Paradise Assisted Care

Type of visit: Office

On 06/15/2026, San Bruno Regional Office-San Jose Unit conducted a non-compliance conference meeting with Licensee Lusanta Kaiyom and Administrator (ADM) Saaj Kaiyom, and Attorney Ryan Keever via Teams meeting. Present in the meeting were Regional Manager (RM) Jackie Jin, Licensing Program Manager (LPM) Christine Kabariti, and Licensing Program Analysts (LPAs) Marcella Tarin and Marcela Yanez. During the non-compliance meeting, the following serious violations were discussed: 87468.2(a)(4) - Additional Personal Rights of Residents in Privately Operated Facilities, 87468.1(a)(2) - Personal Rights of Residents in All Facilities, 87411(c)(3)(D) - 87411 Personnel Requirements, 87203 Fire Safety. During this meeting, the compliance plan was developed and discussed with the licensee which includes more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations: https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers. This report was reviewed with Licensee Lusanta Kaiyom and Administrator (ADM) Saaj Kaiyom. A copy of this report was provided to Licensee and ADM.the state’s words, verbatim · CDSS document, Jun 15, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Other to follow up on a Case Management visit conducted on 12/29/2025 regarding an elopement of a resident on 11/16/2025. LPA met with Staff S1 Betzabel 'Betzy' Torres. S1 informed Licensees/Administrators Lusanta and Saaj Kaiyom of the visit. On 12/29/2025, the Department conducted a Case-Management incident visit to follow up on the elopement of Resident R1 that occurred on 11/16/2025. During record review of R1's record, R1's Appraisal/Needs and and Services Plan Dated 11/10/2025, R1's Background Information states "R1 has occasionally wandered away from the home." The Appraisal/Needs and Service Plan for R1's states staff will re-direct R1 if R1 is wanting to leave. LPA and Administrator/Licensee Saaj Kaiyom reviewed Title 22- 87463 Reappraisals and how resident's reappraisals "shall be updated in writing as frequently as necessary or once every 12 months...shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition." Administrators/Licensees refused to sign the report for today while LPA was writing the report. LPA stated to Administrators/Licensees that signing the report is acknowledging receipt of report. No deficiencies are being cited per California Code of Regulations, Title 22. A Technical Violation is being issued during today's visit. See LIC9102 for more information. LPA was unable to conduct an exit interview with Licensees/Administrators. However, a copy of this report was provided and the LIC 9102 was printed and handed to Licensee/Administrator Saaj Kaiyom.the state’s words, verbatim · CDSS document, Apr 28, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Staff S1 Betzabel 'Betzy' Torres. LPA stated the purpose of the visit. S1 states she informed Licensees/Administrators Lusanta and Saaj Kaiyom. LPA toured the interior and exterior of the facility with S1 to include the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. All exit and passageways were free and clear of obstruction. LPA observed the facility to be clean, safe, sanitary and in good repair. LPA observed all exit/entrance doors to the facility to have an auditory signal/alarm, which functioned properly when tested by LPA and S1. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed facility refrigerators temperatures at 40 F and freezers at 0 F. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. During inspection of facility backyard with S1, LPA observed the facility wooden fence to have loose wooden panels, with nails sticking out. LPA also observed areas of the fence to have broken or missing wooden panels. LPA also observed the wooden fence alongside rooms 17, 18, 19, 21 and activity area, to be supported by wooden beams. Licensee/Administrators were advised to have the fence repaired. LPA advised Licensee/Administrators to keep CCL updated regarding the fence repairs. A Technical Assistance was issued. Page 1 of 2 The facility fire system was inspected by a third party vendor on 11/17/2025 and passed inspection. Fire extinguishers were last serviced on 3/28/2025. The facility emergency drill log was reviewed. The facility's last drill was conducted 1/8/2026. LPA toured 8 random resident bedrooms with S1. All 8 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 8 bathrooms. All 8 bathrooms had hand soap, hand towels (laundered daily), functioning lights, and covered trash bins. LPA measured water temperature with a range of 104 F to 114 F. LPA reviewed 4 resident records. Resident records included emergency contact information, physician’s report, needs and service plans, and personal rights. LPA reviewed 4 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). LPA reviewed 4 staff records. Staff records included fingerprint background clearance, medical assessment with TB result, personnel record, and staff training. No deficiencies were cited during today's visit per California Code of Regulations Title 22. A Technical Assistance was issued, see LIC9102. An exit interview was conducted S1 due to Licensees/Administrators Lusanta and Saaj Kaiyom not available for an exit interview. S1 was provided a signed copy of this report. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, Mar 25, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: POC

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Plan of Correction (POC) visit to follow up on a deficiency cited on 12/29/2025. LPA met with Staff Betzy Torres. LPA stated the purpose of the visit. Staff Betzy stated Licensees Saaj and Lusanta Kaiyom were out buying groceries for the facility. The facility was cited the following Type A deficiency on December 29, 2025: 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities, POC due 12/30/2025 On 12/29/2025 the Licensee submitted the POC. During today's visit a Letter of Deficiencies Citations cleared was provided to Staff Betzy Torres. No deficiencies cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with Staff Betzy Torres and a signed copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 6, 2026

Allegation investigated: Facility staff administered controlled medication that is supposed to be administered by a licensed health care professional. Facility did not seek immediate medical care for resident after fall Facility water temperature is too cold Administrator offered medications of a deceased resident to another resident’s family member

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a complaint investigation visit to deliver the findings. LPA met with Licensee/Administrators Lusanta and Saaj Kaiyom. LPA stated the purpose of the visit. On 1/2/2025 the Department received a complaint with the above allegations. On 1/8/2025, 7/11/2025, 8/8/2025, complaint investigations visits were conducted. It has been alleged that facility staff administered controlled medication that is supposed to be administered by a licensed health care professional. Page 1 of 3 Unsubstantiated W1 states medication administration is being done by ‘non-trained’ staff resulting in medication errors and missing syringes. W1 states he/she did not observe these incidents of medication errors and missing syringes and did not provide information regarding these incidents. On 1/8/2025, 7/11/2025, 8/8/2025, LPAs interviewed 7 Staff (S1 to S7). 5 Out of 7 Staff state he/she has not observed a staff who is not a MedTech in assisting residents with medications. S4 and S7 states he/she has observed staff who are not MedTechs, assisting residents with medications. LPA reviewed 7 staff training records. 6 Out 7 staff have training for medications. Facility did not seek immediate medical care for residents after fall W1 states R1 had a fall on June 20, 2024, and the facility called R1’s family and did not seek medical attention. On 1/8/2025, 7/11/2025, 8/8/2025, LPAs interviewed S1 to S7. 6 Out of 7 Staff states the facility seeks medical care for residents after a fall. S1 states staff will notify the MedTech and call 911 or palliative care, depending on the situation. S5 states he/she observed R1 fall on 6/20/2024 and the facility did not seek medical attention, instead the facility called the resident’s loved one. On 8/6/2025 LPA interviewed R1’s Family Member (FM 1). FM 1 states he/she was informed by facility staff that R1 had a fall. FM 1 states R1 fell “due to medication.” FM states he/she does not remember the date of the incident. FM states he/she took R1 to the hospital for assessment and did not have any injuries. FM 1 did not provide additional information regarding this incident. Facility water temperature is too cold W1 alleges the facility’s water temperature is ‘too cold’. W1 states the water temperature on the second floor takes more than 15 minutes to get warm, and water temperature on the first floor takes 10 minutes to get warm. W1 did not provide additional information regarding the dates when these incidents occurred. On 01/08/2025, LPA Madrigal and Marrufo conducted a complaint investigation visit. During visit, LPA Madrigal toured 7 resident bathrooms on the second floor, and 2 resident bathrooms on the first floor. Page 2 of 3 LPA Madrigal tested the water temperature in 9 random resident bathrooms sinks. 9 random bathroom sink water temperatures measured from 108 F to 119 F. Administrator offered medications of a deceased resident to another resident’s family member W1 alleges he/she observed the facility Administrator offering constipation medication of a deceased resident to another resident’s family. W1 did not provide a date when this incident occurred. LPA interviewed 7 Staff (S1 to S7). 6 Out of 7 Staff state he/she has not observed the Administrator offering medication of a deceased resident to another resident’s family member. S4 states he/she overheard the Administrator on the phone offering constipation medication of a deceased resident to another resident’s family member. S4 did not provide additional information regarding this incident. LPA interviewed 7 Family Members (FM2 to FM8). 5 out of 7 FM stated he/she has never been offered the medications of a deceased resident by the Administrator. FM 2 and FM5 declined to be interviewed. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 26-AS-20250102144601

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced case management visit for an elopement that occurred on 11/16/2025. LPA also followed on a deficiency cited during a complaint visit on 11/7/2025. LPA met with Administrators (ADMs) Lusanta Kaiyom and Saaj Kaiyom. LPA stated the purpose of the visit. On 11/18/2025 the Department received an incident report regarding Resident R1 eloping from the facility on 11/16/2025. The Incident Report states "On 11/16/2025 around 4pm Lusanta called caregiver S1 to check on another resident and S1 informed Lusanta that S1 cannot locate R1. Lusanta told S1 to look for R1 in and around the facility one more time and then call 911 if they can't find R1. S1 called 911 and Saaj Kaiyom informed R1's responsible party. R1's responsible party told Saaj that R1 has an Apple tag. Lusanta called Santa Cruz Police to let them know of the Apple tag and location. S1 found R1 with paramedics in the corner of Capitola Road and Soquel Ave...R1 tripped and fell on the side walk." The incident report states R1 was assessed by paramedics at the scene and taken to the emergency room for further evaluation. R1 returned to the facility at 10PM that same evening, and was taken to their physician on 11/17/2025 for additional treatment. R1 required a sling. Based on Google Maps search, R1 was located approximately 1.3 miles away from the facility. On 11/18/2025 LPA David Maruffo called the facility and requested documentation, which LPA Tarin received on 11/18/2025 from ADM Saj Kaiyom. On 12/3/2025 LPA Tarin called and spoke with ADM Saaj Kaiyom regarding the elopement of R1 on 11/16/2025. ADM stated R1 cannot leave the facility unassisted, has advance neurocognitive disorder and has a history of wandering. ADM states staff can "usually re-direct R1 but not this time." ADM states he believes R1 walked out of the facility 'with someone' on 11/16/2025. LPA Tarin requested documentation from ADM Saaj Kaiyom. On 12/29/2025 LPA Tarin interviewed 2 staff (S1 to S2). S1 stated at approximately 4:00PM he/she was unable to locate R1 within the facility. S1 stated he/she notified ADMs Lusanta and Saaj, and began to search around the facility in his/her vehicle. S1 stated R1 was located at approximately 4:55PM on the corner of Soquel Ave and Capitol Road. S1 states R1 was being treated by paramedics, as R1 had fallen and sustained an injury. S1 states R1 has a history of wandering and attempting to elope from the facility. S1 was unable to provide the dates of times of previous elopement attempts. S2 states he/she was not working on 11/16/2025, but states he/she is aware that R1 has a history of wandering and advanced neurocognitive disorder. S2 states R1 will walk the perimeter of the facility, and staff will re-direct R1 back inside. S2 was unable to provide the dates and times of these incidents. Based on review of R1's physician's report dated 10/27/2025, R1’s diagnosis are listed as neurocognitive disorder. R1’s mental condition is listed as having Behavioral Expressions of disorientation, unsafe wandering, elopement, and is unable to leave the facility unsupervised. R1’s service plan dated 11/10/2025 states "R1 has occasionally wandered away from the home." R1's wandering behavior is not addressed in the care plan. Review of R1's hospital discharge paperwork dated 11/16/2025, R1 sustained a right shoulder fracture during the elopement. An immediate civil penalty of $500.00 is being assessed against the facility today for absence of supervision, which resulted in R1 eloping from the facility. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. Page 2 of 3 LPA Tarin also followed up on a deficiency cited for complaint 26-AS-20250820110316 issued on 11/7/2025. Licensee submitted POC by due date. A Letter of Deficiencies Citations Cleared was provided during today's visit. ADM Saaj and Lusanta stated they would not sign the report, and would be appealing the citation and civil penalty. LPA Tarin stated to ADM that signing the report is acknowledging receipt of report. ADM stated understanding and stated they would not sign the report. This report was reviewed with ADM Lusanta and Saaj Kaiyom and a copy of the report was provided. Appeal Rights were provided. Page 3 of 3 END OF REPORTthe state’s words, verbatim · CDSS document, Dec 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 30, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: 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 was not met as evidenced by:the state’s words, verbatim · CDSS document, Dec 29, 2025

Plan of correction: Licensee will submit a plan of action stating how they will address R1's elopement behaviors, to include additional staff training on dementia care (elopement). Licensee will submit POC to CCLD by 12/31/2025. Based on interview and record review, the licensee did not comply with the section cited above. Resident R1 eloped from the facility on 11/16/2025. R1 is unable to leave the facility unassisted which poses an immediate health, safety or personal rights risk to persons in care.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced case management visit for an elopement that occurred on 11/16/2025. LPA also followed on a deficiency cited during a complaint visit on 11/7/2025. LPA met with Administrators (ADMs) Lusanta Kaiyom and Saaj Kaiyom. LPA stated the purpose of the visit. On 11/18/2025 the Department received an incident report regarding Resident R1 eloping from the facility on 11/16/2025. The Incident Report states "On 11/16/2025 around 4pm Lusanta called caregiver S1 to check on another resident and S1 informed Lusanta that S1 cannot locate R1. Lusanta told S1 to look for R1 in and around the facility one more time and then call 911 if they can't find R1. S1 called 911 and Saaj Kaiyom informed R1's responsible party. R1's responsible party told Saaj that R1 has an Apple tag. Lusanta called Santa Cruz Police to let them know of the Apple tag and location. S1 found R1 with paramedics in the corner of Capitola Road and Soquel Ave...R1 tripped and fell on the side walk." The incident report states R1 was assessed by paramedics at the scene and taken to the emergency room for further evaluation. R1 returned to the facility at 10PM that same evening, and was taken to their physician on 11/17/2025 for additional treatment. R1 required a sling. Based on Google Maps search, R1 was located approximately 1.3 miles away from the facility. On 11/18/2025 LPA David Maruffo called the facility and requested documentation, which LPA Tarin received on 11/18/2025 from ADM Saj Kaiyom. On 12/3/2025 LPA Tarin called and spoke with ADM Saaj Kaiyom regarding the elopement of R1 on 11/16/2025. ADM stated R1 cannot leave the facility unassisted, has advance neurocognitive disorder and has a history of wandering. ADM states staff can "usually re-direct R1 but not this time." ADM states he believes R1 walked out of the facility 'with someone' on 11/16/2025. LPA Tarin requested documentation from ADM Saaj Kaiyom. On 12/29/2025 LPA Tarin interviewed 2 staff (S1 to S2). S1 stated at approximately 4:00PM he/she was unable to locate R1 within the facility. S1 stated he/she notified ADMs Lusanta and Saaj, and began to search around the facility in his/her vehicle. S1 stated R1 was located at approximately 4:55PM on the corner of Soquel Ave and Capitol Road. S1 states R1 was being treated by paramedics, as R1 had fallen and sustained an injury. S1 states R1 has a history of wandering and attempting to elope from the facility. S1 was unable to provide the dates of times of previous elopement attempts. S2 states he/she was not working on 11/16/2025, but states he/she is aware that R1 has a history of wandering and advanced neurocognitive disorder. S2 states R1 will walk the perimeter of the facility, and staff will re-direct R1 back inside. S2 was unable to provide the dates and times of these incidents. Based on review of R1's physician's report dated 10/27/2025, R1’s diagnosis are listed as neurocognitive disorder. R1’s mental condition is listed as having Behavioral Expressions of disorientation, unsafe wandering, elopement, and is unable to leave the facility unsupervised. R1’s service plan dated 11/10/2025 states "R1 has occasionally wandered away from the home." R1's wandering behavior is not addressed in the care plan. Review of R1's hospital discharge paperwork dated 11/16/2025, R1 sustained a right shoulder fracture during the elopement. An immediate civil penalty of $500.00 is being assessed against the facility today for absence of supervision, which resulted in R1 eloping from the facility. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. Page 2 of 3 LPA Tarin also followed up on a deficiency cited for complaint 26-AS-20250820110316 issued on 11/7/2025. Licensee submitted POC by due date. A Letter of Deficiencies Citations Cleared was provided during today's visit. ADM Saaj and Lusanta stated they would not sign the report, and would be appealing the citation and civil penalty. LPA Tarin stated to ADM that signing the report is acknowledging receipt of report. ADM stated understanding and stated they would not sign the report. This report was reviewed with ADM Lusanta and Saaj Kaiyom and a copy of the report was provided. Appeal Rights were provided. Page 3 of 3 END OF REPORTthe state’s words, verbatim · CDSS document, Dec 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 30, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: 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 was not met as evidenced by:the state’s words, verbatim · CDSS document, Dec 29, 2025

Plan of correction: Licensee will submit a plan of action stating how they will address R1's elopement behaviors, to include additional staff training on dementia care (elopement). Licensee will submit POC to CCLD by 12/31/2025. Based on interview and record review, the licensee did not comply with the section cited above. Resident R1 eloped from the facility on 11/16/2025. R1 is unable to leave the facility unassisted which poses an immediate health, safety or personal rights risk to persons in care.

Allegation investigated: Licensee is not preventing resident's room from being infested by ants.

Licensing Program Analyst (LPA) Marcella Tarin conducted a complaint investigation visit to deliver the findings of the above allegation. LPA met with Administrators Saaj and Lusanta Kaiyom. LPA stated the purpose of the visit. On 8/20/2025 the Department received a complaint about the above allegation. On 8/21/2025 LPA Tarin conducted the initial 10-day complaint investigation visit and interviewed staff, residents and inspected random resident rooms. On 8/20/2025, LPA Tarin interviewed Reporting Party (RP). RP states it was brought to his/her attention on 8/11/2025 that R1 had ants in his/her room and on his/her body. Page 1 of 3 Substantiated On 08/21/2025 LPA interviewed ADM. ADM stated it was brought to his/her attention by W1 that R1 had ants in his/her room and on his/her body on 8/11/2025. ADM stated ants come into the facility during the summer months. ADM stated he/she had purchased ant sprays to get rid of the ants inside the facility, but “the ants just keep coming.” ADM stated there were no work orders for pest control, instead bug sprays and pesticides (for outdoors) were being used on the ants. ADM stated he/she offered to move R1 into another room, but there were ants in the room and W1 declined to move R1. On 8/21/2025 and 10/8/2025 LPA interviewed 5 Staff (S1 to S5). 5 out of 5 staff stated he/she is aware of the facility having ants. S1 states it was brought to his/her attention on 8/11/2025 by W1 and W2 that R1 had ants in his/her room and on his/her body. S1 states he/she notified the facility ADM about the ants in R1’s room and on R1’s body on 8/11/2025. LPA interviewed 3 Residents (R1 to R3). 2 Out of 3 residents stated he/she has observed ants in his/her room but did not remember the date of these incidents. R1 did not respond to questions due to neurocognitive disorder. LPA toured 7 resident rooms. In 3 Out of 7 resident bedrooms, LPA observed ant traps in the corners of the room, dead ants along the bedroom floorboard corners, ants crawling on the floor, ants on a windowsill, and ants crawling on the wall. On 10/8/2025 LPA interviewed 2 Witnesses (W1 and W2). W1 stated on 8/11/2025 he/she visited R1 at approximately 9AM, and observed ants on R1’s pillow. W1 stated he/she observed ‘ants on the floor, crawling up R1’s bed and on R1’s beddings (blankets, sheets, pillow) and in R1’s hair’. W1 stated he/she also observed ants in R1’s diaper area. W1 stated R1 was non-verbal and cannot communicate his/her needs. W1 stated he/she told S1 about the ants on 8/11/2025. W1 stated he/she also spoke with S3 about the ants, and S3 told the ADM. W1 stated he/she was contacted by the ADM at approximately 4PM, where ADM offered to move R1 into another room. W1 stated that the room offered to R1 also had ants, and he/she declined to move R1 to the other room. Page 2 of 3 LPA interviewed W2. W2 stated on 8/11/2025 at approximately 10AM, he/she arrived at the facility and W1 spoke with him/her about the ants in R1’s room. W2 stated he/she observed ants on R1’s bed (headboard, footboard), and around R1’s floorboards of the room. W2 stated during a diaper change of R1, both he/she and W1 observed ants in R1’s brief. W2 stated he/she informed S2 about the incident. Based on review of R1’s physician’s report dated 3/10/2025, R1 has neurocognitive disorder, and is unable to communicate his/her needs, as listed under Physical Health Status ‘i. Able to Communicate Needs-No.’ Based on review of R1’s Appraisal/Needs and Services Plan dated 6/30/2025, staff are to assist daily with R1’s Socialization Needs, Emotional Needs, Mental Needs, Physical/Mental Health Needs, and Functioning Skills Needs. Review of R1’s Preplacement Appraisal Information dated 4/1/2025, R1’s Communication is listed as “having severe speech impairment…uses non-verbal communication…has few words…can answer yes or no.” Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be substantiated. California Code of Regulations Title 22, are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided. Page 3 of 3 END OF REPORTthe state’s words, verbatim · CDSS document, Nov 7, 2025 · control 26-AS-20250820110316

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(2) · Plan of correction due date: Nov 8, 2025

87468.1 Personal Rights of Residents in All Facilities (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was not met as evidenced by: Based on observation and interview, the Licensee did not ensure that R1’s room was free of ants, resulting in R1 having ants on his/her body on 8/11/2025. This poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2025

Plan of correction: Licensee will submit a plan of action stating how he will ensure resident’s rooms and residents are free of ants and submit the plan to CCLD by POC due date of 11/8/2025.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management Incident Visit regarding an incident report submitted to the Department. LPA met with Administrators (ADMs) Saaj and Lusanta Kaiyom. LPA stated the purpose of the visit. On 11/6/2025 the Department received an incident report for a medication error on 11/2/2025 by Staff (Referred to as S1), who administered medication for Resident R1 to Resident 2. The incident report states 911 was called and R2 was assessed but did not require medical treatment. All responsible parties were notified of the incident. During today's visit, LPA interviewed ADM and requested pertinent documentation to include physician's reports, care plans and staff medication training records. LPA determined this case requires further investigation. No deficiencies were cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with ADMs and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 7, 2025

Type of visit: Case Management - Other

*This is an amended report to correct a typo and incorrect census listed on 10/23/2025* Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management. The facility census is 22, not 110 listed. No deficiencies were cited. An exit interview was conducted with Licensees/ADM and a signed copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 23, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management visit -other and met with Manager Betzy Torres. LPA stated the purpose of the visit. The purpose of the visit is to amend the findings from unfounded to unsubstantiated for complaint #26-AS-20250102144601. An exit interview was conducted with Manager Betzy Torres and a signed copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 8, 2025

Allegation investigated: Facility refused to warm residents' meal. Resident was retaliated by staff when talking with a former employee. Facility is not providing bathe to a resident.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced inspection visit to deliver the findings of the complaint investigation. LPA met with Manager Betzy Torres. LPA stated the purpose of the visit. On 01/24/2025 the Department received a complaint with the above allegations. On 02/03/2025 LPA Steve Chang conducted the initial unannounced investigation visit and interviewed 6 staff (S1 to S6) and 1 Witness (W1) and 4 residents (R1 to R4). On 5/13/2025 LPA interviewed 1 more staff (S7). Page 1 of 2. Unsubstantiated Facility refused to warm residents' meal Based on the interviews conducted, 5 Out of 7 staff stated residents’ meals are warmed up when requested by residents. S2 states approximately 3 weeks ago, he/she started to not warm R1’s meals due to having to ask permission from facility administrator. S2 did not provide additional information. S4 stated he/she has never been asked to warm meals for R1. House Manager states he/she is not aware of staff having to ask permission from ADM to warm residents food in January 2025. LPA interviewed 4 residents. 4 Out of 4 residents stated staff warm up their meals when requested. W1 states facility staff warm up the resident’s meals when requested. Resident was retaliated by staff when talking with a former employee. Based on interviews, 6 out of 7 staff stated he/she has never observed a staff retaliating towards a resident when resident spoke with a former employee. S3 did not provide any information. LPA interviewed 4 residents (R1 to R4). 2 Out 4 residents stated he/she has no concerns with the facility staff. 2 out of 4 residents did not provide any information. W1 states he/she has no concerns with the facility staff or the care his/her loved one is receiving. Facility is not providing baths to residents. Based on interviews conducted on 02/03/2025 and 05/13/2025, 5 out of 7 staff stated residents are given showers based on resident’s shower schedule. 2 out of 5 staff did not provide any information. 4 out of 4 residents stated he/she are being bathed by facility staff based on his/her shower schedule. Based on record review of the facility’s shower schedule, from December 2024 to January 2025, residents are scheduled for shower 2 to 3 times a week. R1 is on the shower schedule, with 3 showers scheduled per week. S1 and S5 state that in December 2024, R1 became unable to stand with the assistance of 3 staff. Page 2 of 3 S1 and S5 stated R1’s responsible party was made aware that R1 would be given sponge baths to ensure the safety of R1 and staff. W1 stated that their family is showered based on their shower schedules. Based on record review of R1’s care plan dated 10/11/2024, R1 is non-ambulatory and R1s lower body strength has been declining. Based on interviews and record reviews, although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, with Manager Betzy Torres and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 26-AS-20250124125507

Allegation investigated: The facility administrator physically abused a resident while in care. The facility is falsifying staff training documents. The facility served food that was not in good quality and in quantity necessary to meet the residents' needs. The facility did not provide hygiene supplies necessary for personal care to residents in care. The facility is not reporting medication errors to the Department. The facility staff are not trained to provide the services necessary to meet resident needs. The facility does not maintain a comfortable temperature for residents.

**Amended on 8/8/2025 to change findings from Unfounded to Unsubstantiated** Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced inspection visit to deliver the findings of the complaint investigation. LPA met with Manager Betzy Torres. LPA stated the purpose of the visit. On 1/2/2025 the Department received a complaint with the above allegations. On 1/8/2025 the Department conducted an unannounced initial investigation and interviewed 6 staff, 8 residents, and reviewed records such as but not limited to grocery receipts and staff training records. LPA conducted an inspection of the facility such as but not limited to the kitchen, supply cabinet, food pantry and residents rooms. Page 1 of 5 Unsubstantiated The facility administrator physically abused a resident while in care. On 1/8/2025, 5/12/2025 and 5/13/2025, LPAs interviewed 6 staff (S1-S6). 5 Out of 6 staff stated the facility administrator did not physically abuse a resident while in care. S4 stated on 6/20/2025 he/she saw the facility administrator abuse a resident while in care. S4 stated that he/she filed the report but did not provide any additional information and details of the abuse during the interview. On 7/11/2025, LPA interviewed 3 Residents (R1 to R3). 3 Residents states he/she has not observed facility staff abusing residents in care. The facility is falsifying staff training documents. On 1/8/2025, 5/12/2025 and 5/13/2025, LPAs interviewed 6 staff (S1-S6). 5 Out of 6 staff stated the facility is not falsifying staff training documents. S4 stated he/she was asked by the facility administrator to sign training documents for other staff members in 2022. S4 was not able to provide additional information. During review of facility training records, LPA observed that the facility staff signed training documents when training is administered, and certificate is issued based on the staff’s completion of the training required. On 7/11/2025, LPA interviewed 3 Residents (R1 to R3). 3 Residents states staff know what they are doing when providing care to residents. The facility served food that was not in good quality and in quantity necessary to meet the residents' needs. On 1/8/2025, 5/12/2025 and 5/13/2025, LPAs interviewed S1 to S6. 5 Out of 6 staff state the facility serves food that is of good quality and quantity to meet resident’s nutritional needs. S4 states the facility serves soup, small portions, does not ‘complement’ food with vegetables or rice, and has observed brown spots on lettuce served but did not provide additional information. Page 2 of 5 LPA interviewed 8 Residents (R4 to R11). 8 Out of 8 residents states the facility serves food that is good quality and quantity that meets their dietary needs. On 7/11/2025 LPA interviewed 3 Residents (R1 to R3). 3 Residents states the facility serves food that is good quality and in good quantity. LPA inspected the food pantry, kitchen pantry, refrigerator and freezer. LPA observed refrigerator temperature is maintained at 32-degree F and freezer at 0 degree F. LPA observed 2 days of perishable food that are not expired and are of good quality and quantity, 7 days of non-perishable food that are not expired, no dented cans, no open boxes or exposed food was observed. The facility did not provide hygiene supplies necessary for personal care to residents in care. On 1/8/2025, 5/12/2025 and 5/13/2025, LPAs interviewed 6 staff (S1-S6). 5 Out of 6 staff state the facility provides hygiene supplies necessary for personal care to residents. S4 states the facility has no towels or toothpaste for residents but did not provide additional information and details during the interview. On 7/11/2025 LPA interviewed 3 Residents (R1 to R3). 2 out 3 residents state his/her family purchases their hygiene products (toothpaste, shampoo,etc). R3 states the facility provides him/her with hygiene products. LPA inspected the facility bathrooms, living rooms and other high traffic areas. LPA observed trash bins have a cover and are lined with a trash bag. LPA observed the facility bathroom, living room including kitchen and dining surface to be sanitary. LPA observed paper towels, and hand soap used by residents, and staff in the bathroom. LPA observed linen cabinets and observed clean towels for use by residents. Licensee did not ensure the facility had cleaning supplies to maintain cleanliness of facility. Page 3 of 5 On 1/8/2025, 5/12/2025 and 5/13/2025, LPAs interviewed 6 staff (S1-S6). 5 Out of 6 staff state the facility has cleaning products to adhere to the infection control plan by keeping the facility sanitized at all times. S4 states the facility did not allow staff to use the cleaning products because staff “use too much” but did not provide additional information during the interview. LPA inspected the chemical supply cabinet/room and observed cleaning solutions used by the facility to sanitize resident’s room, bathroom and other areas of the facility. LPA observed that the chemicals are stored in a locked cabinet/room not accessible to residents in care. LPA observed PPE (personal protective equipment) available for use by staff and residents. LPA observed bottles of 1 gallon sanitizing product, bottles of hand sanitizer, vinyl gloves, boxes of face mask, laundry detergents and hand soaps, toilet paper, and paper towels in bulk quantity. LPA reviewed facility grocery receipts with a date range from 12/17/2024 to 1/7/2025, documenting 7 grocery purchases to include but not limited to food supply both perishable and non-perishable food. Grocery receipts show purchases of vinyl gloves, personal care wipes and cleaning products, necessary for use in cleaning, disinfecting and sanitizing the facility surfaces and other areas of the facility in compliance with California Code of Regulations (CCR) Title 22, 87470 Infection Control Requirements. The facility is not reporting medication errors to the Department. On 1/8/2025, 5/12/2025 and 5/13/2025, LPAs interviewed 6 staff (S1-S6). 5 Out of 6 staff state he/she has not observed medication errors not being reported to the Department. S4 states residents have been given other residents medication, but did not provide additional information during the interview. LPA reviewed the facility file record and observed no incident reports for medication errors. Based on review of records, LPA did not observe any medication error during the document review of resident’s records from December of 2024 to January of 2025. The facility staff are not trained to provide the services necessary to meet resident needs. On 1/8/2025, 5/12/2025 and 5/13/2025, LPAs interviewed 6 staff (S1-S6). 5 Out of 6 staff stated they have received training to meet residents’ needs. S4 stated he/she was asked by the facility administrator to sign training documents when no training was received. S4 was not able to provide additional information. Page 4 of 5 **Amended on 8/8/2025 to change findings from unfounded to unsubstantiated** During the annual inspection conducted on 03/27/2025, a review of 5 staff records was conducted. 5 Out of 5 staff records contained proof of current training for 2025, that adheres to the regulation requirement under the California Code of Regulations (CCR) Title 22, 87411 Personnel Requirements and under Health and Safety Code 1569.625 and 1569.69. On 7/11/2025 LPA interviewed 3 Residents. 3 residents states facility staff know what they are doing when providing care. The facility does not maintain a comfortable temperature for residents. On 1/8/2025, 5/12/2025 and 5/13/2025, LPAs interviewed 6 staff (S1-S6). 5 Out of 6 staff stated the facility maintains a comfortable temperature for residents. S4 stated the facility is ‘very cold and had to wear long sleeves.’ S4 did not provide additional information. On 1/8/2025, LPA inspected and observed 11 resident rooms on the first and second floor. The facility has a thermostat to measure room temperature. Thermostat was observed to be set at 72 degrees F to 80 degrees F. LPA observed that the facility maintained the temperature in compliance with California Code of Regulations (CCR) Title 22, 87303 Maintenance and Operation by maintaining a comfortable temperature for residents at all times. On 7/11/2025 LPA observed the 2 facility thermostat temperatures on the first floor at 73 and 75 degrees F. LPA observed the facility thermostat on the second floor at 74 degrees F. LPA interviewed 3 Residents. 1 out 3 residents states he/she has no concerns with facility temperature. 2 residents were having lunch and unable to be interviewed. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided. No deficiencies cited during today’s visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with the Manager Betzy Torres and a copy of this report was provided. Page 5 of 5.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 26-AS-20250102144601

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Annual Continuation visit and met with Administrator Saaj Kaiyom. This annual inspection is a continuation of the annual visit that was conducted 3/21/2025. LPA observed 18 residents and 5 staff. The facility was equipped with smoke and carbon monoxide detectors. The smoke detectors were last inspected on 9/16/2024. Fire extinguishers were last serviced on 8/8/2024. LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed. The facility's last drill was on 1/8/2025. LPA reviewed 5 resident records and 5 staff records. LPA reviewed 5 residents Centrally Stored Medication and Destruction Records (CSMDRs). During visit, ADM provided LPA with a copy of Administrator Certificate for Lusanta Kaiyom and documentation of Administrator Certificate training on 1/30/2025 for Saaj Kaiyom. No deficiencies cited during today's visit per California Code of Regulations, Title 22. A Technical Assistance was issued, see LIC9120. An exit interview was conducted with ADM Saaj Kaiyom and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 27, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Administrator (ADM) Saaj Kaiyom. LPA stated the purpose of the visit. LPA observed 18 clients and 3 staff during visit. LPA toured the interior and exterior of the facility with ADM to include the kitchen, resident rooms, dining room, bathrooms, kitchen, back and front of the facility. Facility thermostat temperature display was observed at 72 degrees F. All exit and passageways were free and clear of obstruction. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA refrigerator temperature displayed at 31 degrees F and Freezer at 0 degrees F. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Fire extinguishers were last serviced on 3/4/2024 LPA reviewed the facility first aid kit. The facility emergency drill log was reviewed. The facility's last drill was on 1/8/2025. LPA toured 29 bedrooms. During tour of bedroom 11, LPA observed that the sliding glass door did not open when LPA tried to open door. ADM was also unable to slide door open during inspection. This door is not an emergency exit. LPA advised ADM to have door repaired by maintenance. Due to time constraints this annual will be continued at a later date. No deficiencies cited today per California Code of Regulations. An exit interview was conducted with ADM and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 21, 2025

Allegation investigated: Staff did not respond to resident’s call for assistance in a timely manner Facility staff are not treating residents with dignity Facility staff is not administering medication per doctor's orders Facillity did not provide services to meet the residents needs Facility does not have enough staff to meet residents needs

On 12/10/2024 Licensing Program Analysts (LPAs) Marcella Tarin and Christine Dolores arrived unannounced to deliver the findings of the above allegations. LPAs met with Daysi Calderon. On 9/26/2024 the Department received a complaint. On 10/3/2024 the intial complaint investigation was conducted. The following documents were obtained for this investigation to include physician's reports, need/service plans, staff roster, resident roster, staff schedule, September activity calendar, Medication Administration Records (MARs), pendant logs, staff training for Hoyer lift, email correspondences. It was alleged that staff do not respond to residents calls for assistance in a timely manner on 09/24/2024. It was alleged on one occasion, a resident had to wait 45 minutes to receive assistance. Page 1 of 4 Unsubstantiated On 10/3/2024, the Department interviewed ADM. ADM states there are times during peak hours when response times make take longer than expected, but all residents call for assistance are addressed. ADM states there was a time when R1 “waited 20 minutes once during lunch time, sometime last week or this week.” ADM did not state which day this incident occurred. ADM states during peak times (11:30 am to 12:30 PM, 4:30 PM to 5:30 PM) if a resident calls for assistance, residents are checked on right away. On 10/3/2024, the Department interviewed S1 and S2. 2 out of 2 staff state that residents call for assistance are responded to in a timely manner. S2 states there have been longer wait times (up to 25 minutes) for pendant calls during peak hours (lunch time 11:30am to 12:30pm). On 10/3/2024, LPA Tarin interviewed 5 residents. During interview, R1 pressed his/her pendant during the interview at 10:28AM, and staff to resident’s room at 10:29AM. R2 pressed his/her pendant at 10:37AM, and staff arrived at his/her room at 10:37AM. On 10/9/2024, LPA Tarin interviewed 6 witnesses. W2-W6 state they have no concern with wait times and receive assistance in a timely manner. W1 states on one occasion their loved one had to wait more than 45 minutes on one occasion but could not state the day this incident occurred. LPA Tarin reviewed pendant logs for R1 from 09/17/2024-10/3/2024. The pendant logs documents R1 pressing his/her pendant at least 5 times per day, and up to 20 times per day for assistance. The pendant logs do not have response times, but the resident’s pendant was being pressed for assistance. It was alleged that facility staff are not treating residents with dignity. It was alleged that a staff member threw a banana on a table. On 10/3/2024, the Department interviewed the ADM and S1 and S2. ADM, S1 and S2 state all residents are treated with dignity and respect. 2 out of 2 staff state they help each resident with their needs and provide assistance when residents press their pendants. On 10/3/2024, the Department interviewed 5 residents. 5 out of 5 residents state they are treated with dignity. The Department interviewed 6 witnesses. W1-W6 state their loved ones are being treated with dignity and respect at the facility. W1 states their loved one is not being treated with dignity, that staff threw a banana on a table where her loved one couldn’t reach. W4 states he/she has seen staff engaged with residents, treating residents with respect. W6 states that staff are gentle and kind with their loved one. Page 2 of 4. It was alleged that facility staff is not administering medication per doctor’s orders. It was alleged that Tramadol was not being given to R1. On 10/3/2024, the Department interviewed the ADM and S1 and S2. Adm states residents receive their medication on time, each resident’s medication is given per doctors’ orders. ADM states R1 does has a prescription for Tramadol, and it is a PRN (as needed) prescription. 2 out of 2 staff states resident are given medication based on the times needed for each individual resident. On 10/3/2024, the department interviewed 5 residents. 5 out of 5 residents state they have no concerns with medications and received medication on time. On 10/3/2024, the Department interviewed 6 witnesses. 5 out of 6 witnesses state they have no issues or concerns with medications administered to their loved ones. 1 out 6 witnesses state their loved one’s medication, Tramadol, was not administered per doctor’s orders. On 10/3/2024, the Department reviewed 3 resident Medication Administration Records (MARs) and observed medication is being administered per doctor’s orders and given at the required times, initialed by staff. LPA Tarin reviewed physician’s order for R1’s Tramadol medication, which is PRN (as needed). Tramadol was given on 9/26/2024, and 9/27/2024 medication is as needed. It was alleged that the facility did not provide services to meet the resident’s needs, staff do not know how to use a Hoyer lift on residents. On 10/3/2024, the Department interviewed the ADM and S1 and S2. Adm states the facility has 2 residents that use a Hoyer lift, and staff are trained to use the lift. 2 out 2 staff state they have been trained to use the Hoyer lift. On 10/3/2024, the department interviewed 6 witnesses. 3 out 6 witnesses state his/her loved one does not use a lift. 1 out of 4 witnesses state a lift is used on their loved one, and their loved one has no issues with the lift. 1 out 4 witnesses state they are not sure if their loved one uses a lift. 1 out of 6 witnesses state their loved one has expressed discomfort while being transferred out of his/her bed into their wheelchair. Based on record review, the facility staff are using the Hoyer lift on 2 residents, to transfer out of their beds and into wheelchairs. Facility staff received training for the Hoyer lift on 7/15/2024. Page 3 of 4. It was alleged that the facility did not have enough staff to meet resident’s needs, based on a resident having to wait 45 minutes to receive assistance. On 10/3/2024, the Department interviewed the ADM and S1 and S2. Adm states there are 3 staff on each shift (AM, PM, and NOC shift) daily. ADM states when they are short-staffed, the facility will call in staff that are not scheduled for that day, to come into work. 2 out 2 staff state there are always 3 staff on each shift, and if they are short-staff, staff who are not scheduled for the day are asked to come into work. On 10/3/2024, the Department interviewed 6 witnesses. 5 out 6 witnesses’ state there are enough staff to meet residents needs. 1 out 6 witnesses state the facility does not have enough staff to meet their loved ones needs. W1 states on 9/24/2024, her loved one had to wait 45 minutes to get assistance with getting out of bed. On 10/3/2024, the Department interviewed 5 residents. 5 out of 5 residents stated their needs are met. LPA Tarin reviewed staff schedules for the month of September. 3 staff are scheduled per shift (AM, PM and NOC shift). Based on the interviews conducted with residents, witnesses and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Daysi Calderon, Manager and a copy of the report was provided. Page 4 of 4. On 10/3/2024, the Department interviewed ADM. ADM stated the have bingo, exercise activities for residents. In addition, ADM states they also have celebrity impersonators perform, and volunteers and high school students come and do shows/sing songs for the residents as well. ADM stated when residents refuse activities, they ask residents 3 times to join. ADM provided a copy of September 2024 Activities calendar. On 10/3/2024, the Department interviewed S1 and S2. S1 and S2 states the facility has bingo, and exercise activities for the residents. On 10/3/2024, the Department interviewed 5 residents. 5 out of 5 residents agreed to be interviewed. 5 out of 5 residents stated they facility offers activities. On 10/3/2024, the Department interviewed 6 witnesses. 4 out of 6 witnesses state the facility provides activities for the loved ones, such as bingo, exercise, and sporting events (Super Bowl). 1 out 6 witnesses state he/she is a volunteer at the facility and sets up activities for residents. 1 witness states their facility does not provide activities. During the day of the investigation, LPA Tarin observed residents in the living room area, watching TV and reading. LPA Tarin observed staff having conversation with residents, asking residents what activities they would like to do. Staff were also observed escorting residents from the dining area as they had finished having breakfast. Based on record review and interview, the facility is providing activities for residents. Per September 2024 Activities Calendar, bingo is offered three times a week, exercise two times a week, Piano with Richard on Wednesdays, and ShowTime on Saturdays. It was alleged that staff did not ensure resident was adequately hydrated. On 10/3/2024, the Department interviewed ADM. ADM states there has not been a time when a resident was dehydrated. On 10/3/2024, the Department interviewed S1 and S2, who states residents are offered water anytime they are checked on. 2 out of 2 staff state residents are given water and the staff will remind residents to drink water or juice. S2 stated there was a time a resident was dehydrated, and the resident’s family was informed, and resident was taken to doctor by family. Page 2 of 3. On 10/3/2024, LPA Tarin interviewed 5 residents. 4 out of 5 residents state they are offered water. 1 out of 5 residents did not state an answer. On 10/9/2024, LPA Tarin interviewed 6 witnesses. W2-W6 states their loved ones are always offered water or have cups of water in their rooms. W5 states he/she sees staff going around the facility with cart offering water to residents. W6 states he/she has seen staff with a pitcher of water, offering residents water. W1 states their loved one’s lips were dry but didn’t state if resident was dehydrated. During interviews with residents, LPA Tarin observed cups with water in residents’ room that were within reach of resident. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unfounded meaning the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Manger Daysi Calderon and a copy of the report was provided. Page 3 of 3.the state’s words, verbatim · CDSS document, Dec 10, 2024 · control 26-AS-20240926121705

Allegation investigated: Resident care needs not being met Residents left in bed unattended Bathroom light fixture not working

On 10/18/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Licensee, Lusanta Kaiyom and explained the purpose of today's visit. Regarding the allegations of resident care needs not being met and residents left in bed unattended, Reporting Party (RP) observed R1 to be in soiled diaper, or no diaper, and the same clothes for 1 week, no shower. RP observed other residents lying in bed when RP normally sees them engaged in activities or visiting in the Hub room first floor. These residents use wheelchairs and are unable to get out of bed on their own. RP witnessed resident calling for help and no staff came. RP went and looked for staff. Resident is blind and unable to use a call button system or understand to use a pendant to call for assistance. page 1 of 2 Unsubstantiated LPA was able to interview staff members (S1 & S2). S1 mentioned that they always check the residents every 2 hours, or if we pass by the rooms, we just check on them if there is anything they need. S2 also mentioned that they go around and check the residents if they need anything. Usually, every 2 hours and if some of them calls with the pendant. If we are aware of their incontinence, we also check more frequently. LPA was also able to interview 2 residents (R2 & R3). Both mentioned that they are well taken care of in the facility. R2 mentioned that staff is always there when R2 needs anything. When call button is pressed staff comes, and they assist in anything needed. R3 also stated that they (staff) always take care of R3 and has no issues. They always come when R3 needs help. Regarding the allegation of bathroom light fixture not working, RP stated that bathroom light fixture is not working, or bulbs were burnt out. LPA interviewed the administrator (AD1) and stated that there is a handy man during this time that has come every day to check if there are any thing that needs to be fixed. Based on interviews, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Report is reviewed and copy is provided. Page 2 of 2the state’s words, verbatim · CDSS document, Oct 18, 2024 · control 26-AS-20220405104013

Allegation investigated: Resident was left in soiled clothing for extended period of time. Staff are not providing resident with assistance for activities of daily living. Facility did not safe guard residents personal belongings Facility is not providing recreational activities for residents

On 10/18/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Licensee, Lusanta Kaiyom and explained the purpose of today's visit. Regarding the allegations of resident was left in soiled clothing for extended period of time and Staff are not providing resident with assistance for activities of daily living. RP stated that R1 is incontinent, and the staff did not provide incontinence service and left R1 in his/her feces for several hours in the room. RP stated the facility did not provide a shower for R1 for the first 7 days. RP also stated that the facility staff are only giving R1 showers once per week instead for 2-3 times per week. page 1 of 2 Unsubstantiated LPA was able to interview staff members (S1 & S2). Both mentioned that there's always 3 caregivers and 1 manager. S1 added that there are 3 staff per shift, NOC shift is 2, evening is 3 caregivers and a med tech. S2 mentioned that there might be a delay on help when everyone is like lunch time. S2 also added that Some residents are aggressive sometimes, so they wait and give them time if they refuse showers. S3 also mentioned that some residents refuse showers, so they dress them up with clean clothes and still try to ask if they want to shower after. AD1 also mentioned that they talk to the family and the resident as to how many times and what time the showers will be scheduled. If a resident refuses on the scheduled time, then they ask again 3 time within the day. If the answer is still no, then the shower will be scheduled the next day. Regarding the allegation of facility did not safeguard residents’ personal belongings, RP stated that someone stole R1s big package of diapers that RP had purchased and placed in R1s room. LPA observed the facility to have their own supply of diapers in case a resident runs out. AD1 stated that they use these supplies to also cover the residents who runs out of supply because sometimes families forget to order. AD1 doesn’t remember an incident where a family member complained of diapers being lost. Regarding the allegation of Facility is not providing recreational activities for residents, RP stated that the facility provides no recreational activities for the residents at the facility. During the interviews, S1 mentioned that there is bingo, exercises and a guy who plays piano every Wednesday. There's also a one-man band that comes every Monday. Residents are brought down for the activities. We don’t force residents to join, sometimes they just watch tv in their room. AD1 also added that they have memory games, puzzles, word search and coloring books, some activities for memory care. When residents refuse to join, we ask them at least 3 times. Based on interviews, observations and records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Report is reviewed and copy is provided. page 2 of 2the state’s words, verbatim · CDSS document, Oct 18, 2024 · control 26-AS-20220815150455

Allegation investigated: Facility staff leave medications in residents' rooms. Facility staff left resident on the floor for an extended period of time after falling. Facility does not have adequate staffing.

On 10/18/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Licensee, Lusanta Kaiyom and explained the purpose of today's visit. Regarding the allegation of Facility staff leave medications in residents' rooms, reporting party (RP) stated that Medications have been left in residents’ rooms. LPA observed random rooms during several visits and there were no medications left in the rooms. All medications are locked in the medication room. There is a resident (R1) who is able to manage medications and has this medication in a locked box inside the room. page 1 of 2 Unsubstantiated Regarding the allegation of Facility staff left resident on the floor for an extended period of time after falling, RP stated that a resident (R2) fell from the bed on either 3/4/2023-3/5/2023 during NOC shift and was left on the floor more than 1 hour. Based on records review, an incident report was submitted by the Licensee. R1 was sent to hospital after it was found out that R1 had an unwitnessed fall. Licensee has already addressed the issue with the staff. Regarding the allegation of facility does not have adequate staffing, RP stated that a staff member (S2) let RP know that they are always short staffed especially on the weekends. LPA interviewed the Licensee (L1), and it was stated that for staffing, 3 in the morning, 3 in the afternoon, 3 NOC shift. If it is short staffed, the manger stops managerial work and steps in to help. L1 and L2 will also help, be on the floor, serve meals, clean up. When someone calls off, we have a list of people that are on call or not scheduled that we can ask to come in. Based on interviews and records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. Based on records review, Licensee was able to provide proof of training from Relias for S1. The following topics were used for Medication training: Actions and Interactions of Common Medications; Assisting with Self-Administration of Medications: Guideline, Medication Orders, Procedure, The Basics; Medication Documentation for California; Providing Medication Assistance – California, Psychotropic Medications: Antipsychotics and Beyond. All trainings were finished through online completion on 2/5/2022. Based on interviews and records review, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is reviewed and copy is provided. page 2 of 2the state’s words, verbatim · CDSS document, Oct 18, 2024 · control 26-AS-20230316163646

Allegation investigated: Facility staff have not received required training hours prior to assisting with medications Unqualified staff assisting with medications

On 10/18/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Licensee, Lusanta Kaiyom and explained the purpose of today's visit. Regarding the allegations of facility staff have not received required training hours prior to assisting with medications, and unqualified staff assisting with medications. Reporting party (RP) stated that neither the "med techs" or caregivers have the 24 hours of training, 16 hours hands on, 8 hours instruction and followed by passing an examination testing the employee's comprehension and competency. RP also shared that there is a med tech (MT) on staff during the time of 7-3, the owner was unable to provide evidence if MT had passed the medication test. The owner stated that the MT had been a med tech at the facility earlier and assumed this was done but had not verified it. page 1 of 2 Substantiated Based on records review, Licensee was able to provide proof of training from Relias for MT. The following topics were used for Medication training: Actions and Interactions of Common Medications; Assisting with Self-Administration of Medications: Guideline, Medication Orders, Procedure, The Basics; Medication Documentation for California; Providing Medication Assistance – California, Psychotropic Medications: Antipsychotics and Beyond. All trainings were finished through online completion on 2/5/2022. However, during the interviews of staff members (S2, S3, S4), it was found out that 3 out of 3 didn’t have a documented training with regards to medication. Therefore, based on interviews and records review and information collected, the above allegations are determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed and a copy of this report and appeals rights is provided. page 2 of 2 During RPs interview with LPA Heberle, with regards to loose medication on the floor, it was stated that LPA asked RP if there is any evidence or photographic proof. RP stated that there is none. LPA interviewed AD1 and LPA asked for a walkthrough on how the medication pass is done. A staff member S5 walked the LPA through the process for medication. It was explained by S5 that when new medications come in, they log it in the centrally stored medication and destruction records (CSMDR). They then put in in different plastic storages that are assigned to each resident. Labeled with room number also. All medications are locked in the medication room where only staff have access too. LPA observed the medication room to be always locked, there is also a medication cart that has PRN and Narcotics stored with different keys being used. There are also 2 cabinets where routine medications for residents and overflow are stored which also has separate locks. Regarding the allegations of facility staff spoke to resident inappropriately, RP stated that a staff (S1), called a resident "Boo" Totally disrespectful. S1 had no clue that was not appropriate. LPA Heberle interviewed 3 staff members. S2 stated that they only seen staff members referred to residents by name, never pet names. S3 mentioned that they have not heard any staff members speak to residents inappropriately. Staff members don't use pet names, they always address by name. Based on interviews, observations and records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Report is reviewed and copy is provided. Regarding the allegation of facility staff have not been providing training on emergency preparedness, RP stated that they are not sure that the requirement that "All employees must be trained upon hire and annually on the community's emergency preparedness plan and that all employees must participate in a quarterly emergency preparedness drill is happening. The owner said only 2 employees have to do this. Based on records review, there is a log of training for emergency preparedness dating back 12/21/2021, 3/8/2022, 7/28/2022, 10/10/2022, 12/20/2022, 3/4/2023, 6/20/2023, 9/9/2023 & 12/20/2023. All are signed by staff members present during training and topics covered are fire and earthquake drills. Based on interviews, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Oct 18, 2024 · control 26-AS-20230324170427

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(c)(3)(D) · Plan of correction due date: Oct 19, 2024

87411 Personnel Requirements-General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as ...(3) The training shall include, but not be limited to, the following: (D) Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4)... This was not met as evidenced by: Based on records review, 3 out of 3 staff members don’t have documented training with regards to medication, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 18, 2024

Plan of correction: Licensee to submit a plan to address staff training. Licensee to submit by POC due date.

Allegation investigated: Staff handles resident in a rough manner. Staff barricaded resident's door.

On 10/3/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Licensees, Lusanta & Saaj Kaiyom and explained the purpose of today's visit. Regarding the allegation of staff handles resident in a rough manner, Reporting party (RP) reported that in January of 2022, RP was visiting R1 when it was observed that a caregiver was being rough with R1 while trying to transfer R1 to the wheelchair. LPA Heberle tried contacting the number provided by RP but it was the wrong number. There is also no other information provided or description describing who the caregiver was. con't... Unsubstantiated Regarding the allegation of staff barricaded resident's door, RP stated that in early February 2022, RP observed R1 was barricaded by a recliner, moved in front of R1’s bedroom door so R1 could not get out. LPA Donato interviewed Licensee, and it was mentioned that R1 was never barricaded in the room. R1 sometimes throws things at caregivers but no one has barricaded R1 in. Based on interviews, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and coy is provided.the state’s words, verbatim · CDSS document, Oct 3, 2024 · control 26-AS-20230427141045

Allegation investigated: Facility staff caused multiple bruises to residents in care.

On 8/16/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Licensees Lusanta & Saaj Kaiyom and explained the purpose of today's visit. Regarding the allegation of facility staff caused multiple bruises to residents in care. Reporting party (RP) stated that a resident (R1) disclosed on 10/13/2023 that the night staff have been hitting him/her. Per RP, when R1 was examined, R1 was observed to have bruising from one side of the chest to the other. LPA Dolores interviewed two staff members. S1 mentioned that on 10/10/23, was when NOC shift found R1 on the floor. R1s chest was bruised and it was the front area. Hospice came to check and was aware of the fall. Family was called. Hospice thinks R1s rib broke. They talked to the responisble party (F1) and made the decision not to send R1 out. R1 wasn’t sent to the hospital after the fall. Another staff, S2 mentioned that R1 has a history in falling and transferring on his/her own. In the middle of the night R1 will try to get out of bed himself/herself. page 1 of 2 Unsubstantiated Last month (October 2023) R1 was completely bed bound. R1 would try to transfer himself/herself. Often time R1 would slide off the floor and call for help. R1 would be in that situation and would be off the floor or in between bed and wheelchair. Based on records review, LPA Donato found out that part of R1s behavior is yelling and would keep on trying to get up on his/her own even though it is indicated in the needs and services plan that assistance is needed in providing activities of daily living (ADLs). Based on interviews & records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. page 2 of 2the state’s words, verbatim · CDSS document, Aug 16, 2024 · control 26-AS-20231122171044

Allegation investigated: Staff does not allow resident to exercise. Staff forced resident to be wiped.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Licensee/Administrator, Saaj Kaiyom & Licensee, Lustana Kaiyom and stated the purpose of today’s visit. On 2/20/2024, the Department received a complaint with the above allegations. On 2/22/2024, the Department conducted an initial investigation at the facility. Continuaton on LIC 9099-C, Page 1 of 3. Unfounded Page 2 of 3. Resident sustained UTI while in care. It was alleged a female resident has not sustained rashes but sustained a UTI. On 2/22/2024, the Department interviewed ADM. ADM stated the resident are given water and the staff will remind residents to drink water, however the staff cannot force the residents to drink water. ADM stated one resident (R1) has a history of UTI and doctor has prescribed antibiotics for prevention. On 2/22/2024, the Department interviewed S1. S1 stated R1 has a chronic UTI and is always on medication. Per S1, facility staff during morning shift provide routine incontinence care at approximately 6am, 8am, between 9-9:30am, 12pm, between 1-1:30pm. On 5/16/2024, LPA Rai interviewed 10 residents. 4 Out of 10 residents refused the interview. 6 Out of 10 residents agreed to the interview. 6 Out of 6 residents stated they did not sustain UTI while in care. 2 Out of 6 residents stated they are concerned about UTI so they ensure they are drinking enough water. 6 Out of 6 residents stated the facility staff bring them water and ensure water is available in the rooms. During interview, LPA Rai observed either cups of water or a water bottle filled with water assessable to the resident. 6 Out of 6 residents have not heard about residents sustaining UTI while in care. Based on record review, R1 moved into the facility on 1/11/2022. Per R1’s Physician’s Report dated 1/10/2022 and 3/7/2024, R1 has a secondary diagnosis of urinary Tract Infection. Based on record review of R1’s Physician’s Order for UTI medication and Physician’s Note dated 2/26/2024 for R1, R1 continue to have recurrent UTI and R1 was administered 2 different antibiotics for UTI on 3/12/2024. Staff did not assist resident in a timely manner/ Staff does not respond to resident’s call button. It was alleged when the resident requests to be toileted, it takes one hour for the staff member to come and assist. It was alleged when the resident presses the call button for assistance the staff member(s) does not respond or come assist. Page 3 of 3. On 2/22/2024, the Department interviewed ADM. ADM stated he is not aware of this issue but if there are multiple people requiring assistance, then there is a cue for when staff will respond. The facility does have a call bell system for the residents to press a button to request for help. On 2/22/2024, the Department interviewed staff (S1). S1 stated there are times where multiple residents do request for help at the same time. S1 stated the residents do not wait for more than 20 minutes but the call bell system does not allow for them to check how long the resident has been waiting. S1 stated there are always 4 staff in the facility during AM shift and PM shift and 2 staff present during night shift. S1 stated the staff use the walkie talkie to communicate their location and which resident they are assisting. S1 stated the pager will notify when the resident has requested for help with the pendent. On 2/22/2024, LPA Rai observed the call bell system, but the system does not log the calls, so LPA Rai was not able to review the call bell system for previous requests. During visit, LPA Rai observed the pendent being used by 5 different residents and the pendants were cleared within 5 minutes. On 5/16/2024, LPA Rai interviewed 10 residents. 4 Out of 10 residents refused the interview. 6 Out of 10 residents agreed to the interview. 6 out of 6 residents use the call button to request for staff assistance. 6 Out of 6 residents stated it will take 5-10 minutes before staff will respond to the request. 5 Out of 6 residents stated they did not have any issues with the staff responding in a timely manner. 5 Out of 6 residents stated they cannot recall a time when the facility staff took more than 20 minutes to answer their call button. During one of the interviews, LPA Rai observed 1 resident press the call pendent and the staff checked the resident within 3 minutes. Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Licensee/Administrator, Saaj Kaiyom & Licensee, Lustana Kaiyom and a copy of the report was provided. Page 2 of 3. Staff does not allow resident to exercise. It was alleged a resident was not allowed to exercise in the bed since the resident stays in bed. On 2/22/2024, the Department interviewed ADM. ADM stated the facility does provide exercise activities twice a week but not all the residents have the physically capabilities to do the exercise. ADM stated there is a resident (R1) who wants to do exercises in bed, but R1 would like the staff to do physical therapy exercises and the facility staff are not trained to provide those exercises. ADM stated R1 has been referred to physical therapy sessions and allowed for private caregiver to come in and provide the physical therapy exercises requested. ADM stated R1 attends physical therapy at outside clinic. On 2/22/2024, the Department interviewed staff (S1). S1 stated the facility does provide exercise twice a week. S1 stated R1 is very particular about exercise and R1 would like the staff to do exercise in the bed. S1 stated the NOC shift staff will help R1 be in butterfly yoga position. Based on review of facility’s calendar from November 2023 – February 2024, which stated the facility provides exercise twice a week. Based on R1’s Progress notes, on 8/5/2023, R1’s Physical Therapist suggested R1 to stay upright without support and R1 requested for facility staff to be on standby in the room for breakfast while R1 was upright in bed. On 5/16/2024, LPA Rai interviewed 10 residents. 4 Out of 10 residents refused the interview. 6 Out of 10 residents agreed to the interview. 6 Out of 6 residents stated they are aware the facility has exercise as one of the activities but has not heard of staff doing exercises in the resident’s room. They stated staff do not restrict them to exercise. 3 Out of 6 residents participate in the activities at the facility and have attended the exercise activity and they have no issues or concerns about the exercise activity. 1 Out of 6 resident stated the facility staff encourage him/her to walk. Page 3 of 3. Staff forced resident to be wiped. It was alleged the resident requested to be wiped with soap and water with a paper towel and facility staff forcefully wipes the resident with an “anti-bacterial” wipe. On 2/22/2024, the Department interviewed the ADM. ADM stated the staff do not use “anti-bacterial” wipe but baby wipes which are intended for incontinence use. ADM stated R1 wants to use Bounty paper towels, but the towels are not intended for incontinence use and may be rough over the skin. ADM stated the facility staff have advised R1 about the roughness again the skin. On 2/22/2024, the Department interviewed the staff (S1). S1 stated the facility staff does not use antibacterial wipe but the staff use baby wipes which are for incontinence care. S1 stated R1 prefers to use wet Bounty paper towels for incontinence use. S1 stated R1 has vocalized not to use baby wipes and the staff no longer use them for R1. On 5/16/2024, LPA Rai interviewed 10 residents. 4 Out of 10 residents refused the interview. 6 Out of 10 residents agreed to the interview. 6 Out of 6 residents stated they receive incontinence care, and they receive assistance from the facility staff. 6 Out of 6 residents stated the facility staff will use wet wipes to clean the private area. 6 Out of 6 residents stated they have not seen or heard staff using antibacterial wipes on the resident in the private area. During the interviews, LPA Rai observed wet wipes for incontinence use in the resident’s room and did not observe anti-bacterial wipes in the rooms. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Licensee/Administrator, Saaj Kaiyom & Licensee, Lustana Kaiyom and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 16, 2024 · control 26-AS-20240220124121

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Saaj Kaiyom. LPA Rai observed 1 staff and 3 residents in the Dining Room #2. During visit, LPA Rai toured the inside and outside of the facility. LPA observed two (2) locked sheds in the backyard and they were not used as habitual space. When touring the outside area of the facility, the exits leading from the resident room to the outside were cleared of obstruction. LPA Rai observed the exit door (on the right side of the facility facing the main street 17th Ave) were not able to open. ADM unscrewed a bolt next to the handle which stopped the door from opening. LPA Rai observed a secondary fence approximately 4 feet high which also had a latch on the door and there was a screw next to the latch which stopped the door from opening. ADM stated there was a resident who would open the exit doors in the past. LPA Rai advised ADM to not substitute locked doors for supervision and exit doors needed to be able to open on their own and clear of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the resident bedrooms. 8 out of 8 resident bedrooms had available bedding, drawers, and functioning lights. 3 out of 8 resident rooms did not have window screen or door screen in good repair. During the tour of the outside of the facility, ADM pointed out multiple rooms with door screen or window screen not in good repair. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 105.1F - 109.0F. Fire extinguisher was observed and inspected on 03/29/2023. Facility carbon monoxide detectors were in working condition. Third party vendor inspected the fire alarm and sprinkler system on 1/10/2024 and the facility passed the inspection. The last disaster drill was conducted on 11/10/2023. LPA Rai reviewed facility records for 5 staff and 5 residents. LPA Rai reviewed 1 out of 5 resident's Physician's Report was signed by a Physician's Assistant and not a Physician. Licensee stated they did not apply for a waiver for a non-physician to sign the Physician's Report and they do not plan on applying for a waiver. Licensee will work with R2's family to obtain a Physician's Report which is signed by a physician. LPA Rai reviewed resident medications and central stored medication records. LPA observed first aid kit and evacuation chair on the second floor. Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with Administrator (ADM) Saaj Kaiyom and a copy of the report was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Feb 22, 2024