Monte Vista Village Senior Living

Allegation investigated: Licensee pursued unlawful eviction of resident. Licensee retaliated against a resident. Licensee overcharged resident for services. Licensee did not serve food at correct temperature. Licensee did not employ enough staff. Licensee did not accommodate resident’s personal preferences. Licensee did not address a potential safety hazard.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit on June 5, 2026, to further invistigate and deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to the Executive Director Adrian Guillen On January 24, 2025, Community Care Licensing Division (CCLD) received allegations involving the above- mentioned concerns. The Department’s investigation included an unannounced facility visit, interviews with the Reporting Party (RP), interviews with residents, interviews with staff, and a review of available records. Regarding the allegation that the licensee pursued an unlawful eviction of a resident, it was reported that Resident #1 (R1) was evicted for an amount disputed by the RP. Staff interviews confirmed that a 30- day eviction notice was issued due to non payment. Interviews and documentation indicated that R1’s responsible party had an outstanding balance, and elected to move R1 out prior to the end of the notice period. Billing records provided to the responsible party supported the facility’s claim of delinquent payment. Based on the information gathered, the eviction notice was determined to be valid.Therefore, the eviction notice was valid. Unsubstantiated (Continued from LIC9099) Regarding the allegation of retaliation. More specifically, RP alleged staff were instructed not to speak to her and that facility actions were retaliatory. Resident interviews revealed normal interactions with staff, and no records indicated restricted communication with R1's POA. Department records review reveal facility care notes for R1 that addressed concerns regarding the R1's POA’s behavior toward staff. Department records review reveal a letter addressed to R1’s POA documented that harassment would not be tolerated per facility policy and that efforts had been made to accommodate POA requests. Regarding the allegation that the facility overcharged for services, it was alleged that Resident #1 (R1) was billed for services not requested or provided. Interviews with staff and residents, along with a review of narrative care notes, showed that R1’s assessed care needs and level-of-care plan matched the services documented in the notes. Billing records listed services consistent with the care needs identified in R1’s assessments. No documentation or witness statements were found showing that services were billed that were not part of R1’s assessed care needs. Regarding the allegation that facility had Incorrect food temperature. More specifically, RP alleged food was left out long after meal service.Some residents noted that their plates may not always be picked up right away after they finish eating. No concerns related to food temperature were observed during the LPA’s visit. Photo evidence was provided; however, the time stamp showed the photo was taken after meal service had concluded, and the plate was located in R1’s room. Regarding the allegation of insufficient staffing, it was alleged that staffing levels were not adequate to meet resident needs. During Department interviews, residents stated that their needs were met in a timely manner, including when using their call buttons to request assistance. A review of narrative charting showed regular and consistent check-ins with Resident #1 (R1) throughout shifts, including extended supervision related to R1’s behaviors when taking medication. The Department’s review of staffing levels at or around the time of the allegation did not show staff shortages. Regarding the allegation that staff failed to accommodate preferences. More specifically, it was alleged staff refused R1’s clothing preferences and wake up schedule. Department Interviews with other residents did not support this concern. Department records review revealed there was a conflict between the POA’s preferences and R1’s personal preferences. No documentation indicated refusal by the facility.Regarding the allegation of a safety hazard. More specifically, RP alleged water was found on the resident’s floor near electrical cords. Records review revealed no maintenance reports or photographs regarding the cord. Interviews with staff denied observing water near cords. Resident interviews indicated housekeeping responds within a reasonable amount of time when called. No hazards were observed during the LPA visit. Regarding the allegation that staff failed to follow personal/dietary preferences. More specifically, RP alleged the facility did not follow R1’s care plan and diet preferences. Records revealed the care plan was updated to a higher level on January 16, 2025, per charting. Further records reviews records contained diet preferences, no prescribed diets (“RX diet”). Department resident interviews revealed many residents have dietary preferences (e.g., no spicy food), and the facility accommodates their needs. A secondary menu is always available if residents do not like what is being served. During the course of the investigation, interviews were conducted and records were reviewed. The investigation revealed inconsistent statements, and the information obtained did not present a preponderance of evidence to support or corroborate the allegations. Therefore, the allegations are deemed unsubstantiated. An exit interview was conducted, and a copy of this report along with Licensee Rights (LIC 9058, 03/22) was provided to Executive Director Adrian Guillen , whose signature below confirms receipt of these rights. ]the state’s words, verbatim · CDSS document, Sep 4, 2026 · control 08-AS-20250124092730

Allegation investigated: Facility staff issued an illegal eviction to resident in care Staff do not prevent residents from engaging in verbal altercations with other resident Staff did not prevent resident from engaging in a physical altercation with other resident Staff did not ensure residents personal property was kept safely secured Staff did not prevent resident from exposure to toxic fumes in the facility Staff does not ensure carbon monoxide detectors are in good repair

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced visit to the facility to initiate and deliver investigative findings regarding the above mentioned allegations. LPA identified herself, explained the purpose of the visit and nature of the complaint to Executive Director Adrian Guillen. On July 21, 2026 the Department received this complaint which alleged that facility staff issued an illegal eviction to Resident #1 (R1), staff do not prevent residents from engaging in verbal altercations with R1, staff did not prevent resident from engaging in a physical altercation with R1, staff did not ensure R1’s personal property was kept safely secured, staff did not prevent R1 from exposure to toxic fumes in the facility, and staff does not ensure carbon monoxide detectors are in good repair. [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] (Continued on LIC9099-C) Unfounded (Continued from LIC9099) The Department’s investigation included a facility tour, record reviews, as well as interviews with residents and staff. Records reviewed and interviews with residents and staff revealed that R1 resides in the Independent Living portion of the property and the alleged incidents involve Independent Living residents and property. The facility’s property includes an Independent Living and an Assisted Living section, but Independent Living is not state licensed and therefore not under the jurisdiction of Community Care Licensing. Additionally, during a facility walk through LPA did not observe any health or safety concerns. LPA observed carbon monoxide detectors in good repair. Further records reviewed revealed there was no incident of toxic fumes. LPA interviews with residents from both Independent Living and Assisted Living did not raise any licensing concerns. Based on records reviewed, a facility walk through, and interviews with staff and residents, the above allegations are determined to be unfounded. An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 23, 2026 · control 08-AS-20260721081639

Allegation investigated: Licensee did not safely maintain facility

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to address the above complaint allegation. LPA introduced herself and disclosed the purpose of the visit to Executive Director Adrian Guillen The Department’s investigation included an unannounced visit, interviews with residents and facility staff, observations, and review of relevant facility documentation. It was alleged that the facility Licensee did not safely maintain facility. More specifically, the Reporting Party (RP) alleged: The facility pool contains algae ; Cracked sidewalks near the gazebo causing residents to fall; Ceiling areas opened due to construction allegedly expose mold and dust; residents reportedly inhaling the particles; Palm trees are not adequately maintained, and large palm fronds fall into walkways; one resident was reportedly struck in the head. (Continued on LIC9099C) Substantiated (Continued from LIc9099) Regarding the Dining Room Mold / Ceiling Areas: No evidence could be found regarding details of construction. Interviews with the Executive Director confirmed construction had occurred on the first and second floors to replace portions of the dropped/false ceiling in lounge areas. The Executive Director reported no mold was observed or reported during the construction work. A review of incident reports and interviews with residents confirmed no adverse effects from ceiling work were reported to the facility or to CCLD. Interviews with residents reveal remembering the construction but not the details or recalling anyone being adversely effected by the construction. Regarding the Pool Mold/Algae: Resident and staff interviews revealed the pool occasionally appears discolored; however, residents also stated the pool is generally well maintained and that most residents do not regularly use it. The Executive Director reported the pool is maintained by an outside vendor and any issues are addressed promptly. No evidence of hazardous neglect was found. Regarding the Sidewalk Hazards: LPA observations and review of other complaint investigations confirm that sidewalk concerns were previously addressed under a separate complaint. No new findings were discovered during this investigation. Regarding the Palm Tree Maintenance: LPA observations, interviews, and photographic evidence confirmed that numerous palm trees on the property had dead, hanging fronds and fallen debris in walkways. Resident interviews revealed the fronds were observed obstructing common walking paths, but no evidence could be confirmed that any residents were harmed. Records showed only one trimming during the complaint period on 2/21/24. The facility grounds were not maintained in a manner that ensured resident safety. Based on LPA observations, photo evidence, resident interviews, and records review, the Licensee did not ensure the grounds were free of hazards. Large numbers of palm trees contained dead and hanging fronds. Records show the last trimming occurred on 02/21/2024, and no additional trimming has been documented. This posed a potential safety hazard to residents who use walkways. Therefore, the allegation is deemed substantiated, and one (1) deficiency was cited for it per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 08-AS-20231114155113

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(b) · Plan of correction due date: Aug 28, 2026

87307(b) – Buildings and Grounds: Safety Hazards“The facility shall be free of hazards, including but not limited to… outside walkways, porches, and yard areas...not maintained to prevent resident harm.This requirement has not been met as evidenced by: Based on LPA observations, interviews, and photographic evidence, the facility grounds were not maintained in a manner that ensured resident safety. Failure to properly maintain the palm trees and remove hazardous debris poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: The Executive Director will ensure removal of all dead and hanging palm fronds. A copy of the service order will be submitted to CCLD by the due date.

Allegation investigated: Facility washing machine is in disrepair

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to address the above complaint allegation. LPA introduced herself and disclosed the purpose of the visit to Executive Director Adrian. The Department’s investigation included an unannounced visit, interviews with residents and facility staff, observations, and review of relevant facility documentation. It was alleged that the facility washing machine is in disrepair. On July 8, 2026, the Department received the complaint stating that residents have been dealing with a broken washing machine, leaving only one working laundry room for both sides of the large complex. The Reporting Party (RP) reported that there are more than 100 apartments sharing these laundry facilities and described the situation as reaching a “crisis level.” (Continued on LIC9099) Unsubstantiated (continued from LIC9099) Department interview with the Executive Director (ED) revealed that one of the washers had been out of service and reported that new washing machines are scheduled to be installed in each laundry room. The ED explained that the facility offers optional paid laundry service per the admissions agreement, some resident rooms have their own personal laundry machines, and washers and dryers are available on both ends of the building. The ED further explained—and resident interviews confirmed—that courtesy assistance with personal laundry was offered to residents with mobility challenges while the north wing washer was out of service. Resident interviews revealed that laundry machines on both the north and south wings of the building periodically do not work; however, residents stated that the facility addresses the issues, and repairs or replacements occur as problems arise. Residents confirmed that staff communicate when machines are down and redirect them to alternative options when needed. During the visit, Executive Director Adrian provided LPA Rodgers with a receipt confirming delivery of two new washers and dryers, replacing the unit that had been out of service as well as updating the other machines. LPA observations confirmed that no immediate health or safety issues were present at the time of the inspection. Based upon the information obtained during this investigation, the allegation is UNSUBSTANTIATED. The allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director Adrian, to whom a copy of this report and the Licensee’s Rights (LIC 9058) were provided.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 08-AS-20260708115017

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management - other visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Adrian Guillen. Today's visit was in response to a Fire Clearance that was submitted to Community Care Licensing Department (CCLD). The facility made a 12 unit addition that will be only Independent living. The facility sketch matched the fire clearance forms that were submitted. During today’s visit, LPA performed a facility tour to verify the facility sketch that was submitted with the fire clearance. There were no deficiencies during this visit. An exit interview was conducted with Administrator Adrian Guillen to whom a copy of this report,the state’s words, verbatim · CDSS document, Jun 9, 2026

Allegation investigated: -Licensee unlawfully evicted resident. -Licensee did not refund full amount owed to resident.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to commence a Complaint Investigation regarding the above allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Adrian Guillen. The Complainant alleged that Licensee unlawfully evicted Resident #1 (R1), and that Licensee did not refund the full amount of money owed to R1. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report.] CCLD’s investigation involved an unannounced facility tour/welfare check and interviews of pertinent facility staff and outside sources. The Department also reviewed R1’s facility admissions agreement, billing ledger, and written correspondence. The Complainant said that R1, who was receiving treatment at an offsite skilled-nursing facility, was not allowed to return to their room at Monte Vista Village Senior Living, per a 04/24/2026 conversation that facility manager Staff #1 (S1) had with R1’s responsible person (RP). [CONTINUED ON LIC 9099-C] Unsubstantiated [CONTINUED FROM LIC 9099] The Complainant also said R1 was owed a refund of prepaid rent fees from 04/25/2026 through 05/31/2026, but Licensee agreed to only refund RP/R1 for the prepaid rent fees from 05/04/2026 though 05/31/2026. However, in their own interview, S1 presented a different account of their conversation with the RP. S1 said they advised the RP that additional costs (related to increased care) would be necessarily charged upon R1’s return, in spite of the RP’s protest that they could not afford the increased fees; S1 said R1 was never expressly prohibited from returning to their room at the facility. LPA also interviewed other two other facility managers plus a credible third-party/outside source, all who interacted with both S1 and RP during this time period. These interviews and the available written correspondence more showed that the RP chose for R1 to not return to the facility due to the anticipation of increased costs which were not financially sustainable, rather than R1 being prohibited by S1 from returning to their room at the facility. Per the facility's admissions agreement contract: Licensee reserves the right to reassess a resident upon any observed change in condition, and to immediately charge the care level (according to the disclosed schedule of fees) that the resident requires for their safety. Also, billing ends only after a resident has fully moved out, which is defined as both the resident departing and also vacating their room of personal property. Interviews of all parties unanimously showed: The RP had prepaid R1’s rent through 05/31/2026, and that the RP in practice fully-vacated R1’s room of personal belongings on 05/03/2026. R1 is thus owed a prorated refund of $2,619.35, which Licensee has agreed to issue. Per regulation, RCFE licensees have up to “15 days after the personal property is removed” to refund owed prepaid rent following a move out (which in this case comes out to 05/18/2026). As of the commencement of CCLD’s investigation, Licensee was still in compliance with this deadline. Based on records and interviews, a preponderance of evidence did not exist to show that Licensee unlawfully evicted R1, or that Licensee did not refund the full amount of money owed to R1. Both allegations are therefore Unsubstantiated, and no deficiencies were cited for them. An exit interview was conducted with Executive Director Adrian Gullien, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 14, 2026 · control 08-AS-20260513163917

Allegation investigated: Licensee does not have enough money to meet operating costs.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conclude a Complaint Investigation regarding the above allegation, and to deliver a finding. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Adrian Guillen. The Complainant alleged that Licensee does not have enough money to meet operating costs. CCLD’s investigation involved an unannounced facility tour, interviews of relevant managers, and review of pertinent financial records. When the facility first became licensed by CCLD on 01/19/2023, the joint-Licensees then were two (2) Limited Liability Companies (LLCs) registered with the California Secretary of State (SOS): Pacifica Monte Vista LLC (202103510653) and Monte Vista Mgr LLC (202463816276). [CONTINUED ON LIC 9099-C] Unsubstantiated [CONTINUED FROM LIC 9099] By the commencement of CCLD’s complaint investigation (03/24/2026): Per the SOS website, Pacifica Monte Vista LLC was in “Suspended – FTB” status (i.e., not active) while Monte Vista Mgr LLC was in “Active” status. LPA’s interviews of pertinent managers confirmed Pacifica Monte Vista LLC had completely ceased being involved in the facility’s operations, but Monte Vista Mgr LLC was still active and running the facility. Per CCLD’s review of three (3) consecutive months of the facility’s profit-and-loss financial statements, pertinent to the complaint time period, the facility itself brought in more money than it spent (i.e., it was profitable) over all three (3) months. Per CCLD’s review of Licensee’s bank statements over the same period, Licensee’s bank account consistently had cash reserves. Since 12/12/2025, there was, and remains, an active/pending Change in Ownership (CHOW) facility application in process with CCLD’s Centralized Applications Bureau (CAB). If later approved, the new joint-Licensees would then become: Monte Vista SL Opco LLC (202463816262) and Monte Vista Mgr LLC, operating under a new facility license. Based on records and interviews, a preponderance of evidence does not exist to show that the current Licensee does not have enough money to meet operating costs. The allegation is therefore Unsubstantiated, and no deficiency was cited for it. An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 14, 2026 · control 08-AS-20260318151719

Allegation investigated: Licensee did not ensure resident had clean bedding. Licensee’s staff did not treat the resident with dignity. Licensee did not keep the facility free of insects.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Adrian Guillen. On November 22, 2024, Community Care Licensing Division (CCLD) received a complaint alleging that Licensee did not ensure Resident #1 (R1) had clean bedding, Licensee’s staff did not treat a resident with dignity, and Licensee did not keep the facility free of insects. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, photo evidence review, LPA observations, and record review. (Continued on LIC9099C) Substantiated (Continued from LIC9099) Regarding the allegation that Licensee did not ensure R1 had clean bedding. More specifically, a stained blanket was observed by the Reporting Party on 09/09/2024. Department interviews with Staff #1 and Staff #2 revealed acknowledgment that the facility’s linen inventory included worn or stained items. Department resident interviews revealed that multiple residents reported bedding and towels that were stained, worn, or frayed. Department LPA observations revealed worn linens in circulation during the visit. Photo evidence presented by reporting party showed visibly stained bedding. Regarding the allegation that Licensee’s staff did not treat resident with dignity. More specifically, a caregiver allegedly removed a spoon from a resident and stated, “You’re done now,” abruptly ending the resident’s meal. Department resident interviews revealed a credible eyewitness account confirming that the incident occurred and describing additional instances of abrupt or cold interactions by the same caregiver. Regarding the allegation that licensee did not keep the facility free of insects. More specifically, residents and photographs showed food left out after meal service, and multiple residents reported mosquitos, ants, and spiders inside Building 17 as well as main dinning area. Photo evidence supported that food remained out long after meals in November 2024. Department interviews with Staff #4 revealed awareness of mosquitos and use of a UV insect device in at least one room. Department resident interviews revealed repeated observations of mosquitos, ants, spiders and flies over time. Department LPA observations confirmed exterior doors to Building 17 were propped open and food remnants were left out, contributing to pest presence. LPA observation on 4/10/2026 Blue light pest control traps on the walls of the main dining area. Observation also revealed large sliding glass doors that lead into the common/dinning building and may contribute to insects entering the building. Based on relevant interviews, LPA observations, records review, and photo evidence, the preponderance of evidence has been met that the above violations occurred and are therefore SUBSTANTIATED. Deficiencies are cited per California Code of Regulations, Title 22 (see attached LIC 9099D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. (Continued from LIC9099) Regarding the allegation that licensee did not meet R1’s incontinence care needs, Department interviews with staff revealed no double padding practices, and residents did not report issues with their own care. Department records review revealed documentation did not indicate inadequate incontinence care. Photo evidence showed saturated items but lacked context linking the condition to facility practice. Regarding the allegation that dressing/bathing needs were unmet, Department interviews with staff and residents revealed consistent showering practices, and records review revealed shower logs indicating missed care. Interviews with Residents did not indicate concerns with dressing or bathing. Regarding the allegations related to dietary preferences, activities, medication administration, centrally stored medications, pharmacy selection, staff health, and staff communication ability, Department interviews with staff revealed no confirmed violations; Department resident interviews revealed no consistent concerns; Department records review revealed no documentation supporting the allegations; Department LPA observations revealed no concerns. Based on interviews, direct LPA observations, and records review, the preponderance of evidence does not exist to prove that the alleged violations occurred; therefore these allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 10, 2026 · control 08-AS-20241122162544

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 8, 2026

87303(a) The facility shall be clean, safe, sanitary and in good repair at all times.... for the safety and well-being of residents, employees and visitors. .This requirement is not met as evidenced by: Based on observation and interviews, the licensee did not ensure the facility was clean, safe, and sanitary for multiple residents in Building 17, as LPA observed stained and torn linens, insects inside the building, food left out, and exterior doors propped open, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 10, 2026

Plan of correction: Licensee stated they will remove all damaged linens, purchase replacements, and implement monthly linen checks by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 8, 2026

87468.1(a)(1) Residents shall be accorded dignity in their personal relationships with staff, residents, and other persons. Based on interviews, the licensee did not ensure dignity was accorded to 1 out of 1 resident in care (R1) when staff ended the resident’s meal by removing the spoon while the resident was still eating, which poses a personal rights risk.the state’s words, verbatim · CDSS document, Apr 10, 2026

Plan of correction: Licensee stated they will conduct training on dignity and respect during mealtime practices and complete dining room spot checks by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(2) · Plan of correction due date: Apr 10, 2026

Basic Services. Basic services shall at a minimum include: Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services. This requirement is not met as evidenced by: Based on observations and interviews the licensee did not provide safe and healthful living accommodations for 9 out of 9 residents (R1-R9), which poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 10, 2026

Plan of correction: Administrator stated pest control is involved and will continue. In addition, administrator has called a complany to possibly install fans at openings/sliding glass doors at the main dining area of the facility. Administrator has provided the pest control recepits to LPA.

Allegation investigated: Licensee did not maintain facility in a state of good repair.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director, Adrian Guillen. On 2/11/25, it was alleged that the Licensee did not maintain facility in a state of good repair. During the visit, the LPA toured the facility and was specifically observed the area of the facility that has a downward tilt and at the lowest area there are resident housing. Staff 1 (S1) stated that the facility has been aware of the possibility of flooding because of the downward flow of water and the resident housing being on the lower area of possible flooding. The facility was built many years ago and there has been discussions about how to remedy the situation. (Continued on LIC9099C) Substantiated (Continued from LIC9099) Currently the facility added another water drain and there are multiple water pumps to aid in moving draining water away for the residents housing area. There are also multiple sandbags placed in front of the entrances of the residents housing to prevent water from entering the resident housing. Three (3) residents were interviewed; both denied experiencing any flooding in their housing. The residents interviewed were complementary of the facility and maintaining the grounds during the episodes of increase rainfall. The third resident interviewed had flooding in their housing unit that caused damage to their belongings. Outside source 1 (OS1), reported no concerns observing flooding with the residents housing. Outside Source 2 (OS2) stated that they observed the damage of flooding in a resident's room during high rainfall. A review of facility records, including incident logs, and communication notes, confirm on going repairs to the facility and grounds to make sure the facility is well maintained. The pumps were used during the month of December 2025 for the increase notice of rain, but removed before the January 2026 rains. The facility was aware of the potential flooding of the housing units in the area to remedy flooding of the residents housing. The pumps were not in place when the heavy rain caused flooding in the resident housing. Based on records and interviews, a preponderance of evidence exists to show Licensee did not maintain facility in a state of good repair. Therefore, the allegation is deemed substantiated, and one (1) deficiency was cited for it per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 26, 2026 · control 08-AS-20260211133115

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

87303 Maintenance and Operation: “(a) The facility shall be…safe… 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 was not met, as evidenced by: Based on interviews and LPA observation, Licensee did not maintain the facility’s outdoor draining system in safe and good repair at all times. This posed a potential safety risk to 1 of 111 resident in care.the state’s words, verbatim · CDSS document, Mar 26, 2026

Plan of correction: Licensee agreed to have pumbs in place prior to any reports of rain by POC due date.

Allegation investigated: Licensee did not maintain outdoor walkways in safe condition.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to commence a Complaint Investigation regarding the above allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Adrian Guillen. The Complainant alleged that Licensee did not maintain outdoor walkways in safe condition. CCLD’s investigation involved an unannounced facility tour (to include both daytime and nighttime observation) and interviews of pertinent residents and facility staff. In regard to the allegation, the Complainant said that the facility’s outdoor walking paths/sidewalks had uneven pavement, and that they were poorly lit at night. During today’s visit, which began in the day and ended at night, LPA, accompanied by the administrator, walked the facility’s outdoor path/sidewalks, in both daylight and nighttime conditions. [CONTINUED ON LIC 9099-C] Substantiated [CONTINUED FROM LIC 9099] LPA observed, and manager interviews confirmed: There were a few areas of lift between sidewalk slabs, likely caused by either tree roots or movement of underlying earth. These areas represented potential trip hazards to seniors/elderly. LPA and managers agreed that these gaps were close enough that they could be remedied/smoothed with a concrete grinder. There were also a few areas of paths on the facility campus that were not well lit at night. There were also multiple outdoor light bulbs which were non-working and needed to be replaced. Prior to today’s visit, Licensee had installed one (1) additional outdoor light, but manager interviews, supported by LPA observation, showed that five (5) more of these units were needed to cover other areas. Based on records and interviews, a preponderance of evidence exists to show the Licensee did not maintain outdoor walkways in safe condition. The allegation was therefore Substantiated, and one (1) deficiency was cited for it per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. [CONTINUED FROM LIC 9099-A] During his own tour, LPA observed that while the facility campus/grounds had many trees and areas of foliage, outside most building entrances were multiple covered mouse traps, which had been placed/installed by the above professional pest control company. During his many hours at the facility, LPA did not personally see any rats/rodents indoors. Managers said they had not received any recent reports of rats/rodents entering indoor spaces. LPA also interviewed a knowledgeable representative of the Resident Council, who denied hearing any recent concerns/complaints of rats/rodents entering indoor spaces. Based on records and interviews, a preponderance of evidence does not exist to show that Licensee had not remedied a rat/rodent problem at the facility. The allegation is therefore Unsubstantiated, and no deficiency was cited for it. An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 08-AS-20260318151719

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 24, 2026

87303 Maintenance and Operation: “(a) The facility shall be…safe… 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 was not met, as evidenced by: Based on staff interviews and LPA observation, Licensee did not maintain the facility’s outdoor walkways in safe and good repair at all times. This posed a potential safety risk to 111 of 111 residents (Resident #1 through Resident #111) in care.the state’s words, verbatim · CDSS document, Mar 24, 2026

Plan of correction: Licensee agreed to hire a vendor with a concrete grinder to smooth out all lifted edges of concrete sidewalk on the facility’s premises. Licensee agreed to purchase and install five (5) additional outdoor lights. Licensee agreed to also replace all outdoor light bulbs where they have gone out. Licensee agreed to E-mail: a) the concrete grinding invoice, b) the purchase receipt for the 5 additional lights, and c) a simple list of all locations where existing bulbs were replaced, to LPA, by the POC due date.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Neglect/Lack of supervision resulting in serious bodily injury

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on a complaint investigation. LPA Hurt met with Administrator, Adrian Guillen, and explained the purpose of today’s visit. Regarding the allegation that neglect and lack of care and supervision resulted in Resident 1 sustaining a fall and serious bodily injury, the investigation revealed sufficient evidence to support the allegation. Between August 2024 and January 2025, Resident 1 experienced approximately nine falls while residing at the facility. The majority of these incidents occurred in his bedroom, typically near his bed or recliner. According to his Physician’s Report, Resident 1 was non-ambulatory and required staff assistance for transfers. Resident 1 was identified as a fall-risk resident. Interviews conducted with multiple staff revealed that Resident 1 had a small bed rail installed upon admission; however, the bed rail was insufficient to prevent falls. The resident was not provided with a fall mat, call pendant, or other fall-prevention measures. Facility staff further stated that Resident 1 required two-person assistance for safe transfers. Due to ongoing staffing shortages, the facility only accommodated one-person-assist. LPA interviewed the facility Resident Services Director, who confirmed that the facility was aware of Resident 1's increased care needs and had discussed this with Resident 1's daughter on multiple occasions. Despite this awareness, no action was taken to relocate the resident to a facility capable of meeting his needs. On January 27, 2025, Resident 1 ate lunch in his room. At some point, his water spilled on the floor, and he subsequently slipped and fell, landing on his left side. Initially, he did not complain of pain; however, a few hours later, he began to experience significant discomfort. Substantiated Staff called 911, and Resident 1 was transported to Sharp Hospital, where medical records confirmed an acute left femoral neck fracture. LPA interviewed Dr. Randall Baldassarre from Sharp Hospital. Dr. Baldassarre stated that the term “acute” refers to an injury occurring within a few days, and confirmed the injury was consistent with a fall. Although other causes could not be ruled out entirely, Dr. Baldassarre stated that a fall was the most likely cause, especially for an elderly individual. The investigation revealed that Resident 1's care plan listed him as one-person assist, but staff had determined after move-in that he required two-person assistance. The facility did not update the care plan accordingly and failed to take corrective action to ensure Resident 1's needs were met. The facility also did not terminate residency or relocate the resident to a higher-level-of-care setting, despite knowing it could not meet his supervision and transfer requirements. Based on interviews, record review, and corroborating documentation, the preponderance of evidence shows that the facility failed to provide adequate care and supervision. This failure resulted in a fall causing serious bodily injury. Therefore, the above allegation is found to be SUBSTANTIATED. The following deficiencies are being cited (see LIC 9099D) from the California Code of Regulations, Title 22, and the California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on H&S Code section 1569.49(f). Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted with Administrator Adrian Guillen, and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 23, 2026 · control 08-AS-20250128115727

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

(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). The following requirement has not been met as evidenced by: The facility did not provide Resident 1 sufficient care and supervision, which lead to falls resulting in fracture/injury, which is an immedaite health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: The facility administrator will train all direct care staff on:fall prevention strategies, Proper transfer techniques, Monitoring high-risk residents, Documentation of changes in condition, Training to be completed by (date) and documented in staff files and send proof to LPA by POC date of 02/24/2026.

Allegation investigated: Staff inappropriately had residents on video calls

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit with Administrator Adrian Guillen. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. On 1/14/26 it was alleged that staff inappropriately had residents on video calls. Staff interviews revealed that cell phones are a part of everyone's life in the his current society. Staff state that communication is very important to provide quality care for the residents. When asking about personal cell phones and video face time call during working hours staff stated that personal phone use was not permitted. Substantiated (Continued from LIC9099) Resident interview revealed that they are aware of cell phone use by the staff but the understanding is that the phones are used to complete the staff's work duties. Outside source interview revealed Staff 1 (S1) positioned a personal device, a cell phone, to speak to S1's family members and the position of the personal phone showed residents’ faces and surroundings were visible to multiple bystanders, and at least one call included a third party recording the screen without clear resident consent. Residents were not offered private space or headphones, and no signage or procedure was evident to ensure confidentiality during video communications. The environment and manner of facilitation did not reflect adequate safeguards for resident privacy or informed consent. Records review included admission agreements, resident rights acknowledgments, and facility policies addressing employee communications (telephone/video calls), photography, and social media. The policy states that employees personal use of the telephone for calls are not permitted. The policy of camera phones states that no employee may use a camera phone function on any phone on company property or while performing work due to the potential for issues such as invasion of privacy. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with the Administrator, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 08-AS-20260114114326

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Mar 6, 2026

(a) Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement was not met as evidence by; Based on observations, interviews and records reviewed staff had residents on video calls of 1 0f 104 persons in care which posed a potential Health and Safety risk to person in care.the state’s words, verbatim · CDSS document, Feb 18, 2026

Plan of correction: Administrator agrees to conduct a Resident Rights training for all staff and administrators by POC date

Allegation investigated: Facility staff are not following proper eviction procedures

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the findings in the above-mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Administrator Adrian Guillen. During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents, and outside sources. On 12/02/25, the department received a complaint alleging the Facility staff are not following proper eviction procedures. Staff 1 (S1) was interviewed and stated that the facility did not follow the proper eviction procedures by not informing the department of the 30 day eviction notice given to Resident 1 (R1).S1 confirmed that the notices did not include the reason for eviction or information about appeal rights.They explained that the decision was made due to financial concerns. S1 stated they are now aware of the proper process and will ensure corrective measures are implemented immediately. Substantiated (Continued from LIC9099) Outside source 1 (OS1) revealed that the facility did not follow proper procedures when giving R1 the eviction notice. OS1 reported that the facility did not provide documentation explaining the reason for eviction, or the resident’s right to appeal. OS1 expressed concern that the lack of written notice made it difficult to arrange alternative placement and understand the process. They confirmed that no discharge plan or assistance was offered by the facility and stated that they expected proper notice in compliance with regulations. During the investigation, the LPA reviewed facility records, including eviction notices, communication logs, and resident files. The review revealed that R1 was asked to leave the facility without receiving the required 30-day written notice. Notices lacked clear reasons for eviction and did not include information about appeal rights, as required by Title 22. Additionally, there was no evidence of discharge planning or coordination to ensure safe relocation for affected residents. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Administrator Adrian Guillen, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 08-AS-20251202131425

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: Mar 6, 2026

87224 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 was not met, as evidenced by: Licensee issued 1 of 104 residents (R1) a notice to quit (i.e. a written eviction letter), but the notice did not include specific facts to permit determination of the date, place, witnesses, and circumstances concerning the reason(s) for eviction. This posted a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 18, 2026

Plan of correction: Administrator agrees to complete a training with an outside source. This training was completed by January 2, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Domingo was welcomed by, identified herself to, and discussed the purpose of the visit with Adrian Guillen, Administrator. According to the facility’s license, This facility serves two hundred and nineteen (219) residents 60 and above; 33 who may be non-ambulatory, and eight (8) who can be receiving Hospice services and/or bedridden. LPA, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected several rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Call box was available in each resident unit and were tested for functionality. Resident's room temperatures were within a comfortable range. The facility’s ambient internal temperature was 70 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 112 F, Bathroom #1 sink was 112 F, and Bathroom #2 sink was 112 F. [CONTINUED ON LIC 809C] [CONTINUED FROM LIC 809] Refrigerator temperature was 30 F and freezer temperature was 0 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance and surety bond. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Adrian Guillen, Administrator, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Dec 5, 2025

Allegation investigated: The facility is in disrepair. Facility staff do not ensure that residents are served food of good quality.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to investigate the above-mentioned complaint allegations and deliver the findings. LPA identified herself and discussed the purpose of the visit with Executive Director Adrian Guillen. During the course of the investigation, LPA Domingo collected relevant resident records and facility documentation, and conducted interviews with facility staff, residents, and outside sources. On November 21, 2025, the Department received a complaint alleging that the facility is in disrepair. Staff 1 (S1) was interviewed and stated that the facility conducts regular maintenance checks and addresses repair requests promptly. Staff 2 (S2) was interviewed and confirmed that the kitchen and dining areas are cleaned daily and that no structural or safety issues have been reported. Unsubstantiated Resident 1 (R1) reported no concerns with the condition of the facility and stated that their room and common areas are clean and well maintained. Resident 2 (R2) was interviewed and stated that there was a temperature issue last year but as of this year there has not been a temperature or facility maintenance this year. The facility is clean and well maintained. Outside Source 1 (OS1) stated they visit frequently and has not observed any disrepair or safety issues with the facility. This past year has been exceptionally better with new floors and the temperature is always comfortable. LPA Domingo reviewed Maintenance logs and the logs showed consistent documentation of routine inspections and timely repairs. The temperatures of the common areas are within regulations. The temperatures within the private rooms are within regulation. During the facility tour, LPA observed that the building was clean, free of hazards, and in good repair. No evidence of disrepair was noted in resident rooms, bathrooms, or common areas. On November 21, 2025, the Department received a complaint alleging that the facility staff do not ensure that residents are served food of good quality. S1 was interviewed and stated that there has not been any quality of food complaints at the resident meetings or there has not been any resident or family complaints made known to S1 as of late. S2 stated that meals are prepared fresh daily, menus are rotated weekly, and dietary needs are accommodated. Staff 3 (S3) confirmed that residents are surveyed regularly for food preferences and satisfaction. There have not been any recent complaints regarding food quality. R1 stated that the food is “good and filling” and that they are offered choices and alternatives when needed. R2 stated that the food is of good quality, presented well and tasted very good. There were no overcooked or burnt foods. Resident 3 (R3) was interviewed and there were no complaints of over cooked, poor tasting food. The food was quality foods, good tasting and well prepared. OS1 reported that their loved one has not expressed any concerns about the food and that meals appear well-balanced during her visits. Menus were posted and reflected variety and nutritional balance. Food supply invoices confirmed regular deliveries of fresh ingredients. Food storage areas were clean and well-organized. LPA observed a lunch service during the visit. The meal was served hot, appeared appetizing, and included a protein, vegetable, and starch. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred. Therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058, 03/22) were provided. The signature below confirms receipt of these documentsthe state’s words, verbatim · CDSS document, Nov 26, 2025 · control 08-AS-20251121120053

Allegation investigated: Licensee did not protect resident Unlawful eviction Neglect resulted in resident on resident abuse

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Adrian Guillen. On June 29, 2023 it was alleged licensee did not protect resident, unlawful eviction, and neglect resulted in resident on resident abuse. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Unsubstantiated (continued from LIC 9099) It was further alleged that the licensee failed to protect R1 from another resident. More specifically, RP alleged that the facility did not take appropriate action to ensure R1’s safety despite ongoing conflict with R2, including the existence of a restraining order. Staff interviews confirmed that the facility was aware of the interpersonal conflict and had informed staff during meetings to monitor the situation and report any violations. There was no evidence that the facility failed to intervene or respond to concerns. R1 had a documented history of verbal and physical aggression toward staff and residents. It was alleged that the facility neglected Resident #1 (R1), resulting in resident-on-resident abuse. More specifically, the Reporting Party (RP) alleged that another resident, identified as Resident #2 (R2), physically assaulted R1 on multiple occasions, causing injury. RP stated there were no witnesses to the incidents, and R1 did not report them to staff. A review of facility records revealed no incident reports or documentation supporting the claim that R2 physically assaulted R1. Staff and resident interviews did not corroborate the allegation. A narrative charting entry dated 5/30/2023 documented that R2 sustained a skin tear while defending himself during an altercation involving R1, and police were contacted. R2’s records showed no history of aggressive behavior. It was further alleged that the facility issued an unlawful eviction notice to R1. More specifically, RP alleged that the eviction was retaliatory and followed the issuance of a protective order in favor of R1. A review of the eviction notice confirmed that it was issued in writing with a stated reason and followed Title 22 requirements. Facility documentation showed that R1 had violated house rules through repeated verbal aggression and a physical altercation. There was no evidence that the eviction was retaliatory or procedurally improper. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred; therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Adrian Guillen to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 2, 2025 · control 08-AS-20230629152942

Type of visit: Case Management - Other

LPA Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced Case Management visit. LPA was welcomed by Front Receptionist Gayle Watkins, identified herself, and discussed the purpose of the visit with Executive Director Adrian Gullien. During today's visit LPA conducted and interview with Resident 1 (R1) regarding an existing complaint and a records request. An exit interview was conducted with ED Guillen, to whom a copy of this report, and License Rights (LIC 9058), will be provided. Signature below confirms receipt of the report.the state’s words, verbatim · CDSS document, Aug 19, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced Case Management visit. LPA was welcomed by and identified herself to Marketing Regional Michael Stickler. LPA then met and discussed the purpose of the visit with Executive Director (ED) Adrian Guillen. LPA conducted a visit to obtain signatures on amended complaints. An exit interview was conducted with ED Guillen, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Jul 23, 2025

Allegation investigated: Facility is not following proper Covid-19 infection control protocols.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver findings regarding the above-mentioned complaint allegation. LPA met with Executive Director (ED) Adrian Guillen, identified herself, and stated the purpose of the visit. The Department's investigation consisted of staff and resident interviews and records reviews, and a facility tour. It was alleged the facility did not follow proper COVID-19 infection control protocols. An interview with former Staff1 (S1) revealed they had worked in a unit of the facility where Resident1 (R1) resided and disclosed R1 tested positive for COVID-19. S1 revealed feeling sick the following day and believed to have contracted COVID-19 from R1. The interview with S1 also revealed staff did not put infection control precautions into place. S1 disclosed they had called out sick and was asked to return to take a COVID-19 test. S1 stated the test was administered by the Director of Maintenance (DOM) however, was never given their result. An interview conducted with the DOM revealed they had never administered COVID-19 tests. Unsubstantiated An interview conducted with R1 revealed they felt sick with COVID-19 like symptoms and self administered a COVID-19 test. R1 also disclosed the test had a faint line but they were not sure if they had administered the test correctly. An interview with Staff 2 (S2) and revealed R1 had self administered a rapid COVID-19 test with inconclusive results. S2 also revealed R1 had COPD which can have COVID-19 like symptoms. S2 disclosed R1 was placed in isolation and given a PCR test that yielded negative results. The Department has investigated the allegation listed above. Based on evidence obtained, including interviews and records reviewed, the above allegation was determined to be unsubstantiated, meaning the evidence did not meet the preponderance of the evidence standard. An exit interview was conducted with Executive Director, Adrian Guillen and a copy of this report and Licensee Rights (LIC 9058 01/16) will be provided. Signature below confirms receipt of the reports.the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 08-AS-20230227134000

Allegation investigated: Staff changed level of care for resident without a physicians assessment.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude a complaint investigation and render findings. LPA Correia was greeted by Executive Director (ED) Adrian Guillen, identified herself, and stated the purpose of the visit. The Department’s investigation included staff and outside source interviews and a resident record review. On April 23, 2025, the Department received a complaint that alleged facility staff changed Resident’s 1 (R1’s) level of care at the facility without being reassessed by a Physician. A review of R1’s records revealed they were admitted to the facility on February 28, 2021, with Primary Diagnoses of Hypertension, Hyperlipidemia, Cerebral Vascular Accident, GERD, and Mild Cognitive Impairment (MCI). [Continued on LIC 9099C] *This is an amended version of the original report delivered July 15, 2025. Unsubstantiated [Continuation of LIC 9099] An interview with the Residential Service Director (RSD) disclosed they notified R1’s Power of Attorney (POA) that R1 was displaying increased behaviors, subsequently R1 was taken to a Physician for a reassessment. Based on the reassessment signed and dated April 01, 2025, revealed R1 was prescribed additional medications, and was unable to self medicate, subsequently facility staff determined R1 required a higher level of care. An interview with Outside Source1 (OS1) revealed that the facility had always provided medication management to R1 since they moved in and there was no difference in care being provided to support the increase in price. The interview with OS1 also revealed not being notified regarding the reassessment and increase in level of care due to medication management and OS1 believed R1 was able to self medicate with their assistance. In addition, OS1 disclosed R1 had an outside agency come to the facility daily to provide R1 assistance. However, the RSD disclosed and a record review corroborated, it was OS1 that took R1 to be reassessed, and it was determined by the reassessment that R1's increase in behaviors required an increase in a number of medications which required additional staff time, and a higher level of care was appropriate to meet R1’s needs. An additional record review, dated April 25, 2025, revealed that OS1 had R1 reassessed again by their PCP and was deemed able to self medicate. Subsequently an additional report (issued by the same physician that declared R1 able to self medicate on April 25, 2025, as previously mentioned) that was signed and dated on June 17, 2025, to the contrary of their initial report, revealed R1 was not able to self medicate and their POA would not provide assistance. Based on record reviews and interviews with facility staff and outside sources the above-mentioned allegation was determined to be Unsubstantiated. An Unsubstantiated finding means the preponderance of evidence to prove the violation occurred was not met. An exit interview was conducted with E.D. Guillen, to whom a copy of this report, and Licensee Rights (LIC 9058), will be provided. The signature below confirms receipt of the reports *This is an amended version of the original report delivered July 15, 2025.the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 08-AS-20250423125647

Allegation investigated: Staff did not prevent financial abuse of resident.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude a complaint investigation and render findings. LPA Correia was greeted by Executive Director Guillen, identified herself, stated the purpose of the visit. The Department’s investigation included staff interviews, facility and resident records reviews, and facility tour. On February 10, 2025, the Department received a complaint that alleged the Licensee did not prevent financial abuse of a resident in care. It was alleged Resident1 (R1) was financially abused by Resident2 (R2) who was allegedly R1’s roommate. R1 revealed they felt the roommate was trying to kill them by feeding them sweets that R1 was not supposed to eat due to their Diabetes for financial gain. A review of R1’s facility records revealed they were admitted to the facility on June 9, 2023, with a primary diagnosis of Diabetes and Hyperlipidemia. R1’s records also revealed they were diagnosed with a mood disorder. R1’s facility records revealed at the time of admission R1 was independent and did not require assistance with Activities of Daily Living skills (ADLs). [Continued on LIC 9099C] *This is an amended version of the original report delivered on July 15, 2025. Unsubstantiated [Continuation of LIC 9099] An additional review of R1’s records revealed they had been sent to the hospital on several occasions for behavioral issues including suicidal thoughts. R1’s facility records dated October 8, 2024, revealed they underwent a reassessment that showed R1 required moderate interventions, redirection, and status checks. On October 8, 2024, the reassessment added status checks to their care plan. An interview conducted with the Residential Service Director (RSD) on July 11, 2023, revealed R1 had severe mental health issues, never had a roommate, and everyone at the facility had private rooms unless they were a couple. The RSD also revealed that R1 was fixated on their roommate (referred to as R2) from their previous placement who R1 believed was trying to kill them by feeding them sweets (R1 is Diabetic) after R1 had put R2 in their (R1's) trust. A review of facility records corroborated the RSD’s statement regarding R1 having a private room. An interview with the Executive Director (ED) and a facility tour corroborated the information provided by the RSD. Based on staff interviews and facility and resident records reviews the allegation was determined to be UNSUBSTANTIATED, an unsubstantiated finding means there was not a preponderance of evidence to prove the violation occurred. An exit interview was conducted with the ED and a copy of the report and Licensee Rights (LIC 9058) were provided. Signature below confirms receipt of the reports. *This is an amended version of the original report delivered on July 15, 2025.the state’s words, verbatim · CDSS document, Jul 14, 2025 · control 08-AS-20250210162803

Allegation investigated: Licensee changed resident’s room without their consent. Licensee did not allow resident to use their own transportation provider.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude a complaint investigation. LPA Correia was greeted by Concierge Debra Kramer identified herself, stated the purpose of the visit, and met with Executive Director (ED) Guillen. The Department’s investigation included staff and resident interviews, and resident and outside source records reviews. It was alleged that facility staff transferred a resident to a different room at the facility without consent. On February 14, 2025, the Department received a complaint that alleged when Resident1 (R1) returned from a hospital stay found all their belongings had been transferred to a different room. An interview with R1 revealed they sustained a fall on June 22, 2024, resulting in a knee injury and hospital stay and upon return to the facility on approximately September 19, 2024, found staff had relocated all their belongings to a different room without their knowledge or consent. [Continued on LIC 9099C] *This is an ammended version of the original report date July 11, 2025. Unsubstantiated [Continuation from LIC 9099] Further review of facility records revealed between June 4, 2024, and June 25, 2024, there were several emails between R1 and Facility Management regarding issues R1 had with their current room, and they wanted to change rooms. On June 18, 2024, prior to the fall, R1 had sent an email stating their wheelchair broke and they were unable to walk due to a wound on the bottom of their foot, and they were told not to apply pressure on their foot to avoid an infection. R1’s email indicated a request to move to assisted living and paying for assisted living would not be a problem. Records and interviews revealed R1 was relocated to room 17F that is in a unit where more care is provided. On June 24, 2024, during the move, R1 sent an additional email notifying that they tested positive for COVID-19, and the fall they sustained on June 22, 2024, did not result in a fracture of their knee, but it was still very painful and required a brace. R1 requested staff to allow a close friend to enter both their apartments including 17F (Assisted Living) and unit 7b (Independent Living) to retrieve some of their belongings, while recovering in a Skilled Nursing Facility (SNF). Additionally, R1’s facility records revealed they signed and dated a contract at their time of admission on April 29, 2024. The contract included a clause regarding substitute apartments that states in the event a change of room is required for the safety of the residents directly related to state regulation and/or liability risk we may substitute your apartment to another to comply with any law or lawful order authorized of any authorized public official, or for any other reasonable purpose, as determined by us. We will make reasonable accommodation with respect to your preferences concerning your apartment. We will provide you with thirty (30) days’ written notice before substituting your apartment, unless you agree with the request, it is required to fill a vacant bed, or it is necessary due to an emergency. A facility record review dated June 18, 2024, revealed R1 resided in room 17F. However, on September 03, 2024, facility records revealed R1’s room was labeled O/C, and a review of the same facility record type dated September 30, 2024, disclosed R1’s room number was 17L and a new resident (R2) resided in 17F. An interview with the ED revealed R1 had given a verbal agreement to move their room while they were in the SNF. An email sent by R1, dated November 14, 2024, revealed R1 acknowledged being notified by the ED about the change in room while in the hospital, however stated they were not feeling well and could not remember at the time they had agreed at the time the complaint was filed. [Continued on LIC 9099C] *This is an amended versions of the original complaint delivered on July 11, 2025. [Continuation of LIC 9099C] It was also alleged that the Staff Management required R1 to take their contracted transportation agency and was told they were not permitted to use their own. An interview with ED disclosed that was a false statement and the facility has transportation available for residents in care if needed but they don’t have to use it. A facility record review revealed transportation (without an escort) is made available for specific activities but there is nothing in the contract that binds a resident to use the facility's transportation service. Interviews conducted with residents in care revealed staff had never required them to use the facility’s transportation services. Interview conducted with residents in care revealed staff had never required them to use the facility’s transportation services. Based on staff interviews and facility and resident records reviews the allegation was determined to be UNSUBSTANTIATED, an unsubstantiated finding means there was not a preponderance of evidence to prove the violation occurred. An exit interview was conducted with the ED and a copy of the report and Licensee Rights (LIC 9058) were provided. The signature below confirms receipt of the reports. *This is an amended version of the original report delivered on July 11, 2025.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 08-AS-20250214162151

Allegation investigated: Staff are not assisting resident with obtaining medical care

Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to deliver findings regarding the allegation mentioned above. LPA was allowed entry. LPA identified herself and disclosed the purpose of the visit and elements of the complaint to the Administrator. It was alleged that staff are not assisting Resident 1 (R1) with obtaining necessary medical care. The investigation consisted of a tour of the facility and collecting resident records, and interviews with the Administrator, resident, and observations. The Administrator stated that the facility has a longstanding policy limiting transportation services to a 10-mile radius. While R1 was aware of this policy, the facility had previously made exceptions to accommodate R1’s medical needs by providing transportation to Kaiser in Kearney, which exceeded the 10-mile limit. Continued on 9099C Unsubstantiated Due to an increase in transportation demands from other residents, the facility determined it could no longer continue making exceptions without affecting timely service for others. As a result, the 10-mile transportation policy was reinstated without exception. LPA observed Resident 1 (R1), who resides on the independent living side of the facility. R1 independently opened the door for the LPA and was observed speaking on the phone with Kaiser, on hold while attempting to schedule transportation for an upcoming medical visit. R1 appeared alert and oriented and demonstrated the ability to schedule their appointments and coordinate care. Records and interviews confirmed that staff continued to assist R1 within policy guidelines, and the facility’s driver accommodated R1's documented medical condition by allowing restroom stops during transport and confirmed 10 mile radius for doctors' appointments. R1 also confirmed receiving prior transportation assistance and acknowledged awareness of the policy. Based on interviews, records review, and observation, the allegation is unsubstantiated. Therefore, there is insufficient evidence to support the allegation that staff failed to assist R1 in obtaining medical care. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with the Administrator. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrator, and his signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 08-AS-20250225144112

Allegation investigated: Facility did not provide a higer level of care for resident.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude a complaint investigation and render findings. LPA Correia was greeted by Concierge Debra Kramer, identified herself, stated the purpose of the visit, and met with Executive Director (ED) Adrian Guillen and Resident Service Director (RSD) Monica Maldonado. The Department’s investigation included staff and outside source interviews and resident and outside source records reviews. It was alleged the facility did not provide a higher level of care for Resident1 (R1). A review of resident records revealed R1 was admitted to the facility on January 16, 2016, at the time of admission records showed R1 was independent with all Activities of Daily Living skills (ADLs) and moved into the independent unit of the facility. Review of records dated 2020, revealed R1 was still determined independent and required no assistance with ADLs. On December 10, 2024, a facility records revealed R1 notified facility staff they were having dizzy spells and the facility activated 911. [Continued on LIC9099C] Unsubstantiated [Continuation of LIC 9099] A staff interview and facility record review also revealed R1’s companion notified the facility that R1 had sustained a fall during an outing on that same day, December 10, 2024. A review of Outside Source1 (OS1) records dated December 11, 2024, disclosed R1’s fall resulted in a Traumatic Subdural Hematoma causing a significant change in condition. Upon discharge from the hospital and return to the community on December 11, 2024, R1 started to receive services from an outside agency. An additional interview conducted with Outside Source2 (OS2) corroborated R1 received services from an outside agency from 1:00pm to 5:00pm every day and is in process of obtaining additional services for R1. Interviews and record reviews revealed on March 28, 2025, facility management and R1’s Responsible Parties (RPs) met regarding R1’s need for a higher level of care, including medication management and fall prevention. Facility record reviews also confirmed facility Management is actively trying reach out to R1’s Primary Care Physician (PCP) for an updated Physician’s Report, and trying to work with R1’s RP to ensure R1 is receiving the proper level of care. Based on record reviews and interviews with facility staff and outside sources the above-mentioned allegation was determined to be Unsubstantiated. An Unsubstantiated finding means the preponderance of evidence to prove the violation occurred was not met. An exit interview was conducted with E.D. Guillen, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided. Signature below confirms receipt of the reports.the state’s words, verbatim · CDSS document, Jun 19, 2025 · control 08-AS-20250612162956

Allegation investigated: Staff did not ensure that facility is delivering hot water.

Licensing Program Analyst (LPA) Correia conducted an unannounced visit to deliver the investigative finding regarding the above-mentioned allegation. LPA was met by the front Receptionist Hubbard, identified herself, and was granted entry into the facility. LPA then met with Executive Director (ED) Guillen, who was explained the purpose of the visit. The Department's investigation consisted of staff and resident interviews and a facility tour. On September 6, 2024, the Department received a complaint that alleged the faucets in the women’s restroom sinks located in the facility’s auditorium, which was temporarily used as the dining area for residents in care, were not supplying hot water. An interview with the ED revealed that the facility was building a new memory care unit that resulted in a temporary relocation of the residents' dining area. Interviews conducted with residents in care did not have knowledge of the faucets without hot water in the women’s auditorium restroom. However, during LPA’s facility tour, accompanied by the ED, it was corroborated that the women’s restroom faucets in the auditorium were not producing hot water. Substantiated Once the violation was confirmed, the ED contacted the on-site Director of Maintenance (DOM) who came, diagnosed, and fixed the problem during LPA’s visit. The ED and DOM both revealed they were unaware that the valve to the hot water in the women’s restroom had been turned off, and both felt it was most likely due to construction workers forgetting to turn the hot water back on when they finished working. Based on a facility tour and staff interviews, the allegation was determined to be Substantiated. A Substantiated finding means the preponderance of evidence has been met. Deficiency is cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on the LIC 9099-D. An exit interview was conducted with ED Guillen, and he was informed that a copy of the reports will be provided at the conclusion of the visit. Signature below confirms receipt of the reports. Regarding the facility toilet, an interview conducted with the Executive Director (ED) revealed the facility had on-site maintenance to address any issues, such as disrepair, as they arise. Interviews conducted with the Director of Maintenance (DOM) and residents in care corroborated the facility is kept in good repair by timely on site maintenance. An interview conducted with Staff 1 (S1) regarding the complaint allegations revealed they had worked at the facility for approximately 1.5 years. The Assisted Living (AL) unit of the facility had its own dining area, where the interview took place, however the food is delivered from the same kitchen. S1 has not had any complaints regarding dust in meals or contaminated food by the residents. An interview conducted with Resident 1 (R1) had lived at the facility for approximately one year. R1 revealed they never experienced any issues with the meals served at the facility. LPA asked specifically if they had dust in their food/meals due to the current renovations occurring at the facility, R1 replied "no". LPA also inquired about the facility communal bathroom in the auditorium R1 said they had never used it but reported not having any issues with the facility amenities/appliances in general. R1 reported they were very happy with the facility and the facility staff. Additionally, an interview conducted with Resident 2 (R2) revealed they had lived at the facility for approximately 7 years. R2 stated they have never encountered dust particles in their meals or issues with the food at the facility. R2 revealed that the facility is always very clean, they had not observed any disrepair or uncleanliness. R2 also stated the staff bend over backwards to help the residents. Their only complaint was that the construction was taking a little longer than they expected. R3 lived in the independent living building at the facility. LPA observed R3's room to have a layout as a large open apartment, including a living room area, bedroom, kitchenette, and bathroom. LPA observed R3's room to be well kempt and sanitary. R3 reported no issues with the cleanliness of their room or the facility's communal rooms or facility grounds. LPA checked R3's toilet, and it was functional with no issues. Based on the interviews conducted and observations, the above listed allegations were determined to be Unsubstantiated, as the preponderance of evidence standard was not met. An exit interview was conducted with ED Guillen who was informed that a copy of the reports will be provided at the conclusion of the visit. Signature below confirms receipt of the reports.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 08-AS-20240906100527

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(6) · Plan of correction due date: Mar 12, 2025

Maintenance and Operation(e)Water supplies and plumbing fixtures shall be maintained as follows (6)...hand washing...facilities shall be maintained in operating condition. ...equipment shall be provided in facilities accommodating...based on the residents' needs. This requirement was not met as evidenced by: The facilities faucet used for hand washing were not providing hot water. This posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Mar 12, 2025

Plan of correction: Facility staff fixed the faucets during the LPAs initial visit on 9/6/2024. Deficiency is cleared.

Allegation investigated: Staff do not ensure that the facility is maintained in good repair. Staff do not ensure that facility is maintained at a comfortable temperature for residents. Staff do not ensure that facility is maintained sanitary.

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced subsequent complaint visit regarding the above-mentioned allegations. LPA was met by, identified herself to, and discussed the purpose of the visit with Director Adrian Guillen. Concierge Kathryn Hubbard later joined the visit to sign documents. The Department's investigation consisted of record review, interviews with facility staff and residents, and included LPA observations. It was alleged that the facility is not maintained in good repair. During LPA tour of lounge restrooms it was demonstrated the toilets were not working. Resident and staff interviews confirmed that the toilets were not working. Staff indicated that the bathroom had new plumbing but a piece of metal was lodged in the plumbing pipes and backing up water for the last three months so the bathrooms were closed. Substantiated The electric sliding glass doors on the south and north entrances to the lounge and dining rooms were not in operating condition. Facility staff and LPA entered the building by staff manually pulling the north door open. Staff said the electricity to the door was not working. Staff interviews indicated that the building is open from 7:00am - 6:30pm. LPA observed brown stains in the white ceiling panels in the south dining area. Resident interviews asserted that there were leaks in the ceiling over the past year when it rained. On a subsequent LPA visit, three buckets were observed placed on the floor in the south dining area. LPA noted water in the buckets and drops coming from the ceiling. The ceiling panels were opened up above these areas and the pipes were exposed. Furthermore, LPA observation and resident interviews showed the central overhead light in the auditorium did not work. A tour of the auditorium bathrooms also showed a loose toilet seat and a stall door that could not be locked. LPA observed that the sink faucet in lounge/dining area and auditorium restrooms do not produce hot water. It was also alleged that the facility is not maintained at a comfortable temperature for residents. At the time of the visit, a working thermostat was not present in the south dining room or lounge area. LPA experienced the areas to be cold and not at a comfortable temperature. Residents doing an activity in the lounge were dressed in jackets and blankets were on resident shoulders. Resident interviews stated the area was cold. Staff interviews stated a new HVAC system needs to be installed but it would be a month before it was completed. Furthermore, LPA observed four residents playing cards in the auditorium and the room was not at a comfortable temperature. The thermostat showed the temperature to be 60 degrees. Resident interviews confirmed that the temperature of the room was cold for them. It was alleged that the facility is not maintained sanitary. LPA observed brown water and dirt around the lounge area restroom toilets and around the drain in the restroom. Bathroom surfaces were covered with a layer of powder material. LPA also observed food crumbs on the floor of the south dining area and dirt on the auditorium floor. The Department has investigated the above-mentioned allegations and has found that based upon LPA observations and interviews, a preponderance of evidence exists to support the allegations. Therefore, these allegations are deemed substantiated. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Concierge Kathryn Hubbard, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Mar 10, 2025 · control 08-AS-20241220150424

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 31, 2025

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 premployees and visitors. The procedures for the safety and well-being of residents, equirement was not met as evidenced by: Based on LPA observations and interviews, the licensee did not maintain facility ceiling, bathrooms, and sliding doors in good repair. This posed a potential risk to 111 of 111 residents in care.the state’s words, verbatim · CDSS document, Mar 10, 2025

Plan of correction: Licensee stated the HVAC system, restroom plumbing, and entry/exit sliding glass doors are repaired. Licensee will repair ceiling's plumbing by the POC date of 04/09/2025. Licensee to send receipts of repairs and photos of the ceiling repair. residents in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b)(1) · Plan of correction due date: Mar 31, 2025

MAINTENANCE AND OPERATION (b)(1) The facility shall heat rooms that residents occupy to a minimum of 68 degrees F. This requirement was not met as evidenced by: Based on LPA observations and interviews, licensee did not maintain a comfortable temperature when the facility common areas were observed at 60 degrees F. This posed a potential health risk to 111 of 111 residents in care.the state’s words, verbatim · CDSS document, Mar 10, 2025

Plan of correction: Licensee confirmed the lounge/dining HVAC is repaired. Licensee to set auditorium/lounge thermostat at at least 68 degrees, one hour before resident activities. Licensee to send photo of sign at thermostats asking residents to call staff to set temperature by 04/09/2025. .

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Mar 31, 2025

MAINTENANCE AND OPERATION Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary and odorless condition. This requirement was not met as evidenced by: Based on LPA observations and interviews, the licensee did not ensure facility floors were maintained in a clean, sanitary condition. This posed a potential safety risk to 111 of 111 residents in care.the state’s words, verbatim · CDSS document, Mar 10, 2025

Plan of correction: Licensee will retrain staff to clean dining area floors after meals by sweeping and mopping floors. Licensee to assign staff to do scheduled cleanings of auditorium. A signed training log with class description, staff name and signature is due by POC date 04/09/2025 for each area.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Correia made an unannounced visit to the facility to conduct a case management- annual continuation visit to continue the annual inspection commenced on January 25, 2025. LPA identified herself and was granted entry into the facility by Executive Director Guillen to whom she disclosed the purpose of the visit. During today’s visit, LPA conducted a continuation of resident and facility records reviews. Based on today's continuation of the inspection, no deficiencies are being cited at this time. An exit interview was conducted, and this report was discussed with ED Guillen who was advise a copy of the report and Licensee Appeal Rights will be provided after the conclusion of the visit, and signature on this form acknowledges receipt of the rights and a copy of the report.the state’s words, verbatim · CDSS document, Feb 18, 2025

Allegation investigated: Facility wrongfully evicted a resident. Licensee did not provide a refund. Staff did not report an injury to a resident’s responsible party.

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced follow up complaint investigation visit, and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Adrian Guillen. Throughout the investigation, the Department secured records and conducted interviews with external and internal sources. It was alleged the facility wrongfully evicted a resident. It was reported to the Department the facility forced Resident # 1(R1)’s family and responsible party to move R1. The facility allegedly assessed R1, determined the level of care had increased, and notified the responsible party fees would be increased. The facility allegedly refused to discuss a care plan with R1’s family and R1’s hospice agency. (See LIC 9099C for continuation of report.) Unsubstantiated Interviews with staff revealed R1 would become aggressive and often would hit and bite staff. Staff consistently mentioned R1 had these behaviors since R1’s admission to assisted living. Interviews with the facility’s Resident Service Director (RSD) and Executive Director (ED) confirmed R1 was re-assessed and a change of level of care was determined. R1's decline had progressed and aggressive behaviors had increased in frequency and severity. R1 would hit, bite and not allow staff to provide assistance, or care. The ED and RSD notified R1’s responsible party of this change and advised the monthly fees would be increased. The ED reported the responsible party disclosed the responsible party would not be able to pay the new monthly fees. The responsible party agreed to move R1 to new facility and did so within a few days, before the new monthly fees were charged. An eviction was not discussed as the resident moved out. An interview with an outside source revealed R1’s family member had vented about having to find a new placement for R1. This source did not have any reports noting the facility had pressured R1’s responsible party to move R1. The LPA attempted several contacts with R1’s responsible party, but these were unsuccessful. Based on the investigation, there was not enough evidence to determine the facility wrongfully evicted R1, therefore, the allegation was unsubstantiated. It was alleged the licensee did not provide a refund. It was reported to the Department a refund was provided to R1’s responsible party, but this amount was inaccurate. The LPA reviewed facility records, including R1’s admission agreement, face sheet, refund form and ledger. R1 was admitted to the facility on January 10th, 2022 and moved out May 18th, 2024. R1 paid four thousand five hundred dollars ($4,500) for the month of May. R1 was assessed a late fee of two hundred fifty dollars ($250), and a refund for one thousand six hundred eighty-seven dollars ($1687) was provided. This amount matched the amount provided to the LPA by the reporting party. The LPA attempted to contact R1’s responsible party on several occasions to confirm monthly fees, late fees, and the amount of refund, but these attempts were unsuccessful. The allegation was unsubstantiated. (See the additional LIC 9099C for continuation of report.) It was alleged staff did not report an injury to a resident’s responsible party. In was reported to the Department R1 sustained a bruise on R1’s forehead. That R1’s responsible party was notified of this bruise during a visit to the facility on R1’s birthday. Interviews with staff revealed it was the facility’s protocol to notify physicians, and the residents’ responsible parties when injuries or bruises were sustained. R1 was on hospice, bedridden and bruises were common, as R1 may bump arms against bedrails. These staff members did not recall ever witnessing any bruises on R1’s forehead. Review of narrative charting notes obtained from the facility revealed Staff #1 (S1) noted a bruise on R1’s forehead on the morning of February 28th, 2024, R1’s birthday. S1 also noted a nurse was notified of the bruise. When interviewed, S1 confirmed it was the facility’s protocol to provide first aid as needed, notify physicians, and responsible parties. S1 was not able to recall the incident in question, therefore, S1 was not able to recall who was notified on that date. An interview with R1’s hospice service provider did not reveal any information corroborating R1’s responsible party was not notified of such bruise. The LPA attempted multiple contacts with R1's responsible party, but these attempts were unsuccessful. There was not enough evidence to determine R1’s responsible party was not notified; therefore, the allegation was unsubstantiated. An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report, and License Rights (LIC 9058), were provided via email. An email read receipt confirms the documents were received by the ED.the state’s words, verbatim · CDSS document, Feb 13, 2025 · control 08-AS-20240626104728

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Correia was greeted by the front lobby Receptionist Debra Kramer, Identified herself and met Executive Director (ED) Guillen and explained the purpose of the visit. This facility serves two hundred and nineteen (219) residents 60 and above; 33 who may be non-ambulatory, and eight (8) who can be receiving Hospice services and/or bedridden. LPA conducted a resident and facility records review. Staff records review verified that all staff records were complete and compliant. Resident records were reviewed and confirmed compliant.The ED Certification was up to date and the facility's liability policy was current, At this time, due to time constraints the annual inspection will be completed at a later date. An exit interview was conducted with ED Guillen, to whom copies of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. Their signature on this form acknowledges receipt and a copy of the report was given to ED Guillen after the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 31, 2025

Allegation investigated: Licensee did not ensure facility grounds were free of pest Staff spoke to resident in an inappropriate manner

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Adrian Guillen. On September 12, 2024, Community Care Licensing (CCL) received a complaint alleging licensee did not ensure facility grounds were free of pest and Staff 1 (S1) spoke to Resident 1 (R1) in an inappropriate manner. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to allegation, there have been spiders, cockroaches and flees observed at the facility. Interview with Executive Director revealed that facility has a contract with a pest control company and have regular visits. Interview with staff present corroborated that a pest control company is present periodically. Unsubstantiated Interview with residents did not reveal any information to prove the facility is not acting timely in pest control issues. Records reviewed confirmed facility has a contract in place with a pest control company. It was also alleged that S1 made a comment to R1 that made R1 feel uncomfortable. Interview with S1 revealed that S1 did not make such statement. Interview with R1 revealed that there were no present witnessed to confirm incident. Interview with outside source could not confirm the incident occurred. Based on LPA's interviews, record reviews and inconsistent statements there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Continued from LIC9099-A Interview with staff also revealed that there are twelve current resident units that have appliances that are not working but such rooms are issued with “as-is” terms. Based on interviews, a preponderance of evidence exists to support the allegations. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.the state’s words, verbatim · CDSS document, Oct 10, 2024 · control 08-AS-20240912085819

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 24, 2024

Maintenance and Operation (a) the facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not me in evidence in: Based on observations and interviews the licensee did not maintain appliances in good repair in 12 out of 115 persons in care posed a potential Safety and Personal Rights risk to persons in carethe state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Licensee agrees to provide proof of contract agreement to furnish working kitchenettes by POC date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management Visit to cite a deficiency which was identified during a separate complaint investigation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Adrian Guillen. During a complaint investigation LPA Strong reviewed Resident 1's (R1) Admissions Agreement and found that that the admissions agreement contains a written agreement to waive facility responsibility of the in regards to safety and healthful equipment and accommodations. According to the agreement "Unless the Resident notifies the Community in writing of any alleged defect in the Apartment prior to the commencement of the Term, the Resident shall be deemed to have accepted the Apartment in an 'as-is' condition.....The Community reserved the right to inspect all electrical equipment and appliances for safety and to forbid their use in the Community should they be determined to be hazardous". Based on records reviewed a deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). An exit interview was conducted with Executive Director Adrian Guillen. A copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to her during today’s visit.the state’s words, verbatim · CDSS document, Oct 10, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(h)(2) · Plan of correction due date: Nov 7, 2024

Admission Agreements- The admission aggreement shall not contain the (2) Written agreements to waive facility responsibility or liability for the health, safety or the personal property of residents, or the provision of safe and healthful facilities, equipment and accommodations. Based on records reviewed the licensee included language in the admissions agreement that threatens the residents healful accomodations in one of 115 residents in care which posed a Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Licensee agrees to create an addendum to admissions agreement and provide proof to LPA by POC.

Allegation investigated: Licensee did not comply with the admission agreement

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Adrian Guillen. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the Licensee did not comply with the admission agreement, specific to laundry services. Review of a random sampling of residents’ admission agreements revealed that sometime between 2021 and 2022, the facility began using a different version of their admission agreement. Admission agreements signed prior to the change indicated that the facility provided personal laundry services for a fee and made washing and drying machines available for resident use. Review of the facility’s rate list as of 2021, revealed that the facility did not have a monetary charge for additional personal laundry loads. Continued on LIC9099-C page... Substantiated Review of the admission agreements signed after the change included the statement that the facility provided weekly laundering of linens and towels and that personal laundry was available at an additional charge. Review of the facility’s rate list as of 2023 revealed that the facility did not have a description of personal laundry service listed and additionally, did not have a monetary charge for additional personal laundry. Interviews with residents, staff, and outside sources and review of the written notice revealed that on December 20th, 2023, the facility sent out a written notice to all residents stating that starting on March 1st, 2024, the facility would begin charging for the laundering of resident’s personal clothing items. The notice stated that 1 load of residents’ personal laundry washed per week would be charged at $100 a month, and two loads of laundry per week would be charged at $200 per month. The written notice specifically stated that bed linens would continue to be provided in the standard housekeeping service but that daily trash pickup and bed-making would no longer be provided. Review of the notice revealed that there was no portion of the written notice for residents to sign or any language stating that the notice was considered an amendment to the admission agreement. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. An exit interview was conducted with Executive Director Adrian Guillen, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, May 6, 2024 · control 08-AS-20240228112500

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(F) · Plan of correction due date: May 17, 2024

87307 Personal Accommodations and Services (a)(3) …if the resident is unable or chooses not to provide them, the licensee shall assure the provision of: (F) Basic laundry service (washing, drying, and ironing of personal clothing). This requirement has not been met as evidenced by: Based on interviews and records review, the licensee did not ensure that residents were provided with personal clothing laundry as part of the basic services. This poses a potential personal rights risk to 115 of 115 residents in care.the state’s words, verbatim · CDSS document, May 6, 2024

Plan of correction: Per Executive Director, no residents have been charged for the washing of personal laundry as of 5/6/2024. Executive Director will contact Corporate to gain approval to send a notice via mail to all residents stating that personal clothing will be included in the basic laundry service. Executive Director will provide the Department with a copy of the notice by POC due date of 5/17/2024.

Allegation investigated: Unlawful eviction. Staff did not provide medical attention for resident. Staff did not treat resident with dignity.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude an investigation regarding the above-mentioned allegation. LPA was greeted by the Receptionist, Andrea Maldonado-Odgers, identified herself, and met with Executive Director (ED) Guillen and stated the purpose of the visit. The Department's investigation included facility records reviews and staff and outside source interviews. It was alleged facility staff did not seek medical attention to a Resident 1 (R1) in care after sustaining a fall. A facility and resident records review revealed on December 28, 2023, R1 sustained an unwitnessed fall at the facility and upon staff discovering that R1 had sustained a fall they called 911 and R1 was transferred to the hospital. Records also revealed on January 4, 2024, R1 left the hospital against medical advice and returned to the facility. Unfounded It was also alleged facility staff did not treat R1 with dignity. Facility staff, and R1's records revealed staff tried to assist R1 after sustaining a fall however R1 was resistant and cursed at staff. R1 was also resistant to accepting medical care. Resident records also revealed several prior attempts to assist R1 with their health conditions including seeking medical care and hospital admits. Additionally, it was alleged facility staff served R1 an unlawful eviction. In regard to this allegation Community Care Licensing (CCL) unknowingly accepted this allegation when it was previously investigated and the Department rendered findings on January 8, 2024.[See LIC 811 for Confidential Names] Based on records reviews and interviews, and an allegation previously investigated by the Department the above mentioned allegations were determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with ED Guillen was informed they will be provided a copy of this report and Licensee Rights (LIC 9058), whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Mar 15, 2024 · control 08-AS-20240308160149

Allegation investigated: Unlawful eviction Staff not providing assistance resulting in multiple falls

Licensing Program Analyst (LPA), Mark Mandel conducted an unannounced visit to follow-up on a complaint investigation regarding the above-mentioned allegations. LPA was granted entry and met with Resident Services Director, Monica Maldonado. LPA stated the purpose of the visit and discussed the elements of the complaint with Director Maldonado. LPA delivered the investigative findings to Director Maldonado. Today's visit consisted of resident and staff interviews and observing residents in care. On 01/05/2024, the Department received a complaint alleging that facility staff processed an unlawful evicition. The Department's investigation consisted of facility visits, record reviews and interviews with staff, residents and outside sources. A review of records revealed Resident 1 (R1) was admitted to the facility on 06/29/2023 and observations and interviews with staff and R1 revealed R1 still lives at the (Cont. on LIC9099) Unsubstantiated (Cont. from LIC9099) facility and was not given a 30-Day Eviction Notice, rather, R1 was verbally told by Staff 1 (S1) that they were being evicted. S1 stated the the eviction letter is being worked on, but needs the approval of the facility's corporate office. S1 said the main reason R1 was being evicted was for non-compliance with general policies of the facility as detailed in the Residence and Care Agreement, which R1 signed. Specifically, S1 stated that R1's behavior poses a danger to themselves or others at the Community and R1 has been verbally abusive to staff. Records reviewed and staff interviews corroborate R1's non-compliance with facility policies. Additionally, a review of medical records also reveal a history of non-compliant behavior. S1 added that R1 has also exhibited a change in condition since first being admitted to the facility. Multiple medical reports also document a recent change in R1's condition when these reports are compared to the Physician's Report completed in June 2023 when R1 was admitted to the facility. The medical records also reveal that R1 did not complete recommended physical and occupational therapy referral programs at rehabilitation and skilled nursing facilities. They also show, along with facility records, that R1 discharged themselves from medical facilities against medical advice. It was also alleged that facility staff was not providing assistance resulting in multiple falls, however, interviews conducted with staff and residents did not support the allegation. Resident 2 (R2) stated staff are very helpful and that she has never seen an occasion where staff did not help someone when they needed it. Resident 3 (R3) also said that he was happy with facility staff and that they provide him the assistance he needs and he has never seen an occasion when staff have not helped a resident who needed it. Staff 3 (S3) said she helps residents when they fall and has never heard that staff do not assist residents when they need help. Moreover, R1 stated they do not need help with anything, except garbage and acknowledged that they don't call staff when they need assistance and don't use an emergency alert device that the facility offers all residents. The availability of an emergency alert device for all residents was confirmed by facility records and Resident 4 (R4), who said he has one that facility staff provided. Also, Staff 2 (S2) stated that (Cont. on LIC9099) Cont from LIC9099) R1 insists that they are independent, which corroborates R1's statement that they, "do not need help with anything." In addition, S1 stated that R1 refused a previous offer from S1 to move into the section of the facility that offers a higher level of care that could meet R1' s needs. Now, however, S1 stated the facility no longer has room for R1 in the section of the facility that could meet the new level of care R1 needs. Moreover, S1 stated R1's non-compliant behavior requires that the eviction process proceed. Based on the interviews conducted and records obtained and reviewed, the allegations that facility staff processed an unlawful eviction and were not providing assistance resulting in multiple falls, are Unsubstantiated, as the preponderance of evidence standard was not met. An exit interview was conducted with Resident Services Director, Monica Maldonado. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to Director Maldonado, and their signature on this report confirms receipt of the report. .the state’s words, verbatim · CDSS document, Feb 9, 2024 · control 08-AS-20240105095151

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers was granted entry into the facility by Executive Director Adrian Guillen, after identifying herself and stating the purpose of the inspection. The facility serves 219 ambulatory elderly residents, age 60 and above, of which 33 may be non-ambulatory and 8 may be bedridden. There is an approved Hospice Waiver for 8 residents. This is a multi-unit complex including bungalow units as well as 2 buildings designated for a higher level of care. LPA was accompanied by Executive Director Guillen, during a tour of the facility, which was conducted inside and out and included a sample of resident units, the dining area, recreation rooms, and food storage areas. There is a fire signal system in place and the carbon monoxide detectors were operational. The last disaster drill was conducted on December 2023. Exterior and interior passageways were free from obstructions. According to executive Director Guillen, there are no weapons and/or ammunition stored on the premises. Pull cords were available in each resident units as well as personal pendants. LPA Rodgers observed functionality of signal system. Resident's room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars, and non skid mats were present in some residents’ showers. Hot water temperature in residents’ bathrooms were compliant. [Continued on 809-C] [Continued on 809] Facility has a two-day supply of perishable and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked room. The medication room is located in the higher level of care buildings and in which the medication carts are located. Medications were labeled and kept in compliance with label instructions. LPAs interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA Rodgers also conducted a review of In-service training procedures. Confidential records were stored in locked areas. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No defiencies were issued at the time of th evisit, however there were advisory notes issued. An exit interview was conducted and a copy of this report,Licensee/Appeal Rights - LIC 9058 (rev. 01/16), and the 9102TA, were provided to the Executive Director Guillen, whose signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jan 12, 2024

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Unqualified staff dispensing medication. Staff pre-poured medications. Staff did not assist with medication as prescribed. Lack of supervision resulted in resident AWOL. Staff did not meet resident(s) incontinence needs. Staff did not meet resident(s) basic needs. Staff did not treat resident(s) with dignity.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Monica Maldonado, Resident Services Director. On 3/9/23 it was alleged that unqualified staff dispensed medication, staff pre-poured medications, staff did not assist with medication as prescribed, lack of supervision resulted in resident AWOL, staff did not meet residents' incontinence needs, staff did not meet residents' basic needs, and staff did not treat residents with dignity. The Department’s investigation consisted of unannounced facility visits, review of relevant records, interviews with facility staff, residents, and outside sources. Regarding the allegation, "Unqualified staff dispensing medication", it was alleged that the Medication Technicians "Med Techs" did not receive the required amount of training hours before assisting residents with medication. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) Staff interview revealed that Med Techs receive the required number of training hours through a combination of pharmacy training, seminars, and hands-on shadowing. No staff interviewed were aware of untrained staff administering medications. Review of facility records did not corroborate the allegation, revealing pharmacy certifications for Med Tech staff. Resident interviews did not corroborate the allegation; residents did not express concern regarding medication administration, stating their medications were given on time and correctly. Outside sources did not respond for interview. Regarding the allegation, "Staff pre-poured medications", it was alleged that Med Techs were instructed to prepare medications in advance, to be administered at a later time and by other staff members. Staff interview revealed that staff prepare medication immediately before administering them. Residents interviewed did not have knowledge regarding the preparation of medications. No records were found to corroborate that the preparation for medication exceeded the guidelines in order to be considered a "pre-pour". Outside sources did not respond for interview. Regarding the allegation, "Staff did not assist with medication as prescribed", it was alleged that staff refused to administer a pro re nata (PRN) medication upon request, and forged medication counts after misplacing medication. Staff interviews did not corroborate the allegation, as no staff advised witnessing or being informed of a Med Tech not providing a PRN when requested. Staff interviews with records corroboration further revealed that the medication in question was not misplaced, but had been turned in to management and disposed of, per requirement. The resident in question (R2) denied the allegation, stating that staff were helpful and provided their medications on time and upon request when needed. Outside sources did not respond for interview. Regarding the allegation, "Lack of supervision resulted in resident AWOL", it was alleged that a resident was found multiple times wandering away from the facility. Staff interview revealed that the facility does not have a memory care unit and staff are not allowed to prevent residents from entering or leaving the facility of their own will. Staff interview further revealed that the resident in question (R3) experienced an acute change in condition and the Licensee updated the resident's care plan; Licensee also maintained contact with their physician and responsible party. R3 was transferred to a different facility that provided a higher level of care. R3 was unable to be interviewed. (Continued on LIC9099-C) (Continued from LIC9099-C) Records review confirmed that the facility does not have a memory care unit and is not approved for delayed egress doors to keep residents from exiting the building. Records review further revealed that the resident was able to leave the facility unassisted, and the Licensee updated the resident's care plan when the change in condition was observed. Outside sources did not respond for interview. Regarding the allegation, "Staff did not meet resident(s) incontinence needs", it was alleged that residents were not assisted with incontinence care per their needs and were declined help upon request. Staff interviews did not corroborate the allegation; staff members interviewed denied observing or being informed of a staff member refusing to change a resident when needed. Residents interviewed did not receive incontinence services, therefore were not able to provide information regarding incontinence care. The resident in question (R4) was not able to be interviewed due to no longer living at the facility. Records review revealed that R4 began experiencing confusion that resulted in them requesting to be changed multiple times per hour and when no incontinence had occurred. Records review further revealed that R4 was assisted when requests for incontinence help were made. Outside sources did not respond for interview. Regarding the allegation, "Staff did not meet resident(s) basic needs", it was alleged that staff were instructed not to assist Independent Living residents, and the main building was not open for service according to the listed hours, resulting in basic needs not being met. Staff interview revealed that caregivers and Med Techs were mostly concentrated in buildings 5 and 17, the Assisted Living buildings, but also helped the Independent Living residents when needed. Resident interviews did not corroborate the allegation, informing that Independent Living residents were able to call for, and receive, assistance when needed. No records reviewed gave supporting evidence of Independent Living residents not receiving help from staff. Outside sources did not respond for interview. Regarding the allegation, "Staff did not treat resident(s) with dignity", it was alleged that staff member(s) yelled at a resident(s), pushed a resident, and threw a towel at a resident. (Continued on LIC9099-C) (Continued from LIC9099-C) Staff interviews were mixed, informing that one of the staff members of concern exhibited impatience with residents when they were overwhelmed, but no staff witnessed or corroborated the specific situations named. Resident interviews did not corroborate the allegation, as residents stated staff treat them well. Two residents named in the allegation were unable to be interviewed. Records review revealed that the facility reported the accusation of staff pushing a resident, but the internal investigation was inconclusive. Outside sources did not respond for interview. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Monica Maldonado, Resident Services Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Dec 26, 2023 · control 08-AS-20230309131053