Park Regency Retirement Center

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Maintenance Director (MD) Jorge Garcia and discussed the purpose of the inspection. Administrator (AD) Sabina Nayberg arrived during the inspection. LPA reviewed Infection Control requirements. At about 8:00AM, LPA and MD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication rooms and observed the following: Structure: this is a large commercial facility. Facility is composed of a single, two-story building with a delayed egress memory care unit on the second floor, a commercial kitchen and large dining room on the first floor, medication rooms on both floors, and resident rooms on all floors, along with multiple common areas, storage rooms, and a large central courtyard and a smaller courtyard dedicated to memory care with shaded seating for residents. There are a total of 86 resident rooms. Resident Bedrooms: the 10 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 10 resident bedrooms inspected. LPA tested the call buttons in multiple resident rooms and noted prompt response times. LPA observed the delayed egress system was functioning. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 111 and 119 degrees F in the 10 resident bathrooms tested. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the housekeeping closets. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees have not been paid. LPA provided billing information. At about 10:00AM, LPA reviewed 10 resident files and 6 staff files, interviewed 6 residents and 6 staff, and inspected medications for 6 residents. Facility does not handle resident money. During the inspection, LPA and AD observed the following: based on documents, the facility's liability insurance certificate is expired and there is no certificate confirming the insurance is still active; based on documents, the licensee did not ensure S4 and S6 who are new have documented 40 hours initial training; based on documents, the licensee did not ensure S2, S3, and S5 have documented 20 hours continuing annual training; based on documents, the licensee did not ensure S2, S3, S4, S5, and S6 had current first aid training; based on documents, the licensee did not ensure medication technicians S4 and S6 had documented medication training; based on documents, the physician's reports for R1, R2, R3, R4, R6, R7, R8, R9, and R10 are on the old form and do not contain required information, including behavioral expressions; based on documents, the licensee did not ensure R1, R2, R3, R4, R6, R7, R8, and R10 were reappraised within the last year as their appraisals are all over a year old; and based on documents, the physician's reports for R1, R2, R3, R5, R6, R7, R8, R9, and R10 are over a year old and there is no documentation of an annual routine visit. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 27, 2026

The state marks this report as 9 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Allegation investigated: Facility failed to provide a refund.

On July 13, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director Sabina Nayberg was present and assisted on today's visit. During the course of the investigation, the Department interviewed staff, reviewed and obtained pertinent documents to the complaint such as resident records. Regarding the allegation, facility failed to provide a refund, the following has been concluded: It was alleged that the facility failed to provide a refund for Resident #1 (R1). The Department conducted a file review for R1 and observed that R1 moved into the facility on April 3, 2024. The Department observed that R1 moved out of the facility on May 7, 2024. The Department reviewed R1's admission agreement dated April 1, 2024. On page nine of R1's admission agreement, is states that the admission agreement may be terminated by the resident at any given time by giving the Executive/Operations Director thirty days' prior written notice. CONTINUED ON LIC9099-C Unfounded It also states that the resident will continue to be responsible for the monthly fee until the thirty day period has expired. On page six of the admission agreement, it also states that the resident is entitled to a portion of their community fee, based on the length of their stay at the facility. The Department observed R1's admission agreement to be signed by both R1's Responsible Party, Witness #1 (W1), and a facility representative, indicating that both parties agreed to the terms of the contract. The Department reviewed emails between Witness #1 (W1), and the Executive Director at the time, Staff #1 (S1). The Department observed that W1 provided S1 with a written notice on April 7, 2024, that they intended to move R1 out of the facility. Therefore, R1 would continue to be responsible for the monthly fee until May 7, 2024, when the thirty day period expired. The Department reviewed R1's billing statements and observed the facility charged R1 his monthly fees until May 7, 2024, in accordance to the admission agreement. The Department also observed that the facility refunded R1 a portion of his community fee, in accordance to their admission agreement. Based on the records reviewed, the facility satisfied their obligations under the admission agreement and provided the necessary refunds to R1. The Department observed that R1 was not entitled to any additional refunds and were charged appropriately during their stay at the facility. Based on the evidence gathered during this investigation, the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis. An exit interview was conducted with Executive Director Sabina Nayberg and a copy of the report was provided at time of visit. It states that staff observed R1 run down the hallway and slam his body against a door, in order to exit the memory care portion of the facility. It states that staff immediately began to pursue R1 as he was leaving the facility and that staff immediately called 9-1-1. It states that R1 was able to leave the facility property, but was being followed and observed by staff while he was doing so. It then states that R1 was then transferred to the hospital after the incident. The Department was unable to conduct an interview with R1 for this complaint, due to R1 moving out of the facility on May 7, 2024. The Department conducted a total of six staff interviews. Three staff were unable to provide any information for the allegation due to them not working at the facility at the time, or not recalling the incident in question. However, the Department was able to conduct interviews with three staff who had knowledge of the allegation. The three staff interviewed confirmed the information on the UIIR was accurate and the three staff denied the allegation. The three staff confirmed that R1 was immediately being followed and observed by staff as he was attempting to leave the facility. The three staff confirmed that 9-1-1 was called as a result of the incident and the staff reported that they believed staff responded appropriately to the incident. Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation above is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Sabina Nayberg and a copy of the report was provided at time of visit.the state’s words, verbatim · CDSS document, Jul 13, 2026 · control 22-AS-20240411142922

Type of visit: POC

This unannounced POC inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of verifying correction of deficiencies issued during the complaint inspection conducted on May 12, 2026, in connection with Complaint Control No. 22-AS-20220323083918 and the Case Management – Deficiencies inspection conducted on May 12, 2026. LPA met with Maintenance Director (MD) Jorge Garcia and Administrator (AD) Sabina Nayberg and explained the reason for today’s inspection. During the inspection, LPA and MD inspected the facility, conducted health and safety checks on residents present, and observed no health and safety issues. During the inspection, LPA and MD observed the following: Type B Violation cited under California Code of Regulations (CCR) Title 22, Section 87465(a)(4) pertaining to a resident’s medication not documented as administered has been CLEARED. On June 1, 2026, the former wellness director emailed LPA documentation of medication training. Type B Violation cited under California Code of Regulations (CCR) Title 22, Section 87303(i)(1)(A) pertaining to not checking on residents regularly when the signal system is malfunctioning has been CLEARED. On June 1, 2026, the former wellness director emailed LPA documentation of signal system training. Type B Violation cited under California Code of Regulations (CCR) Title 22, Section 87303(e)(4) pertaining to toilets not having grab bars has been CLEARED. On June 1, 2026, the former wellness director emailed LPA documentation and photographs of grab bars installed in 23 rooms where they were missing. During the inspection, LPA inspected 26 rooms and confirmed they all have grab bars for the toilets. Type B Violation cited under California Code of Regulations (CCR) Title 22, Section 87463(a) pertaining to timely reappraising residents upon change of condition has not been cleared. The plan of correction was to create a protocol to ensure residents are reappraised timely and submit proof to LPA by June 9, 2026. Type B Violation cited under California Code of Regulations (CCR) Title 22, Section 87608(a)(3) pertaining to using postural supports without a doctor’s order has not been cleared. The plan of correction was to conduct training on postural supports and submit proof to LPA by June 9, 2026. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report, clear letters for all citations cleared during this inspection, and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Jul 27, 2026

87463 Reappraisals (a) The pre-admission appraisal … shall be updated in writing as frequently as necessary … to note significant changes in condition … and to keep the appraisal accurate…. This requirement was not met as evidenced by: Based on admission, the licensee started, but did not complete, a reappraisal for R1 based on their change of condition, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 13, 2026

Plan of correction: Licensee stated they will create a protocol to ensure residents are reappraised timely and submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(3) · Plan of correction due date: Jul 27, 2026

87608 Postural Supports (a) … (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record…. This requirement was not met as evidenced by: Based on interview and documents, the licensee used a wheelchair for R1 without a doctor’s order, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 13, 2026

Plan of correction: Licensee stated they will retrain staff on postural supports requirements and submit proof to LPA by POC due date.

Allegation investigated: Staff did not provide proper medication assistance to resident in care Resident's call button was in disrepair Facility did not maintain grab bars for each resident toilet Staff did not complete a reappraisal on resident in care

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Wellness Director (WD) Maria Vasquez and explained the reason for today’s inspection. The investigation into the allegations that staff did not provide proper medication assistance to resident in care, resident's call button was in disrepair, facility did not maintain grab bars for each resident toilet, and staff did not complete a reappraisal on resident in care revealed the following: During the course of the investigation, LPA inspected the facility, interviewed staff and residents, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) care notes, R1’s Medication Administration Records (MAR), the facility’s internal communications, and a copy of R1’s service plan marked up on January 6, 2022. Substantiated Regarding the allegation that staff did not provide proper medication assistance to resident in care: it was alleged that R1 did not take their medication because staff would leave R1’s room without confirming they took the medication. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed five residents and did not obtain information corroborating that medication technicians leave residents’ rooms without confirming residents have taken their medication. However, LPA reviewed R1’s care notes which indicate on May 12, 2021, a reminder was documented for the medication technicians emphasizing the importance of staying in the room and watching R1 drink a liquid medication, advising that R1 missing doses of this medication will alter R1’s potassium levels, and advising that on May 12, 2021 R1’s family reported that R1’s dialysis nurse found R1’s potassium levels to be dangerously high. In addition, LPA reviewed R1’s MAR which indicates R1’s Sevelamer Carbonate 800MG was not documented as being given for the noon dose on January 24, 2022. Regarding the allegation that a resident's call button was in disrepair: it was alleged that R1’s call button was not functioning for three weeks in January 2022. LPA reviewed the facility’s internal communications which document that the entire call system stopped functioning on February 16, 2022, and checks were conducted on all residents in lieu of the call system. However, per the facility’s’ internal communications, on February 17, 2022, a caregiver checked on R1, R1 complained that they had been calling for assistance, but the caregiver documented that the call light system was still not working and they had only checked on R1 because of their rounding. R1’s care notes and the facility’s internal communications do not document any issues with the call button system after February 17, 2022. Facility staff were supposed to conduct regular checks on residents while the call system was not working, but the information obtained shows that R1 was calling for assistance for an unknown length of time, the caregiver did not receive the signal or respond timely, and the caregiver only checked on R1 as part of their last check without realizing R1 had been calling for assistance. Regarding the allegation that facility did not maintain grab bars for each resident toilet: it was alleged that R1’s room did not have grab bars for the toilet and staff did not correct the issue. Per the facility’s resident roster and R1’s MAR, R1 resided in Room 165. LPA interviewed the facility’s maintenance director who stated there are two styles of bathrooms, where the old style has a sink that goes up to the toilet and the sink can be used as a grab bar, and the new style where the sink is far from the toilet and cannot be used as a grab bar. Per the facility’s maintenance director, grab bars are installed when requested by residents’ families. LPA inspected the facility and confirmed that the old style has a sink that goes up to the toilet and could possibly be used as a grab bar, but Room 165 does not have separate grab bar installed on the sink and the edge of the sink does not provide the same gripping surface as a true grab bar, meaning it does not meet the requirement that every toilet have a grab bar. In addition, LPA noted room 206 has the new style where the sink does not reach the toilet and there is no grab bar installed on the toilet. Regarding the allegation that staff did not complete a reappraisal on resident in care: it was alleged that in January 2022, R1 had a fall resulting in decreased arm mobility and the facility did not conduct a reappraisal or update R1’s care plan prior to R1 leaving the facility in February 2022. LPA reviewed R1’s care notes which document that on December 15, 2021, R1 had a fall, went to the hospital, and was picked up by their family to stay with their family. Per R1’s MAR, R1 returned to the facility on January 6, 2022. LPA reviewed R1’s care notes which document that on December 22, 2021, facility staff communicated with R1’s family regarding R1’s change of condition after their fall and documented R1’s new care needs and how they would be met. LPA reviewed a copy of R1’s service plan marked up on January 6, 2022 by the facility’s wellness director at the time that documents R1’s new care needs and documents that the facility would use a wheelchair for R1, but this document was never finalized. Per R1’s care notes, when R1 returned to the facility on January 6, 2022, facility staff requested an updated physician’s report from R1’ doctor and planned to update R1’s service plan. R1’s care notes document that on February 18, 2022, a care plan meeting was held with R1’s family, it was explained to R1’s family that R1’s service plan had not yet been updated because the facility was still waiting on an updated physician’s report from R1’s doctor, R1’s family was advised that staff are all aware of R1’s new care needs and the required care was being provided, and R1’s family advised the facility that R1 would be moving out. While the facility noted R1’s new care level and claimed to provide the newly required services, the facility did not need to wait for the new physician’s report in order to finalize the changes already discussed with R1’s family. In this case, R1 returned to the facility on January 6, 2022 and did not have a finalized updated service plan by the time they moved out on February 19, 2022. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. It was alleged that when R1’s call button did function, R1 had to wait 30 minutes or longer for assistance from staff. LPA interviewed the administrator at the time who stated the average wait time is five to 10 minutes, with the old call button system wait times could not be tracked, but with the pendant system installed on March 1, 2022, they can now track wait times. LPA interviewed five residents and did not obtain information corroborating long wait times. LPA reviewed the facility’s internal communications which document that on February 9, 2022, R1 called for assistance at 5:08AM, requested a medication from the caregiver, and the medication was provided to R1 by the medication technician at 5:20AM. The facility’s internal communications also document that on January 21, 2022, at 5:40AM, R1 requested assistance, assistance was provided by a caregiver, and the encounter was completed and documented by the medication technician minutes later at 5:53AM. These incidents demonstrate rapid response times by staff. Per the facility’s internal communications, on February 11, 2022, R1 requested assistance at 3:08AM, stated they were hungry and wanted the medication technician to warm up the soup in their fridge and feed them, the medication technician advised R1 that they could not because they had to attend to other residents, and the medication technician went back and confirmed R1 was fine prior to 5:36AM when the encounter was documented. This incident demonstrates that R1’s call was answered, R1’s request could not be immediately fulfilled, and the staff checked back later to ensure R1 was doing well, although additional details, including whether R1 withdrew their request to eat so early in the morning or when the staff made their second check, were not documented and the staff no longer works at the facility. The information obtained is conflicting. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, May 12, 2026 · control 22-AS-20220323083918

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 9, 2026

87465 Incidental Medical and Dental Care (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on documents, the licensee did not ensure R1 received assistance with medications when their dose of Sevelamer Carbonate was not documented as administered, which poses a potential health risk to persons in care. CIVIL PENALTY ASSESSEDthe state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Licensee stated they will conduct medication training and submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(A) · Plan of correction due date: Jun 9, 2026

87303(i)(1)(A) – 87303 Maintenance and Operation (i) Facilities shall have signal systems which … (1) … (A) Operate from each resident's living unit... This requirement was not met as evidenced by: Based on documents, the licensee’s signal system malfunctioned, staff were supposed to conduct regular checks, but R1’s attempts to call staff went unanswered until a caregiver happened to check on R1, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Licensee stated they will create a protocol for regular checks if the signal system malfunctions, train staff on the protocol, and submit the protocol and training records to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(4) · Plan of correction due date: Jun 9, 2026

87303 Maintenance and Operation … (e) … (4) Grab bars shall be maintained for each toilet; bathtub and shower used by residents. This requirement was not met as evidenced by: Based on admission and observation, the licensee did not ensure multiple rooms, including Rooms 165 and 206, have grab bars for the toilet, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Licensee stated they will create a list of all rooms without grab bars for the toilet, install grab bars in all these rooms, and submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Jun 9, 2026

87463 Reappraisals (a) The pre-admission appraisal … shall be updated in writing as frequently as necessary … to note significant changes in condition … and to keep the appraisal accurate…. This requirement was not met as evidenced by: Based on admission, the licensee started, but did not complete, a reappraisal for R1 based on their change of condition, which poses a potential safety risk to persons in care. CIVIL PENALTY ASSESSEDthe state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Licensee stated they will create a protocol to ensure residents are reappraised timely and submit proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20220323083918. LPA met with Wellness Director (WD) Maria Vasquez and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, interviewed staff and residents, and obtained and reviewed copies of the resident roster, staff roster, a copy of Resident #1’s (R1) service plan marked up on January 6, 2022, and R1’s medical records. A witness observed R1 being placed in wheelchair at the facility. LPA reviewed a copy of R1’s service plan marked up on January 6, 2022 by the facility’s wellness director at the time that corroborates a wheelchair was used for R1. However, R1’s file and R1’s medical records do not contain a doctor’s order for a wheelchair. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, May 12, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Jun 9, 2026

87608 Postural Supports (a) … (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record…. This requirement was not met as evidenced by: Based on interview and documents, the licensee used a wheelchair for R1 without a doctor’s order, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Licensee stated they will retrain staff on postural supports requirement and submit proof to LPA by POC due date.

Allegation investigated: Resident did not receive medications timely

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Wellness Director (WD) Alex Gutierrez, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that a resident did not receive medications timely revealed the following: During the course of the investigation, LPA inspected the facility, interviewed WD, staff, and residents, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) facility care notes, and R1’s Medication Administration Records (MAR). CONTINUED Unsubstantiated It was alleged that on January 3, 2026, R1 was sick, did not receive their medications timely, and R1’s illness and delayed medications were not reported to R1’s doctor. LPA inspected the facility, conducted health and safety checks on residents, including R1, and observed no health and safety issues. LPA reviewed R1’s MAR, which did not corroborate that any medications were missed or late. LPA inspected the medications for R1 and four other residents and observed no medication errors. LPA interviewed WD and two staff who denied the allegation. WD stated that on January 3, 2026, they personally gave R1 their morning medications and checked on R1 because it was reported that R1 was sick. LPA interviewed R1 who did not report any issues with missed or delayed medications, but stated that on January 3, 2026, they were having cough and headache symptoms, WD was covering as the medication technician in the memory care unit but left without R1’s knowledge, and R1 did not know who to ask for their as-needed medications. When interviewed, WD confirmed that they, along with a trainee, left the facility after the morning and noon medication passes leaving no medication technician in the memory care unit, but stated that all medications had been passed, the assisted living medication technician was present and available for residents, and all care staff have walkie talkies so residents do not need to request anything directly from the medication technicians, as they can request assistance from the caregivers who will call it in to the medication technician. LPA interviewed four other residents who did not report any medication issues. Although R1 was unable to directly request medications from a medication technician, R1 was able to request assistance from caregivers who would have forwarded the request to the medication technician, and R1 confirmed that staff checked on their cough and communicated with their doctor to address their symptoms. LPA reviewed R1’s MAR and facility care notes which show the facility was aware of R1’s symptoms as of January 2, 2026, provided medications as needed, and properly notified R1’s doctor of R1’s symptoms and R1’s doctor provided additional assessment and treatment. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jan 8, 2026 · control 22-AS-20260106082030

Allegation investigated: Staff left resident in a soiled diaper for a long period of time.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Administrator (AD) Miles Mouradian, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that staff left resident in a soiled diaper for a long period of time revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, staff, and residents, and obtained and reviewed copies of the resident roster, staff roster, the facility’s care notes dated December 29, 2025, the facility’s call button logs, and Resident #1’s (R1) Needs and Services Plan dated November 9, 2024. CONTINUED Unsubstantiated It was alleged that R1 had a fall and was discovered soaked in urine. LPA interviewed AD who stated that R1 is currently at the hospital. Per the facility’s wellness director, R1 was hospitalized on December 31, 2025, due to a cognitive change of condition and will be reassessed prior to their return. LPA inspected the facility, conducted health and safety checks, and observed no health and safety issues. LPA reviewed the facility’s care notes dated December 29, 2025, which indicate that on December 29, 2025, R1 had an unwitnessed fall, stated they had rolled out of bed, complained of pain on their tail bone, was sent to the hospital, and returned after a few hours. LPA interviewed the staff that discovered R1 during this incident who confirmed that R1 wears diapers and was found soaked in urine, but stated that R1 was cleaned and changed immediately and was unable to state how long R1 had been soiled. Per the facility’s call button logs, R1 did not call for assistance with incontinence care prior to being found soaked in urine. LPA interviewed the facility’s wellness director who stated that R1 does use diapers, but is independent with diaper changes and does not receive incontinence care from the facility, although facility staff will provide incontinence care if they observe that R1 needs it. LPA reviewed R1’s Needs and Services Plan dated November 9, 2024, which indicates R1 is independent with toileting. The facility’s wellness director stated that R1 will be reassessed to determine if they need to receive incontinence care in the future. While R1 was observed to be soiled, R1 was independent with toileting needs at the time and staff provided incontinence care when they noticed R1 needed it. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. Regarding the allegation that staff did not assist a resident in care: it was alleged that R1 had a fall, was left on the floor for a long period of time, the staff who discovered R1 did not help R1 get up, and other staff had to come to help R1 get up. LPA interviewed AD who stated that R1 is currently at the hospital. Per the facility’s wellness director, R1 was hospitalized on December 31, 2025, due to a cognitive change of condition and will be reassessed prior to their return. LPA inspected the facility, conducted health and safety checks, and observed no health and safety issues. LPA reviewed the facility’s care notes dated December 29, 2025, which indicate that on December 29, 2025, R1 had an unwitnessed fall, stated they had rolled out of bed, complained of pain on their tail bone, was sent to the hospital, and returned after a few hours. LPA interviewed the staff that discovered R1 during this incident who stated that they found R1 on the floor, R1 was complaining of pain on their hip, the protocol for this situation is for paramedics, not staff, to assist the resident up, and that they followed the protocol by calling paramedics and having other staff come and make R1 comfortable until paramedics arrived. This staff was unable to state how long R1 had been on the floor, but reported hearing R1 yelling for help while they were attending to a nearby resident. Per the facility’s call button logs, R1 did not call for assistance in relation to their fall. LPA reviewed R1’s Needs and Services Plan dated November 9, 2024, which indicates R1 is independent with walking and transfers. Per the facility’s wellness director, R1 is independent with activities of daily living, but will be reassessed to determine if they need to receive additional care in the future. Although R1 had a fall, no information was obtained that R1 sustained an injury, as they returned from the hospital after a few hours, and facility staff followed proper protocol by making R1 comfortable but having paramedics assess R1 prior to attempting to help R1 up. Regarding the allegation that staff did not respond to residents call button: it was alleged that multiple staff are not responding to residents’ calls for assistance. LPA inspected the facility, conducted health and safety checks, and observed no health and safety issues. LPA interviewed AD, the facility’s wellness director, and two staff who denied the allegation. LPA reviewed the facility’s call button logs which show that staff are responding to residents’ calls for assistance. LPA interviewed 10 residents and did not obtain information corroborating the allegation. The Department has investigated the above allegations and found them to be Unfounded, meaning the allegations were false, could not have happened, or are without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jan 5, 2026 · control 22-AS-20251230120343

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20251230120343. LPA met with Administrator (AD) Miles Mouradian and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, interviewed AD, staff, and residents, and obtained and reviewed copies of the resident roster, staff roster, the facility’s care notes dated December 29, 2025, the facility’s call button logs, and Resident #1’s (R1) Needs and Services Plan dated November 9, 2024. Per R1’s Needs and Services Plan dated November 9, 2024, and the facility’s wellness director’s admission, R1 has not been reappraised yearly as required as their appraisal is over a year old. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jan 5, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Jan 19, 2026

87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first… This requirement was not met as evidenced by: Based on documents and admission, the licensee did not ensure R1 was reappraised yearly, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 5, 2026

Plan of correction: The licensee stated they will reappraise R1 and submit proof to LPA by POC due date.

Allegation investigated: Facility is not providing enough staff to meet the needs of residents in care.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Staff #1 (S1) Annaliza Yem and explained the reason for today’s inspection. The investigation into the allegation that facility is not providing enough staff to meet the needs of residents in care revealed the following: During the course of the investigation, LPA inspected the facility, interviewed staff and residents, and obtained and reviewed copies of the resident roster, staff roster, the facility’s labor hour reports, staffing agency invoices, and the facility’s termination report. It was alleged that, due to staff turnover, the facility was short staffed in September 2021, instead of four staff covering assisted living and memory care only one staff was observed covering memory care, and residents had to wait a long time to be assisted with personal needs like incontinence care resulting in residents being left in soaked diapers, especially in memory care. Substantiated LPA inspected the facility in October 2021 and noted that there were not enough staff to readily assist LPA with the inspection, as all care staff were occupied providing care, the only office staff present had to cover reception until they were relieved, and the administrator at the time did not arrive until much later in the day. LPA also observed unpleasant odors from one memory care room, an unpleasant odor in the hallway possibly coming from one of the residents, and one memory care room had stains, crumbs, and debris on the floor as well as stains on the walls. When interviewed, the administrator at the time confirmed that the memory care recently had staffing issues, confirmed there was a lot of recent staff turnover, but otherwise denied the allegation, stating the facility was meeting its own staffing ratio with its staff and was also using a staffing agency to supplement staff. LPA reviewed the facility’s labor hour reports which indicate the number of caregiver hours were consistent from June through September 2021. LPA reviewed staffing agency invoices showing a small amount of staffing agency coverage during this time. LPA reviewed the facility’s termination report which shows that from June 2021 to the end of September 2021, 22 staff quit or were terminated. LPA interviewed five staff who corroborated that around September 2021, the facility had severe staffing issues due to staff turnover, there were fewer staff than there were supposed to be, especially in memory care, which negatively affected resident care, increased wait times for care, and increased the workload which caused more staff to leave. Staff interviewed also confirmed that there were instances where there was only one caregiver in memory care, that memory care would pull staff from the assisted living section leaving that section understaffed, and that the overnight shift was unable to meet the needs of the residents and left them all wet in the morning without changes. LPA interviewed six residents, five of whom corroborated that the facility had lost a lot of staff recently and three of whom confirmed residents were impacted by the staffing issues, including with longer wait times. Regardless of whether the facility was meeting its own staffing ratio, interviews with multiple residents and staff confirmed that the facility’s staffing level was insufficient to meet residents’ needs, including incontinence care. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 22-NP-20211007121841

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 19, 2025

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure there were sufficient staff to meet residents’ needs, resulting in residents being left in soiled diapers, which poses an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: The licensee stated they have since increased their staffing levels, will create a plan to address future staffing shortages, and will submit proof to LPA by POC due date.

Allegation investigated: Facility staff do not respond to call buttons timely

Facility staff do not respond to call buttons timely This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Administrator (AD) Miles Mouradian, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that facility staff do not respond to call buttons timely revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, Wellness Director (WD) Alex Gutierrez, and residents, and obtained and reviewed copies of the resident roster, staff roster, and the facility’s call system logs. Substantiated It was alleged that residents have to wait a long time to receive care when they activate their call buttons. LPA interviewed AD and WD who denied the allegation. Per WD, the expectation on staff is that calls for assistance are answered in 10 to 15 minutes, but during peak times such as meals many residents call at the same time to be taken to the dining room which increases response times. WD stated that if a new call comes in while a staff is already assisting a resident, the staff will go check on the new call to ensure it is not an emergency, go back to the resident they were assisting and complete the care they are providing, then address the new call. LPA interviewed 12 residents and obtained information that call button response times range from 15 to 40 minutes and received conflicting information about whether staff already assisting residents are pausing the care they are providing to check on new calls and determine if they are emergencies. LPA reviewed the facility’s call system logs and noted most calls for assistance are resolved within 15 minutes, but there were also multiple calls that took over 40 minutes, 50 minutes, and even an hour to resolve, which is too long for residents to wait for assistance with care needs or possible emergencies. AD stated that resident calls for assistance are first quickly answered by staff to determine the urgency and are only cleared once the care is completely provided. No information was obtained that the long wait times resulted in any injuries or illness to the residents. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. It was alleged that the facility is understaffed resulting in inadequate care and supervision for residents. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed AD and WD who denied the allegation, stating the facility has enough staff and is currently hiring even more staff. Per WD, the average staffing ratio is about seven or eight care staff for the whole building during the day shift and three or four care staff during the overnight shift. LPA reviewed the facility’s staff schedule which shows four or five care staff for the day shifts in assisted living, four or five care staff for the day shifts in memory care, and three or four care staff for the overnight shift for the whole building. LPA interviewed 12 residents and obtained conflicting information, with some residents stating that the facility has enough staff and other residents stating that the facility needs more staff to meet residents’ needs, especially the overnight shift. However, per WD and the facility’s staff schedule, staffing for the overnight shift has already been increased. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Dec 8, 2025 · control 22-AS-20251204153855

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 5, 2026

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by: Based on documents and interview, the licensee did not ensure resident call buttons were answered timely and that these residents received the care they required in a timely manner, which poses a potential safety risk to persons in care. CIVIL PENALTY ASSESSEDthe state’s words, verbatim · CDSS document, Dec 8, 2025

Plan of correction: The licensee stated they will retrain staff on addressing resident calls for assistance and submit proof to LPA by POC due date.

Allegation investigated: Residents are sleeping in common areas.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting an investigation into the allegation listed above. LPA was greeted and granted entry by front desk staff after introducing himself, stating the purpose of the visit and listing the allegation under review. LPA requested the facility's resident census and employee roster before conducting a tour of the physical plant accompanied by staff. Four resident interviews, five staff interviews and three witness interviews were conducted during the visit. Client records and correspondance were provided and reviewed during the visit. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 Regarding the allegation that Residents are sleeping in common areas, the following has been concluded: During a weather event occurring on or around November 20, 2025, significant leakage and flooding of three resident units happened, as corroborated by resident, staff and witness interviews. The three residents involved were identified during the visit and found to have been relocated pending repairs. Damage to the units involved was observed and confirmed none of the three units were fit for habitation at the time of the visit. Other units reviewed did not display any signs of current leaks or flooding. Resident R1 was relocated from unit #169 to shared unit #133. Resident R2 was relocated from unit 167 to single unit 150. Upon family wishes, resident R3 was relocated to a room that was repurposed from being used as an office by the facility administrator. The room was confirmed to include all necessary items of furnishings and had access to shared bathrooms and a shower room in proximity to the room. It was also confirmed to no longer being used as an office, the administrator currently sharing the office typically occupied by the Business Office Manager. No residents, staff or witnesses interviewed provided any evidence corroborating that any residents had to temporary occupy any of the facility's common areas. Administrator clarified in an interview that the possibility of using the living room designated as the "piano room" had been hypothesized as identified as a triage room in the facility's emergency and disaster plan, however no residents were moved there per the statements gathered. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Dec 1, 2025 · control 22-AS-20251125140757

Allegation investigated: Staff did not ensure the facility grounds are properly maintained Staff did not keep the facility free from mold

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegations. LPA met with Administrator (AD) Miles Mouradian, discussed the purpose of the inspection, and explained the allegations. The investigation into the allegation that staff did not ensure the facility grounds are properly maintained and staff did not keep the facility free from mold revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, staff, and residents, and obtained and reviewed copies of the resident roster and staff roster. CONTINUED Substantiated Regarding the allegation that staff did not ensure the facility grounds are properly maintained: it was alleged that the facility’s roof leaked and was damaged during recent rain. LPA inspected the facility and observed that the roof had recently leaked and that several ceiling tiles were damaged, missing, and/or stained in the first floor dining room and adjacent hallway. AD stated that no residents were present when some ceiling tiles had fallen down in the dining room, no leaks were present in any resident rooms, and the facility took measures to address the water damage and to limit the damage during future rain. LPA interviewed 10 residents, none of whom reported additional physical plant issues at the facility. LPA observed ceiling stains in one of these residents’ rooms and also that the bathroom of another resident had leaked during the recent rain. The facility has previously had multiple issues with its leaking roof, including substantial leaks in early 2025 in the same locations as the current leak, and AD admitted that the facility still has not begun a full roof repair and is instead taking temporary measures of placing a tarp over the damaged roof which has not worked to prevent the leaks. Based on the information obtained, the facility has not taken sufficient measures to repair its roof after multiple leaks resulting in continued leaks damaging the first floor and posing a potential slipping risk for residents during rainy days. Regarding the allegation that staff did not keep the facility free from mold: it was alleged that after a recent roof leak, stains on the ceiling and smells in the hallway indicate there may possibly be mold. LPA inspected the facility and observed that the roof had recently leaked and that several ceiling tiles were damaged, missing, and/or stained in the first floor dining room and adjacent hallway. LPA observed ceiling stains in one resident’s room and also that the bathroom of another resident had leaked during the recent rain. In addition to the stains on the ceiling tiles, much of the water damage is deep in the ceiling and could not be seen. During the inspection, a City of La Habra code enforcement official required mold testing based on their observations of the water damage. However, although the leak occurred weeks ago, facility staff stated they still had not tested for mold, meaning the facility did not take proper steps to ensure the facility was free from mold in light of conditions that present the risk for mold. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. It was alleged that the facility is frequently short staffed, and in some instances in late October 2025 there were no caregivers or supervisors on duty. LPA interviewed AD who denied the allegation, stating that two caregivers resigned without notice recently but that the facility’s management team stepped in to cover. LPA interviewed WD who stated that the facility’s assisted living staffing schedule is for three or four caregivers plus one medication technician for the morning and afternoon shifts, with the memory care unit having its own separate set of three or four caregivers plus one medication technician for these shifts, and that during the overnight shift both the assisted living section and memory care unit share a set of three or four staff at least one of whom is a medication technician. Per WD, there were some recent call outs in assisted living and WD tried to get coverage for the call outs and covered some shifts themselves. LPA reviewed the facility’s timesheets for late October 2025 and confirmed that the facility’s staff levels were generally consistent with their staff schedule, although they did dip slightly low during certain afternoon shifts. However, per AD, even during these slight dips, the staffing level was above the facility’s minimum staffing requirement. LPA interviewed 10 residents and only one resident corroborated the allegation, stating that wait times for the call system could get very long, while the rest of the residents did not corroborate the allegation. Review of the facility’s recent call system logs, which includes dozens of calls, shows most calls are resolved within five or 10 minutes, although two calls took a little over 40 minutes. The information obtained is conflicting. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Nov 13, 2025 · control 22-AS-20251107143050

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 4, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by: Based on observation and interview, the licensee did not take sufficient measures to address the facility’s leaking roof which has leaked multiple times previously, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: The licensee stated they will submit a plan to permanently fix the roof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Nov 20, 2025

87307 Personal Accommodations and Services … (d) … (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by: Based on observation and interview, the licensee did not take proper measures to address potential mold after a significant roof leak, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: The licensee stated they will have the affected areas tested for mold and will ensure water damaged areas are timely tested for mold in the future.

Allegation investigated: Staff did not provide resident with adequate supervision, resulting in resident sustaining injuries

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Pending Administrator (PA) Miles Mouradian, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that staff did not provide resident with adequate supervision, resulting in resident sustaining injuries, revealed the following: During the course of the investigation, LPA inspected the facility, interviewed PA, residents, witnesses, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Care Plan, R1’s Care Notes, and R1’s Medical Records. CONTINUED Substantiated It was alleged that due to lack of care and supervision, the facility not allowing R1’s family member to provide extra care, and the facility not assisting R1 with their walker, R1 sustained two falls in early September 2025, one of which resulted in a head injury and hospitalization. LPA inspected the facility, conducted health and safety checks on R1 and other residents, and observed no health and safety issues. LPA interviewed R1 who was unable to provide information regarding this allegation. LPA’s observations of staff ensuring R1 had access to and made use of their walker, as well as LPA’s interview with R1’s family member, did not corroborate that the facility did not assist R1 with their walker. Interviews with PA, facility staff, and R1’s family member revealed that while R1’s family member has a history of providing extra care for R1, during a COVID-19 outbreak in early September 2025, R1’s family member was either strongly encouraged or ordered not to visit with R1 due to COVID-19 precautions, R1’s family member stopped visiting R1 to provide extra care, and during R1’s family member’s absence, R1 suffered a fall resulting in hospitalization. However, regardless of whether R1’s family member was present to provide additional care, it was the facility’s responsibility to provide care and supervision to R1 in light of R1’s fall risk. LPA reviewed R1’s Care Plan which states that R1 is a fall risk and R1’s Care Notes which document previous falls on July 28, 2025, June 14, 2025, and May 19, 2025. Per R1’s Care Notes, R1 tested positive for COVID-19 on September 8, 2025 and interviews with staff revealed that R1’s COVID-19 infection caused R1 to grow increasingly weak. Per R1’s Care Notes, R1 suffered two falls on September 10, 2025, the second of which resulted in hospitalization. LPA reviewed R1’s Medical Records which show that R1 was hospitalized on September 10, 2025 through September 13, 2025 with a primary diagnosis of generalized weakness. Despite R1 being a fall risk with a history of falls and now having increased weakness due to COVID-19, the facility did not provide additional care and supervision to address R1’s increased fall risk resulting in two falls in one day. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. It was alleged that the facility did not notify R1’s responsible party of R1’s falls in early September 2025. LPA interviewed facility staff who denied the allegation, stating that R1’s family member was always notified of incidents involving R1. LPA interviewed R1’s family member who indicated they were made aware of R1’s falls. LPA reviewed R1’s Care Notes which indicate R1’s family member was notified of R1’s recent falls. LPA interviewed one witness who stated that one of R1’s falls was reported after R1 was already at the hospital which did not allow R1’s family to accompany R1 to the hospital. However, based on R1’s Care Notes, R1 was bleeding and 911 was necessary, meaning the first priority for facility staff would be to ensure R1 was on the way to the hospital. While R1’s family member may have been notified after R1 was already at the hospital, the information is conflicting regarding whether the facility should have notified R1’s family earlier. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. It was alleged that multiple residents are not having their briefs changed on a regular basis. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed PA and facility staff who denied the allegation. LPA interviewed R1’s family who did not corroborate any incontinence issues with R1 or other residents. LPA reviewed R1’s Care Schedule for September 2025 which shows staff documenting incontinence care for R1. LPA interviewed five residents who wear diapers and did not obtain information corroborating the allegation. The information obtained did not corroborate the allegation. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Sep 19, 2025 · control 22-AS-20250915130604

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 20, 2025

87464 Basic Services … (f) Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not provide additional care necessary to address R1’s increased fall risk in light of their increased weakness resulting in a fall and hospitalization, which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 19, 2025

Plan of correction: The licensee stated will submit a plan to ensure R1’s fall risk needs are met by POC due date.

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Maintenance Director (MD) Jorge Garcia and discussed the purpose of the inspection. Pending Administrator (PA) Miles Mouradian arrived during the inspection. LPA reviewed Infection Control requirements. At about 8:00AM, LPA and MD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication rooms and observed the following: Structure: this is a large commercial facility. Facility is composed of a single, two-story building with a delayed egress memory care unit on the second floor, a commercial kitchen and large dining room on the first floor, medication rooms on both floors, and resident rooms on all floors, along with multiple common areas, storage rooms, and a large central courtyard and a smaller courtyard dedicated to memory care with shaded seating for residents. There are a total of 86 resident rooms. Resident Bedrooms: the 10 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 10 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 117 and 120 degrees F in the 10 resident bathrooms tested. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the housekeeping closets. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees are paid. At about 10:00AM, LPA reviewed 10 resident files and 5 staff files, interviewed 5 residents and 5 staff, and inspected medications for 5 residents. Facility does not handle resident money. During the inspection, LPA and AD observed the following: based on Guardian records, the licensee did not ensure Staff #1 (S1) was background cleared prior to working at the facility for the last two years; based on documents, the licensee did not ensure Staff #2 (S2), who is a medication technician, had documented medication training; and based on observation and documents, the licensee did not ensure Resident #1 (R1) received their Quetiapine 0.5MG on August 14, 2025 as the pill was still in the bubble pack and the MAR was blank and there is no indication of refusal. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421BG. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 22, 2025

Type of visit: Case Management - Other

This unannounced Case Management – Other inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering amended findings for Complaint Control No. 22-AS-20250707091934. LPA met with Pending Administrator (PA) Miles Mouradian and explained the reason for today’s inspection. During the inspection, LPA and PA reviewed and discussed the previously delivered report and the amended report and LPA delivered the amended report to PA. Due to technical issues, LPA was unable to create an LIC421IM off of the complaint investigation report, so LPA created a manual LIC421IM which was signed by LPA and PA with PA retaining the original and LPA retaining a copy. An exit interview was conducted and copies of this report and the amended report were discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 14, 2025

Allegation investigated: Facility staff were rough with resident

This is an amended report This is an amended reportThis unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Pending Administrator (PA) Miles Mouradian, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that facility staff were rough with resident revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, Resident Care Director (RCD) Annaliza Yem, staff, and residents, and obtained and reviewed copies of the resident roster, staff roster, and Resident #1’s (R1) Physician’s Report dated January 16, 2025, R1’s Medical Records, the facility’s investigation report dated July 8, 2025, staff files, and R1’s Care Notes. Substantiated It was alleged that R1 refused care from a staff, the staff brought another staff and forced care on R1, and R1 fought back and was injured with a skin tear as a result. LPA inspected the facility, conducted health and safety checks on residents, and observed that R1 has three small scabs on their left arm and a very large hand-shaped bruise on their right arm. Per R1’s Physician’s Report dated January 16, 2025, R1 has mild cognitive impairment but R1’s Medical Records indicate that R1 was diagnosed with dementia with behavioral disturbances on July 2, 2025. LPA interviewed R1 who was aware they were injured, but was unable to provide information regarding how the injuries were sustained due to R1’s dementia diagnosis and LPA noted R1 to be confused and easily agitated. LPA interviewed RCD who stated that on June 24, 2025, Staff #1 (S1) noted that R1, who lived in assisted living at the time, was very soiled and tried to provide care to R1, R1 refused, S1 brought Staff #2 (S2) to help, R1 resisted and attacked S1 and S2, and S1 and S2 completed care for R1 but R1 sustained a skin tear during the incident. LPA reviewed the facility’s investigation report dated July 8, 2025, which indicates that R1’s family had noted a recent cognitive decline in R1 prior to the incident and that shortly after the incident on June 24, 2025, R1 was medically reassessed with a diagnosis of dementia and admitted to the memory care unit. AD stated that after the incident, staff were retrained on resident refusals, providing care, and personal rights. LPA reviewed the staff files for S1 and S2 and confirmed they are both background cleared and have up to date training. LPA attempted to interview S1 and S2, but they were not available for interview. However, their statements are incorporated into the facility’s investigation report dated July 8, 2025 and LPA’s observations confirmed R1’s injuries. RCD stated that S1 and S2 did not follow facility protocol when they forced care on R1 and that they should have waited, given R1 time, called the family, called managers, and taken other measures to prevent the incident as it occurred. LPA reviewed R1’s Care Notes which indicate that R1 was observed to be very confused, not making any sense, and being rude and aggressive with staff and other residents since late February 2025, but R1 was allowed to stay in assisted living until the incident on June 24, 2025. Based on the information obtained, S1 and S2 forced care on R1, an assisted living resident who likely should have been in memory care, resulting in skin tears as well as a very large bruise on R1’s arm indicating that R1 was held very firmly during this incident. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. This is an amended reportthe state’s words, verbatim · CDSS document, Jul 9, 2025 · control 22-AS-20250707091934

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Aug 15, 2025

87468.1 Personal Rights of Residents in All Facilities (a) … (3) To be free from punishment, humiliation, intimidation, abuse… This requirement was not met as evidenced by: Based on observation and interviews, the licensee did not ensure R1 was free from abuse when S1 and S2 forced care on R1 resulting in skin tears and a large bruise, which poses an immediate personal rights risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Jul 9, 2025

Plan of correction: The licensee stated they have already conducted staff training on resident refusals, providing care, and personal rights and will submit proof to LPA by POC due date. This is an amended report

Allegation investigated: Facility staff are not dispensing medication as prescribed

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Pending Administrator (PA) Miles Mouradian, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that facility staff are not dispensing medication as prescribed revealed the following: During the course of the investigation, LPA inspected the facility, interviewed PA and staff, and obtained and reviewed copies of the resident roster, staff roster, and the facility’s Medication Administration Records. Substantiated It was alleged that facility staff are not dispensing medications as prescribed. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed PA and three staff and one staff admitted that Resident #1’s (R1) Fosfomycin, which is to be administered every three days to prevent urinary tract infections, was not given as prescribed, as there are still medications from the April 2025 shipment that remain, and the facility did not order a May 2025 supply. LPA inspected R1’s Fosfomycin and confirmed that five doses from the April 21, 2025, shipment, which should have been given to R1, are still present at the facility. LPA reviewed R1’s Medication Administration Records and noted that this medication is document as having been properly given to R1, which is incorrect. Facility staff were unable to provide an explanation as to why R1’s Fosfomycin was not given as prescribed or why it was documented as having been properly given, but stated the situation is being investigated. LPA inspected the Medication Administration Records for five additional residents and noted that Resident #2 (R2) did not receive any of their medications on May 1, 2025 due to lack of supply. Facility staff were unable to provide documentation of their attempts to follow up with R2’s doctor and pharmacy to ensure R2’s medications were delivered timely. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 22-AS-20250612145141

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 19, 2025

87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure R1 received one medication for multiple days and R2 received all of their medications for one day, which poses an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Jun 18, 2025

Plan of correction: The licensee stated they will notify these residents’ doctors of these medication errors, retrain staff on assisting residents with medications, and submit proof to LPA by POC due date.

Allegation investigated: Facility staff did not obtain proper medical care for resident’s skin condition

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Pending Administrator (PA) Miles Mouradian, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that facility staff did not obtain proper medical care for resident’s skin condition revealed the following: During the course of the investigation, LPA inspected the facility, interviewed residents, witnesses, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Care Notes, and R1’s Medical Records. CONTINUED Unfounded It was alleged that R1 contracted a skin condition at the facility around April 1, 2025, facility staff ignored R1’s skin condition as dry skin for weeks, and R1 was not assessed or treated for their skin condition until the end of May 2025. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed two staff responsible for R1’s care who denied the allegation, stating that R1’s condition was noted by facility staff immediately, communicated to R1’s medical providers, and assessed and treated by R1’s medical providers. LPA reviewed R1’s Care Notes which indicate that facility staff first noticed a skin condition on R1 around March 28, 2025 and reported it to R1’s medical providers, applied the prescribed creams to R1 as directed, provided regular updates on R1’s skin condition to R1’s medical providers, requested R1’s medical providers to come check on R1’s condition whenever it worsened, and R1’s medical providers came multiple times to check on R1’s skin. This shows that facility staff reported R1’s skin condition to R1’s medical providers as soon as it was noted and obtained proper medical care for this condition. LPA reviewed R1’s Medical Records which indicate that R1’s medical providers assessed R1’s skin condition and diagnosed it as a rash on April 17 and 21, 2025, as folliculitis on May 6, 2025, and persistent dermatitis on May 27, 2025, and that R1 was prescribed medications for all of these medical conditions. Per R1’s Medical Records, R1 was seen by their medical providers or their representatives on April 8, 2025, and approximately every other day moving forward and that hospice bath aides gave R1 a shower approximately twice a week. This shows that R1’s medical providers saw R1 frequently and would have addressed any skin issues that were not otherwise reported by the facility. LPA interviewed R1 and two witnesses and did not obtain information corroborating the allegation. The information obtained did not corroborate the allegation. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. It was alleged that R1 is not being provided toilet paper or shampoo and as a result of having no shampoo R1’s hair has not been washed for up to a month. LPA inspected 10 resident bathrooms and LPA’s observations did not corroborate the allegation, as all bathrooms had toilet paper and shampoo, including R1’s room. LPA interviewed four staff who denied the allegation. While staff stated that the facility does not provide shampoo, they also denied that residents lack shampoo because shampoo is provided by residents’ families or hospice if the resident is on hospice. Two staff interviewed reported that because R1 is on hospice, the hospice provides both shampoo and showers to R1, R1’s hospice shower aide will get more shampoo if needed, and that there is always shampoo in R1’s room. LPA reviewed R1’s Medical Records which indicate that R1 has been receiving showers from hospice approximately twice a week. LPA interviewed R1 and did not obtain information corroborating the allegation. The information obtained is conflicting. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 22-AS-20250605155117

Allegation investigated: Due to insufficient and incompetent staff, residents are not provided adequate care and supervision. Resident sustained an unexplained injury while in care

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Pending Administrator (PA) Miles Mouradian and explained the reason for today’s inspection. The investigation into the allegations that due to insufficient and incompetent staff, residents are not provided adequate care and supervision and resident sustained an unexplained injury while in care revealed the following: During the course of the investigation, LPA inspected the facility, interviewed Administrator (AD) Ashley Willett, PA, residents, staff, and witnesses, and obtained and reviewed copies of the resident roster, staff roster, facility incident reports, the facility’s payroll records, staff training records, photographs of Resident #1 (R1), R1’s Physician’s Report dated April 11, 2025, R1’s Needs and Services Plan dated January 16, 2025, and R1’s Needs and Services Plan dated April 21, 2025. Unsubstantiated Regarding the allegation that due to insufficient and incompetent staff, residents are not provided adequate care and supervision: it was alleged that the facility is understaffed, residents in the memory care unit wander around causing issues with each other, residents have been observed fighting with each other, and residents are going to the bathroom in the rooms of other residents. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed AD who denied the allegation. Per AD, there are 32 memory care residents, and the staff schedule provides for three caregivers and one medication technician plus a floating caregiver who covers both assisted living and memory care. LPA observed there were three caregivers and one medication technician in the memory care section as required by the staff schedule. LPA’s review of the facility’s payroll records and interview of the staff in charge of business matters corroborated that there are at least three staff in the memory care unit during all shifts. LPA reviewed the training records for five staff assigned to the memory care unit and confirmed that they are all properly trained. LPA interviewed 11 residents and did not obtain information corroborating the allegation. One staff interviewed stated that while facility staff do their best to address behaviors like wandering, aggression, and residents going to the bathroom in improper places, these behaviors are typical in a memory care setting and cannot be completely prevented. Although the behaviors alleged may be happening in the memory care unit, the information obtained did not corroborate that these behaviors are the result of insufficient or improperly trained staff. Regarding the allegation that resident sustained an unexplained injury while in care: it was alleged that, due to lack of care and supervision, R1 was hit by other residents on March 5, 2025 and on March 24, 2025 resulting in a black eye. LPA reviewed photographs of R1 showing R1’s black eye. LPA interviewed AD who stated that R1 is a new resident who is still adjusting to the facility, on March 5, 2025, R1 wandered into another resident’s room and R1 and the other resident hit each other, and there were no injuries from this incident. Regarding the incident on March 24, 2025, interviews with AD, staff, and a witness revealed that R1 sustained a black eye and a cut on their arm. However, no one witnessed this incident and AD and facility staff claim it was caused by R1’s hospice bath aide and not a resident or facility staff and the facility called the police and followed up with the hospice company multiple times but never received a response. LPA reviewed facility incident reports matching AD’s statements regarding the March 5, 2025, and March 24, 2025, incidents involving R1. LPA reviewed R1’s Physician’s Report dated April 11, 2025, which indicates R1 has Dementia. LPA reviewed R1’s Needs and Services Plan dated January 16, 2025, which does not address issues like wandering or aggression. However, review of R1’s Needs and Services Plan dated April 21, 2025, indicates that total assistance with wandering was added in response to R1’s altercation with another resident and that interventions included engaging R1 in activities throughout the day, adequate nutrition and hygiene, and supervision and awareness of R1’s whereabouts at all times. This shows that the facility reassessed R1 and added additional care to address R1’s wandering and aggressive behavior. Per a facility incident report, on June 10, 2025, R1 was involved in another altercation with a resident with no injuries. LPA interviewed PA who stated that in response to this recent incident, the facility will reassess both R1 and the other resident involved in the altercation, make any necessary changes to their care plans, and ensure the facility is able to meet their needs. Staff interviewed stated that while facility staff do their best to address behaviors like wandering and aggression, these behaviors are typical in a memory care setting and cannot be completely prevented. LPA interviewed 11 residents and did not obtain information corroborating any issues relating to safety. LPA’s review of the facility’s payroll records and interview of the staff in charge of business matters corroborated that the facility is following its staffing schedule. LPA reviewed the training records for five staff assigned to the memory care unit did not note any training issues. The information obtained did not corroborate that the incident on March 24, 2025 was caused by other residents or staff of the facility. Although R1 engaged in altercations on May 5, 2025, and June 10, 2025, with other residents, no serious injuries were sustained and the information obtained demonstrated that the facility is reassessing R1 in response to these incidents to ensure the facility is able to meet R1’s needs. The information obtained did not corroborate that the facility is unable to meet R1’s needs or that R1 sustained injuries due to lack of care and supervision. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jun 12, 2025 · control 22-AS-20250326115916

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20250326115916. LPA met with Pending Administrator (PA) Miles Mouradian and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, interviewed PA, and obtained and reviewed copies of the resident roster and staff roster. Per PA, the previous administrator resigned on June 6, 2025, PA has a Nursing Home Administrator license but does not have a current administrator certificate for residential care facilities for the elderly and is in the process of obtaining their certificate, and there is no other staff who is qualified to be appointed as the administrator, meaning the facility currently has no administrator. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jun 12, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Jul 10, 2025

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator.... This requirement was not met as evidenced by: Based on admission, the licensee does not have a certified administrator, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 12, 2025

Plan of correction: Licensee stated they will submit an LIC308, board resolution, administrator certificate, resume, and driver’s license for a new administrator to LPA by POC due date.

Allegation investigated: Facility is in disrepair

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) Ashley Willett and explained the reason for today’s inspection. The investigation into the allegation that facility is in disrepair revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, residents, and staff, and obtained and reviewed copies of the resident roster and staff roster. CONTINUED Substantiated It was alleged that large ceiling leaks developed resulting in wet floors and other unsafe conditions and the facility did not properly address the leaks or communicate the situation to residents’ responsible parties. LPA interviewed AD and facility staff who stated that in February 2025 there was a leak that affected the first-floor hallway and nearby rooms, the situation was communicated to affected residents, measures were taken to mitigate the effects of the leak and ensure the health and safety of residents, and the leak was repaired as quickly as possible. LPA inspected the facility, including 14 resident rooms and all common areas, and observed that the damage from the leak has been repaired. LPA interviewed 11 residents and did not obtain information corroborating the allegation. However, LPA observed large stains under the bathroom sink, as well as water damage on the wall behind the toilet, in one resident room which appeared old and had not been repaired. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. Regarding the allegation that staff did not keep the facility free of mold: it was alleged that large ceiling leaks developed in the first-floor hallway near the dining room and in the second-floor memory care resulting in wet ceilings and mold and the facility did not properly address the mold. LPA interviewed AD and facility staff who stated that in February 2025 there was a leak that affected the first-floor hallway and nearby rooms, the leak was addressed as quickly as possible, the leak did not result in mold, facility staff tested affected rooms for mold and the results were negative, and the leak and ceiling were repaired and the carpets were changed to ensure no mold developed. LPA inspected the facility, including 14 resident rooms and all common areas, and did not observe evidence of mold. LPA interviewed 11 residents and did not obtain information corroborating the allegation. However, LPA observed large stains under the bathroom sink in one resident room as well as water damage on the wall behind the toilet which could possibly be mold. Per facility staff, this water damage has not yet been tested but is going to be repaired soon. The information obtained is conflicting. Regarding the allegation that staff did not take precautions to prevent the spread of illness: it was alleged that there was a large infectious disease outbreak, and the facility did not properly address the outbreak or report the situation to residents’ responsible parties. LPA reviewed facility incident reports dated December 19, 2024, and December 23, 2024, which indicate 11 residents developed gastrointestinal symptoms, the outbreak was reported to local public health, and the facility was following the infection control guidance provided by local public health. LPA reviewed the facility’s infection control plan and noted it to be complete and current. LPA interviewed AD and facility staff who stated the gastrointestinal outbreak affected a total of 15 residents, facility staff reported the outbreak to local public health and followed the infection control guidance they received, facility staff notified the families of all residents, the outbreak ended on January 1, 2025, and no residents were hospitalized because of the outbreak. LPA reviewed the facility’s communications with local public health which show the facility notified local public health of the outbreak and received guidance on infection control protocols. LPA inspected the facility and observed sufficient supplies of masks, gloves, sanitizer, and gowns and also observed staff wearing personal protective equipment (PPE) while providing care to residents. Out of the 11 residents interviewed, some recalled seeing staff take infection control precautions during this outbreak, while many were unable to say. The information obtained did not corroborate the allegation. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. It was alleged that, in late December 2024, there was a large infectious disease outbreak which was not handled properly because AD and facility staff are not properly trained. LPA interviewed AD and facility staff who stated the gastrointestinal outbreak affected a total of 15 residents, facility staff reported the outbreak to local public health and followed the infection control guidance they received, facility staff notified the families of all residents, the outbreak ended on January 1, 2025, and no residents were hospitalized because of the outbreak. LPA reviewed AD’s administrator certificate which is current and indicates that AD’s administrator training is current. LPA reviewed the training records for five staff and confirmed they have completed the required caregiver annual training. Per AD and facility staff, staff are trained on infection control as part of their training. LPA reviewed staff training records dated December 18, 2024, which show staff were trained on gastrointestinal infections as part of the facility’s response to this outbreak. LPA did not obtain any information corroborating this allegation. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, May 5, 2025 · control 22-AS-20250218110455

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 2, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by: Based on observation, the licensee did not ensure one resident’s bathroom was sanitary and in good repair when water damage was not repaired, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, May 5, 2025

Plan of correction: The licensee stated they will repair the bathroom and ensure there is no mold and submit proof to LPA by POC due date.

Allegation investigated: Facility does not provide a safe environment for residents and staff

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA Quiroz toured the facility and interviewed staff, residents and witness. Regarding the allegation that facility does not provide a safe environment for residents and staff, the investigation revealed the following: LPA Quiroz observed multiple instances of physical plant issues including open ceiling areas, stains, leaks, and tarped areas in 10 resident rooms. Ten out of ten witnesses interviewed state leaking issues have been going on for over a year and indicate health and safety concerns for residents. Based on the evidence gathered through observations and interviews conducted, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. Facility is being cited per California Code of Regulations Title 22, Division 6, Chapter 1. An exit interview was conducted and a copy of this report as well as appeal rights were provided at exit. Substantiatedthe state’s words, verbatim · CDSS document, Oct 10, 2024 · control 22-AS-20230106134015

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Oct 11, 2024

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This req is not being met as evidenced by: Based on observation and interviews conducted, Licensee failed to ensure residents are afforded safe and healthful accommodation's. Facility has multiple physical plant issues as noted in LIC 9099. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Licensee to read the regulation and forward a statement of understanding to LPA by POC due date.

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Maintenance Director (MD) Jorge Garcia and discussed the purpose of the inspection. Administrator (AD) Ashley Willett arrived during the inspection. LPA reviewed Infection Control requirements. At about 8:00AM, LPA and MD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication rooms and observed the following: Structure: this is a large commercial facility. Facility is composed of a single, two-story building with a delayed egress memory care unit on the second floor, a commercial kitchen and large dining room on the first floor, medication rooms on both floors, and resident rooms on all floors, along with multiple common areas, storage rooms, and a large central courtyard and a smaller courtyard dedicated to memory care with shaded seating for residents. There are a total of 86 resident rooms. Resident Bedrooms: the 12 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 12 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 110 degrees F and 117 degrees in the 9 resident bathrooms inspected. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication rooms: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees have not been paid and are past due. At about 10:00AM, LPA reviewed 6 resident files and 6 staff files, interviewed 6 residents and 6 staff, and inspected medications for 6 residents. Facility does not handle resident money. During the inspection, LPA and AD observed the following: based on documents, the administrator was changed in October 2023 but not all documents LPA requested were provided and the administrator still has not been updated; based on documents, the licensee has not paid their licensing fees for multiple years which are now past due; based on documents, the licensee did not ensure S1, S2, and S3 had current first aid training as their certificates were expired; and based on documents, the licensee did not ensure R1, who has dementia per their most recent Physician’s Report dated 01/30/23, received an annual medical assessment. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 14, 2024

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Resident developed a severe pressure injury while in care

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility, interviewed staff as well as reviewed and obtained pertinent documentation such as hospice notes and physician report. Regarding the allegation that resident developed a severe pressure injury while in care, the investigation revealed the following: Resident 1 (R1) admitted into hospice care on 09/15/2020 with a diagnosis of Senile Degeneration of Brain. Per hospice notes, resident was being seen by hospice approximately every 7-10 days. Between 10/07/2020 and 12/28/2020, resident was seen by hospice nineteen times. On 09/16/2020, resident was observed to have a blister on lateral side of right calf with instructions given for antibiotic ointment. There is no documentation of any pressure injury on the resident’s back or any wound care being provided by hospice or facility staff. LPA interviewed two staff who were familiar with the resident and two out of two denied resident ever having CONTINUED ON LIC 9099C DATED 12/13/2023 Unsubstantiated any pressure injury including at end of life. Witness interviewed confirmed this as well. Both staff members indicate at time of complaint, resident was ambulatory, always out of the resident’s room and participating in socialization. Hospice notes confirm resident’s ambulatory status. Physician report dated 09/15/2020 indicated a diagnosis of Dementia with no documentation of any pressure injury or history of pressure injury. Resident’s Needs and Care Plan at time of complaint has no documentation of skin breakdown or wound care. Based on record review and interviews conducted, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 13, 2023 · control 22-AS-20201125153256