Parker Villa

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to the facility. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Caregivers Melba Umayam and Royranger Antes. While at the facility, LPA conducted records review and interviews with staff and residents. LPA had noted that there was no Absentee Notification Plan in place as required by California Health and Safety Code 1569.317. Staff interviews revealed confusion about what an Absentee Notification Plan was or what system/steps the facility has in place should a resident be noted missing from the facility. One deficiency was cited per California Code of Regulations, Title 22, Division 6 on the attached 809D. An exit interview was conducted with Managerial staff Patrick Condez over the phone, who gave permission to caregiver Antes to sign off on the report. Caregiver Antes was provided a copy of this report and the Licensee/Appeal Rights (LIC 9058). Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jul 9, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.317 · Plan of correction due date: Jul 23, 2026

"Every residential care facility for the elderly, as defined in Section 1569.2, shall [...] develop and comply with an absentee notification plan as part of the written record of the care the resident will receive in the facility [...]." This requirement was not met, evidenced by: Based on file review and interviews, the Licensee did not have an Absentee Notification Plan in place, which posed an immediate health and safety risk to 5 out of 5 residents in care.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: Licensee will develop an Absentee Notification Plan as required and conduct a training with staff on the plan. Licensee will submit a copy to LPA by POC due date.

Type of visit: POC

Licensing Program Analyst (LPA) Rebecca Borunda conducted a plan of correction visit (POC). LPA was greeted by, identified herself to, and explained the purpose of the visit to Licensee Zayden Chen. The purpose of the visit was to verify if the deficiencies issued on 9/22/2025, 9/25/2025, and 10/2/2025 have been corrected. The licensee was issued deficiency 87158(a) and 87411(f) with a correction due date of 10/3/2025 and deficiency 87415(a)(1) with a correction due date of 10/10/2025. On 10/2/2025, LPA Borunda provided a POC due date extension for regulation 87411(f) until 10/10/2025. As of today’s date, 10/16/2025, the licensee has not submitted POCs to the Department for deficiencies 87158(a), 87411(f), or 87415(a)(1). During today’s visit, LPA Borunda verified that the licensee has not submitted an updated LIC200 and facility sketch requesting a fire clearance for two bedridden residents or a 30-day eviction for one of the bedridden residents to the Department. Therefore, deficiency 87158(a) has not been corrected. An immediate civil penalty of $100 per day totaling $1,400 is being assessed starting on 10/4/2025 for failure to correct and will continue to be assessed until corrected and is noted on the attached LIC421FC form. LPA Borunda verified via record review that the licensee corrected deficiency 87411(f) regarding staff health screening and tuberculosis test and regulation 87415(a)(1) regarding staff schedule showing 24/7 staff coverage. Therefore, deficiencies 87411(f) and 87415(a)(1) have been corrected. LPA provided Licensee with Letters of Deficiency Cleared for both deficiencies. An exit interview was conducted with Licensee Zayden Chen, whose signature below confirms receipt of a copy of this report, LIC421FC, Letters of Deficiency Cleared, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Oct 16, 2025

Allegation investigated: Neglect resulting in pressure injury Licensee did not ensure facility was staffed at night Staff did not assist resident with medication administration

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Caregiver Roy Antes. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the Licensee neglected a resident resulting in pressure injuries, Licensee did not ensure that facility was staffed at night, and staff did not assist resident with medication administration. Review of admission paperwork for Resident 1 (R1) revealed that R1 was admitted to the facility in October 2024. Review of resident assessment records dated October 2024 revealed that R1 was not confused or disoriented, had a history of skin breakdown, required assistance with transferring and was not receiving hospice services. Continued on LIC9099-C page... Substantiated Interviews with R1, staff, and outside sources revealed that R1 was also unable to reposition while in bed and skilled nursing paperwork dated September 2024 revealed that R1 needed to be repositioned every two hours. Interviews with staff and R1 revealed that staff did not initiate repositioning for R1 and instead, R1 had to request assistance with transferring and repositioning, which R1 did not request very often. Interviews with staff and R1 revealed that R1 was receiving wound care from an outside agency in January 2025, however, staff did not have knowledge regarding the name of R1’s outside agency, the frequency of the visits, or specifics regarding R1’s health. Additionally, interviews revealed that the outside agency stopped services in approximately May 2025, due to R1’s pressure injuries being resolved. However, interviews conducted in September 2025 revealed that R1 had at least one pressure injury that was not being treated by an outside agency. Interviews also revealed that facility staff were providing care for R1’s pressure injury. Review of Resident 2’s (R2) assessment records dated July and August 2023 revealed that R2 was bedridden, had a history of skin breakdown, required assistance with all activities of daily living including repositioning every two hours, and was receiving hospice services. Staff stated during interviews that R2 did not have any pressure injuries, however, R2’s hospice care plan dated August 2023 contradicted this information and stated that R2 had multiple Stage 3 and Stage 4 pressure injuries. Interviews with staff revealed that R2 would be repositioned during the day but R2 would not be repositioned overnight. Staff estimated that R2 would be repositioned around 8:00pm and would not be repositioned until the next morning at around 7:00am, which resulted in R2 not being repositioned for approximately 11 hours. Interviews with residents confirmed that there were no awake staff at the facility overnight and staff did not conduct regular rounds or checks on residents overnight. Review of R2’s hospice care plans in 2025 revealed that R2 still had multiple pressure injuries and R2’s hospice nurse care notes revealed that R2 developed a new pressure injury in late August 2025, however the paperwork did note the stage of the new or already identified pressure injuries. Interviews revealed that on at least one occasion in January 2025, a staff member working the afternoon shift left the facility before the overnight staff member arrived, resulting in the facility not having any staff supervision for approximately five (5) minutes. Interviews with staff and residents revealed that there were issues with one specific staff member, Staff 1 (S1), giving residents the wrong medications. Residents denied consuming medication that was not prescribed to them due to residents identifying the incorrect medication and informing staff of the mistake. Continued on LIC9099-C page... Interviews with staff and residents confirmed that S1 was no longer working at the facility as of mid June 2025. [Staff were provided with LIC811 Confidential Names List to identify residents and staff] The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, these allegations are deemed substantiated. The following deficiencies regarding neglect, absence of supervision, and medication administration are cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D pages. Additionally, review of past citations issued within a 12 month period revealed that the facility was cited for absence of supervision on 11/19/2024. Therefore, a civil penalty in the amount of $1,000 was issued for a repeat zero tolerance violation within a 12 month period and noted on the attached LIC421IM form. Additionally, the Department has determined that the allegation of neglect resulting in pressure injuries resulted in injuries to a resident in care, therefore, an immediate civil penalty in the amount of $500 is being assessed and noted on a separate attached LIC421IM form. Per Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted with Caregiver Raymond Abedoza, whose signature below confirms receipt of a copy of this report, the two LIC421IMs forms, and the Licensee Appeal Rights (LIC9058 03/22). Additionally, interviews with residents and outside sources stated that some residents would purchase meals while out in the community or would purchase food items if residents did not want to eat the meals cooked by staff. It was alleged that staff did not treat residents with respect. Interviews with staff and residents revealed that at least one resident, Resident 1 (R1) would get upset with staff and yell. Interviews revealed that R1 would also yell during personal care due to pain. However, interviews with outside sources revealed that R1 would get upset and interviews with R1 revealed that R1 had a health condition which could cause R1 to have emotional outbursts. While interviews with R1 alleged that staff did not treat residents with respect, other residents did not corroborate the allegation that staff did not treat residents with dignity. Additionally, staff denied cursing, yelling, or treating residents disrespectfully during interviews. The Department has investigated the above-mentioned allegations and based on interviews and observations, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Caregiver Raymond Abedoza, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Oct 2, 2025 · control 08-AS-20250110114106

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87415(a)(1) · Plan of correction due date: Oct 10, 2025

87415 Night Supervision (a)(1) In facilities caring for less than sixteen (16) residents, there shall be a qualified person on call on the premises. This requirement has not been met as evidenced by: Based on interviews, the Licensee did not ensure that facility staff were present at all times. This poses an immediate safety risk to 6 of 6 residents in care.the state’s words, verbatim · CDSS document, Oct 2, 2025

Plan of correction: Caregiver stated that shifts are from 7am-7pm and 8am-8pm and there is at least one live-in caregiver present at all times, including overnight. Licensee will submit a copy of staff schedule showing 24 hour supervision to the Department by POC due date of 10/10/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Oct 3, 2025

87468.2(a)… residents… shall have the following personal rights: (8) to be free from neglect… This requirement has not been met as evidenced by: Based on interviews and records review, the Licensee did not ensure that R1 and R2 were repositioned every 2 hours, resulting in pressure injuries. This poses an immediate health risk to 2 of 6 residents in care.the state’s words, verbatim · CDSS document, Oct 2, 2025

Plan of correction: Caregiver stated understanding that R1 and R2 need to be repositioned every two hours, including overnight. Caregiver stated that an outside vendor will provide training regarding repositioning and will submit proof of training to the Department by POC due date of 10/31/2025. Caregiver agreed to create a repositioning tracker to keep record of repositioning of R1 and R2 and will keep a copy of the record within each resident's file.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 22, 2025

87465 Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement has not been met as evidenced by: Based on interviews, the Licensee did not ensure that staff correctly assisted residents with medication administration, which poses a potential health risk for 6 of 6 residents in care.the state’s words, verbatim · CDSS document, Oct 2, 2025

Plan of correction: Caregiver stated that an outside vendor conducted medication training on 9/29/2025. Caregiver will submit proof of medication training to the Department by POC due date of 10/22/2025.

Allegation investigated: Licensee was not responsive to communications from resident's responsible person

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Caregiver Roy Antes. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the Licensee was not responsive to communications from resident’s responsible person. Interviews with outside sources revealed that responsible parties had either not received any communication from any facility representatives or had only had communication with direct care staff. Continued on LIC9099-C page... Substantiated Additionally, interviews with staff and residents revealed that Resident 1 (R1) was hospitalized in early January 2025, and R1’s responsible party was not made aware of R1’s hospitalization by facility staff and interviews revealed that R1’s responsible party had not had any contact with facility staff. Review of incident reports submitted to the Department revealed that the facility did not submit an incident report regarding R1’s hospitalization. The Department has investigated the above-mentioned allegation and based on interviews, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. An exit interview was conducted with Caregiver Raymond Abedoza, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Oct 2, 2025 · control 08-AS-20241104161351

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 2, 2025

87211(a)(1) A written report shall be submitted… to the person responsible for the resident within seven days of the occurrence… This requirement has not been met as evidenced by: Based on interviews and records review, the Licensee did not comply with the section cited above in that the Licensee did not notify R1’s responsible party of R1’s hospitalization. This poses a potential personal rights risk to 6 of 6 residents in care.the state’s words, verbatim · CDSS document, Oct 2, 2025

Plan of correction: Caregiver will conduct inservice training on reporting requirements and when to notify responsible parties and will provide staff sign in sheets to the Department by POC due date of 10/31/2025.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced annual continuation visit to continue the annual inspection started on 9/22/2025. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Roy Antes. The facility is licensed for a maximum capacity of 6 residents, 1 ambulatory, 5 non-ambulatory, 1 of which may be bedridden in bedroom #6. The facility has a waiver for 5 hospice residents. During today’s visit, the facility had a census of 6 residents, 2 of which (Residents 1 and 2) were bedridden due to being unable to reposition independently, which is in violation of the facility's approved fire clearance. [Staff were provided with an LIC811 Confidential Names List to identify R1 and R2] Interviews with staff and residents revealed that Administrator Lynn Drummond is not present at the facility enough hours to oversee its operation, and it was estimated that Drummond was present at the facility approximately once a month. During visits on 9/22/25, 9/25/25, and 10/2/25, LPA toured the facility and inspected each room of the facility, including resident and staff rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 106.4 and 108.7 degrees Fahrenheit in bathrooms for resident use and 111.2 degrees Fahrenheit in the kitchen sink. The facility’s internal temperature was measured at 76 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Raymond Abedoza, no firearms or weapons are stored on the premises. Continued on LIC809-C page… LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 42 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. LPA reviewed multiple resident and staff records. The following deficiencies were cited for Administrator presence and over-capacity for bedridden residents and noted on the attached LIC809-D pages. Additionally, a civil penalty in the amount of $500 was assessed for over-capacity for bedridden and noted on the attached LIC421IM form. An exit interview was conducted with Caregiver Raymond Abedoza, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Oct 2, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit to continue the Required 1-Year visit from 9/22/2025. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Raymond Abedoza. During today's visit, LPA toured the facility, observed residents in care, reviewed facility records, and interviewed residents and facility staff. During the tour of the facility, LPA observed unlocked cleaning chemicals stored under the sink in a common bathroom for resident use. Caregiver Abedoza relocated the cleaning chemicals to locked storage during LPA's visit. Additionally, LPA observed unlocked cleaning chemicals in a bathroom that Caregiver Abedoza stated was for staff use only and residents did not use, however, the bathroom was unlocked. Caregiver Abedoza locked the bathroom during LPA's visit. Therefore, the following deficiency for unsecured cleaning chemicals was cited and noted on the attached LIC809-D page. Review of past citations issued within a 12 month period revealed that the facility was cited for unsecured cleaning chemicals on 10/16/2024. Therefore, a civil penalty in the amount of $250 was issued for a repeat violation within a 12 month period and noted on the attached LIC421FC form. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. An exit interview was conducted with Caregiver Raymond Abedoza, whose signature below confirms receipt of a copy of this report, the LIC421FC, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Sep 25, 2025

Allegation investigated: Staff did not treat residents with dignity Staff did not safeguard resident's personal belongings Staff prohibited resident from consuming alcohol Unlawful eviction

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Caregiver Raymond Abedoza. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that staff did not treat resident with dignity, staff did not safeguard resident’s personal belongings, staff prohibited resident from consuming alcohol, and staff unlawfully evicted Resident 1 (R1). Review of admission and assessment records for R1 dated June 2024 revealed that R1 was known to have aggressive and inappropriate behaviors, including inappropriate sexual behaviors, and had a history of alcohol abuse. Continued on LIC9099-C page... Unsubstantiated Incident reports submitted to the Department from the facility revealed that between late June to early July 2024, R1 behaved inappropriately towards staff, including exposing their genitals in common areas, making sexual comments towards staff, and intentionally urinating on staff. Additionally, R1 was noted to consume alcohol and was under the influence of alcohol on multiple occasions. Interviews described R1 as engaging in inappropriate behaviors when under the influence of alcohol and R1 would cause arguments with staff and residents. Incident reports submitted by the facility revealed that on at least one occasion, R1 yelled for approximately 7 hours overnight, which disturbed staff and other residents. While R1 stated that staff spoke to R1 inappropriately, other residents stated that staff handled interactions with R1 in an appropriate manner, including interactions when R1 acting inappropriately or was under the influence of alcohol. Review of the facility’s admission agreement signed by R1 in June 2024 revealed that facility house rules included a rule that prohibited residents from using alcohol and drugs and prohibited the storage of alcohol in resident rooms, unless the resident had a physician’s order for alcohol. Interviews with R1 and review of R1’s file revealed that R1 did not have a physician's order for alcohol use and R1 was unwilling to request a physician's order for alcohol use. Interviews also revealed that R1 was fully aware of the facility house rule prohibiting alcohol use and R1 continued to consume alcohol while living at the facility despite that knowledge. Interviews with R1 and staff revealed that staff refused to obtain alcoholic beverages for R1 and staff confiscated alcoholic beverages from R1’s room on at least one occasion. Review of documents received and generated by the Department in July 2024 revealed that on 7/16/2024, the Licensee requested a 3-day eviction for R1 on the basis of R1’s inappropriate sexual behavior and consumption of alcohol, which the Department denied on 7/22/2024. In the 3-day eviction notice denial, the Department notified the Licensee that the 3-day eviction denial did not prevent the Licensee from issuing a 30-day eviction notice. On 7/18/24, the Department received a 30-day eviction notice for R1 on the basis of violating house rules regarding alcohol consumption and courtesy towards other residents and staff. Review of the 30-day eviction notice revealed that the notice met all regulatory requirements. Interviews with R1 and outside sources revealed that the Licensee ensured that R1 and their case manager received a written copy of the 30-day eviction notice. Continued on LIC9099-C page... R1 stated during an interview that R1 temporarily relocated to another congregate living facility (CLF) in order to live in at a facility that allowed residents to drink alcohol. R1 stated that they were at the CLF for less than 24 hours and had taken some personal belongings, including clothing, to that other facility. R1 stated that they returned to the assisted living facility sometime been 8:00 and 9:00pm and stated that they left their personal belongings at the CLF. The information obtained from R1 was unclear on how R1 traveled to and from the CLF, why R1 was only at the CLF for less than 24 hours, and why R1 left personal belongings at the other facility. Interviews with R1 did not reveal any evidence showing that facility staff caused or influenced R1 to leave their personal belongings at the CLF. R1 did not make any statements that facility staff were involved in R1’s temporary relocation to the CLF outside of a staff member telling R1 about the CLF. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Caregiver Raymond Abedoza, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Sep 22, 2025 · control 08-AS-20240815112521

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregivers Carmelita Twite and Raymond Abedoza. During today's visit, LPA observed residents in care, reviewed facility records, and briefly inspected the facility kitchen and medication cabinet. LPA was away from the facility for approximately one hour between 12:10pm and 1:10pm. Review of staff records and interviews revealed that Staff 1 (S1) had not completed a health screening prior to working in the facility. [Caregiver provided with an LIC811 Confidential Names List to identify S1] Additionally, LPA observed multiple medication bottles and boxes located in the unsecured kitchen refrigerator door. Caregiver Abedoza relocated the medication to the facility's locked medication refrigerator during LPA's visit. Therefore, the following deficiencies for unsecured medications and staff working without health screening were cited and noted on the attached LIC809-D pages. Review of past citations issued within a 12 month period revealed that the facility was cited for unsecured medications on 10/16/2024. Therefore, a civil penalty in the amount of $250 was issued for a repeat violation within a 12 month period and noted on the attached LIC421FC form. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. An exit interview was conducted with Caregiver Raymond Abedoza, whose signature below confirms receipt of a copy of this report, the LIC811, the LIC421FC, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Sep 22, 2025

Type of visit: Case Management - Other

Regional Manager (RM) Jerry Romero and Licensing Program Manager (LPM) Sabel Martinez conducted an unannounced Case Management visit. The RM and LPM were greeted by Staff, Raymond Abedoza and Carmelita Twite, and were allowed entry to the facility. During the visit, the RM and LPM conducted a tour of the facility, interviewed staff, and reviewed records. No immediate health and safety concerns were observed and no deficiencies were cited on today's date. An exit interview was conducted with Staff Raymond Abedoza, to whom a copy of this report and Licensee/ appeal rights (LIC 9058), were provided via email. An email read receipt confirms the documents were received.the state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Collateral

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Collateral visit. LPA was greeted by, identified herself to, and discussed the purpose of the visit with Caregiver Raymond Abedoza. During today's visit, LPA interviewed a staff member for a complaint investigation filed at another facility licensed by Community Care Licensing. An exit interview was conducted with Caregiver Raymond Abedoza, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Jul 7, 2025

Allegation investigated: Licensee did not ensure facility was staffed at night

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above mentioned allegation. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Caregiver Raymond Abedoza. LPA spoke with Licensee Zayden Chen and Administrator Lynn Drummond on the telephone. During today’s visit, LPA conducted a health and safety check, observed residents in care, and interviewed residents and staff. The Department's investigation consisted of interviews with residents and staff, record review, and a tour of the facility. It was alleged that the Licensee did not ensure the facility was staffed at night. Continued on LIC9099-C page... Substantiated Review of an incident report submitted by the facility to the Department on 11/18/2024 revealed that on 11/16/2024, Resident 1 (R1) left the facility on an outing. Interviews with R1 revealed that R1 told staff of R1's planned outing and staff knew that R1 would be away from the facility. Review of the incident report revealed that R1 notified Staff 1 (S1) that R1 would be returning to the facility at approximately 9:00pm. Interviews with R1 and the incident report revealed that R1 returned to the facility at approximately 9:00pm and there was no staff present at the facility to allow R1 entry into the facility. Interviews with R1 revealed that R1 attempted to get in contact with facility staff and management via telephone with no response. R1 was able to get in contact with one of the facility's management team (S2) and informed S2 that there was no one available to allow R1 entry into the facility. Interviews with R1 also revealed that R1 contacted law enforcement who arrived at the facility to assist R1. Interviews with residents and staff revealed that a staff member arrived at facility and R1 was allowed entry into the facility sometime after 10:00pm. Review of staff schedules for November 2024 revealed that staff were assigned to work two different schedules, one from 7:00am to 6:00pm and the other from 9:00am to 8:00pm. Interviews with staff and facility management revealed that a staff member was supposed to be at the facility overnight and would get up to assist residents as needed. Those interviews also revealed that the overnight staff was not required to be awake and was not paid for the hours where staff were responsible for the overnight supervision of residents. Residents denied that staff were present at the facility overnight and stated during interviews that staff did not provide assistance to residents overnight from approximately 8:00pm in the evening to approximately 7:00am in the morning. Interviews with staff and residents revealed that there are no staff present at the facility on the weekends from approximately 8:00pm to 6:00am. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency for lack of supervision is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. Additionally, a civil penalty in the amount of $500 was assessed for lack of supervision and noted on the attached LIC421IM form. An exit interview was conducted with Administrator Lynn Drummond via telephone and Caregiver Rommel Abedoza, whose signature below confirms receipt of a copy of this report, the LIC421IM, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Nov 19, 2024 · control 08-AS-20241104161351

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87415(a)(1) · Plan of correction due date: Nov 20, 2024

87415 Night Supervision (a)(1) In facilities caring for less than sixteen (16) residents, there shall be a qualified person on call on the premises. This requirement has not been met as evidenced by: Based on interviews and records review, the Licensee did not ensure that the facility had staff present at the facility overnight to provide care and supervision. This poses an immediate safety risk to 6 of 6 residents in care.the state’s words, verbatim · CDSS document, Nov 19, 2024

Plan of correction: Administrator and Licensee understand that a staff member responsible for providing care and supervision must be present at the facility at all times when residents are also present and that the facility management is responsible for covering staff shifts if a staff calls out. Licensee will provide a signed LIC9098 stating the understanding of supervision responsibility to the Department by POC due date of 11/20/2024.

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

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Case Management - Annual Continuation visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Raymond Abedoza. LPA spoke with Licensee Zayden Chen via telephone during the visit. Administrator Lynn Drummond arrived during the visit. During today's visit, LPA observed residents in care, reviewed facility files, and interviewed staff. During the visit, LPA Ruiz observed that Staff 1 (S1) was present and working at the facility. [Administrator was provided with an LIC811 Confidential Names List to identify S1] Review of Guardian revealed that S1's background clearance had expired. Interviews with staff revealed that S1 has been working at the facility for more than 5 days. LPA observed S1 leave the facility prior to the end of the visit. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. The following deficiency was cited for criminal background clearance and noted on the attached LIC809-D page. Additionally, a civil penalty in the amount of $500 was assessed for uncleared staff and noted on the attached LIC421BG form. An exit interview was conducted with Administrator Lynn Drummond, whose signature below confirms receipt of a copy of this report, the LIC811, the LIC421BG, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Oct 30, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Raymond Abedoza. The facility is licensed for a maximum capacity of 6 residents, 1 ambulatory and 5 non-ambulatory, 1 of which may be bedridden in Bedroom #6. The facility has a waiver for 5 hospice residents. During today’s visit, the facility had a census of 6 residents, 1 ambulatory, 4 non-ambulatory, and 1 bedridden. The Administrator for the facility is Lynn Drummond and their certificate was pending. During today's visit, LPA toured the facility, reviewed resident and staff records, and observed residents in care. During the facility tour, LPA observed unsecured cleaning chemicals stored in an unlocked cabinet under the kitchen sink. LPA also observed unsecured knives and scissors stored in a drawer in the kitchen that had a broken lock. LPA observed Caregiver Abedoza relocate cleaning chemicals and sharps to the facility garage which is secured by a number pad lock on the door during the visit. LPA also observed unsecured medications prescribed to a previous resident stored in the bottom of the refrigerator door. Caregiver Abedoza relocated previous resident's medications to a secured location. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. LPA was away from the facility for approximately one hour between 12:00pm and 1:00pm. The following deficiencies were cited for unlocked medications and unlocked hazardous items and noted on the attached LIC809-D page. An exit interview was conducted with Caregiver Raymond Abedoza, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Oct 16, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to conduct follow up regarding an incident report. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Raymond Abedoza. Administrator Lynn Drummond arrived during the visit. On 9/13/2024, the Department received an incident report from the facility regarding Resident 1 (R1). [Administrator was provided with an LIC811 Confidential Names List to identify R1] The incident report stated that on 9/7/2024, R1 decided to move out of the facility and into a private dwelling and left in a ride-share vehicle. Review of records received from the facility revealed that on 7/17/2024, R1 had been issued a 30-day eviction notice in which the 30-day ended on 8/16/2024. During a licensing visit on 8/22/2024 and contacts from facility staff and outside sources, the Department confirmed that R1 had not relocated to alternate placement. During today’s visit, LPA observed residents in care, reviewed and obtained copies of facility records, and interviewed staff and residents. LPA confirmed that R1 was not present at the facility and the facility did not contain any of R1's personal belongings. No deficiencies were cited on today’s date. An exit interview was conducted with Administrator Lynn Drummond, whose signature below confirms receipt of a copy of this report, the LIC811, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Oct 3, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Raymond Abedoza. LPA also spoke with Licensee Zayden Chen via phone during the visit. Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office, involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPA performed a facility tour / welfare check, reviewed pertinent records, and interviewed R1 and relevant staff. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Abedoza. A copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were E-mailed to Chen during the visit.the state’s words, verbatim · CDSS document, Nov 9, 2023

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Dang Nguyen conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. LPA was greeted by, identified himself to, and explained the purpose of the visit to the applicant’s representative, Zayden Chen. The facility fire clearance was granted on 09/25/2023 and reflected that the facility was approved for six (6) residents in total, of which four (4) may be non-ambulatory and one (1) may be bedridden. The bedridden resident may only reside in Bedroom #6 (per the facility sketch). The facility's fire clearance did not include delayed-egress door or secured perimeter endorsements, and neither were present during today's visit. The submitted facility sketch was consistent with the current layout of the facility. During today’s visit, LPA, accompanied by the applicant’s representative, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets, sinks, and showers were in working order. The facility’s ambient internal temperature was compliant at 76 degrees F. Hot water temperature at taps accessible to residents were also compliant: Kitchen sink was 109.6 F, Bathroom #1 sink was 117.4 F, Bathroom #2 sink was 119 F, Bathroom #3 sink was 116.4 F, and Bathroom #4 sink was 117.8 F. The facility has enough linens, hygiene supplies, cooking and dining supplies, and perishable and non-perishable food for resident use. All kitchen appliances were in working order. Kitchen Refrigerator temperature was 39 F, and Kitchen Freezer temperature was 0 F. Garage Refrigerator temperature was 36 F, and Garage Freezer temperatures were -2 F and 0 F, respectively. The Medication Refrigerator temperature was 40 F. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of medication and confidential resident and staff records. No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per the applicant’s representative, no firearms or ammunition are or will be stored at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. All fire extinguisher(s) were serviced within the last 12 months. A complete first aid kit was present. Required licensing postings were observed in visible areas of the facility. The items reviewed were complaint with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. The applicant passed the pre-licensing inspection. LPA also provided the Component III Training during today’s visit. Chen was advised that the facility’s application is pending management final review and approval. An exit interview was conducted with the applicant’s representative, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Sep 29, 2023