in the facility. Resident records: LPA observed records stored in a locked and secured records room on the first floor, inaccessible to residents. Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be current and complete. Staff records: LPA observed records stored in a locked and secured records room on the first floor, inaccessible to residents. Criminal record clearances were present, and Staff are associated to this facility. Staff records appear to be complete and current. However, upon LPA review of Staff roster, and conversation with Administrator, LPA was informed that facility does not have an Activities Director. LPA interviewed three (4) staff that confirmed there is no Activities Director; it was stated to LPA that the previous Activities Director left their position in April of 2024. An exit interview was conducted; deficiency cited on LIC 809-D. Appeal rights discussed, and a copy of the report was provided to the Administrator.the state’s words, verbatim · CDSS document, May 30, 2025

Type of visit: Required - 1 Year

On 05/29/25, 10:00 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced annual visit. LPA met with Facility Administrator, Lori McKay, and reason for the visit was disclosed. Facility is licensed as a two story residence, encompassing 34 shared resident bedrooms, each with bathroom; three (3) public bathrooms are located in hallway areas. Fire clearance approved for sixty-eight (68) non-ambulatory residents; of which, twenty (20) may be bedridden. Hospice waiver for twenty (20) residents. At the time of this inspection, the facility occupied forty (40) ambulatory residents, and eighteen (18) non-ambulatory residents, six (6) of which are bedridden. Currently, four (4) residents are receiving hospice care services. At 10:35 am, LPA conducted a tour of the physical plant with the Facility's Maintenance Director, Saul Aranda, and observed the following: Facility’s main door is the primary access: Three (3) emergency exits are on the first floor, and two (2) emergency exits on the second floor. Exit routes are clear of obstruction. Screening area is located upon entrance. Delayed egress alarm sensors are present at all exit points and are working properly. Visitor sign-in sheet, hand sanitizer, gloves and masks are available. Room temperature is comfortable; wall thermostat displays a setting of 73 °F., within the required range. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on 3/29/2025. [Continued on LIC 809C] Fire Detection/Protection: Fire safety system is present in the facility. LPA observed multiple smoke and carbon monoxide alarms installed, hardwired, and interconnected. Fire system back up and tests are completed and documented on a biannual basis. Fire alarm system was tested and is working properly. Fire drill last conducted 3/29/2025. Fire extinguishers were observed on all floors of the Facility. All extinguishers were last serviced on 4/10/2025. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. Facility stairwells contain a required evacuation chair. Kitchen: LPA observed kitchen to be clean, with an adequate supply of perishable and non-perishable foods located in the refrigerator, freezer, and pantry. LPA observed a variety of fresh fruits, vegetables, meats, dry cereals, and desserts. Foods are properly labeled and stored. Knives and sharps are stored in a designated area of the kitchen. Kitchen is secured and inaccessible to residents. Laundry: Is located on sub-floor level. Laundry room, soaps, and other cleaning agents are stored and inaccessible to residents. Linen storage observed to have adequate supply of linen and towels. Commons: LPA observed upstairs and downstairs hallways, activity room, and dining room, finding them clean; furnishings observed to be in good condition. No obstructions, nor tripping hazards observed. Due to time constraints, LPA was unable to complete this annual inspection visit. LPA will complete at a later date. Exit interview conducted/Copy of report given to Administrator.the state’s words, verbatim · CDSS document, May 29, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Huma Rahimi, met with the front desk receptionist Henny Saftchick, and later with the Administrator Lori Mckay. LPA explained the reason for the case management visit. The purpose of the case management visit is to address deficiencies observed during the course of complaint #31-AS-20250409171120, by the LPA. The deficiencies were not alleged but related to the complaint. During the visit, LPA was informed that R1 had burnt his/her feet on or about 03/07/2025. Additionally, during the course of investigation there were other incidents related to other residents in care where 9-1-1 was called and the residents were taken to the hospital; however, no incident reports were submitted to the Community Care Licensing Department (CCLD) in a timely manner. LPA reviewed all incident reports on a system and did not observe any incident reports regarding R1 or any other residents. In addition, the Administrator admitted that no incident reports were submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. LPA informed the Administrator to submit all incident reports and the incident report relating to R1 which occurred on or about: 03/07/2025. Moreover, LPA was informed that R1 refuses medical and mental health treatments and R1's reappraisal was not updated accordingly to meet R1's needs in a timely manner. Deficiencies are issued and noted on LIC 809D. Appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 14, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Apr 21, 2025

Reappraisals: (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary....... the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical... This requirement is not met as evidenced by: Based on record review and interview during investigation, the licensee did not comply with the section cited above by not completing a resident reappraisal due to changes in R1’s medical condition, which poses/posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 14, 2025

Plan of correction: The Licensee agreed to develop a plan to address reappraisals of residents as frequently as necessary and provide in-service training to all staff regarding the Section 87463. Proof of training should be submitted to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)A,B&D · Plan of correction due date: Apr 21, 2025

Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R1's feet got burnt with boiling water on a unknown date and all of the other incidents regrdling other residents, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 14, 2025

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R1's and all other residents incident reports shall be submitted to LPA by POC date.

Allegation investigated: Licensee is not addressing pests at the facility-

On Tuesday, 12/10/2024, Licensing Program Analyst, (LPA) Raymond Comer, conducted the initial10-day complaint visit at the facility. At 10:05 am, LPA met with facility representative, Saul Aranda, and the purpose of the visit was disclosed. A physical plant tour of the facility was conducted. No health and safety issues were observed. Allegation: Licensee is not addressing pests at the facility- The Reporting Party (RP) alleges that faciity is not addressing incidents of bed bugs and roaches observed in resident bedrooms. [LIC 9099-C Continued]--- Unsubstantiated To investigate the allegation, LPA conducted records review from 10:20 am to 11:10 am, room observations from 11:25 am to 11:50 am, interview with Staff from 12:05 pm to 12:30 pm, and interview with residents from 12:45 pm to 1:30pm. LPA review of facility documents reveal in late September 2024, staff communicating with the facility's pest control vendor (Terminix) concerning observation of bed bugs and roaches observed in resident bedrooms. From October 2024 to the present, Pest Control Vendor has completed both chemical and heat treatments eradicating pests from resident rooms. At this time, bedrooms #102 and #205 have been treated for pests, been provided post-inspection by the pest control vendor, finding these rooms observed as "pest-free". LPA observation found that new bed mattresses (box springs are encased in plastic liner) and furniture has been replaced in pest-treated rooms. Additionally, Pest control vendor is scheduled to continue pesticide treatments to all remaining areas throughout the facility. LPA also conducted interview with facility residents and staff. LPA interview with the staff revealed that the bed bug issue originated with R2 stockpiling items off the street and into their room; Licensee is working with R2's case worker to address this issue. LPA interview with residents revealed that four (4) out of five (5) residents state there are no pest issues at the facility. Based on the information obtained through LPA observation, records review, and interviews, it cannot be proven that staff fails to address pests at the facility. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Dec 10, 2024 · control 31-AS-20241204111738

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst, (LPA) Raymond Comer, made an unannounced site visit to this facility as a continuation of the Required 1 Year Annual Inspection conducted on 06/20/2024. LPA met with Administrator, Alexcis Peralta, and the purpose of visit was disclosed. The following remaining inspection domains were observed, reviewed and inspected: Fire Safety: Fire Detection/Protection system is present in the facility. LPA observed multiple smoke and carbon monoxide alarms installed, hardwired, and interconnected. Fire system back up and tests are completed and documented on a biannual basis. Fire Alarm System was tested and working properly. Fire drill last conducted 5/30/2024. Fire extinguishers were observed on all floors of the Facility. All extinguishers were last serviced on 4/11/2024. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. However, LPA observed there are no evacuation chairs in the stairwells of the facility Kitchen: At 11:30 AM LPA observed kitchen to be clean, with an adequate supply of perishable and non-perishable foods located in the refrigerator, freezer, and pantry. LPA observed a variety of fresh fruits, vegetables, meats, dry cereals, and desserts. Foods are properly labeled and stored. Knives and sharps are stored in a designated area of the kitchen. Kitchen is secured and inaccessible to residents. Medications: Located on the second floor, medication room is secured. locked, and inaccessible to residents. Medications are listed on a centrally stored medication and destruction record log. First Aid kits are complete. Laundry: Room is located on sub-floor level. Laundry room, soaps, and other cleaning agents are stored and inaccessible to residents. Linen storage observed to have adequate supply of linen and towels. [Continued on LIC 809C] Commons: LPA observed upstairs and downstairs hallways, activity room, and dining room, finding them clean and furnishings to be in good condition. No obstructions, nor tripping hazards observed. Bedrooms: At 12:15 PM, LPA observed random bedrooms as clean with sufficient lighting, bed linens, at least one chair, nightstand, closet space, and dresser. Signaling system was tested and is working properly. Staff responded to activated signal within three minutes. Bathrooms: LPA observed bathrooms to be clean and sanitary, with required safety fixtures. (grab bars, anti-slip floor stripping) Hot water temperature measured at 118.°F., within the required range. While inspecting bedrooms #204 #210, #103, and #107, LPA observed multiple deficiencies, such as unstocked paper towel supplies, cracked bathroom glass mirrors, burned out bathroom light bulbs, and loose screws on door handles. Outdoor: Courtyard observed to have a shaded patio area, with a table, and sufficient seating for residents. Outdoor furniture observed to be in fair condition. Multiple sheds in the outdoor area contain tools, supplies, and PPE. All outdoor sheds were observed as locked and inaccessible to Residents. All trash cans were covered. There are no bodies of water in the facility. Resident records: LPA observed records stored in a locked and secured records room on the first floor, inaccessible to residents. 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: LPA observed records stored in a locked and secured records room on the first floor, inaccessible to residents. Criminal record clearances were present, and Staff are associated to this facility. Staff records appear to be complete and current. Per the CCR, Title 22, Division 6, Chapter 8 the following deficiencies were observed and cited: (Refer to the following pages LIC 809-D for list of deficiencies) Exit Interview conducted, report given, and Appeal Rights discussed with Administrator, Alexcis Peralta.the state’s words, verbatim · CDSS document, Jun 21, 2024

Type of visit: Required - 1 Year

On 06/20/24, 9:40 AM, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced Annual visit at this facility. LPA met with Facility Administrator, Alexcis Peralta, and reason for the visit was disclosed. Facility is licensed as a two-story residence, with 34 shared resident bedrooms, each with bathroom, and three (3) bathrooms for public use located in hallways paths. Fire clearance approved for sixty-eight (68) non-ambulatory residents, of which, twenty (20) may be bedridden. Hospice waiver is for twenty (20) residents. At the time of this inspection, the Facility occupied thirty-one (31) ambulatory residents, and seventeen (17) non-ambulatory residents, one (1) of which is bedridden. Currently, eight (8) of the Facility's residents are receiving hospice care services. At 11:40 AM, LPA conducted a tour of the physical plant with the Facility's Maintenance Director, Saul Aranda, and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary access, with three (3) emergency exits on the first floor, and two (2) emergency exits on the second floor. Emergency exit routes are clear of obstructions. Screening area is located upon entrance. Delayed egress alarm sensors are present at all exit points and are working properly. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 72 °F., within the required range. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on 6/19/2024. [LIC 809C-Continued] 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, Alexcis Peralta.the state’s words, verbatim · CDSS document, Jun 20, 2024

Allegation investigated: Staff yells at residents

Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced complaint investigation visit to investigate the above allegation. LPA Smith met with Alexis Peralta (Human Resources Director) and disclosed the purpose of the visit. Staff yells at residents To investigate this allegation LPA requested facility documents,and conducted interviews with staff and resident between 11:05 -1pm. LPA interviews with six (6) of six (6) staff revealed they have not yelled at residents or witness any staff yelling at residents in care. Staff #4 (S4) and Staff # 6 (S6) revealed staff and residents have a bound of respect. Staff #2 (S2) revealed have yelled and talk firmly to a vendor that had disrespected residents in the past but have not yelled at the residents. Staff # 1 (S1) and (S2) revealed staff may talk louder to residents with impaired hearing. Unsubstantiated (Cont from 9099) Interview with six (6) of seven (7) residents revealed staff have not yelled at them and have not witnessed any staff yelling at residents in care. One (1) of seven (7) residents revealed staff have yelled at them and other residents but was unable to recall dates of incidents and/or names of residents who were yelled at. Five (5) of seven (7) residents revealed staff are kind but can speak firmly when they need to. Based on interviews, there is not sufficient information to verify this allegation. Therefore, 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, Jan 30, 2024 · control 31-AS-20240123102907

Allegation investigated: Facility staff are restraining clients. Facility does not have adequate supervision. Facility failed to provide timely medical attention.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with lead staff, Alexcis Peralta, and explained the reason for the visit. --- Facility staff are restraining clients. It was alleged that staff restrain residents using a four-pin restraint mechanism. To investigate the allegation on 11/15/2023, LPA Duguma made observations during the physical plant tour, interviewed three (03) staff from 11:00 AM - 12:00 PM and six (06) residents from 1:00 PM – 2:30 PM. During the unannounced visit, LPA did not witness any residents in restraints. (CONT. on LIC 9099-C) Unsubstantiated During interviews with staff, all staff stated they have never restrained a resident or witnessed any staff restrain a resident. During interviews with residents, all residents stated that they have never been restrained or witnessed others being restrained. Based on observations and interviews, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time. --- Facility does not have adequate supervision. It was alleged that residents that require supervision wander the neighborhood. To investigate the allegation on 05/20/2021, LPA Alex Pitz interviewed staff. On 11/15/2023, LPA Duguma made observations during the physical plant tour and interviewed three (03) staff from 12:00 PM - 1:00 PM. During the physical plant tour, LPA observed delayed egress doors at every exit in working order. During interviews with staff, all staff stated that there are some residents that are very independent and can leave the facility and return without any need for supervision. Staff added that the facility is equipped with delayed egress doors to notify staff when residents are attempting to leave the building and they do not recall any wandering incidents around the time in question. Based on interviews, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time. --- Facility failed to provide timely medical attention. It was alleged that a resident had fallen out of their wheelchair outdoors and was left without assistance for an extended time. To investigate the allegation on 11/15/2023, LPA interviewed three (03) staff from 11:00 AM - 12:00 PM and six (06) residents from 1:00 PM – 2:30 PM. During interviews with staff, all staff stated they have never experienced a situation where a resident fell out of their wheelchair and was unassisted for an extended time. During interviews with residents, all residents stated they have never witnessed anyone left on the floor without assistance after falling out of their wheelchair and have never experienced that for themselves. 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 15, 2023 · control 31-AS-20210510121903