Mountain View Center

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual inspection visit on 09/03/2026 and was greeted by Administrator Laura Hernandez. LPA Ramirez explained the purpose of the visit. The facility is located on a main street and is a single store dwelling. This facility advertises, promotes, and/or otherwise hold themselves out as providing special care, programming and/or environments for residents with Dementia or other related disorders. LPA utilized the Compliance and Regulatory Enforcement (CARE) tool offline for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected five (5) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside shower. LPA Ramirez observed no-slip coating in showers. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). See 809-C Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. During tour, LPA Ramirez observed the facility full-time activities director setting up a bowling activity for residents. LPA Ramirez observed an activities board for the month of September 2026. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted in August 2026. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in kitchen area. Residents with Special Needs: No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. LPA Ramirez tested emergency pull cord in resident room#20 and observed staff respond under 5 minutes. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication cart and medication room and are kept in bubble packs and/or original containers. LPA Ramirez observed Centrally Stored Medication and Destruction Record. The facility provides incidental medical services. Staffing: Administrator Certificate for Laura Hernandez expired in August 2026. LPA Ramirez verified via internal verification that Laura’s renewal application was received by this agency and is pending. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for four (4) out of the four (4) personnel record reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4) out of the four (4) personnel record reviewed. SEE 809-C Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for forty (40) non-ambulatory, of which ten (10) may be bedridden. This facility may retain no more than twenty (20) hospice residents. The facility currently has zero (0) residents on hospice care. Resident Records/Incident Reports: LPA reviewed resident records for six (6) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. No deficiencies were observed during this visit. Exit interview conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 3, 2026

Allegation investigated: Staff does not maintain cleanliness of resident’s room. Staff does not provide toilet paper for residents. Staff failed to provide adequate supervision to resident in care resulting in multiple falls.

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 02/17/2026 to deliver findings related to the above allegations. LPA met with Administrator Laura Hernandez and explained the purpose of the visit. The investigation included a review of the client roster, staff roster, resident face sheets, physician’s reports, ALW care plan, Unusual Incident Reports, and staff/job descriptions. In addition, LPA also conducted interviews with five (5) staff members (S1–S5) and attempted to interview seven (7) residents (R1–R7). Four (4) residents were interviewed, and three (3) residents were unable to be interviewed due to cognitive impairment. (continued 9099C) Unsubstantiated Allegation: Staff does not maintain cleanliness of resident’s room. It is alleged that the facility did not clean soiled adult diapers containing urine under residents’ bed and by the wall. It is further alleged that the facility did not discard a tube of cream with feces stored in R1’s drawer. During staff interviews, Staff stated that resident rooms are checked and cleaned daily. Staff reported that caregivers are responsible for providing morning care, including changing residents, disposing of soiled diapers, and picking up trash observed during care. Housekeeping reported they clean resident rooms and bathrooms after morning care and complete additional cleaning as needed throughout the day. Staff acknowledged that some residents, including R1, frequently discard trash and soiled items on the floor or under beds. Staff stated that these items are addressed when observed or reported. Staff reported that caregivers and housekeeping work together to maintain cleanliness and denied that resident rooms are left unclean. Regarding the incident involving diapers found under R1’s bed, S1 stated the housekeeper assigned that day had just arrived and was unaware of the diapers. S1 reported the issue was discussed with the family, and staff responsibilities were reiterated. S1 denied observing neglect related to room cleanliness and stated that staff routinely follow up to clean resident rooms and remove trash. During R1 interview, R1 stated they are doing well and that everything is okay. R1 reported no complaints. During resident interviews R2-R4, residents R2–R4 reported they were doing well overall. R3 stated they are doing well; reported no complaints regarding the cleanliness of their room. R3 further stated they use plastic bed mats to step on because the floor is often cold, which is why LPA observed a plastic mat under their bed. R5–R7 had cognitive challenges and were unable to understand LPA’s questions. During the complaint visit, LPA conducted observations of resident rooms, including R1’s room. At the time of observation, the resident room appeared clean and orderly. No soiled diapers, trash, or debris were observed on the floor, under the bed, or in visible areas of the room. The resident’s bed, dresser, and surrounding areas were observed to be clean. LPA observed that in one (1) out of eight (8) bedrooms observed, crumpled plastic mats were present under the bed. Housekeeping had not yet been cleaned at the time of observation. LPA later learned that plastic mats are used by the residents for comfort because the floor is often cold. (continued on 9099C) Allegation: Staff does not provide toilet paper for residents. It is alleged that staff do not consistently ensure toilet paper is available in R1’s bathroom. During staff interviews, Staff stated that toilet paper is routinely stocked in resident bathrooms. Staff reported that housekeeping is primarily responsible for checking and refilling toilet paper in resident bathrooms during daily cleaning. Caregivers stated they also replace or add toilet paper as needed when they observe supplies are low or when residents request additional toilet paper. Staff acknowledged that certain residents use large amounts of toilet paper and may require frequent refills. Staff denied that residents are left without toilet paper and reported no known instances in which residents were unable to access toilet paper. During resident R1 interview, R1 reported no concerns regarding access to toilet paper. During resident interviews, R2–R4 reported no concerns related to toilet paper and stated they have access to additional toilet paper when needed. R5–R7 had cognitive challenges and were unable to understand LPA’s questions. During the complaint visit, LPA observed resident bathrooms to be stocked with toilet paper. Toilet paper rolls were observed present in resident bathrooms at the time of observation. No residents were observed without access to toilet paper, and no complaints regarding lack of toilet paper were reported to LPA during the visit. Allegation: Staff failed to provide adequate supervision to resident in care resulting in multiple falls. It is alleged that staff did not provide adequate supervision to the resident in care, resulting in resident falls. During staff interviews, staff stated that residents are supervised at all times. Staff reported that R1 walks independently using a walker and does not typically request assistance. Staff stated that R1 is permitted to walk independently, including outside in enclosed patio area which is consistent with his assessed needs. Staff 1 (S1) acknowledged that R1 has experienced falls; however, S1 reported the falls did not occur due to lack of supervision. (continued on 9099C) S1 stated one fall occurred outside when R1 bent down while attempting to use the restroom. S1 reported that following the falls, additional support was requested, including home health services, physical therapy, and use of a walker. S1 further stated that R1’s family was contacted immediately. S1 stated that staff provide reminders to R1 regarding restroom use. Several staff reported they were not aware of R1 having multiple falls and denied witnessing any falls. Staff denied concerns regarding supervision and stated that residents are monitored while outside through visual observation from inside the facility and through the use of outdoor cameras. During R1 interview, R1 reported no concerns in regard to supervision. During resident’s interviews R2-R4, residents did not report any concerns regarding to supervision. R5–R7 had cognitive challenges and were unable to understand LPA’s questions. During the complaint visit, LPA observed that the facility had outdoor cameras in place to monitor residents while in the patio area. The camera monitor was in the administrator’s office, and LPA observed the system to be operational at the time of the visit. LPA observed caregivers attending to residents and providing supervision during the visit. Based on the investigation conducted, which included interviews with staff and residents, as well as a review of relevant records, there was insufficient evidence to support the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 17, 2026 · control 28-AS-20260210161845

Allegation investigated: Licensee does not ensure facility maintains insurance with plan of operation.

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 02/17/2026 to deliver findings related to the above allegation. LPA met with Administrator Laura Hernandez and explained the purpose of the visit. Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 02/17/2026 to deliver findings related to the above allegation. LPA met with Administrator Laura Hernandez and explained the purpose of the visit. The investigation included a review of the client roster, staff roster, review of facility insurance coverages. LPA also conducted interviews with one (1) staff member (S1),and one witnesses (W1). (continued on 9099C) Unsubstantiated Allegation: Licensee does not ensure facility maintains insurance with plan of operation. It is alleged that the licensee failed to ensure the facility maintains required insurance coverage as outlined in the facility’s Plan of Operation and licensing requirements. During record review, LPA observed liability insurance coverage effective from 03/09/2023 through 04/09/2026. LPA contacted the insurance broker, who confirmed that liability insurance is currently maintained and verified the coverage limits. Based on the investigation conducted, which included interview with staff and witness there was insufficient evidence to support the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 17, 2026 · control 28-AS-20260212132322

Allegation investigated: Staff preventing residents from getting personal belongings.

***This report supersedes the report dated 01/23/2026 to correct the regulatory section cited on that date. The complaint finding remains unchanged; however, the citation has been updated to reflect the appropriate regulatory section. *** Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 02/17/2026 to deliver findings related to the above allegation. LPA met Laura Hernanez, Administrator, and explained the purpose of the visit. The investigation included a review of the client roster, staff roster, resident face sheet, admission agreements, house rules, assessments, care plans, and progress notes. Additionally, LPA toured the facility, inspected seven (7) resident bedrooms, and conducted interviews with six (5) staff members (S1–S5), and seven (7) residents (R1–R7). (continued 9099C) LIC9099C Substantiated Allegation: Staff preventing residents from getting personal belongings. It was alleged R1 requested a sweater from staff member S1 and was denied. It was further alleged that R1’s closet is locked due to R1 removing clothing and creating a mess. It was also alleged that other residents have locked closets while some residents do not. The report alleges staff are preventing residents from accessing their personal belongings. During resident interviews, most residents (R2–R7) reported that their clothing is kept in their closets and stated that their closets were not locked. None of these residents reported that staff had told them they could not have their clothing or personal items. When asked whether they had concerns about staff preventing access to belongings, most residents were unable to answer. Several residents demonstrated limited ability to respond to questions, which appeared consistent with cognitive impairment. R1 reported that her closet is always locked and stated that she cannot access her clothing whenever she wants. R1 reported that staff sometimes assist her in accessing her clothing when she asks and stated that staff have sometimes told her she could not have her belongings. R1 stated that she feels “sad” when she is unable to access her belongings. R1 appeared consistent with cognitive impairment. During staff interviews, staff consistently reported that some residents’ closets are locked due to safety concerns related to cognitive impairment, including residents removing all items from closets, attempting to leave the facility with belongings, or misplacing items. Multiple staff indicated that these behaviors are frequently associated with R1 due to confusion and dementia-related behaviors. Staff generally stated that the decision to lock a resident’s closet is made or approved by administration; however, some staff reported that there was no specific directive and that staff act based on familiarity with resident behaviors. Staff reported that keys to locked closets are accessible to staff, including medication technicians, and that all staff are aware of the combination codes for coded locks. Staff stated that residents may request staff assistance to access their belongings. Several staff reported that they had not observed staff denying residents access to their personal belongings when requested. Staff were unsure whether restrictions on personal belongings are documented in resident records. During the visit, LPA observed resident R1’s closet to be locked. LPA also observed six (6) additional resident bedrooms with closet locks present, some of which were in use or broken. LPA observed that some residents’ closets were locked while others were not. LPA did not observe any posted signage or written notice explaining restrictions on resident access to personal belongings. The LPA reviewed R1’s admission agreement, assessments, and care plan and found no documentation authorizing restrictions on access to personal belongings. S1 confirmed no such documentation existed and stated that no waiver to lock resident closets had been requested to Licensing. No physician order or written consent was observed, and facility policies did not clearly authorize locking resident closets. The LPA attempted to contact the assigned ALW Coordinator and social worker but was unable to make direct contact and left a message with the ALW receptionist. Based on LPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Feb 17, 2026 · control 28-AS-20260120111131

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(12)(13) · Plan of correction due date: Feb 23, 2026

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (12) To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money. (13) To have access to individual storage space for private use. This requirement is not met as evidenced by: It was observed the facility maintains locks on resident closets prohibiting access.the state’s words, verbatim · CDSS document, Feb 17, 2026

Plan of correction: The facility shall ensure residents’ rights to keep and use their own personal possessions and to always have individual access to storage space for private use. The Licensee/Administrator may request a facility wide waiver for locks for review.

Allegation investigated: Staff preventing residents from getting personal belongings.

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 01/23/2026 to deliver findings related to the above allegation. LPA met with Laura Hernanez, Administrator and explained the purpose of the visit. The investigation included a review of the client roster, staff roster, resident face sheet, admission agreements, house rules, assessments, care plans, and progress notes. Additionally, LPA toured the facility, inspected seven (7) resident bedrooms, and conducted interviews with five (5) staff members (S1–S5) and seven (7) residents (R1–R7). (continued on 9099C) Substantiated Allegation: Staff preventing residents from getting personal belongings. It was alleged R1 requested a sweater from staff member S1 and was denied. It was further alleged that R1’s closet is locked due to R1 removing clothing and creating a mess. It was also alleged that other residents have locked closets while some residents do not. The report alleges staff are preventing residents from accessing their personal belongings. During resident interviews, most residents (R2–R7) reported that their clothing is kept in their closets and stated that their closets were not locked. None of these residents reported that staff had told them they could not have their clothing or personal items. When asked whether they had concerns about staff preventing access to belongings, most residents were unable to answer. Several residents demonstrated limited ability to respond to questions, which appeared consistent with cognitive impairment. R1 reported that her closet is always locked and stated that she cannot access her clothing whenever she wants. R1 reported that staff sometimes assist her in accessing her clothing when she asks and stated that staff have sometimes told her she could not have her belongings. R1 stated that she feels “sad” when she is unable to access her belongings. R1 appeared consistent with cognitive impairment. During staff interviews, staff consistently reported that some residents’ closets are locked due to safety concerns related to cognitive impairment, including residents removing all items from closets, attempting to leave the facility with belongings, or misplacing items. Multiple staff indicated that these behaviors are frequently associated with R1 due to confusion and dementia-related behaviors. Staff generally stated that the decision to lock a resident’s closet is made or approved by administration; however, some staff reported that there was no specific directive and that staff act based on familiarity with resident behaviors. Staff reported that keys to locked closets are accessible to staff, including medication technicians, and that all staff are aware of the combination codes for coded locks. Staff stated that residents may request staff assistance to access their belongings. Several staff reported that they had not observed staff deny residents access to their personal belongings when requested. Staff were unsure whether restrictions on personal belongings are documented in resident records. (continued on 809C) During the visit, LPA observed resident R1’s closet to be locked. LPA also observed six (6) additional resident bedrooms with closet locks present, some of which were in use or broken. LPA observed that some residents’ closets were locked while others were not. LPA did not observe any posted signage or written notice explaining restrictions on resident access to personal belongings. The LPA reviewed R1’s admission agreement, assessments, and care plan and found no documentation authorizing restrictions on access to personal belongings. S1 confirmed no such documentation existed and stated that no waiver to lock resident closets had been requested to Licensing. No physician order or written consent was observed, and facility policies did not clearly authorize locking resident closets. The LPA attempted to contact the assigned ALW Coordinator and social worker but was unable to make direct contact and left a message with the ALW receptionist. Based on LPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Jan 23, 2026 · control 28-AS-20260120111131

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(6) · Plan of correction due date: Jan 30, 2026

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility.the state’s words, verbatim · CDSS document, Jan 23, 2026

Plan of correction: The facility shall ensure residents’ rights to make daily life choices, including access to personal belongings. The Administrator shall submit a written plan describing how resident personal rights will be protected. Effective immediately, resident closet locks shall no longer be used, and the Administrator shall submit written confirmation that the locks have been discontinued.

Allegation investigated: Staff did not clean and disinfect items shared between residents in care.

Licensing Program Analyst (LPA), Mayra Cota, conducted a 10-day investigation visit today regarding the above-mentioned allegation. LPA, met with Daisy Fitter, Office Manager and the reason for the visit was explained. Laura Hernandez, Administrator, was informed of the visit telephonically and Jasbindar Singh, Assistant Administrator, continued to facilitate today’s visit. During today’s visit: LPA, obtained copies of staff and resident rosters, toured the facility, inspected facility’s PPE, specifically their glove supply, inspected residents’ clothing protectors (bibs) and conducted interviews with Staff – 1 Staff 7 (S1-S7) and Resident 1 – Resident 6 (R1-R6). LPA attempted to conduct interviews with Resident 7 – Resident 9 (R7-R9); however, R7 and R8 did not respond to LPA’s questions and R9 was away from the facility during today's visit. ***Continues on LIC 9099-C Substantiated Regarding: Staff forced residents to wear bibs. It is alleged that staff is forcing residents to wear bibs during mealtimes. Staff deny the allegation. Interviews with seven (7) out of (7) staff revealed that staff do not force residents to wear bibs/clothes protectors during mealtimes. Staff indicated that the bibs are placed on residents after getting consent for those who need help with feeding. Staff indicated that the bibs help prevent residents’ clothes from getting stained, particularly for those who have their food pureed. Staff further indicated that residents can remove the bib at any time during or after their meals. Interviews with (6) residents revealed that they are not forced to wear bibs during mealtimes. LPA, attempted to interview R7-R9 but R7 and R8 did not respond to LPA’s questions and R9 was not at the facility during visit. LPA, conducted observation during the lunch meal service and did not observe any staff forcing residents to use a bib while being helped with their feeding. Staff and resident interviews and LPA observation do not corroborate the allegation that residents are being forced to wear bibs. Regarding: Staff did not follow proper hand hygiene procedures when assisting residents in care. It is alleged that staff is assisting multiple residents in their room without changing their gloves between residents. Staff deny the allegation. Interviews with (7) out of (7) staff revealed that staff change their gloves between residents in care. Staff indicated that they follow proper hand hygiene and glove protocols when caring for residents. Staff further indicated that gloves are not reused between residents and that gloves are for one-time use. Staff stated that gloves are properly removed and disposed of to prevent contamination as indicated by the training they receive regarding glove use. Staff also stated that the facility has sufficient gloves for all staff to use and when supply becomes low, staff can replenish glove stations with boxes from the supply closet in the med-tech area. Interviews with (6) out of (9) residents indicated that they have no concerns about the use of gloves by staff. Three residents did not provide a statement about the use of gloves by staff. LPA inspected the facility’s glove supply and observed to have sufficient gloves for the use of staff. Further observation of the facility by LPA indicated that the facility has glove holders on the walls of both wings by resident rooms in a variety of sizes, and boxes of gloves are also kept in the bathroom and in the med-tech carts. Staff and resident interviews, and LPA observations, do not corroborate the allegation that proper hand hygiene procedures are not being followed by staff when assisting residents in care. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided. The investigation revealed the following: Regarding: Staff did not clean and disinfect items shared between residents in care. It is alleged that bibs are not washed and that staff is reusing them with other residents. Interviews with (4) out of (7) staff revealed that bibs/clothes protectors are used on residents during mealtimes to prevent their clothes from being stained with pureed food. Staff indicated that if bibs are observed not to be soiled during breakfast after being used on a resident, the bib is then placed on the dining room cart and saved to be used again during the lunch meal service. Staff further indicated that after lunch, staff will then place the soiled bibs removed from residents into the laundry hamper located in the dining room and the night shift will proceed to wash them and have them ready for the dinner meal service. Staff further indicated that the bibs are washed daily; however, they are washed after the second meal service by the night staff after bibs have been used for breakfast and lunch. Interviews with (2) staff further indicated that at times, it is hard to tell which bibs were used by a particular resident during breakfast and bibs may be placed on a different resident during the lunch meal service. During tour of facility, LPA inspected (6) bibs which were folded and stored on a cart in the dining room. LPA observed (4) out of the (6) bibs to have food stains. Staff indicated that the bibs inspected by LPA were going to be used again today for the lunch meal service and had not noticed that the bibs were soiled. LPA attempted to conduct interviews with (8) residents but they were unable to answer questions asked by LPA. R9 was unable to be interviewed due to being away from the facility during visit. Staff interviews and LPA observation corroborated the allegation that items are not clean and disinfected between resident use. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Nov 3, 2025 · control 28-AS-20251024093339

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 11, 2025

87468.1 (a)(2) Personal Rights of Residents in All Facilities (a) Residents...shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: During inspection, LPA observed that (4) out of (6) resident bibs had food stains from the breakfast meal and according to staff, were going to be used again by residents for the lunch meal service.the state’s words, verbatim · CDSS document, Nov 3, 2025

Plan of correction: Licensee, will send LPA, log indicating the washing of all resident bibs: staff name, date and time and number of bibs washed for 8 days. Licensee will also send LPA a copy of receipt of purchase of additional bibs by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Gabby Castro conducted an unannounced required annual inspection visit and was greeted by MedTech Elvira Cortez. LPA Ramirez explained the purpose of the visit. The facility is located on a main street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained the required furniture, linens and lighting. Water temperatures in grooming and bathing areas were measured to be over 120 degrees F. Resident bathroom#8 water temperature was measured to be 123 degrees F. LPA Ramirez will issue type A deficiency based on this observation. LPA Ramirez observed postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed non-slip mat in showers. Showers were observed to be wheelchair accessible. Food Service: LPA Ramirez observed a sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). See 809-C Planned Activities: LPA Ramirez observed staff conducted seated activities with residents during inspection. Facility employs a full-time activity director to plan and carry out activities for residents. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed the facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. The last documented emergency drills were conducted on 05/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed an emergency food supply. Residents with Special Needs: No large bodies of water were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. LPA Ramirez pulled emergency cords in rooms#4 and 7. After waiting a few minutes, staff did not respond and LPA Ramirez asked to see the location of the main signal system. LPA Ramirez and med tech Elvira Cortez observed the main signal box was not "powered on" and was unplugged. Staff advised LPA Ramirez that sometimes residents will sometimes unplug the signal system. LPA Ramirez will issue a type B deficiency based on this observation. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication cart and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. Staffing: Administrator Certificate for Laura Hernandez and it expires 08/25/2026. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. see 809-C Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed some required annual training, CPR and First Aid for four (4) out of the four (4) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4) out of the four (4) personnel records reviewed. Staff#3 (S3) & staff#4 (S4) did not have sufficient annual required training hours on dementia, postural supports, restricted health conditions and hospice care as required by 1569.625(b)(2). LPA Ramirez observed some of the documented in-service trainings did not document the numbers of hours. LPA Ramirez will issue two (2) type B deficiencies based on this record review. Infection Control: They’re using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for forty (40) non-ambulatory, of which ten (10) may be bedridden. This facility may retain no more than twenty (20) hospice residents. The facility currently has nine (9) residents on hospice care. Resident Records/Incident Reports: LPA reviewed Resident files for four (4) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. Four (4) deficiencies were issued. Exit interview conducted. A copy of this report, 809-D, and appeals rights were provided.the state’s words, verbatim · CDSS document, Aug 26, 2025

Allegation investigated: Staff did not seek medical attention for resident in a timely manner.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 06/28/2025 to deliver findings regarding the above allegation. LPA Ramirez conducted an unannounced Health & Safety visit on 03/25/2025 regarding the above allegations and a need further investigation was documented. During today’s visit, LPA Ramirez was greeted by Caregiver Jenny Miranda and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster, Staff interviews conducted by Community Care Licensing-Investigations Branch, Resident interview#1 (R1) conducted by Community Care Licensing-Investigations Branch, Interview of resident#1 (R1) Case Manager conducted by Community Care Licensing-Investigations Branch, copies of R1’s medical records obtained by Community Care Licensing-Investigations Branch, copies of First Rescue ambulance records obtained by Community Care Licensing-Investigations Branch, and physical plant tour. SEE 9099-C Substantiated The investigation revealed the following: regarding the allegation “Staff did not seek medical attention for resident in a timely manner.” It is alleged facility staff did not seek medical attention in a timely manner for R1 on 03/20/2025. Staff interviews conducted by Community Care Licensing-Investigations Branch corroborated this allegation. Due to R1’s cognitive impairments, R1’s interview was unreliable. Interviews conducted revealed facility staff scheduled R1 to be transported via ambulance by First Rescue Ambulance service on 03/20/2025 at 2300 hour to seek medical attention for an injury that was not healing properly. On 03/21/2025, at 0630 hours, Administrator Hernandez arrived at the facility and was informed R1 was still at the facility and had not been transported for medical attention as scheduled. Staff waited 6 ½ hours before seeking medical attention for R1 after ambulance transportation service did not arrive at scheduled time. This poses immediate Health & Safety, or Persons Rights risk to persons in care. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. One (1) type A deficiency was cited during this complaint investigation. Exit interview was conducted. A copy of this report, 9099-D and appeals rights was provided via email. The investigation revealed the following: regarding the allegation “Resident sustained a serious injury due to lack of care from staff.” It is alleged R1 sustained a serious injury on 03/10/2025. Staff interviews conducted by Community Care Licensing-Investigations Branch did not corroborate this allegation. Due to R1’s cognitive impairments, R1’s interview was unreliable. Records reviewed by Community Care Licensing-Investigations Branch did not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiency was cited for this allegation. Exit interview was conducted. A copy of this report was provided via email.the state’s words, verbatim · CDSS document, Jun 28, 2025 · control 28-AS-20250324101502

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 29, 2025

(a) In addition to the rights listed in Section 87468.1,residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, and competency to meet their needs. This requirement was not met as evidenced by: staff failed to seek medical attention for 6 1/2 hours for R1 via ambualnce service for medical treatment. This poses immediate Health & Safety, or Persons Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 28, 2025

Plan of correction: Administrator will certify plan by 06/29/25 that indicates how the facility will comply with this regulation. Plan must be received by 06/29/25. Proof of staff re-training on this regulation must be received by 7/7/25 via email to LPA Ramirez.

Allegation investigated: Facility did not maintain liability insurance. Facility overmedicated resident. Facility improperly restrained resident. Facility staff neglect resulted in resident falling and sustaining injuries. Facility was not feeding resident.

*This is corrected version of LIC9099 and LIC9099-C, dated 11/21/24. LPA Ramirez corrected dates only and there are no changes to findings.* Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 11/21/2024 regarding the above allegations. LPA Ramirez was greeted by Administrator Laura Hernandez and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff roster, Staff#1 - 5 interviews (S1 – S5), Attempted interview of Resident #1 (R1), Interview of Resident#2-3 (R2 – R3), copies of Resident#1 (R1): Medical Assessment (LIC 602A), Hospice Care Training Log, Hospice Progress Notes, Unusual/Special Incident Report (LIC 624) for R1, Medications Administration Record (MAR) for December 2022, Pomona Valley Hospital Medical Center medical reports, Arrowhead Regional Medical Center medical reports, miscellaneous documents related to this investigation, and physical plant tour. see 9099-C Unsubstantiated The investigation revealed the following. Regarding Allegations: Facility did not maintain liability insurance – It is alleged the facility did not maintain liability insurance during 2022 and does not have current liability insurance. During record review, LPA Ramirez observed liability insurance coverage from 03/09/2022 through 03/09/2025. LPA Ramirez called insurance broker to verify liability insurance is currently maintained and verified coverage limits. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Facility overmedicated resident- It is alleged R1 was overmedicated while receiving care at the facility. R1 was admitted to the facility on 12/01/2022 and was discharged on 12/29/2022. R1 began hospice care on 12/01/2022. During record review, LPA Ramirez reviewed R1’s MAR for the month of December of 2022. LPA Ramirez did not observe any notes on MAR, or documentation to collaborate this allegation. Review of hospice progress note did not collaborate this allegation. Five (5) out of the five (5) staff interviewed deny this allegation. R1 is no longer at the facility and unable to be interviewed. LPA Ramirez made several attempts to contact R1’s responsible party, but as of 11/21/2024, LPA Ramirez has not received a call back. Two (2) out of the two (2) residents interviewed deny this allegation. Pomona Valley Hospital Medical Center medical report dated 12/19/2022, did not collaborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Facility improperly restrained resident- It is alleged facility staff improperly restrained resident and wrapped in a baby highchair. Allegedly, this caused R1’s knee to remain bent and unable to walk anymore. R1 was admitted to the facility on 12/01/2022 and was discharged on 12/29/2022. R1 began hospice care on 12/01/2022. During facility tour, LPA Ramirez observed several residents sitting in wheelchairs, recliners, chairs, and couch. LPA Ramirez did not observe a baby highchair at the facility. LPA Ramirez did not observe restraints near chairs, wheelchairs, or recliner. Review of R1’s hospice progress notes and medical notes from Pomona Valley Medical Center, did not collaborate this allegation. Five (5) out of the five (5) staff interviewed deny this allegation. R1 is no longer at the facility and unable to be interviewed. LPA Ramirez made several attempts to contact R1’s responsible party, but as of 11/21/2024, LPA Ramirez has not received a call back. Two (2) out of the two (2) residents interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. See 9099-C for continued report. Facility staff neglect resulted in resident falling and sustaining injuries- It is alleged R1 fell and became injured because of staff neglect. R1 was admitted to the facility on 12/01/2022 and was discharged on 12/29/2022. R1 began hospice care on 12/01/2022. On 12/17/2022, R1 was observed sitting in his wheelchair; in the facility living room area. R1 fell/slid out of his wheelchair and began to complain of a headache. Hospice and R1’s responsible party was notified. Facility staff called 911. R1 was admitted to Pomona Valley Medical Center on 12/17/2022 and cleared for discharge on 12/19/2022 back to the facility. Per Pomona Valley Medical Center report, R1’s responsible party agreed to discharge R1 back to the facility and continue hospice care. According to Pomona Valley Medical Center report, R1 was deemed stable on 12/19/2022 and cleared by Neurosurgery to be discharged. Five (5) out of the five (5) staff interviewed deny this allegation. R1 is no longer at the facility and unable to be interviewed. LPA Ramirez made several attempts to contact R1’s responsible party, but as of 11/21/2024, LPA Ramirez has not received a call back. Two (2) out of the two (2) residents interviewed deny this allegation. Although, R1 did suffer a fall and did sustain a minor injury, LPA Ramirez did not observe documentation or interviews to suggest this was as a direct result from staff neglect. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Facility was not feeding resident- It is alleged R1 was not being fed and R1’s responsible party had to bring R1 food. R1 was admitted to the facility on 12/01/2022 and was discharged on 12/29/2022. R1 began hospice care on 12/01/2022. Review of R1’s Medical Assessment dated 11/30/2022, recorded R1’s weight as 125lbs. Per Pomona Valley Medical Center report dated 12/19/2022, R1’s weight was recorded as 54.9 kg (121lbs) on 12/18/2022. Five (5) out of the five (5) staff interviewed deny this allegation. R1 is no longer at the facility and unable to be interviewed. LPA Ramirez made several attempts to contact R1’s responsible party, but as of 11/21/2024, LPA Ramirez has not received a call back. Two (2) out of the two (2) residents interviewed deny this allegation. During facility tour, LPA Ramirez observed staff serving lunch and assisting residents with their meals. LPA Ramirez sufficient food supply in kitchen. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No violations were observed during this investigation. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 10, 2024 · control 28-AS-20241118105915

Allegation investigated: Facility did not maintain liability insurance. Facility overmedicated resident. Facility improperly restrained resident. Facility staff neglect resulted in resident falling and sustaining injuries. Facility was not feeding resident.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 11/21/2024 regarding the above allegations. LPA Ramirez was greeted by Administrator Laura Hernandez and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff roster, Staff#1 - 5 interviews (S1 – S5), Attempted interview of Resident #1 (R1), Interview of Resident#2-3 (R2 – R3), copies of Resident#1 (R1): Medical Assessment (LIC 602A), Hospice Care Training Log, Hospice Progress Notes, Unusual/Special Incident Report (LIC 624) for R1, Medications Administration Record (MAR) for December 2022, Pomona Valley Hospital Medical Center medical reports, Arrowhead Regional Medical Center medical reports, miscellaneous documents related to this investigation, and physical plant tour. see 9099-C Unsubstantiated The investigation revealed the following. Regarding Allegations: Facility did not maintain liability insurance – It is alleged the facility did not maintain liability insurance during 2022 and does not have current liability insurance. During record review, LPA Ramirez observed liability insurance coverage from 03/09/2022 through 03/09/2025. LPA Ramirez called insurance broker to verify liability insurance is currently maintained and verified coverage limits. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Facility overmedicated resident- It is alleged R1 was overmedicated while receiving care at the facility. R1 was admitted to the facility on 12/01/2022 and was discharged on 12/29/2022. R1 began hospice care on 12/01/2022. During record review, LPA Ramirez reviewed R1’s MAR for the month of December of 2022. LPA Ramirez did not observe any notes on MAR, or documentation to collaborate this allegation. Review of hospice progress note did not collaborate this allegation. Five (5) out of the five (5) staff interviewed deny this allegation. R1 is no longer at the facility and unable to be interviewed. LPA Ramirez made several attempts to contact R1’s responsible party, but as of 11/21/2024, LPA Ramirez has not received a call back. Two (2) out of the two (2) residents interviewed deny this allegation. Pomona Valley Hospital Medical Center medical report dated 12/19/2022, did not collaborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Facility improperly restrained resident- It is alleged facility staff improperly restrained resident and wrapped in a baby highchair. Allegedly, this caused R1’s knee to remain bent and unable to walk anymore. R1 was admitted to the facility on 12/01/2022 and was discharged on 12/29/2022. R1 began hospice care on 12/01/2022. During facility tour, LPA Ramirez observed several residents sitting in wheelchairs, recliners, chairs, and couch. LPA Ramirez did not observe a baby highchair at the facility. LPA Ramirez did not observe restraints near chairs, wheelchairs, or recliner. Review of R1’s hospice progress notes and medical notes from Pomona Valley Medical Center, did not collaborate this allegation. Five (5) out of the five (5) staff interviewed deny this allegation. R1 is no longer at the facility and unable to be interviewed. LPA Ramirez made several attempts to contact R1’s responsible party, but as of 11/21/2024, LPA Ramirez has not received a call back. Two (2) out of the two (2) residents interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. See 9099-C for continued report. Facility staff neglect resulted in resident falling and sustaining injuries- It is alleged R1 fell and became injured because of staff neglect. R1 was admitted to the facility on 12/01/2022 and was discharged on 12/29/2022. R1 began hospice care on 12/01/2022. On 12/17/2024, R1 was observed sitting in his wheelchair; in the facility living room area. R1 fell/slid out of his wheelchair and began to complain of a headache. Hospice and R1’s responsible party was notified. Facility staff called 911. R1 was admitted to Pomona Valley Medical Center on 12/17/2024 and cleared for discharge on 12/19/2024 back to the facility. Per Pomona Valley Medical Center report, R1’s responsible party agreed to discharge R1 back to the facility and continue hospice care. According to Pomona Valley Medical Center report, R1 was deemed stable on 12/19/2022 and cleared by Neurosurgery to be discharged. Five (5) out of the five (5) staff interviewed deny this allegation. R1 is no longer at the facility and unable to be interviewed. LPA Ramirez made several attempts to contact R1’s responsible party, but as of 11/21/2024, LPA Ramirez has not received a call back. Two (2) out of the two (2) residents interviewed deny this allegation. Although, R1 did suffer a fall and did sustain a minor injury, LPA Ramirez did not observe documentation or interviews to suggest this was as a direct result from staff neglect. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Facility was not feeding resident- It is alleged R1 was not being fed and R1’s responsible party had to bring R1 food. R1 was admitted to the facility on 12/01/2022 and was discharged on 12/29/2022. R1 began hospice care on 12/01/2022. Review of R1’s Medical Assessment dated 11/30/2022, recorded R1’s weight as 125lbs. Per Pomona Valley Medical Center report dated 12/19/2022, R1’s weight was recorded as 54.9 kg (121lbs) on 12/18/2022. Five (5) out of the five (5) staff interviewed deny this allegation. R1 is no longer at the facility and unable to be interviewed. LPA Ramirez made several attempts to contact R1’s responsible party, but as of 11/21/2024, LPA Ramirez has not received a call back. Two (2) out of the two (2) residents interviewed deny this allegation. During facility tour, LPA Ramirez observed staff serving lunch and assisting residents with their meals. LPA Ramirez sufficient food supply in kitchen. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No violations were observed during this investigation. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 28-AS-20241118105915

Allegation investigated: Due to staff neglect, resident fell resulting in injury. Staff did not seek timely medical care for resident. Staff did not follow resident's fall plan.

*** This licensing report issued on today’s visit, 11/01/2024 supersedes that licensing report dated 10/11/2024, LPA Vaid is reissuing the report and citations, however, the investigation findings will remain the same*** Licensing Program Analyst (LPA) S. Vaid conducted a subsequent complaint visit regarding the allegations listed above to reissue the report and to reissue citation for the investigated complaint findings. On 09/08/2023, Program Analyst (LPA) V. Maldonado made an unannounced initial visit to the facility to conduct a Health and Safety check inspection, in response to the above-mentioned allegations. LPA met with staff Elvira Cortez and explained the purpose for the visit. Investigation consisted of the following: Continued on 9099C......... Substantiated LPA requested a copy of staff and resident rosters, conducted a tour of physical plant and common areas with assistance of staff Daisy Fitter, and obtained the following documents for Residents# 1-4 (R1-R4): Face sheet, Physician's Report, Needs and Services Plan, and Fall Prevention Plan. LPA did not observe any immediate health and/or safety concerns. Regarding the allegation: Due to staff neglect, residents fell resulting in injury, it was alleged that on 09/01/23, in the early morning, resident R3 had an unwitnessed fall and sustained injuries. Staff/Caregivers discovered R3 on the floor near the R3’s bed. Staff put R3 back in bed and staff did not notify the Facility Administrator of R3s fall. Staff did not assess R3 after the fall. Interviews with Eight (8) out of (8) staff denied the allegation. Staff reported to being aware that R3 has a history of fall and R3s family member supplied the facility with a Life Station device that would alert 911 if R3 fell in the facility, however, staff could not recall if R3 was wearing the device during the 08/31/23 fall or when he was taken to the hospital on 09/01/23. Staff reported they were following the orders and instructions given by management staff. Interviews with three (3) out of three (3) residents could not corroborate the allegation and did not have any information to provide regarding the allegation. Resident #3 was moved to healthcare facility and was not interviewed during the investigation due to R3’s cognitive impairment. The investigation revealed that on 08/31/23, R3 fell in the facility and staff were aware of R3s fall, staff did not assess R3 for injury and did not inform the administrator of R3s fall. Additionally, staff did not seek immediate medical treatment for R3 after the 09/01/23 fall. R3 was taken for medical treatment the next day. The hospital staff assessed the R3 and observed R3 sustained multiple fractures; fracture to the left ribs, punctured lung, a skin tear to left mid back, abrasions and bruising to left elbow, arm, and back area. The facility did not properly assess R3 for injury after the R3’s fall, and it was discovered on 09/01/23 that R3 sustained serious injury. Regarding the allegation: Staff did not seek timely medical attention for the resident, it was alleged that on 09/01/23, resident R3 had an unwitnessed fall and sustained injuries. Interviews with Eight (8) out of (8) staff denied the allegation. Staff reported that R3 has a history of fall and R3s family member supplied the facility with a Life Station device that would alert 911 is R3 fell, however, staff could not recall if R3 was wearing the device during the 08/31/23 fall or when he was taken to the hospital on 09/01/23. Staff reported they were following the orders and instructions given by management staff. Staff present during the night shift did not report obtaining medical treatment for R3 after the 08/31/23 fall. Continued on 9099C.... Administrator reported staff did not notify her of the 08/31/23 fall. Interviews with three (3) out of three (3) residents could not corroborate the allegation and did not have any information to provide regarding the allegation. Resident #3 was moved to healthcare facility and was not interviewed during the investigation due to R3’s cognitive impairment. The investigation revealed that on 08/31/23, R3 fell in the facility in early morning, staff placed R3 back in resident’s bed, did not make administrator aware of R3s fall, did not assess R3 for injury and did not obtain timely medical attention for R3 after the fall. R3 was sent out for medical treatment the next day, 09/01/23. Hospital staff observed R3 had multiple fractures; fracture to the left ribs, punctured lung, a skin tear to left mid back, abrasions and bruising to left elbow, arm, and back area. Regarding the allegation: Staff did not follow the resident’s fall plan, it was alleged that on 09/01/23, in the early morning, resident R3 had an unwitnessed fall and sustained injuries. Interviews with Eight (8) out of (8) staff denied the allegation. Staff reported to being aware that R3 has a history of falls and staff were aware that R3 would get out of bed at night to urinate. R3s family member supplied the facility with a Life Station device that would alert 911 if R3 fell in the facility, however, staff could not recall if R3 was wearing the device during the 08/31/23 fall or when he was taken to the hospital on 09/01/23. Staff reported they were following the orders and instructions given by management staff. Interviews with three (3) out of three (3) residents could not corroborate the allegation and did not have any information to provide regarding the allegation. R3 is currently deceased and was not interviewed during the investigation due to R3’s cognitive impairment. Per the investigation, review of R3s records, it was observed that R3s Individual Service Plan dated 02/16/2023 noted that R3 was totally dependent, needed assistive devices; needed a walker and wheelchair, and shower chair. Section C page 9 of the R3’s assessment tool indicated that R3 requires assistance with ADLs due to weakness, fatigue, confusion and R3 is at risk for falls. Page 24 indicated the risks to R3s personal safety, as potential for falls, unsteady gait, and a fall history. R3’s resident appraisal dated 03/17/2023, indicated under services needed: R3 needs help getting up due R3’s balance and R3 being very wobbly. Bathing: R3 needs to be monitored so they do not fall. R3’s Functional Capability Assessment dated 03/17/2023 indicated R3’s balance is off. Additionally, on 06/03/2023, R3 had a fall in the facility patio and was helped by staff. On 06/22/2023 R3 had an unwitnessed fall off their bed and hit R3s head. On 08/31/2023 around 11:30PM , staff found R3 on the floor near R3s bed, and put R3 back into bed without assessing R3 for injury. Continued on 9099C......... Staff did not inform the administrator of R3’s fall and staff did not seek immediate medical attention for R3 after the fall. The investigation revealed that staff did not follow R3s fall plan as R3 was admitted to the facility with a history of falls, required assistance to getting up due balance issues, and had two prior falls in the facility on 06/03/24 and 06/22/24. Staff did not render services needed for R3 as required per R3’s resident assessment/fall plan risk dated 02/16/23 that indicated the following: staff to assist R3 with ADL, staff to assist supervise/assist R3 with ambulation and transfer, staff monitor for R3 fall, the lack of care and supervision, resulted in R3 falling the facility on 08/31/24, which resulted in R3 sustaining injury that required medical treatment. Based on IBs and LPA's interviews conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are cited on the attached LIC 9099D. ***Immediate Civil Penalty in the amount of $500.00 is being issued today, due to staff neglect resulting in R3’s injury. Refer to LIC 421IM*** The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f). If the department determines the injury of the resident is due to neglect. Exit interview was conducted with Laura Hernandez and a copy of this report, LIC 9099D, LIC 421 and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 1, 2024 · control 28-AS-20230907141335

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 2, 2024

87468.2(a)(4) Addtional Personal Rights of Residents in Privately Operated Facilities. (a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Staff did not asses R#3 for injury after fall and staff didnot follow R3's careplanthe state’s words, verbatim · CDSS document, Nov 1, 2024

Plan of correction: Administrator will give provide staff and direct staff personnel, training for understanding the care as listed in the residents’ careplans and residents’ personal rights by due date 11/08/24. Administrator will send a letter to licensing indicating Licensee has read and will comply section 87468 by 11/02/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Nov 2, 2024

87465(a)(1) Incidental Medical and Dental Care.(a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Resident not receiving timely medical assistance.the state’s words, verbatim · CDSS document, Nov 1, 2024

Plan of correction: Administrator will give direct staff personnel, training for fall precautions, emergency procedures, reporting procedures by due date 11/08/24. Administrator will send a letter to licensing indicating Licensee has read and will comply section 87465 by 11/02/24.

Allegation investigated: Due to staff neglect, resident fell resulting in injury. Staff did not seek timely medical care for resident Staff did not follow resident's fall plan

*** This licensing report issued on 10/11/2024 supersedes that licensing report dated 09/12/24, LPA Vaid obtained additional information, however, the investigation findings will remain the same*** Licensing Program Analyst (LPA) S. Vaid conducted a subsequent complaint visit regarding the allegations listed above to reissue the report and to reissue citation for the investigated complaint findings. On 09/08/2023, Program Analyst (LPA) V. Maldonado made an unannounced initial visit to the facility to conduct a Health and Safety check inspection, in response to the above-mentioned allegations. LPA met with staff Elvira Cortez and explained the purpose for the visit. Investigation consisted of the following: LPA requested a copy of staff and resident rosters, conducted a tour of physical plant and common areas with assistance of staff Daisy Fitter, and obtained the following documents for Residents# 1-4 (R1-R4): Face sheet, Physician's Report, Needs and Services Plan, and Fall Prevention Plan. LPA did not observe any immediate health and/or safety concerns. Coninued on 9099C......... Substantiated On 08/20/2024. Licensing Program Analyst (LPA) S Vaid made an unannounced subsequent visit to the facility to conduct further investigations, in response to the above-mentioned allegations. LPA met with the staff Daisy Fitter and explained the purpose for the visit. Administrator Laura Hernandez joined shortly after. The investigation consisted of the following: Review of staff and resident rosters, tour of the physical plant with Administrator and viewed common areas and resident rooms. Obtained and reviewed the following documents for Residents# 3: Face sheet, Physician's Report, Needs and Services Plan, and Fall Prevention Plan. LPA interviews with four (4) staff members and two (2) residents. Investigation Branch, Investigator Olivia Spindola conducted further investigation. Regarding the allegation: 1) Due to staff neglect, residents fell resulting in injury, 2) Staff did not seek timely medical attention for the resident and 3) Staff did not follow the resident’s fall plan. Four (4) out of four (4) staff denied the allegation and reported they were following the orders and instructions given by management staff. Two out of Two (2) residents could not corroborate the allegation and stated they were not aware of the incident happening at the facility. It is alleged that on 09/01/23, in the early morning, resident R3 had an unwitnessed fall and sustained injuries. Staff/Caregivers discovered R3 on the floor near the R3’s bed. Staff put R3 back in bed and staff did not notify the Facility Administrator of R3s fall. Staff did not assess R3 after the fall. According to staff statements (investigated by Spindola), the morning staff/caregiver mentioned R3 was feeling very sore and complained of pain. Staff/caregiver(s) did not perform a fall assessment to R3. After breakfast, upon rising from R3’s dining seat, R3 screamed in pain and staff sent R3 to Pomona Valley Hospital for emergency medical care. Investigator Olivia Spindola conducted further investigation. R3 was sustained multiple fractures; fracture to the left ribs, punctured lung, a skin tear to left mid back, abrasions and bruising to left elbow, arm, and back area. The Individual Service Plan dated 02/16/2023, received by Mountain View facility, noted that R3 was totally dependent, and required assistive devices for mobility; needs walker and wheelchair, shower chair. Section C page 9 of the assessment tool indicated R3 is at risk for falls. Section C page 24 identifies risks to personal safety; potential for falls, unsteady gait and fall history. R3’s resident appraisal dated 03/17/2023, indicated under services needed: balance is off, very wobbly. Bathing: needs to be monitored so they do not fall. R3’s Functional Capability Assessment dated 03/17/2023 indicated balance is off. On 06/03/23, R3 had a fall in the patio and was helped by staff. On 06/22/2023 R3 had an unwitnessed fall off R3s bed and hit their head. In the early morning hours of 09/01/2023, caregiver found R3 on the floor near R3s bed, and put R3 back into bed without assessing them. Overnight shift staff/caregivers did not inform the facility administrator of R3s fall and staff did not seek immediate medical attention for R3 after the 09/01/2023 fall. Staff neglected to render R3 assistance in meeting necessary medical assessment needed when fall occurs and pain is displayed, due to fall plan not being followed as shown in the documents reviewed. Based on LPA's interviews and conducted of record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to staff neglect resulting in injury. Refer to LIC 421IM*** The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f). If the department determines the injury of the resident is due to neglect. Exit interview was conducted with Laura Hernandez and a copy of this report, LIC 9099D, LIC 421 and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 11, 2024 · control 28-AS-20230907141335

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(4) · Plan of correction due date: Oct 11, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not being met as evidenced by: Based on record review, facility person(s) responsible for reviewing and implementing a residents Fall Care Plan, failed to give proper instructions to the residents’ caregiving staff. Resulting in the resident sustaining injuries. As indicated in SIR 09/01/23 and hospital report dated 09/04/23.the state’s words, verbatim · CDSS document, Oct 11, 2024

Plan of correction: Administrator will give caregiving staff and direct staff personnel, training for understanding the care as listed in the residents’ IPP (Individual Program Plan) and residents’ personal rights by due date 10/25/24. On 10/11/24:Proof of correction was provided with Staff In-Service training for Falls,Resident Care, precautions and fall precautions, emergency procedures, hospice care.

Allegation investigated: Due to staff neglect, resident fell resulting in injury. Staff did not seek timely medical care for resident Staff did not follow resident's fall plan

Licensing Program Analyst (LPA) Sanjay Vaid conducted a subsequent complaint visit regarding the allegations listed above to deliver complaint investigation findings. Conducted physical tour with Daisy Fitter, no health and safety issue were noted. Laura Hernandez arrived shortly after. On 09/08/2023, Program Analyst (LPA) V. Maldonado made an unannounced initial visit to the facility to conduct a Health and Safety check inspection, in response to the above-mentioned allegations. LPA met with staff Elvira Cortez and explained the purpose for the visit. Investigation consisted of the following: LPA requested a copy of staff and resident rosters, conducted a tour of physical plant and common areas with assistance of staff Daisy Fitter, and obtained the following documents for Residents# 1-4 (R1-R4): Face sheet, Physician's Report, Needs and Services Plan, and Fall Prevention Plan. LPA did not observe any immediate health and/or safety concerns. On 08/20/2024. Licensing Program Analyst (LPA) S Vaid made an unannounced subsequent visit to the facility to conduct further investigations, in response to the above-mentioned allegations. LPA met with the staff Daisy Fitter and explained the purpose for the visit. Continued on 9099C..... Substantiated Investigation consisted of the following: LPA requested a copy of staff and resident rosters, conducted a tour of physical plant and common areas. Requested and obtained the following documents for Residents# 3: Face sheet, Physician's Report, Needs and Services Plan, and Fall Prevention Plan. LPA conducted interviews with four (4) staff members and two (2) residents. LPA observed resident rooms to be free of hazards. Investigation Branch, Investigator Olivia Spindola conducted further investigation. Regarding the allegation: (1) Due to staff neglect, residents fell resulting in injury. (2) Staff did not seek timely medical attention for the resident. (3) Staff did not follow the resident’s fall plan. Four (4) out of four (4) staff denied the allegation. Two out of (2) residents could not corroborate the allegation. It is alleged that resident R3 had an unwitnessed fall and sustained injuries in the early hours of the morning, on 09/01/2023. Caregivers discovered R3 on the floor near the bed. Staff put R3 back in bed and did not notify the Facility Administrator, did not make assessment of the fall. According to staff statements (investigated by Spindola), morning caregiver mentioned R3 was feeling very sore and complained of pain. Caregiver(s) did not apply fall care assessment to resident. After breakfast, upon rising from dining seat R3 screamed in pain, was sent to Pomona Valley Hospital for emergency medical care. Investigator Olivia Spindola conducted further investigation. R3 was diagnosed at Pomona Valley Hospital with multiple fractured left ribs and punctured lung, a skin tear to left mid back, abrasions and bruising to left elbow, arm, and back area. The Individual Service Plan dated 02/16/2023, received by Mountain View facility, noted that R3 was totally dependent, need assistive devices; needs walker and wheelchair, shower chair. Section C page 9 of the assessment tool indicates resident is at risk for falls. Section C page 24 identifies risks to personal safety; potential for falls, unsteady gait and fall history. Residential appraisal dated 03/17/2023, indicates under services needed: balance is off, very wobbly. Bathing: needs to be monitored so they do not fall. Functional Capability Assessment dated 03/17/2023 indicates balance is off. 06/03/2023, R3 had a fall in the patio and was helped by staff. On 06/22/2023 R3 had an unwitnessed fall off their bed and hit their head. On the early morning hours of 09/01/2023, caregiver found R3 on the floor near their bed, and put R3 back into bed without assessing them. Overnight shift caregivers did not inform the facility administrator nor seeking medical attention and failed to render R3 services needed, due to fall plan not being followed as shown in the documents reviewed. Based on LPA's interviews and conducted of record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to Resident # 3, (1) Due to staff neglect, residents fell resulting in injury. (2) Staff did not seek timely medical attention for the resident. (3) Staff did not follow the resident’s fall plan. Refer to LIC 421IM*** The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49 (f); if the department determines the injury of the resident is due to neglect. Exit interview was conducted with Laura Hernandez and a copy of this report, LIC 9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 12, 2024 · control 28-AS-20230907141335

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87458.2(4) · Plan of correction due date: Sep 12, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met evidenced by: Based on record review, the findings indicate that on 09/01/2023, Facility person(s) responsible for giving clear instructions and explanations of R3’s Fall Care Plan to the facility staff and to R3’s caregivers, resulting in R3’s injuries sustained.the state’s words, verbatim · CDSS document, Sep 12, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit and was greeted by MedTech Leslie Pimiento. LPA Ramirez explained the purpose of the visit. The facility is located on a main street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observe postings encouraging proper handwashing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. Showers were observed to be wheelchair accessible. LPA Ramirez observed a tear in outdoor canopy. LPA Ramirez will issue Type B deficiency based on observation. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). Planned Activities: LPA Ramirez observed staff leading cognitive memory games with residents during inspection. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 04/26/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply. Residents with Special Needs: No large bodies of water were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. LPA Ramirez observed sewing pins in room#16. LPA Ramirez will issue Technical Advisory based on observation. Auditory devices and delay egress perimeters were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication cart and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. Staffing: Administrator Certificate for Laura Hernandez and it expires 08/25/2024. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for three (3) out of the three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel records reviewed. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for forty (40) non-ambulatory, of which ten (10) may be bedridden. This facility may retain no more than twenty (20) hospice residents. Resident Records/Incident Reports: LPA reviewed Resident files for six (6) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. One (1) deficiency was cited and two (2) technical advisories were issued. Exit interview conducted. A copy of this report, 809-D, LIC 9120 and appeals rights was provided.the state’s words, verbatim · CDSS document, Jul 27, 2024

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff neglect led to resident sustaining severe burns while in care which resulted in hospitalization.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced complaint visit to the facility for the purpose of delivering findings in regard to the above-mentioned allegation. LPA Maldonado met with Office Manager, Daisy Fitter, and explained the purpose for the visit. On 12/04/23, LPA Maldonado made an initial visit to the facility. During the visit, LPA obtained a copy of resident/staff rosters, water temperature logs for November-December 2023, conducted a tour of physical plant with staff, Daisy Fitter, and obtained the following documents for Residents# 1-3 (R1-R3): Facesheet, Physician's Report, Needs and Services Plan, Incident Reports for November-December 2023, and hospice care plans. LPA observed resident rooms and common areas to be free of hazards. The hot water was tested and measured between 105*F-109.6*F, which is in compliance. LPA also observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. No immediate health and/or safety concerns were observed during the visit. (Report continued on LIC9099-C...) Unsubstantiated The investigation was conducted by the licensing agency's Investigation Bureau (IB) and was assigned to Investigator, Laura Garcia. IB's investigation consisted of the following: Interviews were conducted with Staff#1-3 (S1-S3), Witness# 1-2 (W1-W2), and Hospice Staff#1-2 (H1-H2), and hospital records for Resident#1 (R1) were obtained. IB was unable to interview R1 due to R1's cognitive impairment and being non-verbal. IB's investigation revealed the following: Regarding allegation: Staff neglect led to resident sustaining severe burns while in care which resulted in hospitalization. It is alleged that on 11/29/23, R1 was taken to the hospital with severe burns/blisters to R1's face, back, arms and hands, and was reported by facility staff it was possibly due to a chemical reaction. Per IB's interviews conducted, (3) of (3) staff denied neglect/lack of care and supervision to R1, which resulted in R1 sustaining severe burns/blisters. Per staff, on 11/29/23, H2 was providing R1 with a shower. During the shower, H2 noticed R1's skin beginning to redden and immediately notified S3 of it. S3 went to check on R1 and observed the reddening/irritation and notified S1 of the incident. S1 then notified R1's responsible party of the incident and and medical attention was sought for R1 and R1 was taken to the hospital for treatment. IB attempted to interview R1 but was unable to due to R1's cognitive impairment and being non-verbal. Per interviews conducted, (2) of (2) witnesses denied staff being neglectful or unable to provide adequate care and supervision to residents in care W1 denied facility staff being responsible for R1's burns sustained. Per interview with W1, H2 was the only individual responsible for providing showers to R1. W1 stated to have been notified immediately of the incident occurred on 11/29/23, by the facility. Per hospital records obtained, IB discovered that on 11/29/23, R1 was brought to the hospital and presented with blistering wounds on R1's face, back, and hands. The medical decision was stated to be consistent with scalding hot burns. Per IB's interview conducted with H2, H2 stated to be the only individual responsible for providing R1 with showers. H2 admitted that on the noted date, H2 came to the facility at about 8:30AM to give R1 a shower. H2 tested the water prior to showering R1 and felt it was at a comfortable temperature. While showering R1, H2 immediately noticed that R1's skin began to redden/blister and immediately notified S3 of it and left the facility. Facility staff were not responsible for R1's showers. Therefore, this allegation is Unsubstantiated. LPA Maldonado agrees with IB's investigation and findings. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Per California Code of Regulations, Title 22, and Health & Safety Code, no deficiencies were observed or cited during the visit. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 14, 2024 · control 28-AS-20231201131036

Allegation investigated: Staff pushed a resident in care. Staff pinched a resident in care. Staff stomped on a resident in care. Staff used foul language towards residents. Staff left resident in the same clothing for a long period of time. Staff discouraged a resident from reporting an incident to Law Enforcement. Staff did not serve a meal to a resident in care.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint investigation visit on 01/25/2024 to deliver findings regarding the above allegation(s). LPA Ramirez was met by Administrator Hernandez and explained the purpose of the visit. The investigation consisted of the following: Initial complaint investigation was conducted on 11/13/2023LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 6 interviews (S1 – S6), Personnel Records for Staff # 1-6 (S1-S6), Resident#1-3 interviews (R1- R3), attempted interview of resident#4 (R4) copies of resident #1, 2, 3 (R1- R3) physician report, face sheet, and other pertinent documents related to this investigation and physical plant tour. Unsubstantiated The investigation revealed the following: Regarding Allegation(s): Staff pushed a resident in care- It is alleged staff pushed R1 against wall. Four (4) out of six (6) staff interviewed deny this allegation. Three (3) out of three (3) residents interviewed deny this allegation. LPA Ramirez reviewed R1’s facility records and did not observe any documentation of injury from suspected fall or from being pushed. During interview of R1, LPA did not observe any visible injuries. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Staff pinched a resident in care- It is alleged facility staff pinches R4. Four (4) out of six (6) staff interviewed deny this allegation. Three (3) out of three (3) residents interviewed deny this allegation. LPA Ramirez reviewed R4’s resident record and did not observe any documentation of injury sustained from a pinch or suspected pinch. LPA Ramirez attempted to interview R4 but was unable to due to R4 refusing to answer questions. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Staff stomped on a resident in care- It is alleged facility staff stomp on R4. Four (4) out of six (6) staff interviewed deny this allegation. Three (3) out of three (3) residents interviewed deny this allegation. LPA Ramirez reviewed R4’s resident record and did not observe any documentation of injury sustained from a stomp or suspected stomp. LPA Ramirez attempted to interview R4 but was unable to due to R4 refusing to answer questions. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Staff used foul language towards residents- It is alleged facility staff use foul language against residents in care. Four (4) out of six (6) staff interviewed deny this allegation. Three (3) out of three (3) residents interviewed deny this allegation. During tour of facility on 11/13/2023, LPA Ramirez observed staff providing care and supervision to residents. LPA Ramirez did not observe any staff using foul language towards residents. LPA Ramirez reviewed six (6) personnel records and did not observe documentation that staff was reprimanded for use of foul language towards residents. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. SEE 9099-C for continuation. Staff did not serve a meal to a resident in care- It is alleged staff did not serve R3 a meal due to R3 refusing to change clothing. Four (4) out of six (6) staff interviewed deny this allegation. Three (3) out of three (3) residents interviewed deny this allegation. LPA Ramirez toured kitchen on 11/13/2023 and observed sufficient supply of perishables and non-perishables. LPA Ramirez reviewed R3 resident record and did not observe documentation that suggest staff withheld meals to R3. LPA Ramires did not observe documentation that suggest R3 became ill or malnourished due to being denied meals. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Staff left resident in the same clothing for a long period of time- It is alleged staff leave R1 in the same clothing for weeks at a time. Four (4) out of six (6) staff interviewed deny this allegation. Three (3) out of three (3) residents interviewed deny this allegation. During tour of R1’s room, LPA Ramirez observed multiple sets of clothing in R1 closet and dresser. LPA Ramiez observed R1 to be clean clothing during interview. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Staff discouraged a resident from reporting an incident to Law Enforcement- It is alleged staff discouraged a resident from reporting an incident to Law Enforcement. Four (4) out of six (6) staff interviewed deny this allegation. Three (3) out of three (3) residents interviewed deny this allegation. Review of six (6) staff records revealed staff signed Statement of Acknowledgement Requirement to Report Suspected Abuse of Dependent Adults and Elders. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted with Administrator Hernandez and a copy of this report and appeals rights was providedthe state’s words, verbatim · CDSS document, Jan 25, 2024 · control 28-AS-20231109122637

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit in relation to the deficiencies cited on 5/16/23. On 5/16/23, a deficiency was issued for the signal system in the resident rooms being non operable. Staff stated the new signal system was purchased and is pending installation. During the visit today, LPA conducted a walk through to verify the new signal system is working. Each room has a pull cord located by the door. Once it is pulled, the room number appears on the call box that is placed on the nursing station. The nursing station is located in the common area of the resident building. The beeping sound is heard until staff goes in the room and manually turns it off. LPA checked random rooms and the signal system appears to be working properly. Therefore, the deficiency is being cleared today. An exit interview was held and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Dec 5, 2023

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of citing deficiencies. LPA Maldonado met with Administrator, Laura Hernandez, and explained the purpose for the visit. During a complaint visit initiated on 12/04/23, LPA Maldonado conducted a tour of the physical plant with Staff, Daisy Fitter, and conducted a file review for Residents# 1-3 (R1-R3). During the inspection of the facility kitchen, LPA observed an insufficient amount of the required 2-day perishables, for the amount of residents currently in care- 39 residents. LPA observed (1) box of frozen hamburger patties, about (3) boxes of frozen breakfast waffles, (1) gallon of milk, (2) packages of frozen chicken, (2) frozen full size hams, (1) package of frozen ground beef, about (9) tubs of yogurt, about (11) bags of frozen sliced sandwich bread, about (50) fresh eggs, one tub of varied fresh vegetables were observed in the refrigerator, and one and a half bags of assorted vegetables in the freezer. No fresh fruits were observed. Per Laura, the facility should be receiving a food delivery later today or tomorrow. During the resident file review, LPA discovered that R2's file was missing an updated medical assessment (Physician's Report) as required annually for residents with dementia. The current Physician's Report is dated 11/18/22. Per California Code of Regulations, Title 22, deficiencies were observed and cited on the LIC809-D. An exit interview was conducted with Administrator, Laura Hernandez, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 4, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(26) · Plan of correction due date: Dec 5, 2023

87555 General Food Service Requirements (b) The following food service requirements shall apply:(26)Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by: Based on LPA's observation, there was an insufficient amount of the required 2-day persihable foods for the amount of residents in care, which poses an immediate Health, Safety, or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Dec 4, 2023

Plan of correction: Licensee will submit pictures of receipts and purchased foods to LPA, via email, by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(5) · Plan of correction due date: Dec 15, 2023

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment... which shall include a reassessment of the resident’s dementia care needs. This rquirement was not met as evidenced by: Based on LPA's observation and interview, the licensee failed to obtain an annual medical assessment/Physician's Report for R2 as required, which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 4, 2023

Plan of correction: Licensee provided LPA a copy of updated Physician's Report dated 12/03/23. POC cleared.

Allegation investigated: . Resident sustained bruises while in care. 2. Staff did not assist resident with obtaining medical care. 3. Staff did not assist resident with ambulating which resulted in resident developing rashes. 4. Staff did not communicate with resident's responsible party. 5. Staff did not release resident's personal belongings to responsible party. 6. Staff did not safeguard resident's personal belongings.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to deliver findings for the allegations listed above. LPA met with Receptionist, Daisy Fitter, and explained the reason for the visit. The investigation consisted of the following: On 5/16/23, LPA Chan toured the facility and inspected six rooms. LPA also obtained copies of documents pertaining to Resident #1 (R-1) and interviewed 2 Staff. Sufficient food supplies of 2-day perishable and a week of non-perishable were observed. There were no immediate health and safety concerns observed during that visit. On 9/21/23, LPA Chan conducted interviews with the Administrator, 3 Staff, and 4 Residents. (Continue on next page) Unsubstantiated The investigation revealed the following: Allegation #1 - Resident sustained bruises while in care. This allegation was investigated by Investigator Juan Lozano from the Department Investigations Branch. Interviews were held with the facility staff, a family member, and a personal caregiver. Medical records were also obtained and reviewed to determine this finding. The medical records did not indicate Resident #1 (R-1) had visible bruising by staff during a hospital visit. R-1’s caregiver also had not observed any visible injuries when visited R-1 at the facility. LPA interviewed additional staff for this allegation. They stated R-1 had bruises upon admission on 12/1/22 and did not observe any new ones during the short stay at the facility. In addition, LPA interviewed a hospice liaison who confirmed R-1 had bruises prior to being admitted to the facility and has skin issues which causes resident to bruise easily. Allegation #2 - Staff did not assist resident with obtaining medical care. It was alleged R-1 had a fall and did not seek medical attention. Documentation showed that R-1 had a fall on 12/17/22 and complained of a headache. Staff interviewed stated that due to the fall and the headache, they immediately contacted 911. They came and transferred R-1 to the hospital. The facility notes indicated the fall, 911 was called, and reported to the hospice nurse and R-1’s wife. According to the administrator and staff, when a resident sustains a fall, they would check the resident and contact the paramedics as a safety precaution. All 4 residents interviewed stated the staff would seek medical attention for anyone that needs it. Allegation #3 - Staff did not assist resident with ambulating which resulted in resident developing rashes. It was alleged that R-1 developed rashes due to sitting in a chair for prolonged periods of time and not ambulating from chair. Per administrator and staff, they encourage residents to move around throughout the day to prevent rashes. Those in wheelchairs are transferred to and from their beds and/or repositioned in their seats. Residents are brought out to common areas and encouraged to participate in activities. Staff interviewed did not recall seeing any rashes on R-1 and stated they did not allow R-1 or any residents in wheelchairs to sit for long periods of time. Allegation #4 - Staff did not communicate with resident's responsible party. It was alleged that Resident #1 (R-1) fell and did not inform the responsible party of the fall. Staff who witnessed the fall stated they contacted R-1’s responsible party after calling 911. R-1’s responsible party was upset at staff for calling the paramedics and hung up on staff. Administrator and staff stated they had always been in communication with R-1’s family member during visitations and would return phone calls. LPA obtained a copy of the staff notes which documented the communications with resident’s wife. They stated they communicate with other residents’ families as well and provide updates of residents’ conditions when necessary. Allegations #5 - Staff did not release resident's personal belongings to responsible party and #6 - Staff did not safeguard resident's personal belongings. Per the administrator and staff, when a resident moves in, they fill out the Resident Personal Property and Valuables form to indicate any items brought into the facility. As for R-1, they stated R-1’s inventory form only listed articles of clothing. When R-1 moved out, the clothes were returned and R-1’s responsible party signed. LPA reviewed and obtained a copy of the signed list of inventories returned. Staff interviewed stated that they would safeguard resident’s personal belongings by washing their clothes separately so they do not mix them up with another resident's. They keep an eye on where residents go and make sure they do not take things that do not belong to them. They stated no residents had reported anything missing. Residents interviewed stated did not have any thing missing as well. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Daisy Fitter. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 13, 2023 · control 28-AS-20230512120959