Oakmont of Orange

Allegation investigated: Staff are not responding to residents call buttons in a timely manner Staff did not ensure resident was dressed for appointments

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the investigation, LPA toured the facility and interviewed staff, witness and resident as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegations that staff are not responding to residents call buttons in a timely manner and staff did not ensure resident was dressed for appointments, the investigation revealed the following: Per review of call button response records, there are three instances of response times over 27 minutes between 06/26-07/05/2026 for Resident 1 (R1). Facility is unable to print out the records prior to 06/26/2026. Email thread between R1's family and facility acknowledge a response time of approximately two hours on 06/26/2026. LPA pushed the emergency button in the first floor common restroom at 11:33 AM and waited until 11:50 AM and received no staff response even as LPA observed staff walking by and lingering near the restroom. R1 indicated through interview that staff responses to call button can take one to two hours depending on the day. CONTINUED ON LIC 9099C DATED 07/07/2026. Substantiated LPA tested R1's call button two times during the visit and staff responded one time. Per physician report dated 07/03/2025, R1 has no cognitive decline and can manage own medications. R1 indicates two recent times in June when the resident had an appointment in the morning and was not assisted with getting ready timely for the appointment. Email correspondence and interviews conducted confirm the resident was not ready for the appointments on 06/22/2026 and 06/25/2026 thus family had to assist in getting the resident ready to leave for the appointment. R1's care plan dated 07/01/2026 shows resident requires "Hands on assistance with dressing." Email correspondence between family and facility show facility was notified of the appointment times in advance. Based on record review and interviews conducted, the preponderance of evidence standard has been met. Therefore the allegations are deemed substantiated. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of the report provided as well as appeal rights.the state’s words, verbatim · CDSS document, Jul 7, 2026 · control 22-AS-20260630144919

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 8, 2026

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This req is not met as evidenced by: Based on record review and interviews conducted, Licensee failed to ensure R1's call button was responded to timely which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: Licensee to provide an in-service to staff on responding to call buttons and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jul 21, 2026

Basic services shall at a minimum include: Personal assistance and care as needed by the resident.., with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications..This req is not met as evidenced by: Based on record review and interviews conducted, Licensee failed to ensure R1 was assisted with dressing per care plan dated 07/01/2026 which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: Licensee to provide an in-service to staff on following resident care plans and forward proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr made an unannounced case management visit in conjunction with Unusual Incident/Injury Report (UIIR) dated June 10, 2026. LPA was greeted and granted entry by Executive Director (ED) Dennis Robeniol. LPA explained the reason for the visit. Per UIIR, Resident 1 (R1) returned to the community at approximately 2:30 p.m. after leaving unsupervised on June 9, 2026, in his electric wheelchair. During today's visit LPA reviewed the Medical Assessment dated January 20, 2026, for R1. Per Medical Assessment, R1 is unable to leave the facility without assistance. A Health and Safety inspection was conducted, and LPA Ramirez observed no Health and Safety concerns during today's visit. Based on observations and records reviewed during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with ED Robeniol and a copy of this report and Appeal Rights were provided at the time of exit.the state’s words, verbatim · CDSS document, Jun 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 18, 2026

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Per UIIR, R1 left the facility unassisted in their electric wheelchair. Per Medical Assessment, R1 is unable to leave the facility without assistance. This poses an immediately health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Licensee to submit a written plan to ensure basic services including care and supervision are provided to residents in care at all times. Licensee to submit POC by POC due date.

Allegation investigated: Facility did not respond to a resident's call light in a timely manner Facility did not call medical services in a timely manner

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of delivering findings. LPA met with Executive Director (ED) Dennis Robeniol and explained the purpose of the inspection. Regarding allegations, Facility did not respond to a resident's call light in a timely manner and Facility did not call medical services in a timely manner, the following was revealed: It is alleged facility staff did not respond to Resident 1’s (R1’s) call light in a timely manner or call medical services for R1 in a timely manner. During the course of the investigation, LPA obtained a copy of Charting Notes for R1 signed by Staff 1 (S1) which indicated that on October 16, 2025 at 4:00 a.m., R1 had an unwitnessed fall while walking to the restroom and hit their head. Per Charting Notes, R1 pressed their bathroom alarm but cleared themselves while they kept pressing on it. Charting Notes do not specify the time lapse between R1’s fall and staff response time. Charting Notes for R1 signed by Staff 2 (S2) also indicated that on October 19, 2025, R1 had another fall at approximately 5:45 p.m. (Cont. LIC9099-C) Unsubstantiated R1 was using their walker to walk over to the dining room for dinner with their daughter when they fell back and hit their head. Charting Notes do not indicate if R1’s pendant was pressed at that time or how staff was alerted of R1’s fall. Interviews were conducted with one witness, two staff, and six residents. During their interview, R1’s daughter, Witness 1 (W1) stated that on October 16, 2025 at 4:00 a.m., R1 called them crying and stated they had pressed the call button in their bathroom due to having fallen and had waited for staff to arrive. Per W1, R1 informed them they got back in bed because no one came and had fallen asleep. W1 stated R1 woke up again because their head was hurting. Per W1, they told R1 to call 911 and stated it was R1 who had called 911 “as far as” they knew. W1 stated they then called the front desk to inform them of R1’s fall and questioned why staff had not gone to check on R1. W1 stated staff apologized and stated they thought it was a “false alarm” because R1 had never pressed their call button before. W1, however, was unable to identify staff alleged to have stated they thought it was a “false alarm.” Per W1, on October 19, 2025, they had been present at the time of R1’s fall and had pressed R1’s pendant, but no one came, so they pressed it again and no one came until they called the front desk and were subsequently informed staff were tending to another resident emergency, and paramedics were already on-site. R1 is no longer a resident at the facility. Three separate attempts were made to reach R1 by phone, however, R1 could not be reached to confirm or deny allegation. During their interview, S1 stated that on October 16, 2025 at approximately 4:00 a.m., they received a call from W1 notifying them that R1 had an unwitnessed fall in their bedroom and had been pressing their call button. S1 stated they did not know how long it had been since R1’s fall or how many times R1 had pressed their call button. Per S1, if a resident keeps pressing their pendant and staff go to clear another resident’s call, the call system will inevitably clear their call as well. S1 stated that upon responding to R1’s room they found R1 sitting on the edge of their bed. Per S1, R1 informed them they had gotten up to go use the restroom and had fallen and hit their head on the television stand and that is when paramedics were called. S1 stated they could not recall ever personally telling W1 they had not checked on R1 due to R1 never pressing their pendent nor did they recall any other staff making that statement. S1 stated they had called the paramedics as soon as R1 informed them that they had hit their head and paramedics arrived between “five to six minutes” later. During their interview, S2 stated on October 19, 2025, R1 was walking with their walker with the assistance of W1, when they fell back and hit their head. Per S2, W1 reported pressing R1’s pendant, however, S2 was tending to another resident emergency at the time and stated they were unsure how long it had taken for them to respond but estimated "it could have been ten to fifteen minutes." (Cont. LIC9099-C) Per S2, once they were informed R1 had hit their head, paramedics on-site were called to assess R1 and transported them to the hospital. During interview, Resident 2 (R2) and Resident 3 (R3) stated that in the event they need assistance they are able to alert staff using their pendant, and staff respond within minutes. Per R2 and R3, emergency services have been called for them personally on at least one occasion and stated they were contacted immediately and an ambulance arrived without delay. During their interview, Resident 4 (R4) stated their pendant has been tested by staff and they were informed it tested operational; however, they believe it often malfunctions and therefore, they use their personal cell phone to call for assistance and staff "come right away." R4 denied having any knowledge of any delays in staff seeking medical care for residents. During their interview, Resident 5 (R5) and Resident 6 (R6) stated they have not personally required emergency services be called. Per R5, they do not need staff assistance and in the event they accidentally press the pendant around their neck, staff "come right away" and if they are not in their room, staff will find them walking around the facility and ask if they need assistance. Per R6, in the event they need assistance, they call the front desk using their personal cell phone or use the pendant around their neck and staff arrive immediately. Based on record review of R1's Charting Notes and due to allegation being uncorroborated during interviews conducted, the Department is unable to determine if Facility did not respond to a resident's call light in a timely manner or if Facility did not call medical services in a timely manner. Although the above 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 at this time the above allegations are unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 22-AS-20260114075555

Allegation investigated: Facility staff did not assist resident with incontinence care as needed. Facility staff did not assist resident with showering as needed. Facility staff handled the resident in a rough manner.

On May 28, 2026, Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose of concluding the investigation into the above allegations. LPA met with Health Services Director (HSD) Angela Boyd and stated the reason for the visit. During the course of the investigation, the Department toured the facility, interviewed eight residents, three staff, and obtained documentation for review: Resident Rosters, Personnel Rosters, Face Sheets, Physician's Reports, Individualized Service Plans, and Resident Care Notes. The investigation is as follows: On June 25, 2024, the Department received the complaint. The investigation was initiated by LPA Jenifer Tirre on July 3, 2024. LPA Tirre toured the physical plant of the facility including resident rooms. LPA Cho continued the investigation on today's date, conducted interviews, and review of records. Regarding the allegation, Facility staff did not assist resident with incontinence care as needed, it is alleged that Resident #1 (R1) would lie soiled in feces or urine. Unsubstantiated Based on the review of R1's service plan dated June 19, 2024, R1 was provided complete assistance with toileting according to schedule, needs, and requests. Based on the review of R1's care notes, there were written documentation providing brief changes on May 12, 13, 30, 31, 2024, and during the nocturnal shifts. R1 also refused to use the toilet and requested brief changes in bed on May 30, 2024. Based on an interview with a witness, R1 alleged "waiting for hours" when staff was called for assistance. Care notes reveal that R1 was checked on "multiple times throughout shifts" even though R1 "voiced complaints of staff not checking in overnight." Based on the interviews with eight residents who resided at the facility in 2024, none of the residents are incontinent. Three of eight residents required assistance with toileting which also aligned with their care plans at the time; however two of three residents that required toileting, confirmed toileting assistance was provided as needed per their requests. LPA was unable to qualify the statement of the third resident due to their medical condition, and two of three staff denied the allegation while the third indicated not providing care to R1 at the time. Regarding the allegation, Facility staff did not assist resident with showering as needed, it is alleged that R1 received sporadic showers. Based on the review of R1's service plan, complete assistance with showering/bathing was provided four times a week for R1. There were no documentation regarding showers per the care notes. However, based on the interviews with eight residents who resided at the facility in 2024, seven confirmed showers were provided timely which aligned with their individual plans. LPA was unable to qualify one resident due to their medical condition. Two of three staff denied the allegation while the third staff indicated not providing care to R1 at the time. Regarding the allegation, Facility staff handled the resident in a rough manner, it is alleged that the handling of R1 was "roughed up." Based on the interviews, seven of eight residents who resided at the facility in 2024 denied experiencing aggressive handling also denied by two of three staff who were employed at the time. However, one resident confirmed one caregiver was rough in the way they assisted them during transfers. The remaining one staff did not provide care to R1 at the time. Based on interviews and record review, 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, all allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Health Services Director Angela Boyd, and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, May 28, 2026 · control 22-AS-20240625085618

Allegation investigated: Resident sustained multiple falls while in care due to staff neglect

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of delivering findings. LPA met with Executive Director (ED) Dennis Robeniol and explained the purpose of the inspection. Complaint alleges Resident 1 (R1) sustained multiple falls while in care due to staff neglect. During the course of the investigation, interviews were conducted with R1, one witness, and two staff. During their interview, R1’s responsible party, Witness 1 (W1), was unable to confirm or deny if R1 had sustained multiple falls due to staff neglect. Per W1, R1 may have sustained a fall in May 2024 and October 2024, however, stated they could not recall any of the details regarding the falls. W1 stated that per R1's Care Plan, staff should be conducting routine checks, which consist of staff checking on R1 on a regular basis and reporting back to W1 in the event of a fall. (Cont. LIC9099-C) Unsubstantiated Per W1, when they are personally present at the facility, staff routinely check on R1, however, stated they did not know if staff routinely check on R1 when they are not present at the facility. During their interview, R1 denied ever sustaining a fall and stated if they did, “it was a long time ago” and could not remember. LPA obtained a copy of Incident Report (LIC624) which indicated that on May 11, 2024, R1 had an unwitnessed fall in their bedroom and had been found as a dining room tray was being delivered to their room. LIC624 identifies S1 as the person who observed the incident, however, S1 is no longer employed at the facility. Three separate attempts were made to reach S1 by phone, however, S1 could not be reached to confirm or deny the allegation. LPA obtained a copy of a separate LIC624, which indicated that on October 8, 2024, R1 had an unwitnessed fall in their bedroom and had been found on the floor by Staff 2 (S2) as they were conducting routine checks. During their interview, S2 stated they could not recall specific details regarding the incident, however, stated routine checks are conducted for R1 during shifts and R1 is also escorted to meals and activities by staff, which enables staff to conduct additional checks on R1. LPA obtained a copy of Individualized Service Plan (ISP) for R1, which indicates R1 is at moderate risk for falling, and is to be provided with a status check each shift and escorted to meals and activities. Per ISP, fall management protocol consists of ensuring R1 is using assistive mobility devices at all times, reminding and encouraging R1 to use pendant to call for staff assistance, and staff continuing with frequent check-ins. During their interview, Staff 3 (S3) stated they did not have any knowledge regarding R1’s fall on May 11, 2024 or October 8, 2024, however, stated that due to R1’s moderate risk for falling, staff are to conduct status checks. Per S3, status checks are conducted every two to three hours and consist of staff physically observing the resident to ensure they have not fallen. During the course of the investigation, LPA observed R1 being checked on by care staff on at least two occasions. Based on record review of R1’s Individualized Service Plan and LIC624, and due to allegation being uncorroborated during interviews conducted, the Department is unable to determine if Resident sustained multiple falls while in care due to staff neglect. Although the above 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 at this time the above allegation is unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, May 21, 2026 · control 22-AS-20241010090602

Allegation investigated: Staff did not prevent resident from smoking in the facility

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of delivering findings. LPA met with Executive Director (ED) Dennis Robeniol and explained the purpose of the inspection. Complaint alleges Staff did not prevent Resident 1 (R1) from smoking in the facility. During the course of the investigation, interviews were conducted with ten facility residents, including R1, and four staff. During their interview, R1 stated that upon their admission to the facility on March 31, 2026, they had smoked a cigarette in their bedroom on two occasions. Per R1, they were immediately informed by Staff 1 (S1) they could not smoke in their room and that a designated smoking area was available outside. R1 denied smoking inside the facility since being informed they could not smoke inside and stated they have since quit smoking. During their interview, S1 stated they had not personally witnessed R1 smoking inside, however, they had informed R1 they could not smoke in their room. (Cont. LIC9099-C) Unsubstantiated Per S1, R1 agreed to give their cigarettes to staff and request them at their own leisure to ensure they are not smoking in their room and instead using the designated smoking area outside. S1 stated to their knowledge R1 has been using the designated area outside to smoke, however, stated R1’s clothing does become pungent with cigarette smoke, and the smell may linger in the hallway. During their interview, Staff 2 (S2) denied ever witnessing R1 or any other resident smoking inside the facility and stated they personally escort R1 to the designated smoking area outside to smoke. Interviews were conducted with two housekeeping staff, Staff 3 (S3) and Staff 4 (S4), who denied smelling smoke or witnessing R1 or any other resident smoking in their room. During their interview, Resident 2 (R2) stated they had not personally witnessed R1 smoking inside the facility, however, stated R1 had been continuously smoking cigarettes in their room because they could smell the smoke. During their interview, R3 stated they had smelled smoke in the facility hallway, however, stated they had not personally witnessed R1 smoking inside the facility. Per R3, the smell was coming from the windows in the hallway, which are facing the street. During their respective interviews, Resident 4 (R4) and Resident (R5), whose bedrooms are next door to R1’s bedroom, denied smelling smoke or having any knowledge of R1 or any other resident smoking in their bedroom. Five of five additional residents interviewed denied smelling smoke or witnessing any resident smoking inside the facility. Due to the allegation being uncorroborated during interviews conducted, the Department is unable to determine if Staff did not prevent resident from smoking in the facility. Although the above 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 at this time the above allegation is unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, May 21, 2026 · control 22-AS-20260515103726

Allegation investigated: Resident sustained multiple falls while in care Staff neglected resident while in care

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit to deliver findings on an investigation. LPA was greeted and granted entry into the facility by staff and explained the reason of the visit with Executive Director Dennis Robeniol During course of the investigation, the Department reviewed & obtained records including Physician’s report, fall risk evaluation assessment, Resident assessment, charting notes, hospital records and service plan. Department also interviewed staff and witness. The investigation revealed the following regarding allegations: Resident sustained multiple falls while in care and Staff neglected resident while in care: Regarding Resident sustained multiple falls while in care: Based on resident records, Resident was fully independent of mobility back on 5/29/2020 upon admission to facility. R1 had a Fall Risk Evaluation assessment back on 3/22/22 where resident scored 8 indicating high risk of falling. At the time service plan interventions were put into place. CONTINUED ON 9099C Unsubstantiated Six months later R1 was assessed again for Fall Risk Evaluation and scored a 3, indicating Minimal Risk of falling. R1’s charting notes stated that R1 had a fall on October 28, 2022 , where resident tripped on a rug but got up immediately and underwent a Physical therapy assessment where therapist noted R1 is alert oriented x3 and demonstrates poor safety awareness due to impulsive movement. Physical Therapist recommended R1 to improve safety by using an assistive device such as cane or walker. On 7/3/2023 Hospital Records stated that R1 had tripped over themselves causing an unwitnessed fall. R1 went to hospital. On 7/12/2023 Facility conducted a assessment on R1 due to a change in condition with behaviors and mobility issues. Residents Needs and Service Plan was updated same day 7/12/2023 indicating R1 needs assistance in grooming, dressing, assist with transfers, frequent checks throughout shifts and documentation by staff. Per staff interviews, one of four staff members recalled R1 and stated that they were in assisted living and remembers R1 being independent of their Activities of daily living (ADL’s) for a long time and it wasn’t till the last few months of R1 requiring assistance due to mobility issues. Regarding Staff neglected resident while in care: Based on records reviewed, R1 was independent up till their unwitnessed fall on 7/3/2023. R1 had charting notes dated from 1/16/22 to 7/10/2023, where care providers logged notes on type of care or behaviors monitored by staff. R1 also had a home health agency that came out weekly to monitor R1’s foot sore on left foot. On 6/19/2023, R1 was admitted to Hospice due to generalized weakness. Hospice notes also indicated type of care provided. Per staff interviews, four of four staff members stated that Residents who are a fall risk are typically checked in on & monitored every half hour. One of four staff mentioned that R1 was fairly independent and had a change of condition towards their last month. Per SOC 341, R1’s family member stated that they had no concerns regarding care provided at facility. Based on information gathered from complaint, the allegations Resident sustained multiple falls while in care and Staff neglected resident while in care were deemed Unsubstantiated meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur as reported. An exit interview was conducted with Activity Director Rebecca Lint and copy of report was provided.the state’s words, verbatim · CDSS document, May 18, 2026 · control 22-AS-20230706083051

Allegation investigated: Facility staff did not provide adequate supervision resulting in resident being injured.

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of delivering findings. LPA met with Executive Director (ED) Dennis Robeniol and explained the purpose of the inspection. Complaint alleges Staff did not check on Resident 1 (R1) for approximately two hours, resulting in R1 sustaining a fall and being injured. During the course of the investigation, LPA obtained a copy of Resident Care Notes for R1 signed by Staff 1 (S1) which indicated that on June 27, 2024, R1 had been found on the floor by their bed with lacerations by their right eye and skin tear to right wrist, 911 was called, and R1 was transported to the hospital. The Care Notes, however, do not specify if there was a lapse in time between R1’s fall and R1 being found, and do not indicate the time R1 was last checked on by staff prior to being found on the floor. R1 could not be interviewed due to their passing on July 10, 2024. (Cont. LIC9099-C) Unsubstantiated S1 is no longer employed at the facility and three separate attempts were made to reach S1 by phone, however, S1 could not be reached to confirm or deny the allegation. Interviews were conducted with one witness, eight facility residents, and four staff. During their interview, R1’s responsible party, Witness 1 (W1), attributed R1's fall to their medical diagnosis and stated they were unsure if R1 had sustained a laceration or skin tear as a result of the fall. W1 stated they believed there could have been a lapse of about "15 minutes" between R1’s fall and R1 being found on floor, however, stated they did not believe it was two hours. Per W1, they had no concerns regarding the care provided to R1 by the facility. During their interview, seven of eight residents denied staff not providing adequate supervision and stated that in the event they need assistance they are able to alert staff using their pendant, and staff respond within minutes. One of eight residents stated their pendant has been tested by staff and they were informed it tested operational; however, they believe it often malfunctions and therefore, they use their personal cell phone to call for assistance and staff "come right away." During their interview, four of four facility staff denied having any knowledge of R1’s fall or injury and denied having knowledge of R1 or any other resident sustaining a fall with a two hour lapse in supervision by staff. Based on record review of R1's Care Notes and due to allegation being uncorroborated during interviews conducted, the Department is unable to determine if Facility staff did not provide adequate supervision resulting in resident being injured. Although the above 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 at this time the above allegation is unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, May 14, 2026 · control 22-AS-20240709164259

Allegation investigated: Staff did not seek timely medical care for resident in care

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of delivering findings. LPA met with Executive Director (ED) Dennis Robeniol and explained the purpose of the inspection. Complaint alleges Staff did not seek timely medical care for Resident 1 (R1). During the course of the investigation, LPA obtained a copy of Charting Notes indicated that on November 26, 2024 at approximately 12 p.m., R1 had reported pain to left hip and leg and was unable to bare any weight on their left leg. An ambulance was called and arrived at approximately 12:15 p.m. to transport R1 to the hospital. Interviews were conducted with one witness and eight facility residents, including R1. During their interview, R1 was unable to confirm or deny the allegation. During their interview, R1’s responsible party, Witness 1 (W1), stated that on the morning of November 26, 2024, they received a call from a staff member who informed them R1 had fallen. (Cont. LIC9099-C) Unsubstantiated W1 was unable to recall the exact time of the phone call or the events leading up to R1’s fall and could not recall which staff member had called to inform them of the fall. W1 stated that during the call they were informed no injuries or pain had been reported by R1 and no injuries had been observed by staff. Per W1, they later received a second call on the same date indicating R1 was experiencing pain and was being transferred to the hospital. W1 denied staff not seeking timely medical care as R1 had not initially reported any pain and staff had not observed any injuries. W1 stated they did not have any concerns regarding the care provided by the facility. During their interview, seven of seven residents denied having any knowledge of staff not seeking or delaying medical care for residents. Based on record review of R1's Charting Notes and due to allegation being uncorroborated during interviews conducted, the Department is unable to determine if Staff did not seek timely medical care for resident in care. Although the above 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 at this time the above allegation is unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, May 14, 2026 · control 22-AS-20241126135236

Allegation investigated: Staff did not follow physician's order to monitor resident's blood pressure Staff falsified resident records

An unannounced complaint investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above. LPA met with Executive Director (ED) Dennis Robeniol and Health Services Director (HSD) Angela Boyd. Regarding the allegation, Staff did not follow physician's order to monitor resident's blood pressure, the following was revealed: It is alleged that Staff did not follow physician's order to monitor Resident 1’s (R1’s) blood pressure. An interview was conducted with R1’s responsible party, Witness 1 (W1), who stated that the facility had informed them they could not accept a verbal request to monitor R1’s blood pressure. Per W1, on January 13, 2026, they provided a printout of the physician’s order, which also had a medical stamp with R1’s care provider information, however, the facility would still not accept it and stated physician’s hand signature was required. Per W1, they were then provided with the incorrect fax number for the facility and by January 19, 2026, one full week of the prescribed monitoring period had passed with no blood pressure readings taken. (Cont. LIC9099-C) Substantiated During the course of the investigation, LPA obtained a copy of R1’s physician order dated January 12, 2026, which states, “continue with blood pressure monitoring for the next two weeks.” LPA also obtained a copy of R1’s vital signs readings from January 12, 2026 to January 20, 2026 and observed R1’s blood pressure was only taken on two days, January 19, 2026 and January 20, 2026. During their interview, R1 corroborated the allegation and stated their blood pressure had not been taken during that time frame. Regarding the allegation, Staff falsified resident records, the following was revealed: It was alleged staff falsely documented R1’s blood pressure readings. During their interview, W1 stated R1’s doctor requested their blood pressure be taken daily for one week due to critically low readings. Per W1, R1’s blood pressure was only taken once between December 27, 2025 and December 31, 2025, however, the report they received on January 2nd, 2026 contained five readings, of which four were falsely presented as if they had been measured. LPA obtained a copy of blood pressure readings in question and observed Staff 3 (S3) had taken R1’s blood pressure on December 27, 2025, December 28, 2025, and December 29, 2025 and Staff 1 (S1) had taken R1’s blood pressure on December 30, 2025 and December 31, 2025. During their interview, S1 corroborated the allegation and stated the blood pressure readings had been falsified, but they were unsure of who had entered them. S1 denied taking R1’s blood pressure during that time frame due to having been on vacation at the time. During their interview, S3 corroborated the allegation and stated the blood pressure readings had been falsified, but they were unsure of who had entered them. Per S3, they did take R1’s blood pressure on December 27, 2025, however, denied having taken R1’s blood pressure on December 28, 2025 or December 29, 2025 as that was their day off. During their interview, R1 also corroborated the allegation and stated their blood pressure had only taken once by S3 on December 27, 2025. Based on R1’s record review and Staffs’ and R1’s interview, the preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of regulations (see LIC9099-D). An exit interview was conducted. A copy of this report, and appeal rights were left at the facility. LPA obtained email records between W1 and the former Executive Director, Staff 2 (S2) and on an email dated February 2, 2026, S2 states they asked S1 if they had offered the pill cutter to R1, which S1 admitted, however, there is no indication the medication in question was in fact cut or managed by S1. During their interview, W1 stated that S1 had entered R1’s room with a doctor’s letter indicating R1’s blood pressure medication dose had been decreased and asked R1 to cut their blood pressure medication in half. Per W1, they received a call at the time of the incident and were able to intervene and prevent staff from managing or cutting R1’s medication as R1 already had the decreased dose of the medication and there was no need to cut it half. The Department has investigated the complaint alleging Staff mismanaged resident's medication. After a review of R1’s records and interviews conducted with staff and witnesses, We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 22-AS-20260114213328

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 23, 2026

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on record review and staff and resident interviews, the Licensee did not comply with the section cited above as R1’s physician order to continue with blood pressure monitoring was not followed, which posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: ED stated an in-staff service meeting will be held to ensure all physician orders are followed and a copy will be provided to LPA via email by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: Apr 23, 2026

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: Based on staff and resident interviews, the Licensee did not comply with the section cited above as staff falsely documented R1’s blood pressure readings, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: ED stated staff training will be conducted regarding false claims and accurate record keeping for all residents and a copy will be provided to LPA via email by POC date.

Allegation investigated: Staff mismanaged resident's medications. Staff did not respond to resident's call button in a timely manner.

On April 1, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannouned visit to the facility to continue the investigation into the allegations listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Health Services Director Angela Boyd was present and assisted on today's visit. During the course of the investigation, LPA conducted seven resident interviews, six staff interviews, reviewed and collected pertinent documents for this complaint. Regarding the allegation, staff mismanaged resident's medications, the following has been concluded: It was alleged that staff mismanaged Resident #1 (R1) medication on September 2023, April 2025, and August 2025. LPA reviewed the medication administration records for R1 for September 2023, April 2025, and August 2025. LPA observed that the facility did not provide R1 her presribed Vitamin D3 medication on September 13, 2023, due to the facility not having the medication on hand, despite R1 having active orders for the medication. CONTINUED ON LIC9099-C Substantiated LPA also observed that the facility did not provide R1 her prescribed Olopatadine solution medication on April 20, and April 21, 2025, due to the facility not having the medication on hand, despite R1 having active orders for the medication. LPA conducted an interview with R1. R1 corroborated the allegation and reported that her medications were not given to her as prescribed on multiple occasions. LPA conducted six staff interviews. Four out of the six staff interviewed denied the allegation. However, two out of the six staff interviewed corroborated the allegation and reported that there were previous medication errors with R1's medication. Regarding the allegation, staff did not respond to resident's call button in a timely manner, the following has been concluded: It was alleged that staff did not respond to R1's call button in a timely manner on November 2022 and on July 2023. The facility was unable to provide any call button records for R1 from November 2022 or July 2023 due to their system not storing records for more than thirty days. However, LPA was able to obtain email records between the Reporting Party (RP) and the former Health Services Director, Staff #7 (S7). On an email dated November 18, 2022, S7 admits to the RP that it took staff forty three minutes to respond to R1's call button request on November 16, 2022. On an email dated July 17, 2023, S7 admits to the RP that it took staff ninety minutes to respond to R1's call button request on July 16, 2023. On an email dated September 20, 2025, S7 admits to the RP that it took staff forty five minutes to respond to R1's call button request earlier that day. LPA conducted an interview with R1. R1 corroborated the allegation and reported that she has had to wait extended periods of times to be assisted by staff after she presses her call button. LPA conducted an six staff interviews. Two out of the six staff interviewed denied the allegation. However, four out of the six staff interviewed corroborated the allegation and acknowledged that there have been incidents in which residents have had to wait extended periods of times to be assisted after pressing their call buttons. Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegations that, staff mismanaged resident's medications, and staff did not respond to resident's call button in a timely manner. The preponderance of evidence standards has been met; therefore, the above allegations are SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D page. An exit interview was conducted with Health Services Director Angela Boyd. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Apr 1, 2026 · control 22-AS-20260122100814

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 2, 2026

87465 Incidental Medical and Dental Care :(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not evidenced by: Based on records reviewed, the Licensee did not ensure that R1's medications were given as presribed on 09/13/23, 04/20/25, and 04/21/25. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 1, 2026

Plan of correction: The Health Services Director stated that she will conduct an in service training with all staff regarding medication management. The Health Services Director agreed to provide LPA proof of training via email or fax by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 10, 2026

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not evidenced by: Based on records reviewed, the Licensee did not ensure that R1 was assisted in a timely manner after pressing her call button. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 1, 2026

Plan of correction: The Health Services Director stated that she will conduct an in service training with all staff regarding reponding to call buttons timely. The Health Services Director agreed to provide LPA proof of training via email or fax by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Health Services Director (HSD) Angela Boyd and explained the purpose of the inspection. During the inspection, LPA and HSD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, dining rooms, activity rooms, and observed the following: This is a three-story building with a parking garage on the basement floor. The first floor is used primarily for memory care, and the second and third floor are designated for assisted living. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. There are two separate courtyards, and both contain shaded sitting areas. LPA observed residents socializing in common areas and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, and faucets and toilets were operational. Water temperature tested between 105.4 - 116.9 degrees Fahrenheit. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. A fire extinguisher was observed along every facility hallway with service tag dated March 20, 2025. Facility appliances, including gas stove, refrigerator, freezer, laundry washer and dryer were inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. LPA reviewed nine resident files and four staff files. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jan 16, 2026

Allegation investigated: Licensee is not ensuring that resident has the ability to make and receive confidential phone calls.

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez. LPA met with Executive Director (ED) Anna Pastores and Health Services Director (HSD) Alyson Womack and discussed the purpose of the inspection. Regarding the allegation, Licensee is not ensuring that resident has the ability to make and receive confidential phone calls, the following was revealed: It is alleged R1 does not have the ability to make and receive confidential phone calls. During the course of the investigation, interviews were conducted with R1, six additional facility residents, and two staff. During their interview, R1 stated they are able to make and receive and make private phone calls, however, was unable to indicate how the phone calls are made or received. During their interview, six of six additional facility residents stated they are able to make and receive private phone calls from their respective bedroom, using a landline or a personal cell phone. (Cont. LIC9099-C) Unsubstantiated During their interview, two of two staff denied the allegation and stated residents are able to make and receive private phone calls in their respective bedrooms using a land line or their own personal cell phone and stated a tablet is also available at the receptionist area and residents are able to use the tablet to make video calls at their own discretion and in the privacy of their own bedroom. Due to allegation being uncorroborated during interviews conducted, the Department is unable to determine if Licensee is not ensuring that resident has the ability to make and receive confidential phone calls. Although the above 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 at this time the above allegation is unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection. LPA obtained a copy of R1’s Admission Agreement dated October 31, 2025 and observed it had not been signed by listed individuals in order in which they will serve and did not include named POA, W1’s signature. Based on R1’s record review and witness interview, the preponderance of evidence standard has been met; therefore, the above allegations is found to be substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of regulations. (See LIC9099-D). An exit interview was conducted and a copy of this report, and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 22-AS-20251114161246

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87457(b) · Plan of correction due date: Nov 20, 2025

(b) No person shall be admitted without his/her consent and agreement, or that of his/her responsible person, if any. This requirement is not met as evidenced by: Based on record review and witness intervew, the Licensee did not comply with the section cited above as R1's POA did not consent nor sign R1's admission agreement.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: AD stated an admission agreement will be entered with R1's POA and a signed and dated copy will be provided to LPA via email.

Type of visit: Case Management - Legal/Non-compliance

On this day, Licensing Program Analyst (LPA) Edward Kim made an unannounced Case Management visit to the facility to serve an Immediate Exclusion Order to staff member S1. LPA met with Executive Director Anna Pastores and explained the purpose of the visit. The Immediate Exclusion Order was explained to the Executive Director. The Order to Individual for Immediate Exclusion from Facility letter and the Order to Licensee/Facility of Immediate Exclusion from Facility letter were both served to ED Pastores. ED Pastores stated they understood the Order and said they had no additional questions. Facility will adhere to the exclusion order and not schedule S1 for future shifts. An exit interview was conducted, and a copy of this report and LIC811 was provided to Executive Director Anna Pastores.the state’s words, verbatim · CDSS document, Jul 30, 2025

Allegation investigated: Caregiver was rough with resident resulting in bruising

Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced and met with Health Services Director (HSD) Alyson Womack to deliver findings for the above complaint allegations. The department conducted interviews with facility staff, resident and a facility observation was done to investigate this allegation. Interviews with staff indicated there had been no witnessed issues with staff members handling residents in a rough manner. Interviews indicated Resident #1 (R1) did bruise/discolor easily. During LPA visit on 07/14/2025 LPA observed staff to be engaging with residents and assisting residents in an appropriate manner. LPA was unable to obtain any additional information as the caregiver and resident are no longer at the facility. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted a copy of the report and appeal rights were left at the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 14, 2025 · control 22-AS-20221122101417

Allegation investigated: Resident sustained fractures while in care due to neglect. Staff failed to seek resident medical attention in a timely manner. Insufficient staffing to meet residents' needs. Staff failed to respond to resident's call assistance button in a timely manner.

Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced and met with Health Services Director (HSD) Alyson Womack to deliver findings for the above complaint allegations. During the investigation, the department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: ***Report continued on 9099-C*** Unsubstantiated Allegation: Resident sustained fractures while in care due to neglect.-Unsubstantiated Resident #1 (R1) was not documented as a fall risk and did not require two- hour checks. R1 stated their fall occurred in their room without any witnesses in October 2022. When staff did respond to the fall, R1 confirmed they refused to be transported to the medical center for further assessment. Allegation: Staff failed to seek resident medical attention in a timely manner.-Unsubstantiated In an interview with R1 they confirmed they refused to be transported to a medical center for further assessment of injury after their fall in October 2022. Facility did keep records of R1 reporting they had no pain in the following days. R1 did not inform staff that they were going to the doctors due to an injury after the fall. R1 was found to have a “minimally displaced fracture of undetermined age.” Records reviewed documented R1 as having a pathological fracture. Consulting physicians explained this type of fracture implies the fracture was a result of underlying illness of disease. Allegation: Insufficient staffing to meet residents' needs. - Unsubstantiated The department conducted interviews with staff and residents. Staff interviews indicated they feel like they have enough staff to meet the needs of the residents in care. Resident interviews indicated that some residents feels like their needs are being met. While others feel like their needs to be more checks throughout the day. LPA conducted a tour of the facility and observed multiple staff members on the floors assisting residents. Allegation: Staff failed to respond to resident's call assistance button in a timely manner. - Unsubstantiated A sample of resident call button response logs was reviewed for the last few weeks. Staff are to respond to pages within twenty (20) minutes, but they normally respond under ten (10) minutes. Residents interviewed stated it can take any where from fifteen (15) to thirty (30) minutes. Staff interviews indicated that staff usually respond to resident’s call buttons right away unless they are with another resident. If staff forget to clear the call button after they respond they are to document that in the shift reports. Based upon the information obtained during investigation, the above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted a copy of the report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jul 14, 2025 · control 22-AS-20230130113643

Allegation investigated: Facility staff refused to assist resident with toileting and changing

Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced and met with Health Services Director (HSD) Alyson Womack to deliver findings for the above complaint allegations. The department conducted interviews with facility staff and residents. Interviews with residents revealed they feel like staff come when they call for assistance but it can take a while. Interview with staff revelaed that staff will assist in changing the resident and cleaning up the area. LPA was unable to interview involved staff as this complaint was made in March of 2023. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted a copy of the report and appeal rights were left at the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 14, 2025 · control 22-AS-20230301143239

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Business Office Director (BOD) Dianna Kuhn and explained the purpose of the inspection. Executive Director (ED) Anna Pastores arrived at approximately 9:00 a.m. During the inspection, LPA, ED, and Health Services Director (HSD) Alyson Womack conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, dining rooms, activity rooms, and observed the following: This is a three-story building with a parking garage on the basement floor, first floor is used primarily for memory care, and the second and third floor are designated for assisted living. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. There are two separate courtyards and both contain shaded sitting areas. LPA observed residents participating in leisure activities, including live music, and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 112.6 - 120.5 degrees Fahrenheit. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. At least two fire extinguishers were observed in every facility hallway with service tags dated March 29, 2024. Facility appliances, including gas stove, refrigerator, freezer, laundry washer and dryer were inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. LPA reviewed nine resident files and six staff files. LPA interviewed six residents and four staff. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 5, 2024

Allegation investigated: Resident is not getting proper nutrition. Staff failed to provide care and supervision.

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above and for the purpose of delivering findings. LPA met with Wellness Director (WD) Alyson Caluza and explained the purpose of the inspection. Interviews were conducted with six facility staff and five residents regarding allegation resident is not getting proper nutrition. Interviews conducted with six out six staff could not corroborate this allegation, as all staff interviewed acknowledged R1 was on a special diet and reported assisting him as needed at mealtimes. Interviews conducted with five out of five residents also could not corroborate allegation. Four out of five residents reported no complaints regarding facility food or nutrition and stated they received sufficient food in quantity. One out of five residents was unable to confirm or deny allegation. Per Physician’s Fax report dated 5/04/22 facility reported to R1’s Physician “difficulty swallowing noted.” Physician’s order was to “downgrade diet to pureed and regular fluids.” (Cont. LIC9099-C) Unsubstantiated LPA Gutierrez reviewed facility progress notes for R1 which indicated between 5/22/22 to 6/222/22 R1 lost 10 lbs. Client Coordination Note Report dated 6/20/22, indicated staff reported R1, "does not eat his pureed diet." Physician was notified and requested a diet change. Physician's Fax Report dated 6/20/22, indicated current diet order was discontinued and Physician ordered "advance diet to mechanical soft diet and regular fluids. Finger foods ok to give as tolerated." LPA reviewed progress notes from May to June 2022, and all notes indicated staff continued to monitor resident. Interviews were conducted with six facility staff and five residents regarding allegation staff failed to provide care and supervision. Reporting Party (RP) stated staff spend time on their phone or socializing and will ignore residents. Six out of six staff denied staff is not providing care and supervision and denied observing staff spending time on their phone or ignoring residents. Four out of five residents interviewed reported no complaints regarding staff and reported they are assisted as needed. One out of five residents interviewed was unable to confirm or deny allegation. Initial 10-day inspection on 7/11/22 was conducted by LPA Sean Haddad. Per LPA Haddad, staff was responsive, tending to residents, and were not observed to be on their phones. During today’s inspection, LPA Gutierrez also did not observe any staff on their phones. Staff were observed engaging with residents in various activities, such as guided exercises, grooming, and setting up for lunch. Based on observations, conflicting information received during interviews conducted, and after a review of R1’s doctor’s orders, weight log, and facility progress notes, LPA is unable to determine if resident was not getting proper nutrition or if staff failed to provide care and supervision. Although the above 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 at this time the above allegations are unsubstantiated. An exit interview was conducted with WD and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Dec 18, 2023 · control 22-AS-20220705155653

Allegation investigated: Staff did not safeguard resident's personal property. Resident sustained bruising while in care.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the two allegations listed above. LPA was greeted and granted entry by front desk staff after introducing himself and stating the purpose of the visit. Executive Director Anna Pastores was notified and present during the visit. The initial complaint investigation was conducted on November 6, 2023. Records for resident R1, including the admission agreement and a waiver to inventory personal property upon admission were reviewed. LPA verified the required posting of the facility's theft and loss policy and reviewed the theft and loss log maintained by facility staff at the front desk. Documentation of staff training on theft and loss was also provided. One staff interview, one witness interview and one resident interview were also conducted during the visit. CONTINUED ON LIC9099-C Unsubstantiated CONTINUED FROM LIC9099 Regarding the allegation that Staff did not provide resident's responsible party with complete paperwork at resident's admission to the facility, the following has been concluded: Based on a review of R1's records maintained at the facility and provided during the initial investigation visit, the resident and their authorized representative were provided with the following elements required by Title 22 regulations: R1's Pre-admission appraisal, Identification and Emergency contact form, signed and dated Admission agreement and all its required components including the facility's theft and loss policy. The Safeguard for Cash and Valuables form is also observed to be included in the records and is observed to be blank. Both the resident and their authorized representative declined to place any specific belongings into facility safeguarding. The resident's Individual Service Plan and updated physician report are also present. Based on the records reviewed and their corresponding dates and signatures, LPA was able to corroborate that facility staff has provided the resident and their authorized representative with all necessary items of documentation upon the resident's admission on or around August 21, 2022. As a result, the allegation is determined to be Unfounded, meaning that meaning the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM LIC9099 A follow-up visit was conducted on November 29, 2023. LPA was informed that the local law enforcement investigation was still ongoing and led an interview with facility administrator Anna Pastores. Additional witness interview attempted or conducted via telephone prior to the present visit. Regarding the allegation that Staff did not safeguard resident's personal property, the following has been concluded: Based on interviews conducted, site observation and records reviewed, it was confirmed that the facility meets all Title 22 requirements for its theft and loss policy. LPA also confirmed that the missing or stolen item reported as part of the present complaint was not placed under the facility's safeguarding responsibility. Law enforcement reporting was conducted appropriately by facility staff and is still pending at the time of the present visit. Additionally, the unit where R1 is observed to be residing is equipped with a lock to be used by the resident or their authorized representative at their own discretion. The evidence available at this time could not corroborate facility staff responsibility in misplacing or stealing the item reported missing or stolen. Therefore, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Regarding the allegation that Resident sustained bruising while in care, the following has been concluded: Based on interviews conducted, a skin discoloration was observed on the R1's left hand by their authorized representative and facility staff multiple days after the reported incident involving a lost or stolen item. None of the interviews conducted were able to associate the discoloration with facility staff mishandling R1 or failing to provide adequate care and supervision. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Dec 7, 2023 · control 22-AS-20231101104331