Neighborhood Suites - Costeau

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced Case Management visit for the purpose to verify facility closure. LPA arrived to facility, greeted at the door by Ofelia Angeles, Administrator and granted entry. The LPA was informed on October 28, 2025, that licensee decided to close the facility and there no residents in care. At the time of closure, the facility census was one resident and resident moved out on October 14, 2025, to a licensed facility. The facility is officially closed and no longer operating as a licensed facility as of October 28, 2025. The administrator surrendered license to LPA on today’s visit. The reason for today's inspection is to confirm the closure of the licensed facility. LPA toured the facility and observed no residents in care. LPA observed the home to be empty and found no evidence the home is operating as a licensed facility. Based on observation, the facility is no longer operating as a licensed facility and is closed. Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Administrator, and a copy of this report was provided and left at facility.the state’s words, verbatim · CDSS document, Nov 6, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced case management visit to the facility today in conjunction with a complaint investigation. LPA was greeted by caregiver and were granted entry. LPA met with Ignatius Rusli, Administrator, and explained the nature of the visit. Ofelia Angeles, Administrator arrived after and met with LPA. This visit is being conducted to obtain pertinent documents needed. During today’s visit, LPA toured the interior of the facility and inspected the physical plant. LPAs inspected the food supply, observed medication storage, resident’s bedrooms and attached garage. LPA reviewed resident records and obtained copies of pertinent documents. An exit interview was conducted with facility representatives, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 11, 2025

Allegation investigated: -Neglect/Lack of Care and Supervision resulting in a resident's death. -Neglect/Lack of Care and Supervision resulted in resident's serious injury.

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA arrived at facility and was greeted at the door by staff and granted entry. LPA spoke with Ofelia Angeles, Administrator and explained the purpose of the visit. The complaint was investigated by the Department. Findings are based upon this investigation which included interviews with 6 staff and 5 witnesses and the following records review: medical records from Oasis Haven Hospice dated March 4, 2024, and County of Orange Death Certificate dated February 28, 2025, and resident’s facility file. It is alleged Neglect/Lack of Care and Supervision resulting in a resident having a fall and sustaining a fractured hip and passed away. Resident (R1) moved into the facility on March 8, 2024, diagnosed with Continued on LIC9099-C Unsubstantiated 3:30 AM. Staff found R1 on the floor yelling for help due to the pain. Staff lifted R1 from the floor and placed back in bed. Staff did not notify the administrator or hospice until 8 AM. Hospice nurse assessed R1, and caring physician ordered mobile x-ray service. Mobile x-ray services were conducted on December 3, 2024, at 3:30 PM. Results reflecting a fractured left hip were received at 4:55 PM. Interview with staff revealed that they were instructed to notify hospice first when a resident is under the care of a hospice agency. Staff did not call 911 when R1 was found on the floor in great pain and discomfort. The staff lifted the resident off the floor in pain and placed the resident back in bed with no regard for the seriousness of their pain and possible injury. During the course of the investigation, there was sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, this allegation is deemed Substantiated. See LIC-9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations and the assessed immediate civil penalty in the amount of $500. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f). An exit interview was conducted with the Administrator, and a copy of this report, Appeals Rights, and LIC-421IM Civil Penalty Assessment and the LIC-811, identifying confidential names were provided. Alzheimer’s and was receiving hospice care as need for R1’s on-going health conditions. R1 was able to ambulate around the facility with stand by assistance when mobile. The facility operates with three-four staff that reside in the home during their work-week shifts. The staff works 12-hour shifts and care for three-five residents. There is one caregiver for the overnight shift. The facility utilizes Oasis Haven Hospice as needed. On December 2, 2024, at about 3:30 AM, R1 requested assistance to go to the bathroom. Staff assisted R1 and staff went to help another resident with an activated motion sensor alarm. Upon return R1 was observed on the floor and appeared to be in pain and discomfort. Staff called Administrator and hospice company notifying them of the incident. Hospice nurse visited R1 at the facility and an x-ray was ordered by attending physician. X-ray results revealed that R1 had sustained a fracture left hip, due to R1’s age and health family was unable to find a surgeon for the reported injury. On December 6, 2024, R1 passed away at the facility under medical care of Oasis Haven Hospice. Interview with caring doctor for R1 stated that the cause of death was Alzheimer’s and not the reported injury. During the investigation there was not enough information to support the alleged allegations. Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with the facility representatives and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Jun 23, 2025 · control 22-AS-20250105223133

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(g) · Plan of correction due date: Jul 8, 2025

87465(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by:R1 sustained a fracture hip while in care due to an unwitnessed fall at 3:30am. R1 complained of pain. Staff did not notify administrator hospice till 8AM, which posed a potential health risk to persons in care. A civil penalty will be assessed.the state’s words, verbatim · CDSS document, Jun 23, 2025

Plan of correction: Licensee to provide staff in-services so all staff understand the regulation for Incidental Medical and Dental Care. Licensee to include date of inservice, topics covered and participant signature and email proof to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Ruth Martinez and Hanna Gough are conducting this unannounced visit for the purpose of completing the annual required inspection. LPAs arrived at the facility and was greeted and granted entry by staff. LPAs met with Administrator (AD) Ofelia Angeles and explained the nature of the visit. There are three residents at the facility. LPAs accompanied with (AD) began the tour of the inside and outside of the facility. LPAs observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishable foods available. There is additional food storage in a spare refrigerator and pantry located in the garage. The facility is maintained at a comfortable temperature. LPAs inspected that medication is centrally stored in a safe locked storage cabinet located in the kitchen. LPAs reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPAs inspected the bathroom and LPAs measured the hot water temperature between 111.7-119.6 degrees Fahrenheit. The bathrooms observed to have a supply of soap, toilet paper and paper towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPAs observed that toxic chemicals, cleaning solutions and disinfectants are stored locked underneath kitchen sink and in a locked storage cabinet located in the garage. The facility has an available clean supply of linens. LPAs inspected residents’ bedrooms. All bedrooms observed to have all required components and furnishings. Storage space is provided for residents in their bedrooms. Smoke detectors/ carbon monoxide were tested and found to be operational. Continued on LIC809-C LPAs toured the outside of the facility and observed outdoor passageways are free of obstructions. LPAs observed the pool gate has an entry door which opens away from the pool. The fence has a lock that requires a key at the gate for inaccessibility. LPAs measured the pool fence which measured 5ft from base of the floor to the top of the fence and it was observed to enclose the entire pool area. LPAs observed a fire extinguisher in the kitchen with a service date of January 02, 2025. The last fire drill conducted was on January 21,2025. LPAs began review of records. LPAs reviewed two resident records. All the required documentation was present and current in the residents’ files. LPAs reviewed two employee records which had all the required documentation. One out of two caregivers present did not have a criminal record clearance and are not associated to the facility. Based on this inspection, deficiencies were observed at this time in the areas evaluated per Title 22 Division 6 of the California Code of Regulations. See LIC 809-D for deficiencies. Civil Penalties were assessed on this date. This report was reviewed with Administrator and a copy of this LIC809, LIC809-D report was provided and left at facility. Appeal rights reviewed, and a copy provided.the state’s words, verbatim · CDSS document, Feb 20, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez and Faith La is conducting this unannounced visit for the purpose of completing an annual required inspection. LPAs arrived at the facility and was greeted and granted entry by caregivers Ang Siong and Ronald Tumbio and LPAs explained the nature of the visit. There are four residents at the facility and there are two residents receiving hospice services currently. Ignatius Rusli, Administrator arrived shortly after and met with LPAs. Four residents reside at this facility. There were four residents at the time of the visit. LPAs accompanied with Administrator Ignatius Rusli began the tour of the inside and outside of the facility. LPAs observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in storage a spare refrigerator and pantry in the garage. The facility is maintained at a comfortable temperature. LPAs inspected that medication is centrally stored in a safe locked storage cabinet located in kitchen. LPAs reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPAs inspected the bathroom and LPAs measured the hot water temperature which measured 112.8 Fahrenheit degrees. All two bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPAs observed that toxic chemicals, cleaning solutions and disinfectants are stored locked underneath kitchen sink and locked storage cabinet in the garage. The facility has an available clean supply of linens. LPAs inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors/ carbon monoxide were tested and found to be operational. Continued on LIC809-C LPAs toured the outside of the facility and observed outdoor passageways are free of obstructions. LPAs observed the pool gate has an entry door which opens away from the pool. The fence has a lock that requires a key at the gate door for inaccessibility. LPAs measured the pool fence which measured 5ft from base of the floor to the top of the fence and it was observed to enclose the entire pool area. LPAs observed a fire extinguisher with service date of January 02, 2024, in kitchen. Fire drills are conducted every three months. LPAs began review of records. LPAs reviewed two resident records. All the required documentation was present and current in the residents’ files reviewed. LPAs reviewed two employee records. All employees present a criminal record clearance and are associated to the facility. LPAs observed records reviewed have a current First Aid certificate. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. LPAs are issuing an LIC 9102 (Technical Advisory) in lieu of a citation. This report was reviewed with the Administrator and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, May 9, 2024