Montgomery Springs Manor

Type of visit: POC

On this day, July 10, 2026, at 5:10 pm, Licensing Program Analyst (LPA) Delmundo conducted an unannounced Proof of Correction (POC) visit. LPA was granted entry by staff, Melody Tria. LPA called and spoke over the phone with Mirriam Paras, administrator (ADM) and informed the reason for visit. ADM arrived at around 5:50 pm. On 7/02/26, LPA issued a citation for deficiency section # 87202(a)(1) of which the administrator stated she'll have resident (R1) move to their other facility with non-ambulatory fire clearance as plan of correction. However, the POC submitted on 7/03/26 indicated R1 will stay at the facility on the first floor and that there's available bed on the first floor, when on 7/02/26, there was no available bed on the first floor. LPA interviewed R1 who stated and confirmed R1 is now on the first floor. LPA also interviewed ADM who stated there's now a vacancy at the other facility and R1 will move to that facility on July 14, 2026. No deficiency cited during today's visit, however, ADM to submit proof of R1's move-out. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Jul 10, 2026

Type of visit: Case Management - Health Checks

On this day, July 2, 2026, at 1:50 pm, Licensing Program Analyst (LPA) Delmundo conducted case management inspection to ensure the health and safety of residents as a result of the Department receiving a Priority 2 complaint (Complaint Control Number: 15-AS-20260630155242). LPA met with Mirriam Paras, administrator (ADM), and informed the reason for visit. LPA toured the facility with ADM. LPA inspected the living and dining rooms, kitchen, bathrooms and residents' bedrooms on the first and second floors. LPA reviewed resident records. LPA observed and learned about the following: R1 and R2 had an incident. LPA observed R1 with bruises and wounds/lacerations, and when verified, ADM stated she did not submit incident report. R2's Physician's Report indicated R2 has advancing neuro cognitive disorder and non-ambulatory and R2 is in the bedroom not cleared/approved by the fire department for non-ambulatory. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. An immediate $1,000.00 civil penalty is assessed for repeat violation within 12 month of deficiency section 87202(a)(1) and will continue for $100.00/day until corrected. Deficiencies, plan and proof of corrections and civil penalty assessment were discussed with ADM. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty assessment and copy of this report provided.the state’s words, verbatim · CDSS document, Jul 2, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(1) · Plan of correction due date: Jul 3, 2026

87202 Fire Clearance: (a) All facilities shall maintain a fire clearance approved by...... the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by....... ...(1) Nonambulatory persons. -This requirement is not met as evidenced by: -Based on review of records and inspection, the licensee did not comply with the section above in having R1 who is non-ambulatory in the bedroom fire cleared for ambulatory only which poses an immediate safety risk to person in carethe state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Administrator stated she'll have the resident moved to their other facilty with non-ambulatory fire clearance. Proof to be submitted by 7/03/26. A $1,000.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Jul 16, 2026

87211 Reporting Requirements: (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as.... ...required by Welfare and Institutions Code.... -This requirement is not met as evidenced by: -Based on interviews, the licensee did not comply with the section above when R1 and R2 had incident and report not submitted which posed a potential health, safety and/or personal rgihts risks to persons in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Administrator to do the following and submit proof by 7/16/26: 1. Read the Regulations and submit self-certication of understanding and ensure timely reporting. 2. Submit incident report.

Type of visit: Case Management - Deficiencies

While at the facility conducting pre-licensing inspection for change in ownership of this facility and upon review of resident's (R1) record, Licensing Program Analyst (LPA) Delmundo observed the following: -at 12:30 pm, vitamins and razor in the closet in the resident's room. -at 1:30 pm, resident (R1) whose LIC602A Physician's Report indicated major neurocognitive impairment and non-ambulatory is in the bedroom fire cleared for ambulatory only. The above deficiencies were discussed with Mirriam Paras, administrator (ADM). Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $500.00 civil penalties for section # 87202(a)(1) and will continue for $100.00/day until corrected. A $250.00 civil penalty is also assessed for section # 87309(a) for repeat violations within 12 month period and failure to submit proof of correction may result in additional civil penalty. Deficiencies and plan and proof of corrections were discussed with the ADM. Exit interview conducted. Appeal Rights, LIC421IM and LIC421FCs Civil Penalty Assessments, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Jun 18, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(1) · Plan of correction due date: Jun 19, 2026

87202 Fire Clearance: (a) All facilities shall maintain a fire clearance approved by...... the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance ...(1) Nonambulatory persons. -This requirement is not met as evidenced by: -Based on review of records and inspection, the licensee did not comply with the section above in having R1 who is non-ambulatory in the bedroom fire cleared for ambulatory only which poses an immediate safety risk to person in carethe state’s words, verbatim · CDSS document, Jun 18, 2026

Plan of correction: Administrator stated she'll have the resident moved to their other facilty with non-ambulatory fire clearance. Proof to be submitted by 6/19/26, A $500.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Jun 19, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage.... ..and are not left unattended if outside the locked storage. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above in vitamins and razor in the closet in resident's room which pose an immediate health, safety and/or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jun 18, 2026

Plan of correction: Staff removed the items while LPA was at the facility. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 6/19/26. $250.00 civil penalty is assessed.

Type of visit: Required - 1 Year

On this day, March 24, 2026, at 11:20 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Jonalyn Legarto, and informed the reason for visit. LPA called and left message on Mirriam Paras', administrator (ADM), voicemail. ADM arrived at around 12:06 pm. LPA also met with other staff, Charlaine Rose De Leon and Melody Tria. LPA started the inspection with Jonalyn Legarto and continued with ADM. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was locked. Hot water temperature in one of common bathrooms was tested and measured at 117.8 degrees Fahrenheit. Fire extinguishers were observed fully charge with tags showed serviced September 24, 2025. Carbon monoxide and smoke detectors were tested and observed in operating condition during today's visit. Facility only conduct fire drills and records showed conducted January 16, 2025 and February 8, 2026. LPA reviewed 5 residents and 5 staff files and interviewed 1 resident. Residents medications were checked. Facility does not handle residents' cash resources and/or P&I. .....continued on 809C LPA learned that one of the residents (R6) was sent out to the hospital on March 3, 2026 but the facility did not submit incident report. LPA observed the following: -at 11:37 am, unlocked cabinet where peritoneal cleanser are kept. -at 11:40 am, half bed rails of 2 residents have no doctor's order on file. -at 11:45 am, broken drawer knob in residents' room. -at 11:58 am, broken glass window in resident's room; cat's feces, rusted paint pan, paint roller, piece of wood and metal in top stairs leading to the backyard. -at 12:04 pm, Neosporin and muscle rub in resident's room. -at 12:09 pm, unlocked gate leading to storage where cleaning supplies are kept and Clorox bleach in the backyard. -at 12:15 pm, pieces of wood, rusted grills, soiled placemat, empty milk container on the backyard ground. -at 12:17 pm, rubbing alcohol, rust remover and hammer in unlocked basement room. -at 12:30 pm, rusted sink and medications in unlocked refrigerator in area adjacent to the kitchen -at 1:00 pm, two residents' beds with half bed rails but no doctor's order on file. -at 3:00 pm, staff (S2) has no LIC501 Personnel Record on file. -at 3:15 pm, staff (S3), a cook, does not have food preparation training on file -at 3:30 pm, records showed facility does not conduct disaster drills every quarter and only conducted fire drills. -at 4:15 pm, residents' (R1 and R2) LIC602A Physician's Report/medical assessments on file are over a year old. -all 5 residents have no doctor's orders for current medications. .......continued on 809C Administrator to submit updated/current copies of the following by April 7, 2026: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610D Emergency Disaster Plan (9 pages) 4. Proof of $3M Liability Insurance coverage Deficiencies are cited from Title 22 California Code of Regulation, and listed on 809Ds. A $250.00 civil penalties for each of section # 87303(a), 87463(h) for repeat violations within 12 month period and will continue for $100.00/day until corrected. Failure to submit proof of corrections for other deficiencies may also result in civil penalties. Deficiencies and plan and proof of corrections were discussed with the ADM. Exit interview conducted. Appeal Rights, LIC421FCs Civil Penalty Assessments, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 24, 2026

Allegation investigated: -Staff do not provide modified diet to resident. -Staff do not provide appropriate care to the resident.

On this day, August 14, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations and met with staff, Jonalyn Legarto. LPA called and spoke with Mirriam Paras, administrator (ADM), and informed the reason for visit. ADM arrived at around 12:17 pm. LPA reviewed residents's files and obtained copies of the following documents: LIC601 Identification and Emergency Information; Face Sheet; LIC602A Physician's Reports; doctor's order; facility notes. LPA inteviewed staff (S1, S2, S3 and ADM) and residents (R1, R2, R3, R4), and conducted inspection. Allegation: Staff do not provide modified diet to resident. Reporting party (RP) reported that resident (R1) indicated calling R1's social worker and the facility staff has been advised to give R1 soft foods; however, according to R1, R1 is not being fed with food R1 can eat. ....continued on 9099C(page 2) Unsubstantiated Page 2 Review of R1's record showed request to update R1's diet order to reflect R1's preference which the doctor approved. Approved order showed low-fat diet, cut-up texture, thin liquid with special instruction of no milk, apples, nuts and to provide R1 softer food and food preferred by R1 such as tender meat with sauces, soft fruits such as bananas, fruit cups, apple sauce and soft vegetables. LPA observed the meal served for lunch on this day consisted of pasta with ground meat, steamed vegetables and fresh fruit for dessert. LPA observed the dinner prepared by S1 consisted of mash potato, tender chicken with sauce and steamed vegetables. Food supplies were inspected and observed of different varieties which includes apple sauce, fruit cups, canned mixed fruits, fresh bananas and other fresh fruits. Review of other resident's LIC602A showed R2 and R3 with special diet. R2 stated the staff does not give R2 food that is indicated in LIC602A not to be given to R2. R2 stated she can not have food with tomato and tomato sauce and that she is given other meal option when food to be served has tomato and/or tomato sauce. R3 stated she is happy with the food serve. R4 who is not on special diet stated he is given option when the meal is that of R4's preference. R1 stated staff cut the food serve to her to small pieces. All staff interviewed stated R1 is served soft food. S2 and S3 stated R1 is served food cut into pieces. S1 also stated she cuts the food served to R1 except burrito because R1 does like it to be cut. R1 has fruit cups. Based on information obtained, the allegation is unsubstantiated. Allegation: Staff do not provide appropriate care to the resident. RP stated that R1 feels that R1's care needs are neglected by staff. The 2 staff who are providing assistance to R1 denied the allegation and stated that whenever R1 calls for help, they assist. They assist other residents who need assistance. ......continued on 9099C (page 3) Page 3 R1 stated staff assist her with activities of daily living (ADLs) and when she calls for help. Two of the other 3 residents stated the staff assist them whenever they need help while one of these 3 residents stated not needing assistance with ADLs. One of these 3 residents stated not observing staff not providing assistance whenever R1 calls for help. Therefore, the allegation is unsubstantiated. Based on interviews, inspection, observation and records review, the 2 allegations are unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Aug 14, 2025 · control 15-AS-20250808113155

Type of visit: Case Management - Deficiencies

While at the facility investigating a complaint (Control # 15-AS-20250808113155) and upon review of residents' files and interviews, Licensing Program Analyst (LPA) Delmundo learned that resident (R1 and R2) LIC602A Physician's Reports are outdated. R1's LIC602A was dated 1/09/17 and showed R1 able to bathe, dress/groom and feed self and care for own toileting needs; however, R1's condition has changed and is now dependent on the staff on all activities of daily living. R2's LIC602 dated 4/14/24 indicated ambulatory but R2 uses walker to ambulate. Deficiencies are cited from Title 22 California Code of Regulation, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violations within 12 month period may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with the ADM. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Aug 14, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(e) · Plan of correction due date: Aug 28, 2025

87463 Reappraisals (e) The licensee shall immediately, or as soon as reasonably possible, bring any significant change in condition....to the attention of the appropriate licensed medical professional .... -This requirement is not met as evidenced by: -Based on record review, interviews and observation, the licensee did not compy with the section above for not having R1's LIC602A updated when R1's conditions changed which poses a potential health and/or personal rights risks to person in care.the state’s words, verbatim · CDSS document, Aug 14, 2025

Plan of correction: Administrator to have the resident assessed and submit copy of updated LIC602A by 8/28/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87615(a)(5) · Plan of correction due date: Aug 28, 2025

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition.....shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them...... -This requirement is not met as evidenced by --Based on record review, interviews and observation, the licensee did not compy with the section above in retaining R1 who is dependent on all ADLs which poses a potential health and/or personal rights risks to person in care,the state’s words, verbatim · CDSS document, Aug 14, 2025

Plan of correction: Administrator stated she'll submit request for exception. Signed written request with supporting documents to be submitted by 8/28/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(c)(5) · Plan of correction due date: Aug 28, 2025

87458 Medical Assessment: (c) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101, ..The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition, or both.... -This requirement is not met as evidenced by: -Based on record review and observation, the licensee did not comply with the section above in R2's LIC602A not consistent with R2's ambulatory statusthe state’s words, verbatim · CDSS document, Aug 14, 2025

Plan of correction: Administrator to have the LIC602A updated and submit copy by 8/28/25.

Allegation investigated: -Staff does not ensure food is of good quality for residents in care. -Staff allow residents to be left in soiled clothing for extended periods of time. -Staff does not ensure residents receive adequate hydration. -Staff do not ensure resident has personal privacy. -Staff do not ensure residents are provided supervision.

On this day, May 1, 2025, at 11:05 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with staff, Melody Tria, and informed the reason for visit. MIrriam Paras, administrator (ADM) arrived around 11:40 am. LPA inspected the food supplies and obtained copy of LIC9020 Register of Facility Clients/Residents. LPA reviewed residents' files and obtain copies R1's following documents: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; LIC625 Appraisal/Needs and Services Plan. LPA interviewed residents (R1, R2, R3, R4, R5, R6) and staff (S1, S2, S3 and ADM). ....continued on 9099C (page 2) Unsubstantiated Page 2 Allegation: Staff does not ensure food is of good quality for residents in care. All 4 staff interviewed stated residents are never serve hard bread and/or stale food. LPA inspected the food supplies and didn't observed stale and/or expired food. Resident (R1) stated the staff serve bread that is hard and stale. Three out of the 5 other residents stated food serve is good and that staff never serve stale food. Due to medical diagnosis, LPA was not able to obtain information from the other 2 residents. Therefore, the allegation is unsubstantiated. Allegation: Staff allow residents to be left in soiled clothing for extended periods of time. R1 stated staff do not change residents out of their urine filled diapers and will leave them in soiled diapers all day. LPA conducted inspection and did not observed any resident smelling urine or soaking wet. The 3 staff stated they change residents who need assistance in changing diapers at least 3x during their shift. ADM stated residents are changed 9x in 24 hours and as needed. Two out of the 5 other residents can toilet on their own. One of these 5 residents stated wearing diaper but does not need assistance in changing. Due to medical diagnosis, LPA was not able to obtain information from the other 2 residents. Therefore, the allegation is unsubstantiated. Allegation: Staff does not ensure residents receive adequate hydration. R1 stated that the staff do not provide water or other fluids to residents to drink throughout the day except during meal time. All four staff interviewed stated residents are provided water, juice, coffee and/or tea during meals. Water is also provided during snacks time and when medications are administered. Three out of 5 residents stated they are provided water and juice during meals. They also stated they have water containers in their rooms which the staff filled regularly. Due to medical diagnosis, LPA was not able to obtain information from the other 2 residents. Therefore, the allegation is unsubstantiated. Allegation: Staff do not ensure resident has personal privacy. R1 stated that R1's room mate has dementia and wakes up R1 constantly when R1 tries to sleep. .....continued on 9099C (page 3) Page 3 Two of the 4 staff stated when R1 has a visitor, the visitor comes inside R1's room shared with R5. R1 would not want R5 to be inside the room so they keep R5 in the living room. One of these staff stated R1 stays outside the room, however, when R5 is already sleepy, she asks R1 and tell that R5 wants to sleep. Three out the other 5 residents stated staff accord them privacy. Due to medical diagnosis, LPA was not able to obtain information from R5. Therefore, the allegation is unsubstantiated. Allegation: Staff do not ensure residents are provided supervision. R1 stated that another resident grabbed R1's arm hard a month ago and that R1 called the staff but the staff did not come to help. All four staff and 3 out the other 5 residents stated not observing the incident. Due to medical diagnosis, LPA was not able to obtain information from the other 2 residents. Therefore, the allegation is unsubstantiated. Based on interviews, inspection, observation and records review, the 5 allegations are unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided. Page 2 Allegation: Staff do not provide meal substitutions for residents in care. R1 stated that R1 has a hard time eating and cannot eat the meat but the staff do not offer substitute. LPA reviewed R1's file which didn't indicate R1 cannot eat meat. Progress Notes from medical provider dated 9/30/24 showed approved diet order which includes food minced and soft. LPA observed during lunch other residents were served fried chicken, mixed vegetables, potato salad and fresh fruit while R1's was served fish fillet cut into small pieces served with tartar sauce, mixed vegetables, potato salad and fresh fruits. R1 told LPA that the fish fillet were hard; however, when LPA tested in front of R1, the fish fillets were soft. The 4 staff interviewed stated they provide substitute. One of these 4 stated stated that R1 began complaining of not wanting to eat meat about 4, 5 days ago, but R1 ate hamburger 2 days ago. R1 wants R1's food cut into pieces in front of R1, which the staff do. Therefore, the allegation is unfounded. Allegation: Staff does not ensure facility has adequate food supply for residents in care. The 3 staff stated that ADM does food shopping 2x a month which LPA confirmed with ADM. All these 4 staff stated they never run out of food supplies. LPA inspected the food supplies and observed more than adequate. Therefore, the allegation is unfounded. Allegation: Licensee does not ensure staff receive training in CPR. R1 stated the staff are not CPR certified and don't do anything when a resident is choking on food and will only give the residents water. All staff interviewed stated there was no incident of resident choking. LPA has not received incident report from the facility indicating resident(s) choked. The staff interviewed stated that R1 thinks that when R5 coughs, R5 is choking. R5 observed R5 wearing mask and R5 stated she's coughing. During investigation, LPA heard R5 coughing. LPA checked the 5 staff records which showed all of them have current First Aid certificate. Therefore, the allegation is unfounded. Based on interviews, records review, inspection and observation, the 3 allegations are closed as unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, May 1, 2025 · control 15-AS-20250430080657

Type of visit: Case Management - Deficiencies

While at the facility investigating a complaint (Control # 15-AS-20250430080657) and upon reviewing residents' records, Licensing Program Analyst (LPA) Delmundo observed the two residents' (R1 and R2) LIC602A Physician's Reports were over a year old. LIC602As showed they have major neuro cognitive disorder. The above were discussed with MIrriam Paras, administrator. Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty. Deficiency, plan and proof of correction were discussed. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, May 1, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(h) · Plan of correction due date: May 15, 2025

87463 Reappraisals (h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. -This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with section above in R1 and R2's LIC602A more than a year old which pose a potential health and/or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, May 1, 2025

Plan of correction: Administrator agreed to make appointments and submit copies of LIC602A by 5/15/25.

Type of visit: Required - 1 Year

On this day, March 5, 2025, at 12:00 noon, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Charlainerose De Leon, and informed the reason for visit. LPA called and spoke over the phone with Mirriam Paras, administrator (ADM). ADM arrived at around 12:20 pm. LPA also met with other staff, Jonalyn Legarto, Melody Tria and Medelmira 'Mira' Cloma. LPA started the inspection with Charleinerose De Leon and continued with ADM. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was locked. Hot water temperature in common bathroom was tested and measured at 111.9 degrees Fahrenheit. Fire extinguishers were observed fully charge with tags showed serviced 9/03/24. Carbon monoxide and smoke detectors were tested and observed in operating condition during today's visit. Facility conducts disaster drills and records showed last conducted 1/16/25. LPA reviewed 5 residents and 5 staff files and interviewed 1 resident. Residents medications were checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. LPA observed the following: -at 12:09 pm, pocket utility knife in unlocked in the drawer adjacent to the kitchen. -at 12:11 pm, food items in the refrigerator still in the shopping bags and box packaging materials. Sausage links and Bologna in opened plastic packaging material. -at 12:13 pm, rotten mushrooms, Serrano peppers, radish, celery and carrots with mold in another refrigerator. .....continued on 809C (page 2) Page 2 -at 12:27 pm, rusted dirty dining chairs. -at 12:32 pm and 1:02 pm, rusted trash cans on the 1st and 2nd floor bathrooms. -at 12:40 pm, cracked cement in between transition and heavily scratched door post in the common bathroom on the 1st floor. -at 12:45 pm, skin protector in the common bathroom. -at 12:47 pm, razor and skin protector in unlocked closet by the hallway adjacent to the common bathroom. -at 12:49 pm, rusted broken trash can, empty box, heavy stained non-skid mat, box with toilet seat and radio, bag of garbage, hoyer lift and bed with mattress in the ramp leading to the backyard. -at 12:54 pm, broken night stand door and heavily soiled upholstered chair in one of the resident's room. -at 1:00 pm, stained stairs steps' carpet covering. -at 1:02 pm, shower door with mildew and water damaged lavatory with stained faucet in the common bathroom on the 2nd foor. -at 1:15 pm, dusty exit door on the 2nd floor. -at 1:24 pm, worn out dirty and ripped patio chair cushions, rusted shopping cart, broken dishwasher, rusted broken trash can, broken construction cones and equipment boxes with trash in the backyard. -at 1:26 pm, unlocked cleaning supplies storage, construction tool, burnt out light bulbs, pails and gallons of paint in the side yard with unlocked gate. -at 1:29 pm, staff medications in unlocked small refrigerator in the area adjacent to the kitchen. -at 4:30 pm, S4, a cook, does not have food preparation training on file. S4 does not have LIC503 Health Screening Report on file. S3's LIC503 incomplete. -at 5:00 pm, staff, S5,does not have First Aid training. S5's required training for 2024 (first year of employment) incomplete. S3 and S5 do not have restricted health conditions training and have only 2 hours of medication training for 2024. -at 5:30, staff not CPR certified. -at 5:45 pm, resident (R1) has no pre-admission appraisal and LIC9172 Functional Capability Assessment. R1 and R3's bed rails have no doctor's order on file. .....continued on 809C (page 3) Page 3 -at 6:00 pm, residents' (R3, R4 and R5) LIC625 missing 2 pages. R3 and R4's LIC625 not signed. -at 6:40 pm, R5's two medications frequency of administration and date filled were incorrectly recorded on LIC622. Administrator to submit updated/current copies of the following by March 19, 2025: 1. Proof of $3M Liability Insurance coverage 2. Proof of Control of Property/Lease Agreement Deficiencies are cited from Title 22 California Code of Regulation, and listed on 809Ds. A $250.00 civil penalties for each of section # 87309(a), 87303(a), 87608(a)(3) and 87506(a) for repeat violations within 12 month period and will continue for $100.00/day until corrected. Deficiencies and plan and proof of corrections were discussed with the ADM. Exit interview conducted. Appeal Rights, LIC421FCs Civil Penalty Assessments, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 5, 2025

Allegation investigated: -Staff are not ensuring that resident receives their medication(s) as prescribed. -Facility is in disrepair. -Staff not treating resident with respect and dignity.

On this day, 2/14/25, at 11:30 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation, and met with staff, Jonalyn Legarto, and informed the reason for visit. LPA called and spoke over the phone with Mirriam Paras, administrator (ADM), who arrived at around 12:10 pm. LPA reviewed resident's (R1) file and obtained copies of the following: ePrescription; LIC622 Centrally Stored Medication and Destruction Records; Medication Administration Record. LPA conducted inspection with the Jonalyn Legarto and interviewed staff (S1, S2, S3 and ADM), resident (R2) and R1's doctor (PCP1). Allegation: Staff are not ensuring that resident receives their medication(s) as prescribed. On 2/06/25, R1 stated that R1 tested positive of UTI on 1/31/25 and PCP1 prescribed medications but R1 has still not received the medication and staff are not making sure that prescription is picked up. Unsubstantiated Review of records showed facility has copy of ePrescription dated 2/01/25 with antibiotics prescribed 3 times a day for 3 days with out-of-state pharmacy listed and with comments 'deliver by CPN tomorrow'. This document showed received 2/06/25. PCP1 stated that PCP1 prescribed the antibiotics on 1/31/25 and that if the medications need to be delivered immediately, it should be delivered by the local pharmacy. PCP1 stated that it could be pharmacy issue that the medication was not delivered the following day the prescription was written. S1 stated she only came to know about the prescription and was only informed by R1 once. S1 and ADM stated they called the Center for Elder's Independence to follow-up. S1 stated the medication was received on 2/06/25 and started the administration dinner time on 2/06/25. Based on information gathered, the allegation is unsubstantiated. Allegation: Facility is in disrepair. R1 stated that residents have to put their used (soiled) toilet paper in the garbage because they are not allowed to flush the toilet paper in the toilets. R1 also stated that staff tell residents to use the garbage because if they flush the toilet paper the toilets get clogged up. LPA conducted inspection and flushed all the toilets. LPA observed all the toilets draining properly. The 3 staff, ADM and R2 stated the toilet in the big bathroom was not draining properly but did not overflow, and was replaced with a new one recently. Therefore, the allegation is unsubstantiated. Allegation: Staff not treating resident with respect and dignity. R1 stated that when R1 was asking S1 about R1's antibiotics medication, S1 told R1 to shut up. S2 and S3 stated not hearing S1 and denied telling R1 such. R2 stated not hearing S1 or other staff respond to any residents inappropriately. Therefore, the allegation is unsubstantiated. Based on review of records, interviews and inspection, the 3 allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Feb 14, 2025 · control 15-AS-20250206094236

Allegation investigated: Facility is unsanitary.

On this day, 2/14/25, at 11:30 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation, and met with staff, Jonalyn Legarto, and informed the reason for visit. LPA called and spoke over the phone with Mirriam Paras, administrator (ADM), who arrived at around 12:10 pm. LPA conducted inspection with Jonalyn Legarto and observed the following: strong smell of urine in the big bathroom; mouse droppings in the area adjacent to the kitchen; stain and dusty floor in the dining room where the 2 refrigerators are located; dusty air vents. Based on observation, the preponderance of evidence standard is met, therefore, the allegation is substantiated. ....continued on 9099C Substantiated Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. A $250.00 civil penalty is assessed for repeat violation within 12 month of section 87303(a). Failure to submit proof of correction by plan of correction due date may result in additional civil penalty. Deficiency, plan and proof of correction, and civil penalty were discussed with ADM. Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Feb 14, 2025 · control 15-AS-20250207120824

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

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for the following which pose a potential health and/or personal rights risks to persons in care: strong smell of urine in the bathroom; mouse droppings; dusty air vents; stain and dusty floorthe state’s words, verbatim · CDSS document, Feb 14, 2025

Plan of correction: Staff cleaned and removed the mouse droppings. In addition, administrator to do the following and submit proof by 2/28/25: 1. Have the bathrooms cleaned thoroughly. 2. Have all the vents and flooring cleaned properly. A $250.00 civil penalty is assessed for repeat violation. A citation was issued on 9/04/24.

Type of visit: Case Management - Deficiencies

While at the facility investigating a complaint (Control # 15-AS-20250206094236) and upon review of resident's (R1) file, Licensing Program Analyst (LPA) Delmundo observed R1 has prescribed antibiotics medication to be administered 3 times a day for 3 days. The medication was received by the facility on 2/06/25 and administration was started same day; however, the medication was not recorded on LIC622 Centrally Stored Medication and Destruction Record nor administration of this medication recorded on Medication Administration Record (MAR). Staff (S1) stated the medication was received and administered but she didn't record. These were discussed with Mirriam Paras, administrator (ADM). Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty. Deficiency, plan and proof of correction were discussed with ADM. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Feb 14, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Feb 28, 2025

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. -This requirement is not met as evidenced by: -Based on record review and interview, the licensee did not comply with the section above in not completing the record when R1's medication was received and administered which posed a potential personal rights risk to person in care.the state’s words, verbatim · CDSS document, Feb 14, 2025

Plan of correction: Administrator to do the following and submit proof by 2/28/25: 1. Complete the LIC622. 2. In-service the staff.

Allegation investigated: -Staff not treating resident with respect and dignity. -Staff does not respond to resident's request in a timely manner. -Staff does not provide resident a safe environment. -Staff does not provide adequate food service to resident. -Facility failed to maintain a comfortable room temperature.

At 11:05 am, Licensing Program Analysts (LPAs) A. Delmundo and A. Gharachorloo arrived unannounced to investigate the above allegations. LPAs met with Mirriam Paras, administrator (ADM), and informed the reason for visit. During the course of investigation, LPA reviewed residents' records and obtained copies including but not limited to the following: LIC602A Physician's Report; hospital After Visit Summary. LPAs also obtained copies of LIC9020 Register of Facility Clients/Residents and menu. LPAs conducted inspection and interviewed residents (R1, R2, R3, R4, R5, R6, R7, R8), staff (S1, S2, S3, ADM) and witness (W1). Allegation: Staff not treating resident with respect and dignity. Reporting party (RP) stated staff (S1) yelled at R1 when R1 asked for assistance. It was further alleged that staff (S2) laughed at R1 when R1 asked for lighter. ...........continued on 9099C (page 2) Unsubstantiated Page 2 R1 stated S1 yelled at R1 when R1 asked for help. R1 also stated when she asked S2 for lighter because her lighter is broken, S2 did not provide and instead laughed at her. Both S1 and S2 denied the allegation. W1 stated he was at the facility when the incident happened and it was R1 who yelled at the staff. Five out of 8 residents interviewed stated not observing staff yelled nor dis-respected R1. One out of the 8 residents stated hearing S1 screamed back when R1 screamed at S1 but does not know what transpired and where it happened. The other resident stated he maybe in his room when the incident about the lighter happened. Due to the medical diagnosis of the other resident, LPA was not able to obtain information. Based on information obtained, there's not enough preponderance of evidence to prove that a violation occurred, therefore the allegation is closed as unsubstantiated. Allegation: Staff does not respond to resident's request in a timely manner. R1 stated when R1 called S1 to help care for her room mate, S1 will not come. R1 also stated when she had something red on her ear and thought it was blood, S1 provided R1 a napkin to blot her ear. S1 did not call 9-1-1 and R1 called 9-1-1 herself. R1 stated it was not blood but a piece of red plastic of unknown origin. S1 stated she attended to R1 when R1 called her about the blood in R1's ear. S1 stated she checked R1's ear and observed a red dot on the middle outside part of R1's left ear and it's not blood so she gave R1 a napkin but R1 scolded her and called 9-1-1 herself. ADM stated the incident was reported to her by S1. All staff interviewed stated R1 does not provide care to R1. One of the resident (R6) stated he does not think R1 takes care of R1 and that what R1 thinks of care is down playing others. Due to medical diagnosis, LPA was not able to obtain information from R1's room mate. Based on information obtained, there's not enough preponderance of evidence to prove that a violation occurred, therefore the allegation is closed as unsubstantiated. ....continued on 9099C (page 3) Page 3 Allegation: Staff does not provide resident a safe environment. R1 stated R2 makes R1 feel threatened, R3 does not allow R1 eat with the rest of the residents and staff are not doing anything about it. R1 also stated that she is not allowed to eat in her room. All staff interviewed stated not observing R2 and R3 threaten and prevent R1 from eating with the rest of the residents. All the staff also stated residents are allowed to eat in their room. LPA observed R1 eating in the dining room with other residents. LPA also observed during investigation 2 residents eating in their rooms. LPA was not able to get information from R2 and R3 regarding the allegation. Therefore, the allegation is unsubstantiated. Allegation: Staff does not provide adequate food service to resident. R1 stated S1 would not provide alternative food options and serves certain foods S1 cannot eat. R1 also stated that on 11/19/24, she asked S3 for sandwich because she can not eat meat and S3 did not give her sandwich. S1 stated residents are given substitute if they do not want the food served. S3 stated when R1 asked for sandwich on 11/19/24, she gave R1 peanut butter sandwich and R1 ate the sandwich, pork stroganoff and half of the pasta that was served to R1 that day. Six out of 8 residents interviewed stated there's no issue on the food serve. R4 stated if she does not like the food serve, she is offered substitute. One of the 8 residents stated being serve small servings of salad but didn't ask for seconds. Due to medical diagnosis of one of the resident, LPA was not able to obtain information. LPAs inspected the food supplies which were observed sufficient and different varieties. LPA Delmundo observed staff served dinner which consisted of pasta with ground pork, salad and fita bread which LPA observed R1 ate. Based on information obtained, the preponderance of evidence is not met, therefore, the allegation is unsubstantiated. Allegation: Facility failed to maintain a comfortable room temperature. R1 stated it's cold in her room. LPAs conducted inspection and observed a portable heater in R1's room. LPA Delmundo tested the temperature at R1's room which was measured at 69.8 degrees Fahrenheit. ....continued on 9099C (page 4) Page 4 All staff interviewed stated the facility has centralized heater which LPA Gharachorloo checked with ADM and observed the temperature at 72 degrees Fahrenheit. However, one of the residents stated it's cold. The other 5 residents stated temperature is comfortable. Due to medical diagnosis, LPA was not able to obtain information from 1 of the resident. Therefore, the allegation is unsubstantiated. Based on interviews, inspection and observation, all 5 allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 15-AS-20241118162509

Allegation investigated: Staff spoke to resident in an inappropriate manner.

At 1:15 pm on this day, September 4, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with staff, Joseph Michael Madarang. LPA called and spoke over the phone with Mirriam Paras, administrator (ADM), and informed the reason for visit. ADM arrived at around 3:10 pm. During the course of investigation, LPA reviewed residents' records and obtained copy of LIC602A Physician's Report and interviewed staff (S1, S2, S3, S4) and ADM. Allegation: Staff spoke to resident in an appropriate manner. It was alleged that staff (S1) told R1 that R1 is heavy. S1 stated she was assisting R1 and asked R1 to assist/help out in getting up from the chair and denied telling R1 she's heavy. .......continued on 9099C (page 2) Substantiated Page 2 One of the staff stated not working on the day the incident happened while the other one indicated not working on the same shift S1 worked. One of the four staff stated R1 told her about S1 telling R1 she's heavy. ADM stated S1 told her that she (S1) told R1 to help out in getting up from the bathing chair because she's heavy. Based in interviews conducted, the preponderance of evidence has been met, therefore the allegation is found to be substantiated. Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. A $250.00 civil penalty is assessed for repeat violation within 12 month of section 1569.269(a)(1). Failure to submit proof of correction by plan of correction due date may result in additional civil penalty. Deficiency, plan and proof of correction, and civil penalty were discussed with ADM. Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided. Page 2 Allegation: Staff do not answer resident's (R1) request. R1 indicated she requested the staff to move the wheelchair away from the door and staff did not answer the request. All the staff interviewed indicated not observing wheelchair blocking the door nor R1 requesting to remove the wheelchair. R2 and R3 stated not observing a wheelchair blocking the door. Allegation: Staff does not ensure resident (R1) is accorded privacy. R1 indicated she needed to use the bathroom and was not accorded privacy. One of the staff interviewed stated she was to give R1 eye drops and looked for R1 by calling her who was at the time was in the bathroom. The other staff indicated there are times when R2 will knock when R1 is in the bathroom to check first if someone is inside and that there's another toilet but these 2 residents prefer to use the big bathroom. The other residents interviewed stated being accorded privacy and staff are respectful. Allegation: Staff does not provide adequate food service. It was alleged that R1 had diarrhea for several days and was told by a nurse that it's due to the food. R1 was interviewed who stated she's having diarrhea for days and her doctor told her it's because of the abscess tooth and that she was referred to the dentist. Copy of documents obtained by LPA showed R1 is prescribed anti-biotics. The other 2 residents interviewed stated food serve is always good. All the staff interviewed indicated not serving stale food. LPA conducted inspection and didn't observe any expired food. Based on information gathered, the above allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 15-AS-20240830112641

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(1) · Plan of correction due date: Sep 18, 2024

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. -This requirement is not met as evidenced by -Based on interviews, the licensee did not comply with the section when staff made an inappropriatec comment toward resident which posed personal rights risk to person in care. This is a repeat violation. The first citation was issued on 3/08/24.the state’s words, verbatim · CDSS document, Sep 4, 2024

Plan of correction: Administrator to in-service the staff and submit copy of training topic with attendees signatures by 9/18/24. A $250.00 civil penalty is assessed.

Type of visit: Case Management - Deficiencies

On this day, September 4, 2024, while at the facility investigating a complaint (Complaint Control # 15-AS-20240830112641), Licensing Program Analyst (LPA) Delmundo observed the following: 1. Staff (S1) is not fingerprinted and cleared. 2. Flies flying around the residents' rooms, kitchen area, bathroom and living room. 3. Lavatory in the common bathroom not properly draining and cabinet in this bathroom in disrepair. 4. Inside of the refrigerator untidy. Deficiencies are cited from Title 22 California Code of Regulation, and listed on 809Ds. Civil penalties were assessed on this same day for the following: 1. Deficiency section 87355(e)(1) - $100.00 and will continue for $100.00/day until corrected. 2. Deficiency section 87303(a) - $250.00 for repeat violation within 12-month period. Failure to submit proof of corrections may result in additional civil penalties. Deficiencies, plan and proof of corrections, and civil penalties were discussed with the administrator. Exit interview conducted. Appeal Rights, LIC421IM and LIC421FC Civil Penalty Assessments, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Sep 4, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Sep 5, 2024

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance ............ -This requirement is not met as evidenced by: -Based on observation and interviews, the licensee did not comply with the section in S1 working without fingerprint clearance which poses an immediate risk to persons in care. Civil penalty assessed.the state’s words, verbatim · CDSS document, Sep 4, 2024

Plan of correction: Administrator stated she'll have the staff fingerprinted. Proof by 9/05/24. In addition, administrator not to allow S1 to work until cleared and associated. $100.00 civil penalty assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 18, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by -Based on observation, the licensee did not comply with the section above in the following which pose a potential health and/or personal rights risks to persons in care: untidy refrigerators; bathroom cabinet in disrepair; clogged lavatory; flies. This is a repeat violation within 12 month.the state’s words, verbatim · CDSS document, Sep 4, 2024

Plan of correction: Staff cleaned the refrigerators while LPA was at the facility. In addition, administrator to do the following and submit proof by 9/18/24: 1. Have the bathroom cabinet repaired. 2. Have the lavatory unclogged. 3. Eradicate the flies and install door mesh. A $250.00 civil penalty is assessed.

Allegation investigated: -Staff do not provide adequate food service to resident in care. -Staff do not meet resident's dietary needs.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with Mirriam Paras, administrator, and informed the reason for visit. During the course of investigation, LPA reviewed residents' records and obtained copies including but not limited to the following: LIC602A Physician's Report, Pre-placement Appraisal, Hospital Visit Summaries, Pre-procedure Instructions. LPA interviewed residents (R1, R2, R3, R4 and R5) and staff (S1, S2 and administrator). Allegation: Staff do not provide food service to resident in care. It was alleged that on 7/30/24, when resident (R1) came back to the facility after an appointment, R1 was only given chicken broth and juice. Unsubstantiated R1 confirmed that staff gave R1 chicken broth and juice. The two staff interviewed stated that on 7/31/24, R1 had a procedure and there's instruction that R1 should not be given solid foods day before the procedure which LPA confirmed from the document obtained during investigation. The other staff was not able to provide information as this staff is new and was not working yet at the time of the said incident. Allegation: Staff do not meet resident's dietary needs. It was alleged that staff serve meat a lot and that R1 can not eat meat and staff does not offer substitute. LPA observed during inspection that residents were served barbecued meat during lunch. R1 stated she ate the barbecue and is not on special diet. Review of records showed R1 is not on special diet nor on diet restrictions. Two of the staff stated R1 eats meat and there are times when R1 does not want to eat meat but is not on special diet. These 2 staff stated facility offers substitute. The other four residents stated the food served is good. Three out of these 4 residents stated staff provides substitute if they don't want what is served. Based on information gathered, the above allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Aug 6, 2024 · control 15-AS-20240731080957

Type of visit: Case Management - Deficiencies

On this day, 8/06/24, while at the facility investigating a complaint (Complaint Control # 15-AS-20240731080957), Licensing Program Analyst (LPA) Delmundo observed the following: 1. Staff (S1) is not fingerprinted and cleared. 2. Portable bed in resident's room and foldable bed in the closet in this resident's room. LPA verified, and according to the administrator, the beds are that of the staff. LPA also observed staff's personal stuff in the same room. Deficiencies are cited from Title 22 California Code of Regulation, and listed on 809Ds. Civil penalties were assessed on this same day for the following: 1. Deficiency section 87355(e)(1) - $200.00 and will continue for $100.00/day until corrected. 2. Deficiency section 87307(a) - $250.00 for repeat violation within 12-month period. Failure to submit proof of corrections may result in additional civil penalties. Deficiencies, plan and proof of corrections, and civil penalties were discussed with the administrator. Exit interview conducted. Appeal Rights, LIC421IM and LIC421FC Civil Penalty Assessments, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Aug 6, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Aug 7, 2024

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance ............ -This requirement is not met as evidenced by: -Based on observation and interviews, the licensee did not comply with the section in S1 working without fingerprint clearance which poses an immediate risk to persons in care. Civil penalty assessed.the state’s words, verbatim · CDSS document, Aug 6, 2024

Plan of correction: Staff left while LPA was at the facility. Administrator to have the staff fingerprinted and submit proof by 8/07/24. In addition, administrator not to allow S1 to work until cleared and associated. $200.00 civil penalty assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(a) · Plan of correction due date: Aug 20, 2024

87307 Personal Accommodations and Services: (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, ........ -This requirement is not met as evidenced by: -Based on observation and interviews, the licensee did not comply with the section above in making the resident's room storage for staff's belongings/beds. This is a repeat violation within 12-month period. The first citation was issued 3/08/24.the state’s words, verbatim · CDSS document, Aug 6, 2024

Plan of correction: Staff removed the items. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 8/20/24. $250.00 civil penalty is assessed.

Type of visit: POC

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a proof of correction (POC) visit. LPA met with Jonalyn Legarto, staff, and informed the reason for visit. LPA called and spoke over the phone with Mirriam Paras, administrator, who authorized to sign and receive this report. On 4/26/24, LPA continued the annual inspection and issued citation section 87705(c)(1) for having residents (R3 and R4) in bedrooms not fire cleared for non-ambulatory. For plan of correction, the administrator stated she'll have the residents move-out. The administrator submitted the POC;however, the POC didn't indicate when the residents moved-out. On this day, 5/01/24, LPA toured the facility with staff (S1). and didn't observed R3 and R4. LPA interviewed S1 who confirmed R3 and R4 were moved-out. Deficiency is cleared. Exit interview conducted, and copy of this report provided.the state’s words, verbatim · CDSS document, May 1, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a proof of correction (POC) visit. LPA met with Mirriam Paras, administrator, and informed the reason for visit. On 3/08/24, LPA issued citations for the following deficiencies with POCs to be submitted by 3/09/24. On 3/09/24, the administrator submitted the LIC9098 Proof of Correction form, however, the POCs submitted were either missing or the in-service training do not pertain to the deficiencies cited. LPA informed the administrator about these on 4/17/24 and requested to submit the POCs before the end of the day that day, but the POCs were not submitted up to this date, 4/26/24: 1. Section 87202(a) – picture showing the storage on the 2nd floor is converted back to it’s original use. 2. Section 87309(d)(6) - in-service pertaining to the cited deficiency is missing. The in-service training submitted is not related to the cited deficiency. 3. Section 87309(a) - in-service pertaining to the cited deficiency is missing. The in-service submitted is also not related to the cited deficiency. On this day, 4/26/24, the above deficiencies are re-cited. On this same day, LPA toured the facility with the administrator. LPA observed the storage on the 2nd floor is converted back to it's original use. Deficiencies and proof of corrections were discussed with the administrator. Failure to submit proof of corrections by plan of correction due dates may result in civil penalties. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.the state’s words, verbatim · CDSS document, Apr 26, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202a · Plan of correction due date: Apr 27, 2024

87202(a) Alll facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshall........ -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section cited above in converting the storage into staff bedroom which poses an immediate safety and/or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 26, 2024

Plan of correction: Corrected. LPA observed the storage is converted back to it's original use.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(d)(6) · Plan of correction due date: Apr 27, 2024

8730787307 Personal Accommodations and Services: (d)(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section cited above in stairway on the second floor from resident's room going to the backyard blocked with rusted lamp and commode which poses an immediate safety and/or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 26, 2024

Plan of correction: Administrator to in-service the staff, and submit proof by 4/27/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Apr 27, 2024

87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section cited above in .... the following: unlocked staff medications, scissors, razors, cleaning supplies, tools cart, shovel, pails of paint, bleach, rubbing alcohol, Hydrogen Peroxide; bread toaster in one of the residents' rooms, These pose an immediate health, safety and/or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Apr 26, 2024

Plan of correction: Administrator to in-service the staff, and submit training topic with attendees signatures by 4/27/24.

Type of visit: Case Management - Annual Continuation

On this day, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual required inspection that was started on 3/08/24. LPA met with Mirriam Paras, administrator, and informed the reason for visit. LPA reviewed 5 staff and 5 residents files, and interviewed 2 staff. Residents' medications were checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources. LPA obtained updated/current copies of the following documents: 1. LIC308 Designation of Facility Responsibility 2. LIC610E Emergency Disaster Plan (9 pages) 3. Proof of $3M liability Insurance coverage 4. Proof of Control of Property/Lease Agreement (expiration: 1/31/25) LPA observed the following: -at 1:35 p.m., S1 has no First Aid certificate on file (expired 6/2017). -at 1:45 p.m to 2:35 p.m., staff (S2, S3 and S5) do not have First Aid certificate. Required training for 2023 for postural support/restricted health condition/hospice care and medication training incomplete - only 2 hours medication, 2 hours postural support on file. -at 2:40 p.m., staff (S4) no training record on file for 2019, 2020, 2021. No First Aid certificate on file. -at 2:45 p.m., residents' (R1, R2, R3) LIC602A Physician's Report over a year old (on file dated 8/05/21 for R1, 2/20/23 for R2, 7/08/22 for R3). .....continued on 809C (page 2) Page 2 -no doctor's order on file for R1, R3 and R5's half bed rails. -residents (R3 and R4) who are not able to exit on their own due to medical diagnosis/condition (non-ambulatory) are in bedrooms not fire cleared for non-ambulatory. -at 3:40 p.m., resident (R5) has no medical assessment (LIC602A) on file. -at 5:00 p.m., no doctor's order on file for the following: R1's 10 medications; R2's 5 medications; 2 of R5's medications. Deficiencies are cited from Title 22 California Code of Regulation, and listed on 809Ds. A $500.00 civil penalty is assessed for deficiency section 87705(c)(1) and will continue for $100.00/day until corrected. Any repeat violation within 12 month period may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with the administrator. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Apr 26, 2024

Allegation investigated: Staff are not meeting resident's (R1) medical needs.

At 11:35 a.m., on this day, 4/19/24, Licensing Program Analyst (LPA Delmundo arrived unannounced to investigate the above allegation. LPA met with Mirriam Paras, administrator, and informed the reason for visit. It was alleged that staff do not check R1's blood pressure nor give eye drops. It was further alleged that R1 ran out of fungus cream. During investigation, LPA reviewed resident's file including but not limited to doctor's order of medications and Medication Administration Record (MAR). LPA interviewed R1, 4 staff (S1, S2, S3 and S4) and administrator. R1 stated staff do not check R1's blood pressure (BP), do not give her eye drops, and her fungus cream run out. .......continued 9099C Substantiated Although 3 of the 4 staff interviewed stated they check R1's BP when requested and put cream on R1's forehead, ears and on the back of R1's ears, the fungus cream run out which was confirmed by LPA with the administrator. MAR showed R1 is given eye drops. Review of records showed R1 has doctor's order for other cream for the scalp in August 2023, however, this particular cream was never refilled, and administrator admitted to not following-up with the doctor. Based on records review and interviews, the preponderance of evidence is met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the administrator. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided. Page 2 Allegation: Staff did not ensure the bathroom has hot water. R1 stated the bathroom has no hot water. All 4 staff, administrator and 2 other residents interviewed stated the facility never run out of hot water. LPA tested the water temperature which was measured at 105.2 degrees Fahrenheit. Allegation: Staff are not meeting residents needs. R1 stated when R1 wet self and asked to be changed, staff told her she'll come back and it took more than 1 hour to be changed. R1 futher stated that the bedsheet was not changed. Staff (S3) stated that on the date of incident, she was assisting other resident in the bathroom and told R1 to wait. S3 stated she came back in less than 20 minutes and assisted R1 to the bathroom and changed her. All 4 staff stated they change residents bed covers daily. During today's inspection, LPA observed the residents beds clean and R1's bed with 2 chux on top of the bed cover. None of the beds were observed wet. Allegation: -Staff did not prevent resident from engaging in inappropriate behaviors. R1 stated resident R4 laughs and stares at her, R2 grabbed her water bottle and R3 stares at her. All 4 staff interviewed confirmed the incident happened but the other 2 residents who were laughing were talking to each other. Staff also confirmed R2 grabbed R1's water bottle; however the R4 and R2 have dementia and they separate and redirect residents when incidents happen. Allegation: Staff made inappropriate comments towards resident. R1 stated when R4 made fun of her and reported the incident to the administrator, the administrator told her to be nice and mind her own business. Although the administrator stated saying to R1, "Be nice, because the residents have dementia", she denied saying 'Mind your own business." All 4 staff and other 2 residents stated not hearing the administrator made inappropriate comments to R1. LPA was not able to obtain information from other 3 residents either due to residents' medical condition/diagnosis or resident was not at the facility. .....continued on 9099C (page 3) Page 3 Allegation: Staff did not ensure facility furniture was clean. R1 stated chairs in the living room never get washed. LPA interviewed 4 staff who stated the chairs and couches in the living room have covers and at times get soiled when residents spill food or have accidents but when these happen, they removed the covers, and covers are washed. The administrator stated the couches have covers and when get soiled, one of the staff does the washing. LPA conducted inspection and didn't observed any of chairs and couches soiled or dirty. Allegation: Facility has bed bugs. R1 stated she has bed bugs in her body. LPA interviewed 4 staff and 2 residents who all stated not observing bed bugs. LPA conducted inspection and didn't observed any. Based on information obtained and LPA unable to obtain information from 3 residents, all 7 allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Apr 19, 2024 · control 15-AS-20240412115612

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 20, 2024

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility......by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. -This requirement is not met as evidenced by: -Based on review of records and interviews, the licensee did not comply with the section above when R1's cream run out and did not obtain nor follow-up with the doctor for the other cream.the state’s words, verbatim · CDSS document, Apr 19, 2024

Plan of correction: One of the cream is delivered on 4/18/24. Administrator to check with the doctor if the other cream is still needed and submit proof by 4/20/24.

Allegation investigated: -Staff made inappropriate comments towards resident. -Staff did not prevent resident from engaging in inappropriate behaviors

At 10:45 am on this day, 3/08/24, Licensing Program Analyst (LPA Delmundo arrived unannounced to investigate the above allegations. LPA met with staff, Jonalyn Legarto and Medelmira Cloma, and informed the reason for visit. LPA called and spoke with Mirriam Paras, administrator, who stated she can not come to the facility, and authorized Jonalyn Legarto to sign and receive this report. During investigation, LPA interviewed four (4) staff and 2 residents, and reviewed residents record and obtained copies of documents. LPA were not able to interview other residents either due to their diagnosis or not at the facility. LPA also made observation. ....continued on 9099C Substantiated Allegation: Staff made inappropriate comments towards resident. It was alleged that staff (S1) tells R1 "that's your problem" and call R1 "bitch". Although 4 of the staff stated it was R1 who always say "bitch" to the staff and other residents, S1 admitted to telling R1 "it's your problem if you don't ignore e R1" when R1 called S1 when R2 was bothering R1. Allegation: Staff did not prevent resident from engaging in inappropriate behaviors. It was alleged that R2 keeps on following resident (R1) around and barging into residents rooms and staff is not doing anything. It was further alleged that R1 was upset due to staff sitting R2 next to R1 in the dining table. Four of the staff stated R2 has wandering behavior. One of the two residents interviewed stated staff do nothing to get R2 out of his room while the other one stated the staff yells at R2 to have R2 go out from the residents' room but most of the time, do nothing at all and R1 gets agitated when R2 goes to R1's room. Review of R2's record showed R1 has wandering behavior which LPA observed R2 wandering and going in and out of residents' rooms, kitchen, dining and hallways the whole time LPA was conducting investigation. LPA further observed and upon interview learned that there's only caregiver on duty from 6:00 a.m. to 3:00 p.m., and 1 caregiver from 3:00 p.m. to 11:30 p.m. and most of the time not able to redirect R2 right away when R2 goes to residents' rooms. Based on the information obtained, the preponderance of evidence has been met, therefore the allegations of "Staff made inappropriate comments towards resident" and "Staff did not prevent resident from engaging in inappropriate behaviors." are substantiated. Deficiencies are cited from Title 22 California Code of Regulations, and listed on 9099Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with Mirriam Paras over the phone. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided. All 3 staff interviewed stated they check R1's blood pressure when requested and record the reading, All 3 staff confirms R1's roommate (R5) screams when being changed; however, they try to calm R5 down. LPA was unable to interview R5. There was record of R1's blood pressure but only for 1 day. Allegation: Staff are not providing a comfortable environment for resident. R1 stated that her room is cold at night. All 3 staff interviewed stated that R1 complained about R1's room being cold. Facility has centralized heater but when R1 complained about the room being cold, R1 was provided a portable heater. LPA observed a portable heater in R1's room and the room's windows with coverings/curtains. LPA also checked the room temperature at around 4:00 pm which was measured at 68.7 degrees Fahrenheit. LPA was not able to obtain information from R1's roommate. Two other residents were interviewed who stated the temperature is at comfortable level. Allegation: Staff did not ensure facility furniture was clean. It was alleged that chairs in the living room are not clean. LPA interviewed 4 staff who stated the chairs and couches in the living room have covers and at times get soiled when residents spill food or have accidents but when these happen, they removed and wash the covers. LPA conducted inspection and didn't observed any being soiled or dirty, Based on information obtained and LPA unable to obtain information from R1's roommate, all 3 allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 8, 2024 · control 15-AS-20240308084431

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.269(a)(1) · Plan of correction due date: Mar 22, 2024

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. -This requirement is not met as evidenced by: -Based on interviews, the licensee did not comply with the section when staff made an inappropriatec comment toward resident which posed personal rights risk to person in care.the state’s words, verbatim · CDSS document, Mar 8, 2024

Plan of correction: Administrator to in-service the staff, and submit proof by 3/22/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 22, 2024

87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs........ -This requirement is not met as evidenced by: -Based on interviews, observation and records review, the licensee did not comply to the section above in not having sufficient staffing to be able to redirect resident timely and properly which poses potential personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Mar 8, 2024

Plan of correction: Administrator stated she'll hire additional staff. Copy of staff schedule to be submitted by 3/22/24.

Type of visit: Required - 1 Year

On this day, March 8, 2024, at 10:45 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Jonalyn Legarto and Medelmira Cloma. LPA called and spoke with Mirriam Paras, administrator, who stated she can not come to the facility, and authorized Jonalyn Legarto to sign and receive this report. Facility has LIC808 Mitigation Plan. Administrator submitted the LIC9282 Infection Control Plan on March 5, 2024. LPA toured the facility inside out with Jonalyn Legarto. Facility is a two level home. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked. Hot water temperature in one of the bathrooms on the ground floor was tested. Fire extinguisher was observed fully charge with tag showed serviced 9/22/23. LPA interviewed 2 residents. LPA observed the following: -at 11:15 a.m., staff medications and vitamins, scissors and disinfecting spray in area adjacent to the kitchen. -at 11:21 a.m., cleaning agents in kitchen cabinet under the sink without lock. -at 11:23 a.m, rubbing alcohol, medications and scissors in resident's room. Razors in the ensuite bathroom in this resident's room. .continued on 809C CONTINUATION: -at 11:34 a.m., Icy Hot pain reliever ointment in another resident's room on the ground floor. -at 11:35 a.m., Lysol toilet bowl cleaner in the common bathroom on the ground floor. Toilet paper holder in this bathroom broken and door paint dilapidated. -at 11:42 a.m., Tums, motor oil for shredder in another resident's room. Trash can in this room and rooms on the second floor without lids. -at 11:46 a.m., toilet paper holder in another common bathroom on the first floor broken, dilapidated door paint and rotten wood transition on the flooring. - at 11:49 a.m., storage on the second floor converted into staff's room. -at 11:50 a.m., mildew on the shower door in second floor bathroom. - at 11:52 a.m., bread toaster. Hydrogen Peroxide and medications i n one of resident's room on the second floor. -no auditory signals on the exit doors of 2 residents rooms. -at 12:01 p.m., staff clothing, personal belongings, medications and scissors in other residents' room on the second. Two staff were interviewed who stated staff sleeps and use the resident's bed. -at 12:19 p.m., tools in unlocked tool cart. bleach, shovel, pieces of wood, Pine Sol cleaning agent in the backyard. -at 12:34 p.m., hot water temperature in one of the common bathroom was measured at 137.8 degrees Farenheit. -at 2:50 p.m., cleaning supplies, pails of paint and pieces of wood in the side yard. -no disaster drill on file. LPA interviewed 2 staff and administrator who all stated they don't do disaster drill. Deficiencies are cited from Title 22 California Code of Regulations, and cited on 809Ds. A $500.00 civil penalty is assessed for fire safety violation in converting the storage into staff bedroom, and will continue for $100.00/day until corrected. Deficiencies, plan and proof of corrections and civil penalty was discussed with administrator over the phone. Due to time constraint, LPA will come back to continue inspection. Exit interview conducted. Appeal Rights, LIC421IM, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 8, 2024

Allegation investigated: Facility has pest.

On 2/23/2024 10:15am, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct the 10-day initial visit for the above allegation. LPA met with Arturo Flores, Caregiver, and explained the reason for the visit. Administrator, Mirriam Paras, arrived at 10:25am. During the visit LPA interviewed four (4) staff, residents, obtained the facility resident list and personnel record (LIC500) dated 2/26/2023. Other residents were not able to be interviewed due to diagnosis or absence from facility. During interviews four (4) residents stated that facility has rodents. Resident 6 (R6) stated that sticky traps are placed in the room by the resident. Three (3) staff stated that rodents have been seen recently. Staff 1 (S1) stated that facility had a problem but Continued on LIC9099C. Substantiated Continued from LI9099. it was last year and Terminix came out. LPA obtained a Terminix invoice dated 8/2/2023 and 9/7/2023. LPA observed droppings in cabinet underneath kitchen sink, Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights and this report providedthe state’s words, verbatim · CDSS document, Feb 23, 2024 · control 15-AS-20240216120227

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 4, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observation and interview the Licensee did not comply with the section cited above in having facility free of rodents, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: Administrator agreed to rehire Terminx and submit invoice to CCLD by POC date.

Allegation investigated: Staff called the residents inappropriate names while in care Staff do not provide adequate care and supervision to the residents

On 2/23/2024 12:45pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct the 10-day initial visit for the above allegation. LPA met with Mirriam Paras, Administrator, and explained the reason for the visit. During the visit LPA interviewed four (4) staff, residents, obtained the facility resident list and personnel record (LIC500) dated 2/26/2023. Other residents were not able to be interviewed due to diagnosis or absence from facility. Allegation: Staff called the residents inappropriate names while in care. During interviews three (3) residents stated that they have not heard any staff call residents names. Only one (1) resident stated that staff member calls residents names. Staff stated during interview that no other staff calls residents names or speaks to residents in appropriately. LPA did not observe any residents being nervous of afraid around staff Continued on LIC9099C. Unsubstantiated Continued from LIC9099. Allegation: Staff do not provide adequate care and supervision to the residents Residents stated during interview if they require any medical assistance or just help in the facility the staff will oblige. Staff stated during interview that if the residents require help that they can not provide they would notify the Administrator or call 9-1-1. LPA observed Residents in care appear to be safe, groomed, and there are no imminent health/safety concerns on today's date. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 23, 2024 · control 15-AS-20240221085509

Type of visit: Case Management - Other

On 2/23/2024 at 1:20pm Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Mirriam Paras, Administrator, and explained the purpose of the visit. While LPA L. Hall was conducting a complaint investigation (15-AS-20240221085509) on 2/23/2024. While touring facility LPA observed residents' beds did not have a mattress cover, top sheet, and some did not have a blanket. Staff stated beds are changed weekly or more often if necessary. LPA also observed two (2) slide latch locks on front entry/exit door. Staff 1 (S1) stated during interview that facility uses lock at night for a resident that wanders. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Feb 23, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(3)(c) · Plan of correction due date: Mar 4, 2024

87307 (3) Equipment and supplies necessary for personal care... shall be readily available to each resident... C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads... The quantity shall be sufficient to permit changing at least once per week or more often when indicated... This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in have appropriate linen on bed, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: Administrator agreed to put appropriate linen on each resident bed and submit a self-certification that it has been completed to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(l)(6) · Plan of correction due date: Feb 24, 2024

87705 (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors... (6)Locked exterior doors or perimeter fences.. shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited in using a lock on entry/exit door for wander residents, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: Administrator agreed to remove locks from entry/exit door and submit a photo to CCLD by POC date.