Peninsula Pointe by Cogir

Allegation investigated: Staff neglect resulted in a resident sustaining a pressure injury Staff do not properly reposition a resident while in care Staff do not timely address a resident's change in medical condition Staff mishandled a resident's medications Staff do not provide adequate care and supervision to a resident

On 09/03/26 Licensing Proulgram Analyst (LPA) Mario Leon conducted an unannounced, subsequent, complaint visit at the facility to deliver an updated complaint investigation report. The purpose of today's report is to provide additional information only; the findings remain as Unsubstantiated. The investigation consisted of the following: On 07/21/26 CDSS requested staff and resident rosters (dated: 07/21/26) and between 9:30AM and 11:30AM, CDSS interviewed six (6) residents (R2-R7) and two (2) staff (S6-S7). On 07/08/26 CDSS requested hospice notes of R1 (Dated 11/09/25) and medication administration record (MAR) of two residents (R1-R2) (dated: September through November, 2025). CDSS interviewed six (6) residents (R2-R7) and four (4) staff (S2-S5). On 11/19/25 CDSS requested resident and staff rosters (dated: 11/25) and documents listed for residents one (1) through four (4) (R1-R4), listed as follows: Medical Assessments (R1-R4), Care Plans (R1-R4), Medication Administration Records (MARs) for the past seven (7) days (R1-R4), Emergency ID/Face sheets (R1-R4) and Admissions Agreements (R1-R4). Report continues, please see LIC9099-C. Unsubstantiated The investigation revealed the following: Regarding the allegation “Staff neglect resulted in a resident sustaining a pressure injury”, it is being alleged that due to staff neglect resident R1 has developed a pressure injury. Record reviews indicate that R1 began receiving wound-care visits on 10/23/25. Records also show that on 11/07/25, R1 was admitted to Beacon Hospice Care Inc. for hospice services. Interviews revealed that six out of six residents (R2-R7), one (1) witness (W1) and four out of four staff (S2-S5) interviewed have denied the allegation. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff do not properly reposition a resident while in care”, it is being alleged that staff did reposition residents on a regular basis. Record reviews revealed the following: On 11/07/25 Beacon Hospice Care Inc.’s hospice care plan indicates that staff are to reposition R1 at least once every two (2) hours, as tolerated. Interviews revealed that six out of six residents (R2-R7), one (1) witness (W1) and four out of four staff (S2-S5) interviewed have denied the allegation. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff do not timely address a resident's change in medical condition”, it is being alleged that a resident (R1) is not receiving wound care for their injury. Record reviews indicate that R1 began receiving wound-care visits on 10/23/25. Records also show that on 11/07/25, R1 was admitted to Beacon Hospice Care Inc. for hospice services. Records indicate that Beacon Hospice Care Inc. staff visited R1 on: 11/07/25, 11/09/25, 11/12/25, 11/13/25, 11/18/25, 11/20/25, and 11/21/25. Interviews revealed that all six (6) residents (R2-R7), one (1) witness (W1) and all four (4) staff (S2-S5) have denied the allegation. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Report continues, please see LIC9099-C. Regarding the allegation that “Staff mishandled a resident’s medications,” it is alleged that resident’s medications are not administered as prescribed. Record reviews of R1’s Medication Administration Record indicate that all oral medications were discontinued on 11/16/25. Documentation from Beacon Hospice Care Inc. on 11/17/25 shows that R1’s oral medications were discontinued due to a risk of aspiration. The physician recorded that R1 was “nothing by mouth” (NPO) except for comfort medications as of 11/17/25. Interviews revealed that all six (6) residents, one (1) witness and all four (4) staff have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff do not provide adequate care and supervision to a resident”, it is being alleged that staff neglected R1’s needs. Observations revealed the following: CDSS observed staff’s average response time to a resident’s call button to be 11 to 15 minutes. Records reviews revealed the following: On 11/07/25 Beacon Hospice Care Inc.’s hospice care plan indicates that staff are to reposition R1 at least once every two (2) hours, as tolerated. Interviews revealed that six out of six residents (R2-R7), one (1) witness (W1) and four out of four staff (S2-S5) interviewed have denied the allegation. Based on observations, record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with Julius Osorio - Executive Director and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Sep 3, 2026 · control 11-AS-20251117223742

Allegation investigated: Staff neglect resulted in a resident sustaining a pressure injury Staff do not properly reposition a resident while in care Staff do not timely address a resident's change in medical condition Staff mishandled a resident's medications Staff do not provide adequate care and supervision to a resident

On 07/21/26 Licensing Program Analyst (LPA) Mario Leon conducted an unannouned, subsequent, complaint visit at the facility to conduct additional interviews and to deliver findings. California Department of Social Services (CDSS) was met by staff two, Erica Lombardo - Business Director (S2) and the purpose of the visit was explained. The investigation consisted of the following: On 07/21/26 CDSS requested staff and resident rosters (dated: 07/21/26) and between 9:30AM and 11:30AM, CDSS interviewed six (6) residents (R2-R7) and two (2) staff (S6-S7). On 07/08/26 CDSS requested hospice notes of R1 (Dated 11/09/25) and three months medication administration record (MAR) of two residents (R1-R2) (dated: September through November, 2025). Between 11:00AM and 3:30PM, CDSS interviewed six (6) residents (R2-R7) and four (4) staff (S2-S5). On 11/19/25 CDSS requested resident and staff rosters (dated: 11/25) and documents listed for residents one (1) through four (4) (R1-R4), listed as follows: Medical Assessments (R1-R4), Care Plans (R1-R4), Medication Administration Records (MARs) for the past seven (7) days (R1-R4), Emergency ID/Facesheets (R1-R4) and Admissions Agreements (R1-R4). Report continues, please see LIC9099-C. Unsubstantiated Regarding the allegation “Staff neglect resulted in a resident sustaining a pressure injury”, it is being alleged that due to staff neglect a resident has developed a pressure injury. Record reviews of the resident’s files have indicated that resident one (R1) has been visited by a hospice agency, beginning on 11/07/26. The number of visits are listed as follows: 11/07/25, 11/09/25, 11/12/25, 11/13/25, 11/18/25, 11/20/25, 11/21/25. During these visits R1 has received wound care and skin protectant has been applied, along with other physician’s orders which include repositioning R1 at least once every two hours. Interviews revealed that all six (6) residents (R2-R7), one (1) witness (W1) and all four (4) staff (S2-S5) have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff do not properly reposition a resident while in care”, it is being alleged that staff rarely reposition residents in care. Record reviews of Beacon Hospice Care Inc. have indicated that staff are to reposition a resident at least once every two hours. Interviews revealed that all six (6) residents, one (1) witness and all four (4) staff have denied the allegation has taken place. Due to R1 having always been together with family (R2), family has reported any discomfort R1 has had. Furthermore, W1 has clarified that they too were present during the period of November, 2025. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff do not timely address a resident's change in medical condition”, it is being alleged that a resident is not receiving wound care for their injury. Record reviews of Beacon Hospice Care Inc. have indicated that resident has been visited by a hospice agency, beginning on 11/07/26. The number of visits are listed as follows: 11/07/25, 11/09/25, 11/12/25, 11/13/25, 11/18/25, 11/20/25, 11/21/25. Furthermore, R1 has also been visited by a home health agency, prior to hospice initiation, on 10/23/25 for wound care. Interviews revealed that all six (6) residents (R2-R7), one (1) witness (W1) and all four (4) staff (S2-S5) have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Report continues, please see LIC9099-C. Regarding the allegation “Staff mishandled a resident's medications”, it is being alleged that a resident’s medication is not being provided as prescribed. Record reviews have indicated that R1’s medication was discontinued on 11/16/25. Physician’s orders, from Beacon Hospice Care Inc., have indicated that R1 is “nothing by mouth” (NPO) except comfort medication on 11/17/25. Interviews revealed that all six (6) residents, one (1) witness and all four (4) staff have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff do not provide adequate care and supervision to a resident”, it is being alleged that a resident is not receiving proper care and supervision regarding their current situation. Record reviews of physician’s orders have indicated that staff are to reposition a resident at least once every two hours. CDSS observed staff’s average response time to a resident’s call button to be 13 minutes. Interviews revealed that all six (6) residents, one (1) witness and all four (4) staff have denied the allegation has taken place. Due to R1 having always been together with family (R2), family has reported any discomfort R1 has had. Furthermore, W1 has clarified that they too were present during the period of November, 2025. Based on CDSS observation, record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with staff two, Erica Lombardo - Business Director (S2), and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Jul 21, 2026 · control 11-AS-20251117223742

Type of visit: Required - 1 Year

On 05/08/2025, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CAREs Inspection Tool. California Department of Social Services (CDSS) met with Julius Osorio - Executive Director and CDSS explained the purpose of today’s visit. The facility is licensed to serve (121) elderly adults ages 60 and above, of which one-hundred and twenty-one (121) residents can be non-ambulatory and twenty (20) residents bedridden on the 1st floor rooms: 116-120, 123-127, 135-137, & 147. Facility is approved for delayed egress doors and secured perimeters. The facility has an approved hospice waiver for fifteen (15) residents. Currently the facility hosts eighty-nine (89) residents, of which fourteen (14) residents reside in the memory care unit. The facility is a commercial building situated in a residential neighborhood. It includes a terrace level (basement), first floor, second floor, kitchen, common areas, medication room, records room, and an outdoor patio with shaded areas. CDSS and the Executive Director toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of eight (8) bedrooms and eight (8) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms and showers were found to be within Title 22 regulations and were operational, without mold or mildew present. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 111.2°F (degrees Fahrenheit) to 116.9°F, and the room temperature ranged from 67.4°F to 74°F. Report continues, please see LIC809-C During the visit, CDSS observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient 2-days' perishable and 7-days' non-perishable food was available, which was adequately maintained. All fire extinguishers were charged and operable, last maintained 12/10/25. The last Fire/Disaster Drills were conducted on 3/25/26. CDSS conducted a review of five (5) residents' service files and five (5) staff personnel files, no discrepancies were observed. CDSS reviewed five (5) Medication Administration Records (MARs) and found no discrepancies. A copy of liability insurance was provided to CDSS. Facility Annual Fess are not current and were due on 4/12/26; CDSS provided PIN number (#): 673854 to Executive Director, Julius Osorio. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with Julius Osorio and a copy of this report has been provided.the state’s words, verbatim · CDSS document, May 8, 2026

Allegation investigated: Staff left residents in soiled diapers for an extended period of time. Staff did not ensure the facility was free of odors. Staff are not documenting incidents. Staff are forging medication logs.

On January 15, 2026, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegations and to deliver findings. The Department was met by Administrator Julius Osorio, and the purpose of the visit was explained. Investigation consisted of the following: On November 25, 2025, the Department conducted an unannounced initial visit to the facility to investigate the complaint allegations mentioned above. During the visit, it was determined that the complaint required further investigation. The department obtained pertinent documents including staff roster (dated 11/25/25) resident roster (dated 11/25/25), R1-R7 physicians reports and hospice care information (dates varies). The department toured the facility, and interviewed Administrator (A1), and 5 staff (S1-S5). On January 15, 2026, the Department obtained the following documents: Incontinent Management Program policy (dated 12/1/23), staff training on caring for incontinent residents (dated: 1/2/26, 11/14/25, 8/11/25, 8/12/25), Service plans for R1, R2, R7 (dated 11/19/26, and 8/26/25), daily housekeeping log (no date), Laundry schedule (dated 1/10/26), and Care Staff Assignment schedule. The department conducted interviews with 1 staff (S6), 1 Witness (W1) and 5 residents (R2-R5, R7). page 1 of 5 Unsubstantiated The investigation revealed the following: Allegation: Staff left residents in soiled diapers for an extended period of time The detail of the complaint alleges “the staff lets residents walk around with 'saggy' diapers in the facility instead of changing them.” On November 25, 2025, and January 15, 2026 the Department interviewed (A1) who denied the allegation stating that residents are not left soiled for an extended period of time. A1 further stated that the protocol for changing residents’ diapers: “…is based on typical checks of 1 to 2 hours and based on the needs of the residents whether they need to be changed and whether they are checked for urine output or bowel movements.” On November 25, 2025, between 8:00am and 4:00pm, the Department interviewed staff (S1-S5) regarding the allegation. Of those interviewed, 5 out of 5 denied the allegation stating they haven’t observed any residents left soiled for an extended period of time. 5 out of 5 staff stated that they are trained to care for residents who are incontinent. Additionally, 5 out of 5 staff stated that they typically change residents every 2 hours and/or sooner if necessary. On January 15, 2026, between 10:00am and 12:30pm, the Department interviewed 5 residents (R2-R5, R7) and Witness #1(W1). The department could not interview R1 as R1 no longer lives at the facility (passed away as of 11/24/25), R6 was not available at time of visit. Of those interviewed, 4 out of 5 state that they are never left in soiled diapers for extended periods of time. 1 out of 5 was not responsive to questions due to cognitive level. 4 out of 5 state that staff change them when they need changing. W1 a private/hire caregiver for R5 states staff is attentive and that she has not witness any instances where R5 complained of being left soiled since she worked with her. page 2 of 5 On January 15, 2026, the Department inspected 4 resident rooms and common areas and observed that the facility was clean, sanitary, and free of odors at time of visit. On January 15, 2026, the Department reviewed and evaluated the following documents: Incontinent Management Program policy (dated 12/1/23), staff training on caring for incontinent residents (dated: 1/2/26, 11/14/25, 8/11/25, 8/12/25), Service plans for R1, R2, R7 (dated 11/19/26, and 8/26/25). During review of the documents, the Department found that the facility appropriately maintains incontinent care for the residents. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Staff did not ensure the facility was free of odors The detail of the complaint alleges that the facility smells like urine. On January 15, 2026, the department inspected 4 resident rooms and common areas and the department observed that the facility was clean, sanitary and free of odors. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Page 3 of 5 Allegation: Staff are not documenting incidents The detail of the complaint alleges “that when there is an incident, it is not documented.” On November 25, 2025, and January 15, 2026 the Department interviewed Administrator (A1) and 6 staff regarding the allegation. Staff and the Administrator denied allegation stating that incidents are always reported. S6 added, “Staff writes the incident down and they hand it to me, then I complete in the system and sign it, I also make sure they report the incident right away.” On January 15, 2026, the Department reviewed a sample of incident reports, which shows that the facility follows the reporting requirements. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Staff are forging medication logs The detail of the complaint alleges, “...they are told to sign logs for medications that they don’t have due to the refills not being delivered yet.” On November 25, 2025, and January 15, 2026 the Department interviewed (A1) and 6 staff (S1-S6). 6 out of 6 staff and A1 denied the allegation stating that there has been no reports of staff being asked to sign medication logs for medications they don’t have. Page 4 of 5 On January 15, 2026, the department reviewed and evaluated R1-R7 Medication Administration Record (MAR) for November and December 2025. The department found no evidence to support the allegation. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today’s visit. Exit interview conducted with Administrator and copy of report provided. Page 5 of 5the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 11-AS-20251120144808

Allegation investigated: Staff left residents in soiled diapers for an extended period of time. Staff did not ensure the facility was free of odors. Staff are not documenting incidents. Staff are forging medication logs.

On January 15, 2026, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegations and to deliver findings. The Department was met by Administrator Julius Osorio, and the purpose of the visit was explained. Investigation consisted of the following: On November 25, 2025, the Department conducted an unannounced initial visit to the facility to investigate the complaint allegations mentioned above. During the visit, it was determined that the complaint required further investigation. The department obtained pertinent documents including staff roster (dated 11/25/25) resident roster (dated 11/25/25), R1-R7 physicians reports and hospice care information (dates varies). The department toured the facility, and interviewed Administrator (A1), and 5 staff (S1-S5). On January 15, 2026, the Department obtained the following documents: Incontinent Management Program policy (dated 12/1/23), staff training on caring for incontinent residents (dated: 1/2/26, 11/14/25, 8/11/25, 8/12/25), Service plans for R1, R2, R7 (dated 11/19/26, and 8/26/25), daily housekeeping log (no date), Laundry schedule (dated 1/10/26), and Care Staff Assignment schedule. The department conducted interviews with 1 staff (S6), 1 Witness (W1) and 5 residents (R2-R5, R7). page 1 of 5 Unsubstantiated The investigation revealed the following: Allegation: Staff left residents in soiled diapers for an extended period of time The detail of the complaint alleges “the staff lets residents walk around with 'saggy' diapers in the facility instead of changing them.” On November 25, 2025, and January 15, 2026 the Department interviewed (A1) who denied the allegation stating that residents are not left soiled for an extended period of time. A1 further stated that the protocol for changing residents’ diapers: “…is based on typical checks of 1 to 2 hours and based on the needs of the residents whether they need to be changed and whether they are checked for urine output or bowel movements.” On November 25, 2025, between 8:00am and 4:00pm, the Department interviewed staff (S1-S5) regarding the allegation. Of those interviewed, 5 out of 5 denied the allegation stating they haven’t observed any residents left soiled for an extended period of time. 5 out of 5 staff stated that they are trained to care for residents who are incontinent. Additionally, 5 out of 5 staff stated that they typically change residents every 2 hours and/or sooner if necessary. On January 15, 2026, between 10:00am and 12:30pm, the Department interviewed 5 residents (R2-R5, R7) and Witness #1(W1). The department could not interview R1 as R1 no longer lives at the facility (passed away as of 11/24/25), R6 was not available at time of visit. Of those interviewed, 4 out of 5 state that they are never left in soiled diapers for extended periods of time. 1 out of 5 was not responsive to questions due to cognitive level. 4 out of 5 state that staff change them when they need changing. W1 a private/hire caregiver for R5 states staff is attentive and that she has not witness any instances where R5 complained of being left soiled since she worked with her. page 2 of 5 On January 15, 2026, the Department inspected 4 resident rooms and common areas and observed that the facility was clean, sanitary, and free of odors at time of visit. On January 15, 2026, the Department reviewed and evaluated the following documents: Incontinent Management Program policy (dated 12/1/23), staff training on caring for incontinent residents (dated: 1/2/26, 11/14/25, 8/11/25, 8/12/25), Service plans for R1, R2, R7 (dated 11/19/26, and 8/26/25). During review of the documents, the Department found that the facility appropriately maintains incontinent care for the residents. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Staff did not ensure the facility was free of odors The detail of the complaint alleges that the facility smells like urine. On January 15, 2026, the department inspected 4 resident rooms and common areas and the department observed that the facility was clean, sanitary and free of odors. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Page 3 of 5 Allegation: Staff are not documenting incidents The detail of the complaint alleges “that when there is an incident, it is not documented.” On November 25, 2025, and January 15, 2026 the Department interviewed Administrator (A1) and 6 staff regarding the allegation. Staff and the Administrator denied allegation stating that incidents are always reported. S6 added, “Staff writes the incident down and they hand it to me, then I complete in the system and sign it, I also make sure they report the incident right away.” On January 15, 2026, the Department reviewed a sample of incident reports, which shows that the facility follows the reporting requirements. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Staff are forging medication logs The detail of the complaint alleges, “...they are told to sign logs for medications that they don’t have due to the refills not being delivered yet.” On November 25, 2025, and January 15, 2026 the Department interviewed (A1) and 6 staff (S1-S6). 6 out of 6 staff and A1 denied the allegation stating that there has been no reports of staff being asked to sign medication logs for medications they don’t have. Page 4 of 5 On January 15, 2026, the department reviewed and evaluated R1-R7 Medication Administration Record (MAR) for November and December 2025. The department found no evidence to support the allegation. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today’s visit. Exit interview conducted with Administrator and copy of report provided. Page 5 of 5the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 11-AS-20251120144808

Allegation investigated: Facility staff caused bruising to resident in care

On 05/29/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent complaint investigation at the facility to deliver findings on the allegations listed above. LPA was met by Julius Osorio (S14), and the purpose of the visit was explained. The investigation consisted of the following: On 11/14/2024 Licensing Program Manager (LPM) Ulysses Coronel and LPA obtained the following records: Staff Roster, Resident Roster, Staff schedule, five (5) staff records, two (2) resident records, three (3) incident reports and a surveillance record from SafelyYou. CCLD staff toured the facility, inside and out. CCLD interviewed Administrator, Desiree Kitigawa (S3) and resident one (R1). On 05/13/25 LPA interviewed witness (W1) and obtained hospital medical records, dated 11/11/24. On 05/14/25 LPA interviewed five (5) residents (R2-R6), one witness (W2), and six (6) staff (S8, S10 - S14). S1 and S2 were not available during the investigation. Report Continues, see LIC9099-C. Substantiated The investigation revealed the following: Regarding the allegation “Facility staff caused bruising to resident in care”, it is being alleged that a resident was bruised by staff while being redirected back to their room during an elopement. Record reviews indicate the following: Surveillance records (dated: 11/08/24) indicates that R1 was brought back to their room through a two-person carry by S1 and S2. S1 was carrying R1 by the legs and S2 was carrying R1 by the armpits, as the staff transported R1 back to their room. LPA observed S1 grasp R1's left elbow while S1 attempts to close R1's door, before redirecting R1, by the armpits, further into their room. Hospital Medical record (dated: 11/11/24) indicates that R1 was admitted at Torrance Memorial Medical Center (TMMC) on 11/11/24 at 3:25PM by ambulance, with bruising on R1’s upper extremities. Hospital Medical record included photography of R1’s upper extremities and armpits, which depicted three (3) purple marks on R1’s left forearm, three (3) purple marks on R1’s right forearm and bruising in R1’s armpits. Interviews revealed that S3 has agreed that Emergency Medical Services (911) should have been contacted after R1’s first elopement incident on 11/08/24. Based on CCLD’s record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be substantiated. California Code of Regulations, Title twenty-two (22), Division six (6), is being cited. Please see the attached LIC 9099D.the state’s words, verbatim · CDSS document, May 29, 2025 · control 11-AS-20241113165545

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Jun 6, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in...care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This has not been met as evidenced by: The licensee did not ensure that staff would follow residents personal rights, resulting in bruising of a resident in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: The licensee and LPA have agreed that inservice training will be conducted with staff regarding personal rights of residents in all care facilities, with a focus on elopement procedures related to cognitively impaired residents.The training will also include a reminder of various redirection methods for safely redirecting a resident, when a resident presents exit seeking behavior, and when to contact Emergency Medical Services. This training information, sign-in sheet & time spent will be forwarded on or prior to POC due date to LPA, via email, at MARIO.LEON@DSS.CA.GOV

Allegation investigated: Facility staff caused bruising to resident in care

On 05/29/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent complaint investigation at the facility to deliver findings on the allegations listed above. LPA was met by Julius Osorio (S14), and the purpose of the visit was explained. The investigation consisted of the following: On 11/14/2024 Licensing Program Manager (LPM) Ulysses Coronel and LPA obtained the following records: Staff Roster, Resident Roster, Staff schedule, five (5) staff records, two (2) resident records, three (3) incident reports and a surveillance record from SafelyYou. CCLD staff toured the facility, inside and out. CCLD interviewed Administrator, Desiree Kitigawa (S3) and resident one (R1). On 05/13/25 LPA interviewed witness (W1) and obtained hospital medical records, dated 11/11/24. On 05/14/25 LPA interviewed five (5) residents (R2-R6), one witness (W2), and six (6) staff (S8, S10 - S14). S1 and S2 were not available during the investigation. Report Continues, see LIC9099-C. Substantiated The investigation revealed the following: Regarding the allegation “Facility staff caused bruising to resident in care”, it is being alleged that a resident was bruised by staff while being redirected back to their room during an elopement. Record reviews indicate the following: Surveillance records (dated: 11/08/24) indicates that R1 was brought back to their room through a two-person carry by S1 and S2. S1 was carrying R1 by the legs and S2 was carrying R1 by the armpits, as the staff transported R1 back to their room. LPA observed S1 grasp R1's left elbow while S1 attempts to close R1's door, before redirecting R1, by the armpits, further into their room. Hospital Medical record (dated: 11/11/24) indicates that R1 was admitted at Torrance Memorial Medical Center (TMMC) on 11/11/24 at 3:25PM by ambulance, with bruising on R1’s upper extremities. Hospital Medical record included photography of R1’s upper extremities and armpits, which depicted three (3) purple marks on R1’s left forearm, three (3) purple marks on R1’s right forearm and bruising in R1’s armpits. Interviews revealed that S3 has agreed that Emergency Medical Services (911) should have been contacted after R1’s first elopement incident on 11/08/24. Based on CCLD’s record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be substantiated. California Code of Regulations, Title twenty-two (22), Division six (6), is being cited. Please see the attached LIC 9099D.the state’s words, verbatim · CDSS document, May 29, 2025 · control 11-AS-20241113165545

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Jun 6, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in...care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This has not been met as evidenced by: The licensee did not ensure that staff would follow residents personal rights, resulting in bruising of a resident in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: The licensee and LPA have agreed that inservice training will be conducted with staff regarding personal rights of residents in all care facilities, with a focus on elopement procedures related to cognitively impaired residents.The training will also include a reminder of various redirection methods for safely redirecting a resident, when a resident presents exit seeking behavior, and when to contact Emergency Medical Services. This training information, sign-in sheet & time spent will be forwarded on or prior to POC due date to LPA, via email, at MARIO.LEON@DSS.CA.GOV

Type of visit: Case Management - Other

On 5/14/25, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a Case Management visit at the facility. The LPA met with Julius Osorio, the Executive Director, and explained the purpose of the visit. On 3/27/25, during an annual evaluation visit at the facility, LPA Iniguez observed during the physical tour that fire extinguishers were locked and not easily accessible in case of emergency. LPA Iniguez consulted the fire regulations, which state that “fire extinguishers shall be conspicuously located along normal paths of travel where they will be readily accessible and immediately available in the event of a fire.” On 5/14/2025, LPA Iniguez and the Executive Director toured the entire facility. During the tour, LPA Iniguez observed that the fire extinguishers were locked. However, (1) out of (8) had a sticker that said, “PULL HANDLE FIRMLY IN CASE OF EMERGENCY.” LPA Iniguez was able to open the fire extinguisher case. Acording to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Julius Osorio /Executive Director.the state’s words, verbatim · CDSS document, May 14, 2025

Type of visit: Required - 1 Year

On 3/27/2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Julius Osorio /Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (121) elderly adults ages 60 and above, of which (121) can be non-ambulatory and (22) bedridden on 1st floor rooms: 116-120, 123-127, 135-137, & 147. Approved for delayed egress doors and secured perimeters. The facility has an approved hospice waiver for (15). Currently the facility has (35) residents. The facility is a commercial building situated in a residential neighborhood. It includes a terrace level (basement), first floor, second floor, kitchen, common areas, medication room, records room, and an outdoor patio with shaded areas. LPA Iniguez and the Executive Director toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (8) bedrooms and (8) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 109.1°F to 111.3°F, and the room temperature ranged from 76°F to 78°F. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 1/25/25. A review of (5) residents' service files and (5) staff personnel files was done. LPA reviewed (5) Medication Administration Records (MARs) and found no discrepancies. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was given to LPA. Facility Annual Fess due on 4/12/25, LPA Iniguez provided PIN number: 128891 to Executive Director. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -MedTech with no First Aid/CPR card on file. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Julius Osorio / Executive Director.the state’s words, verbatim · CDSS document, Mar 27, 2025

Allegation investigated: Staff are exposing residents to a contagious illness.

On 08/21/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation. LPA Cloyd spoke with Executive Director Desiree Kitagawa and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA Cloyd reviewed facility records and interviewed three residents and eight staff members. Continue to LIC9099-C. Substantiated Allegation(s): Staff are exposing residents to a contagious illness. The investigation revealed the following: Regarding the allegation "Staff are exposing residents to a contagious illness,” it is being alleged that the Licensee allowed two staff members who tested positive for COVID-19 continue to work while wearing cloth masks. Record review reveals that the facility was not following the most recent (04/22/2024) Los Angeles County Department of Public Health (LAC DPH) COVID-19 and Common Respiratory Viruses Guidance for Community Congregate Settings. It states, for non-healthcare staff “who test positive for… COVID-19 must go home immediately if onsite and must be excluded from the workplace for five days after symptoms began or after testing positive if no symptoms. Isolation may end and staff may return to work after Day 5 if all the following criteria are met…”. Record review revealed that two staff members worked within five days of testing positive. Six (6) out of eight (8) staff interviews, including the Executive Director, indicated that staff was allowed to return to work within five days of testing positive for COVID-19. Regarding the allegation “Staff are exposing residents to a contagious illness,” based on record review and interviews, the preponderance of evidence has been met therefore the allegation is Substantiated. Deficiencies were issued. An exit interview was conducted and plans of correction developed. A copy of this report, LAC DPH Guidance provided, and appeals rights was reviewed and left with the Executive Director Desiree Kitagawa.the state’s words, verbatim · CDSS document, Aug 21, 2024 · control 11-AS-20240816112443

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Aug 22, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents... shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above for two staff members which poses an immediate health risk to persons in care. LPA Cloyd observed that Staff #2 & #3 worked within five days after testing positive for COVID-19 which is against LAC DPH guidelines.the state’s words, verbatim · CDSS document, Aug 21, 2024

Plan of correction: The Administrator will review Los Angeles County Department of Public Health (LAC DPH) COVID-19 and Common Respiratory Viruses Guidance for Community Congregate Settings (04/22/2024) and implement its guidance for non-healthcare staff with positive COVID-19 diagnosis to the facility's procedures and email it to regina.cloyd@dss.ca.gov by the POC due date. The Administrator will continue to review updated Provider Information Notices (PINs) and implement the strictest guidance COVID-19.

Type of visit: Post Licensing

On 5/8/24, Licensing Program Analyst-LPA Alfonso Iniguez conducted an unannounced post-licensing visit and met with Desiree Kitagawa/Executive Director, and the purpose of the visit was explained. The facility is licensed to serve (121) elderly residents ages 60 and over. The fire clearance is approved for (101) non-ambulatory and (20) bedridden where twenty (20) can be bedridden on first floor #116-120, 123-127, 135-137 and 147. Basement and second floor for non-ambulatories only. Approved hospice waiver for (15). Currently, the facility has (8) residents. Per CAB, the following item(s) need to be reviewed during the post-licensing inspection: · Personnel Policies · Abuse Reporting Procedures · In-Service Training and Medication Procedures During the visit, LPA and Executive Director collaborated closely, reviewing the policies and procedures the facility submitted to CAB on initial application of license. The facility also has current policies available upon request. A joint tour of the facility was conducted. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Desiree Kitagawa/Executive Director.the state’s words, verbatim · CDSS document, May 8, 2024

Type of visit: Prelicensing

On 4/3/24 Licensing Program Analysts (LPA’s) Alfonso Iniguez and Wendy Gibbs conducted a pre-licensing evaluation for an RCFE facility type. Today’s pre-licensing evaluation was conducted with authorized licensee: Desiree Kitagawa/Administrator. The licensee has applied for a license to serve (121) elderly residents age range 60 and over. The fire clearance is approved for (101) non-ambulatory and (20) bedridden where twenty (20) can be bedridden on first floor #116-120, 123-127, 135-137 and 147. Basement and second floor for non-ambulatories only. Approved hospice waiver for (15). A tour of the entire facility was conducted: basement floor, first floor, second floor, kitchen, common areas, outside of facility, medication room, records room, generator bathrooms, activity program, weekly menus. The following was observed during this visit: MEDICATIONS There is a locked centralized storage area for Resident medications. PHYSICAL PLANT Facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68°F. degrees and 73°F. degrees. Open porches, and areas of potential hazard are well-lit. Smoke alarms operate properly. Carbon monoxide detectors operate properly. Report continues LIC 809C. BEDROOMS There is a space for client’s own furniture that will accommodate a bed, a chair, a nightstand, a lamp, reading lights and a chest of drawers. BATHROOMS There is at least (95) toilet and washbasin per six (6) clients, family, and personnel. There is at least (87) shower or bathtub per ten (10) clients, family, and personnel. Hot water temperature is between 105F°. and 120F°. Bathrooms are located inside clients’ bedrooms. There are nightlights in the hallways outside non-private bathrooms. SUPPLIES There are client personal hygiene supplies to include soap, toothpaste, toilet paper, and comb. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths. FOOD SERVICE Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0° Fahrenheit. Refrigerator is a maximum of 45° Fahrenheit. A seven (7) day supply of non-perishable food is present. There are enough tableware, tables, dishes, and utensils. There is enough equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean. RECORDS There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility ADMINISTRATION The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy will be posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings. ACTIVITIES There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors. MISCELLANEOUS There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for commercial laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries. Copy of liability insurance was email to LPA during this visit. DELAY EGGRESS and SECURE PERIMETER Delay egresses are located on the 1st floor memory care entry and courtyard gate and stairwell access LPA Gibbs observed the functioning of it. Facility will use a Wander guard system as perimeter to secure residents with cognitive issues. Check points are located at exits, it will signal an alarm and a signal to the facility signal system, LPA Iniguez observed the functioning of the system. During this pre-licensing inspection, LPAs did not find corrections are needed. LPA Iniguez conducted the Component III Orientation with the Licensee and copy of this report was provided. A copy of the facility evaluation report will be available to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with their assigned CAU Analyst. Exit interview conducted with Desiree Kitagawa/Administratorthe state’s words, verbatim · CDSS document, Apr 3, 2024

Type of visit: Office

Component II completion: Successful Facility Type: Initial Application Type: Residential Care Facility for Elderly (RCFE) Capacity: Census (if any clients in care): none COMP II Participants: Desiree Kitagawa, Administrator Benoit Levesque, Applicant Interview Method: Telephone interview On January 29, 2024 at 11:00 AM, applicant and administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant and Administrator’s understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing Requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readiness Exit interview conducted with Applicant and Administrator. Copy of report sent via email and request to return sign copy by end of business day today to CAB.the state’s words, verbatim · CDSS document, Jan 29, 2024