Oakmont of Pacific Beach

Allegation investigated: Resident sustained fractures due to staff neglect.

Licensing Program Analyst(LPA) Janet Ngallo conducted an unannounced subsequent visit to deliver findings regarding the above mentioned complaint allegation. LPA was greeted by, introduced themselves to, and discussed the purpose of the visit with Executive Director Shawn Amirhoushmand. On 05/08/2026, it was alleged that a resident(R1) sustained fractures due to staff neglect. The department's investigation consisted of interviews and records review. [Cont. on LIC 9099-C] Unsubstantiated [Cont. from LIC 9099] Regarding the allegation, R1 had an unwitnessed fall in the bathroom on 05/05/2026, and was sent out for evaluation and treatment due to pain in their right leg. R1 was diagnosed with a right hip fracture at the hospital. Interviews revealed that R1 had been experiencing a noticeable decline beginning in mid-April 2026. Staff consistently reported that R1 required increased assistance with activities of daily living, including grooming, dressing, bathing, reminders for meals, and escorts due to fall-risk concerns. Interviews indicated that R1 demonstrated at times some confusion, periods of disorientation, and resistance to accepting assistance due to a desire to remain independent. Staff stated that R1 rarely used the call pendant, despite frequent reminders about using the device, and preferred to perform most tasks independently. Interviews further revealed that, in response to R1’s decline, R1's care plan was updated through a change of condition assessment. Staff reported performing more frequent safety checks, two to three times per shift or more due to R1's decline. Staff stated that these checks were conducted to monitor R1’s safety, ensure R1 was getting to meals, and prevent falls. Staff stated they routinely checked on R1 in the mornings, during meal periods, and throughout their shifts due to concerns about R1's decreased awareness and occasional confusion or forgetfulness. Records review corroborated staff statements. A change of condition assessment dated April 2026 documented that R1 required increased assistance with ADLs, including medication assistance, standby help for grooming and toileting, and hands-on assistance for bathing, and notes that R1 was at moderate risk for falling according to the fall risk assessment and was to be provided personalized interventions, per fall management protocol. R1 did not require status checks. Records review of R1's incident report dated 05/05/2026 documented that R1 sustained an unwitnessed fall in the bathroom, was unable to bear weight, and was transported to the hospital where a right hip fracture was diagnosed. Review of charting notes reflected that staff discovered the fall during routine medication pass and took appropriate steps, including contacting emergency services and completing all required notifications. Based on interviews and records review, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. An exit interview was conducted with Executive Director Shawn Amirhoushmand and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.the state’s words, verbatim · CDSS document, Aug 7, 2026 · control 08-AS-20260508135811

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to and discussed the purpose of the visit with Executive Director Shawn Amirhousehmand. Today's visit was in response to licensee’s self-reported incident of Resident 1 (R1) received at the CCLD San Diego Regional Office on 06/26/2026. [See LIC 811 Confidential Names List for a description of (R1]. Per the report, R1 informed staff that on 06/23/2026, an unknown individual came into R1's room and slapped them. R1 was assessed for injuries in which no injuries were noted. The facility initiated an internal investigation which resulted in no findings of the information to be true. During today’s visit, LPA performed a brief facility tour and welfare check on R1, finding no safety concerns. LPA reviewed pertinent records, and interviewed staff. No deficiencies were observed or cited during today’s visit. An exit interview was conducted with Regional Business Office Specialist Cynthia Espinoza, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jul 15, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Shawn Amirhousehmand. According to the facility’s license, the facility has a maximum capacity of 92 residents, of whom all may be non-ambulatory and 8 may be bedridden with a hospice waiver for 8. LPA toured the interior and exterior of the facility and inspected multiple rooms. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Cooking/dining equipment and utensils were present. LPA toured the commercial kitchen. There was seven days of non-perishables and two days of perishables safely stored. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, as required, and stored in locked areas. Water temperatures measured in five resident bedrooms were all compliant. Fire extinguishers were serviced within the last 12 months. No pools or bodies of water are present. Per Executive Director, no firearms or ammunition are kept at the facility. First aid kits were complete and readily accessible. Resident records reviewed had required documentation. Staff records reviewed contained required documentation. No deficiencies were cited on todays visit. An exit interview was conducted with Regional Business Office Specialist Cynthia Espinoza, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jul 15, 2026

Allegation investigated: Resident sustained injuries due to staff neglect. Facility did not ensure maintenance of resident’s personal care equipment.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above mentioned allegations. LPA identified themselves and met with Executive Director Shawn Amirhoushmand to discuss the purpose of the visit and elements of the complaint. On 05/21/2026, it was alleged that a resident(R1) sustained injuries due to staff neglect, and that the facility did not ensure maintenance of R1's personal care equipment. The department's investigation consisted of interviews, records review, and LPA observations. [Cont. on LIC 9099-C] Unsubstantiated [Cont. from LIC 9099] Regarding the allegation that R1 sustained injuries due to staff neglect, an incident that occurred on 11/20/2024, where R1 attempted to pet a visiting dog at the facility, resulted in the dog injuring R1 and causing a laceration that required medical attention. Interviews consistently reported that staff at the time of the incident responded immediately to the incident, contacted emergency services, and ensured the resident received prompt medical care. Staff further stated that the dog involved in the incident belonged to a visitor and that the staff involved had no ability to predict or control the behavior of the visiting animal. Staff also reported that R1 remained ambulatory following the incident, was assisted with ADLs as needed, and received ongoing redirection, monitoring, and wellness checks consistent with R1’s care needs. Interviews regarding a more recent fall incident that occurred on 05/18/2026, reported that R1 attempted to get out of bed independently in order to use the bathroom, resulting in an unwitnessed fall. Staff reported that they routinely encourage R1 to use mobility supports such as a walker, remind R1 to move slowly, and provide escort assistance as needed, however R1 often will refuse to use assistive devices. Records review of R1's incident report from 05/18/2026 revealed an unwitnessed fall that occurred as R1 attempted to get out of bed to use the bathroom. Emergency services were called, and R1 was transported for treatment and diagnosed with a hip fracture requiring surgery. Review of R1's service plan documented that R1 was able to independently transfer and ambulate within the facility with walker use, required staff observation due to fall risk, and to receive regular status checks and reminders to use assistive devices. Records also revealed that R1 had a history of refusing assistance and demonstrating impulsive behaviors related to advanced Alzheimer’s disease. Regarding the allegation that the facility did not ensure maintenance of R1's personal care equipment, specifically related to R1's hospital bed provided by a hospice agency, staff reported that they observed no mechanical issues with R1's bed prior to its removal. Staff consistently stated that the bed functioned properly, had operational half-rails, and assisted R1 with getting in and out of bed. Interviews further indicated that R1’s recent fall occurred as R1 attempted to get up independently despite being a high fall risk, and not due to any equipment failure. Interviews additionally reported that R1's bed was taken due to being discharged from their hospice agency following the fall since R1 was admitted to the hospital. [Cont. on LIC 9099-C pg.1] [Cont. from LIC 9099-C] Records review confirmed that on 05/18/2026, R1 was discharged from hospice services, as documented in the hospice discharge summary dated 05/19/2026. During the visit, LPA observed R1’s room to be clean, well-kept, and free of safety hazards. The hospital bed was no longer present, and R1 was still hospitalized at the time of the investigation. Interview attempts with R1's responsible party were unsuccessful during the time of the investigation. Based on interviews, records review, and LPA observation, the preponderance of evidence standard has not been met, therefore the above allegations are found to be unsubstantiated. An exit interview was conducted with Executive Director Shawn Amirhoushmand and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.the state’s words, verbatim · CDSS document, May 28, 2026 · control 08-AS-20260521152203

Type of visit: Office

Licensing Program Analyst Janet Ngallo, Licensing Program Manager Lizzette Tellez, and Regional Manager Jerry Romero met with Shawn Amirhoushmand, Executive Director and facility representatives to address previously cited deficiencies related to Elopement Procedures, Medication Management, and Observation of Resident. During the meeting, Regional Manager Jerry Romero reviewed the circumstances surrounding each deficiency and discussed the facility’s current practices, corrective actions taken, and plans to prevent recurrence. The licensee and representatives were provided clarification on regulatory requirements and were reminded of their responsibility to ensure staff are trained and procedures are consistently implemented. The licensee expressed commitment to improving internal oversight, maintaining compliance, and ensuring resident safety. The department and the licensee jointly reviewed expectations moving forward and were advised that should any serious violations occur within the facility, a non-compliance conference may be held. No deficiencies were cited during today's office meeting. An exit interview was conducted with Executive Director Shawn Amirhoushmand, to whom a copy of this report was provided.the state’s words, verbatim · CDSS document, May 18, 2026

Allegation investigated: Illegal eviction. Staff does not ensure resident's room is clean and sanitized. Staff are not meeting resident's restroom needs. Staff do not respond to resident's call button in a timely manner.

Licensing Program Analyst (LPA) Renita Hall conducted an unannounced phone call to deliver findings regarding the above-mentioned allegations. LPA spoke with the Administrator. LPA identified herself, disclosed the purpose of the call, and reviewed the elements of the findings with the Administrator. On March 27, 2024, a complaint was received regarding an illegal eviction, lack of cleanliness and sanitation in resident rooms, failure to meet restroom needs, and delayed response to resident call buttons by staff at Oakmont of Pacific Beach. The investigation included a review of resident records, interviews with facility staff, direct observations of staff practices and responses, and analysis of call button response logs. Continued on 9099C Unsubstantiated No evidence of illegal eviction was found. Interviews with the management team confirmed that all eviction procedures followed proper protocols. Resident 1 (R1) had not been evicted from the facility and moved out of the facility on March 30, 2024. It was additionally noted that the Power of Attorney (POA) refused to sign the arbitration agreement. Direct observations and spot checks revealed that resident rooms were clean and properly sanitized. There was no evidence to suggest that staff were neglecting cleaning or sanitation duties. Observations confirmed that staff assisted residents with restroom needs promptly and respectfully. The average call button response time was approximately 15 minutes. The longest recorded wait time within the last 30 days was 30 minutes for Resident 1. Records review and observations confirmed that staff generally responded to call buttons in a timely manner; however, it was noted that staff often required reminders to clear call buttons after assistance was provided. It was also determined that additional services related to housekeeping beyond one time per week were not added to the resident’s care plan. Direct observations confirmed that staff responded to call buttons appropriately during the course of the investigation. The Department’s investigation found that all allegations were unsubstantiated. Facility records, staff interviews, and direct observations support the conclusion that the care and services provided meet required standards. A finding of unsubstantiated means that although the allegations may have occurred or may be valid, there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with the Administrator. A copy of this report and Licensee’s Rights (LIC 9058 03/22) were provided to the Administrator electronically, and receipt of the Licensee Rights was confirmed.the state’s words, verbatim · CDSS document, May 6, 2026 · control 08-AS-20240327160215

Allegation investigated: Facility is in disrepair.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to initiate a complaint investigation regarding the above-mentioned allegation. LPA introduced themselves and disclosed the purpose of the visit and elements of the complaint to Executive Director Shawn Amirhoushmand. On 03/25/2026, it was alleged that the facility is in disrepair. The department's investigation consisted of interviews, LPA observations, and records review. (Cont. on LIC 9099-C) Unsubstantiated (Cont. from LIC 9099) Regarding the allegation, interviews reported that a neighboring individual has repeatedly made complaints to the facility about noise, safety hazards, and general disrepair, however, staff reported no structural or maintenance issues inside or outside the building. Staff stated that the neighbor has contacted the facility dozens of times, approached staff in person, and filed multiple complaints with city departments, all of which were investigated and determined to have no validity. Staff further stated that the facility’s mechanical systems, including the exhaust/fan units, were inspected by maintenance personnel and multiple outside vendors, who found no malfunctioning equipment. Interviews indicated that staff identified a single exhaust fan that may have been the source of the noise and turned the fan off. Staff stated that the facility recently passed a fire inspection, and no concerns were cited. Records review revealed an invoice from an HVAC company for a replacement fan designed to operate more quietly. LPA Ngallo toured the interior and exterior of the facility with the Executive Director. LPA observed no unusual, loud noises or malfunctioning fan units, and no trash or debris obstructing equipment. LPA observed a coffee shop on the left-hand corner of the property that is attached to the facility structure but operates separately and is undergoing its own permitted construction. A few construction materials were positioned neatly along the side of the building. No hazards were observed in any inspected area. The Department has investigated the above-mentioned allegation and based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate the allegation and therefore deemed unsubstantiated. An exit interview was conducted with Executive Director Shawn Amirhoushmand., to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Apr 1, 2026 · control 08-AS-20260325095141

Allegation investigated: Facility staff did not meet the needs of a resident with dementia.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Health Services Director Keisha Bean. The Complainant alleged that facility staff did not meet the needs of resident [Resident #1 (R1)] with dementia. [See LIC 811 Confidential Names List for of select person identifiers used in this report.] CCLD’s investigation involved multiple unannounced facility tours/welfare checks and multiple interviews of relevant managers, frontline staff, and outside sources. The Department also reviewed pertinent administrative files, care records, and E-mail correspondence. [CONTINUED ON LIC 9099, 1 of 2] Substantiated [CONTINUED FROM LIC 9099] According to their LIC602 Physician’s Report, R1 was diagnosed with Alzheimer’s Dementia. Their doctor wrote that R1 was able to walk without any motor impairment or assistive device, but due to their cognitive impairment, R1 was not safe to leave the facility unassisted. Interviews of staff and outside sources unanimously showed that R1 resided in the Assisted Living (AL) section of the facility, where there were neither secured perimeter nor delayed-egress doors present. During the allegation period, Licensee employed a Phillips Roam Alert system at the facility, which helped staff monitor residents in AL who were diagnosed with dementia. The system worked by having selected residents wear a Roam Alert Bracelet device. When such residents came near the thresholds of perimeter door exits, the system would trigger an audible localized alarm at that door and send a wireless signal to the pager devices which the caregivers carried, prompting staff to then redirect the resident away from the door. The system did not physically prevent residents from exiting (such doors remained unlocked from the inside). Licensee’s Phillips Roam Alert system was consistent with CCR 87705, titled Care of Persons with Dementia, which requires Licensees to install “an auditory device or other staff alert feature to monitor exits on exterior doors” that are accessible to residents who “who may be at risk for elopement.” The facility’s written Plan of Operation (on file with CCLD) and Admissions Agreement contract both reiterated that the Roam Alert Bracelet was a safety requirement for any resident diagnosed with dementia living in the facility’s AL section. Licensee’s written Individual Service Plan (i.e., Care Plan) for R1 reiterated that R1 had dementia, was not safe to leave the facility unassisted, and needed to continuously wear their Phillips “Roam Alert Bracelet” for their personal safety. Per manager interviews, Licensee required its caregivers to respond to Roam Alert alarms as quickly as possible, but not longer than five (5) minutes. Staff interviews, corroborated by R1’s Admissions Agreement and an E-mail from a senior manager, also showed that that facility’s exterior exit doors (including the lobby’s front door) were required to be physically locked from the outside at nighttime, for resident safety. The Complainant claimed that on a day in March 2021, they personally observed that R1’s Roam Alert Bracelet wrist strap had been cut, and the device was sitting atop R1’s bedside table; R1 allegedly told them that they had not worn the bracelet “for a while.” Interviews of two facility managers [Staff #1 (S1) and Staff #2 (S2)] showed that at some point during the allegation period, R1’s Roam Alert Bracelet indeed had been cut off/removed, and that S2 subsequently reattached the device to R1. The totality of interviews did not clearly establish how long the Roam Alert Bracelet had been detached from R1 before discovery/correction (making it difficult to evaluate Licensee fault/culpability). [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 812-C, 1 of 2] The Complainant claimed that on a day in March 2021, and again on a day in May 2021, the facility’s front door was not locked form the outside at nighttime, as required. They also claimed that during the May 2021 date, R1’s Roam Alert Bracelet triggered the lobby front door audible alarm, but it took over twenty-five (25) minutes for the first facility staff to respond to it. CCLD subsequently obtained video recording, which was filmed around 9:30 PM on 05/02/2021. The video showed: a) The facility’s front door was unlocked during this night, allowing any person to enter from the outside without staff awareness/involvement; and, b) A loud audible alarm continuously sounded at the lobby front door, which facility staff did not respond to during 13-minute video. The person who filmed the video told CCLD that the video ended there because there was no more storage space on their smart phone camera, but that it actually took staff nearly twice as long to respond to this alarm. Based on records and interviews, a preponderance of evidence exists to show that facility staff did not meet the safety needs of a resident diagnosed with dementia. The allegation is therefore Substantiated, and one (1) deficiency was cited for it per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plans of Correction was jointly developed with the Licensee. An exit interview was conducted with Health Services Director Keisha Bean, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. [CONTINUED FROM LIC 9099-A] All chips were also physically carried through multiple exterior exit doors thresholds (to include the lobby front door), for a total of three (3) passes per door. The chips consistently triggered a loudly audible alarm at the door annunciator itself and sent signals to multiple pager devices which the caregivers carried. Both types of alerts continued to be active until staff silenced them by entering a manual key code at the triggering door. This battery of tests, corroborated by interviews of facility managers and frontline caregivers, showed the facility’s egress alert system was reliably working, from a technical/hardware standpoint. Based on records and interviews, a preponderance of evidence does not exist to show that the facility’s egress alert system was unreliable. The allegation is therefore Unsubstantiated, and no deficiency was cited for it. An exit interview was conducted with Health Services Director Keisha Bean, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 16, 2025 · control 08-AS-20210602083905

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 16, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a) …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: Based on video, records, and interviews, Licensee did not ensure that 1 of 75 residents (R1) had the care and supervision needed to meet their individual needs. This posed a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 16, 2025

Plan of correction: Licensee agreed to retrain all current caregivers and receptionists on the following points: a) Roam Alerts represent a close-elopement event, and are thus high priority signals which take precedence over other care tasks, resident call lights, and shift change meetings; b) When a Roam Alert is triggered, staff must continue to search until the resident who that device is tied to confirmed safe; c) List of all current residents who wear Roam Alert devices, and where staff can look for an updated listing of such residents, in real time; d) The importance of timely alerting management if staff observe a Roam Alert bracelet is missing from a designated resident, and e) The importance of double-checking that all facility exterior doors are locked from the outside at night, before the receptionist leaves shift. Licensee agreed to submit the training sign-in sheet to LPA, by the POC due date.

Allegation investigated: Licensee did not ensure reesident received needed toenail care.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Executive Director Emily Turner.-On May 20, 2025, Community Care Licensing (CCL) received a complaint alleging licensee did not ensure Resident 1 (R1) received needed toenail care. During investigation, the Department collected pertinent resident records as well as facility documentation and conducted interviews. According to R1 records collected, R1 needs assistance with grooming. Care plan state facility is to provide assistance with keeping nails clean but excludes nail trimming. Interview with staff revealed staff provided regular toenail filing. Interview with outside source revealed that R1 was receiving end of life care as well as regular nail care. Lastly, outside source interviews did not reveal any information to establish facility was no providing care to R1.-Based on interviews, outside source interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director Emily Turner, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 30, 2025 · control 08-AS-20250520161358

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Emily Turner. According to the facility’s license, the facility has a maximum capacity of 92 residents, of whom all may be non-ambulatory and 8 may be bedridden with a hospice waiver for 8. LPA toured the interior and exterior of the facility and inspected multiple rooms. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Cooking/dining equipment and utensils were present. LPA toured the commercial kitchen. There was enough dry food for two weeks and enough perishable food for two or more days. LPA also observed the emergency food supplies properly stored. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, as required, and stored in locked areas. Medication administration record was complete. Water temperature was measured at 106.8 degrees F in assisted living and 107 degrees F in memory care. No pool or body of water present. Per Executive Director, no firearms or ammunition are kept at the facility. Facility has an internal fire system. First aid kits were complete and readily accessible. Resident records reviewed had required documentation. Staff records reviewed contained required documentation. No deficiencies were cited on todays visit. An exit interview was conducted with Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jul 30, 2025

Allegation investigated: Staff did not ensure facility is kept free of pests for residents in care

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit regarding the above-mentioned allegation. LPA met with the Executive Director, Emily Turner. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff and outside sources. It was alleged that staff did not ensure the facility is kept free of pests for residents in care. An outside source reported the facility had bed bugs in a resident’s apartment and the facility was not taking care of the infestation. Today, LPA observed the apartment, there were no residents, furniture, or belongings present. The resident couple that resided in that apartment are no longer at the facility. Staff interviews revealed bed bugs were not observed in the residents’ room, when they would enter daily to collect the trash and check on the residents. Staff explained they did not provide care for the residents, as they were independent of their activities of daily living, only medication management was provided. An outside source interview revealed that the resident couple also had private companions daily. Continued on an LIC 9099C. Unsubstantiated On 06/14/25, staff went to the resident’s room to dispense medications, the resident was lying in bed. The staff observed smears on the bedroom wall and inquired with the residents. The residents reported they had bugs in their apartment and had smashed them the night prior. The staff immediately reported the issue to management. The Maintenance Director inspected the room and contacted their contracted pest control company to inspect. The Pest control company came on the same day, 06/14/25 to inspect, and confirmed there were bed bugs. The Maintenance Director explained as soon as they were made aware, the residents’ bodies were checked for bites, residents were showered, relocated, clothes washed, items disposed, and inspected by pest control. They also had a dog groomer come in to treat the resident couple’s dog to ensure safety. As of 06/16/25 the apartment had one full chemical treatment completed by the pest control company. The Executive Director reported the bed bug treatment was completed, no visible sign of bed bugs post treatment, follow up treatment to be completed out of precaution, and the neighboring rooms inspected with no signs of bed bugs in any other area. It was discovered the contracted company was unable to treat with heat, which was needed. Therefore, the facility contacted another pest control company that was able to assist. LPA spoke with a representative of the newly obtained pest control company that verified the resident couple’s apartment had a bed bug infestation but was being treated. The representative also stated they felt the issue would be resolved and confirmed this was a new bed bug infestation. The representative also stated the facility was following necessary precautions. The facility’s housekeeper was assigned to change the linens once a week. The housekeeper did not report any bed bugs or signs of bed bugs. Staff that are assigned to wash the residents’ clothing did not observe any bugs on the residents’ clothing. It is unknown when the bed bug infestation began. The Executive Director confirmed 06/14/25 was the first observation of bed bugs and prior to that it was not reported by staff, residents, or the private companions. The facility acted appropriately to rid the facility of pests/bed bugs by contacting the contracted pest control company and relocating the residents. When it was discovered, the contracted company could not treat with heat, the facility hired another pest control company, relocated the residents and followed guidelines for bed bug infestation. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Emily Turner whose signature below confirms receipt of these rights. This agency has investigated the complaint, alleging staff did not ensure reporting requirements were followed. 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 and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Emily Turner whose signature below confirms receipt of these rights. LPA was absent from the facility from 12:45pm-1:45pm.the state’s words, verbatim · CDSS document, Jul 8, 2025 · control 08-AS-20250702091127

Allegation investigated: Facility did not provide medical attention.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Interim Executive Director Kathleen Olson. On 1/27/2021 it was alleged that the facility did not provide medical attention to a resident by not initiating 911 services after the resident suffered a fall with evidence of a head injury. The Department’s investigation consisted of a virtual facility visit, an unannounced facility visit, review of facility and outside source records, interviews with facility staff, residents, and outside sources. Staff interviews revealed that on the day of incident, Resident 1 (R1) was found sitting on the floor of their room with evidence of a head injury. Interviews further revealed that approximately one (1) hour after the fall, an outside provider arrived to the facility and initiated 911 services for R1 after contacting R1's physician, who recommended R1 be sent to the hospital. (Continued on LIC9099-C p.2) Substantiated (Continued from LIC9099 p.1) Staff involved in the incident informed that the facility policy regarding falls with evidence of a head injury required the initiation of emergency services. These same staff acknowledged that 911 services were not initiated per protocol and that it should have been done. Outside source interviews corroborated staff interviews, informing that upon arriving to the facility, the outside provider contacted R1's physician and then 911 approximately one (1) hour after R1's fall. Outside sources confirmed that evidence of a head injury existed due to R1 having a forehead wound, which was covered by a bandage. The Unusual Incident/Injury Report submitted by the facility regarding the incident corroborated interview statements that the outside source contacted 911 for further evaluation of R1 after the fall. Review of facility document, "Falls Quick Reference Guide", revision date December 2013, stated, "If a licensed nurse is not immediately available, observe the resident for the following: ...The resident tells you, or was observed, or it appears, that they hit their head...If any of the above signs are present - Do not move resident, call 911 immediately". Staff knowledge and understanding of this rule was confirmed through interviews. Review of R1's hospital admission records the day of the incident showed that R1 was admitted for evaluation after a fall with head injury. The medical records showed that R1 was assessed to have a closed head injury and abrasion. These records confirm that staff did not follow facility protocol regarding falls with evidence of a head injury. While R1 ultimately did receive 911 medical care, the initiation of assistance was due to the outside provider who visited R1 the day of incident, not facility staff. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and is therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Interim Executive Director Kathleen Olson, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from LIC9099 p.1) R1's Physician's Report dated 12/2/2020 revealed that R1 was "Able to feed self” and did not indicate that R1 needed help with tasks such as using their cell phone. These documents do not corroborate the allegation, as they do not show an expectation that staff were responsible for feeding R1 or assisting with the use of R1's cell phone. Staff interviews were consistent regarding R1's assistance needs. Staff informed that R1 required assistance with Activities of Daily Living (ADLs), specifically noting transferring in and out of bed to wheelchair, dressing, toileting and bathing. Interviews with staff regarding services provided to R1 were consistent with R1's needs listed in the Physician's Report and facility assessment. Staff interviews did not provide corroboration to the allegation. During interview R1's Responsible Party did not corroborate the allegation. R1's Responsible Party stated that facility staff did a wonderful job caring for R1, and that R1 was thriving at the facility. Interview with R1 did not corroborate the allegation. R1 informed that staff treated them well and did not inform of any services denied to them by facility staff. Regarding the allegation, "Facility staff did not provide client supervision resulting in injuries", it was alleged that staff neglect resulted in R1 falling seven (7) to ten (10) times during the timeframe of complaint. Staff and outside source interviews did not corroborate this allegation, informing that R1 had never fallen from a standing position due to not being able to walk or stand without assistance. Review of facility records did not corroborate that the resident fell 7-10 times. Evidence shows that the resident fell once on 12/11/2020, suffering a head injury without immediate 911 initiation from staff. This incident was investigated by the Department and the facility was cited for failure to assist with medical care. During interview the reporting party admitted that they did not directly witness the alleged falls and had not found R1 on the floor or with injuries, with the exception of R1's fall on 12/11/2020. Outside sources further revealed that R1's claims of falling may have been a hallucination due to a medical condition. Review of R1's Physician Report and facility assessment showed that R1 required assistance with transferring in and out of bed to wheelchair, bathing, and specific Activities of Daily Living (ADLs) such as putting on pants. No records were found to show that facility staff neglected to consistently provide these services to R1. (Continued on LIC9099-C p.3) (Continued from LIC9099-C p.2) During interview R1's Responsible Party did not corroborate the allegation. R1's Responsible Party stated that facility staff did a wonderful job caring for R1, and that R1 was thriving at the facility. Interview with R1 did not corroborate the allegation. R1 informed that staff treated them well and did not inform of any numerous falls or lack of supervision by facility staff. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Interim Executive Director Kathleen Olson, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 08-AS-20210127183451

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Dec 6, 2024

87465(a)(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: Based on records review and interviews, Licensee did not assist in arranging medical care appropriate to the conditions and needs for 1 out of 60 residents (R1). This posed an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Nov 26, 2024

Plan of correction: Executive Director agreed to coordinate retraining for all direct service staff regarding the facility’s fall policy, to specifically include circumstances where there is evidence of a head injury and initiation of 911 services. The training sign-in sheet(s) will be submitted to LPA by the POC due date, as proof.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to and discussed the purpose of the visit with Executive Director Caroline Senteno. Today's visit was in response to licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 08/23/2024. [See LIC 811 Confidential Names List for a description of (R1]. Per the report, (R1) passed away on 08/14/2024. During today’s visit, LPA performed a brief facility tour and welfare check on remaining clients, finding no safety concerns. LPA also collected copies of and reviewed pertinent records, and interviewed relevant staff. No deficiencies were observed or cited during today’s visit. An exit interview was conducted with Caroline Senteno, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 27, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was allowed entry and discussed the purpose of the visit with Executive Director Caroline Senteno. According to the facility’s license, the facility has a maximum capacity of ninety two (92) residents. All of whom may be non-ambulatory. Hospice waiver approved for eight (8) residents. Eight (8) residents may be bedridden. LPA, accompanied by Executive Director toured the interior and exterior of the facility, and inspected five rooms on all three floors. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. Hot water temperature was measured in the facility at 116 degrees F. The ambient temperature inside the facility was measured at 72 degrees F. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas. Their are no bodies of water on the premises. Per Executive Director, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C] LPA reviewed multiple staff and resident records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Caroline Senteno whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jul 22, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident visit. LPA met with Executive Director, Caroline Senteno and discussed the purpose of the visit. Community Care Licensing received a self reported incident involving the death of Resident #1 (R1). The Death Report stated on 04/07/24, R1 was found in their bed by staff. R1 had signs of illness and was found with an opened bottle of body wash in their room. R1's Physician' Report dated 07/13/23 indicated R1 had a diagnosis of a Major Neurocognitive Disorder and was allowed direct access to personal grooming and hygiene items without risk. The facility contacted 911 and R1 was transported to the hospital. R1 passed away at the hospital on 04/07/24. Today, LPA requested records and conducted interviews with staff. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Caroline Senteno whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Apr 15, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA's) Amy Rodgers and Julianna Barfield conducted an unannounced Case Management - Incident visit. LPA's was welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Caroline Senteno. LPA then met with Health Service Director Freida Long. Today's visit was to conduct a CCLD visit, which occurred on 2/5/2024. Visit was in response to licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 2/6/2024. [See LIC 811 Confidential Names List for a description of R1]. Per the report, R1 passed away on 2/5/2024. During today’s visit, LPA's performed a brief facility tour and welfare check on remaining residents, finding no safety concerns. LPA also collected copies of additional pertinent care records and interviewed additional staff. No deficiencies were cited during today's visit. An exit interview was conducted with Health Service Director Long, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Feb 9, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Caroline Senteno. LPA then met with Assisted Living Coordinator Norma Munoz. Today's visit was follow-up to CCLD’s first visit, which occurred on 10/06/2023. Both visits were in response to licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 10/05/2023. [See LIC 811 Confidential Names List for a description of R1]. Per the report, R1 passed away on 09/25/2023. During today’s visit, LPA performed a brief facility tour and welfare check on remaining residents, finding no safety concerns. LPA also collected copies of additional pertinent care records and interviewed additional staff. No deficiencies were cited during today's visit. An exit interview was conducted with Munoz, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Feb 1, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Daniel Pena conducted a case management visit to investigative the circumstances surrounding a Death Report received on January 16, 2024. LPA met with Executive Director Caroline Senteno and discussed the purpose of the visit. LPA reviewed R1's facility file, requested relevant records, and conducted interviews. The Death Certificate was also requested during the visit. No deficiencies were issued during the visit. An exit interview was conducted with Executive Director Senteno and a copy of this report and Licensee Rights (LIC9058 01/2016) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 17, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Caroline Senteno. Today's visit was in response to licensee’s self-reported death of Client #1 (C1), received at the CCLD San Diego Regional Office. [See LIC 811 Confidential Names List for a description of C1]. Per the report, C1 passed away on 09/25/2023. During today’s visit, LPA performed a brief facility tour and welfare check on remaining clients, finding no safety concerns. LPA also reviewed and collected copies of pertinent records, and interviewed relevant staff. No deficiencies were cited during today's visit. An exit interview was conducted with Senteno, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Oct 6, 2023