Platinum Crown

Allegation investigated: Staff is not assisting resident with obtaining medical appointment. Staff did not provide copy of admission agreement to responsible person. Staff did not ensure the resident had appropriate clothing.

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with the facility staff, Behrouz Atri (S2), and explained the reason for the visit. At 9:50 AM administrator arrived, Tamara Aleksani, arrived and explained the reason of the visit. To investigate the allegation on 04.22.2026, LPA took a tour of the physical plant at 8:35 AM. LPA requested copies of resident #1 (R1) physician report, admission agreement, appraisal needs and service plan, and other documents pertaining to the investigation. LPA reviewed documents at 11:00 AM, interviewed two (2) staff, and six (6) who are at the facility from 9:05 AM to 10:55 AM. Allegation: Staff is not assisting resident with obtaining medical appointment. Continue to LIC 9099-C Unsubstantiated It is reported that the facility does not assist R1 in obtaining medical appointments. To investigate this allegation, LPA conducted an interview with the Administrator and staff, who stated that the facility provides timely medical care to all of the residents in care, including obtaining a specialist appointment for R1. Interviews with six (6) residents revealed no concerns regarding the allegation, stating that their medical needs are being met. Interview with R1 at 10:00 AM confirmed that they had an appointment with a specialist on 4.20.2026 which was scheduled by the administrator. Record review confirmed R1 appointment. Therefore, based on interviews, this allegation is deemed unsubstantiated at this time. Allegation: Staff did not provide copy of admission agreement to responsible person. It is alleged that staff did not provide a copy of admission agreement to R1’s responsible person. Interview with R1 stated that they are responsible for themselves and did not authorize anyone to be responsible for them. During record review, LPA did not observe any legal document for R1 to have an authorized representative. Per Identification and Emergency Information sheet dated: 04.03.26, R1 is self responsible. Admission agreement signed on 04.05.26 was signed by R1. Interview with all the residents revealed that they are all responsible for themselves. During interviews with administrator and staff, it was revealed that if a responsible person is available, they would communicate the necessary information to the authorized representative. Based observation and interview, there is not enough information to verify the allegation. There is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff did not ensure the resident had appropriate clothing. In regard to the allegation, it was reported that R1 does not have footwear. Interview with the staff confirms that facility provides all of the necessary supplies’ residents need. The interview with R1 revealed that they were provided with footwear but prefer sneakers instead of slip-ons. Interview with residents revealed that they are properly supplied with all their needs and requests. Based on the information and observation obtained, there was insufficient evidence to corroborate the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 31-AS-20260417141106

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted unannounced initial visit to this facility in conjunction with a complaint control #31-AS-20260417141106. LPA met with Staff #2 (S2) Behrouz Atri, who granted access to facility. S2 is not associated with facility, immediate civil penalty will be issued in LIC 421BG. During physical plant tour, the following was observed: LPA observed in bedroom #2, R6 having a pocket knife beside his bed on the floor, who shared a room with a dementia resident. S2 was observe using bedroom #3 without knocking to enter and access the patio. Per S2 they have been working at the facility has been working since December 2025. LPA review background clearance is cleared but not associated with the facility. During record review, the following was observed: R6 not having a file at the facility, they have been residing at the facility for more than 2 weeks. R1 not having medication at the facility. S1 and S2 not having files at the facility. Exit interview conducted, Citations issued, Appeal rights given and a copy of this report delivered.the state’s words, verbatim · CDSS document, Apr 22, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Apr 23, 2026

The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.This requirement is not met as evidence by: Based on interview and review of Guardian Background System Check facility Staff S2 is criminal background is clearanced but not associated to the facility. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Administrator has agreed to complete Guardian association of S2 to facility by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Apr 23, 2026

The licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, ...which could pose a danger to residents are in locked storage and are This requirement is not met as evidenced by: not left unattended if outside the locked storage. Based on LPA's observations, staff did not comply with the section cited above. LPA observed R6 pocket knife were not locked in a cabinet which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Administrator locked away R6 knife.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(A)(1) · Plan of correction due date: May 6, 2026

To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement was not met as evidenced by: LPA observe S2 entering bedroom #3 without knockling to access the patio as a passageway.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Administrator will write a plan to LPA acknoledging a correction for deficiency BY POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: May 6, 2026

Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident,... of the resident’s home health agency, if any, and any other. appropriate parties, to prepare a writtenrecord of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility. This requirement is not met as evidenced by: R6 does not have a file at the facility, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Administrator will create a file for R6.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(F)(6) · Plan of correction due date: May 6, 2026

Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by: LPA observe R1 did not have any medications at the facility.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Administrator agreed to pick-up R1 medication immediately.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: May 6, 2026

The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by: No files were available for LPA to review for S1 and S2.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Administrator agrees to create and retain S1 and S2 file at the facility by POC date.

Type of visit: Prelicensing

On 5/1/25 at 9:30am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted a Pre-Licensing Inspection with the facility Administrator Tamara Aleksani. Upon arrival, LPA introduced herself by showing her department badge. This is a single story house which will be operating as Residential Care Facility for Elderly (RCFE). A fire clearance was approved on February 11th, 2025 for six (6) Non-Ambulatory residents of which one (1) may be Bedridden for bedroom #3, and one (1) Ambulatory resident for bedroom #1. Facility also received Hospice approval for five (5) residents. The smoke alarms and carbon monoxide detectors are hard wired and inter-connected, they were tested and are operational. The facility has two (2) fire extinguishers that was purchased on 10/18/2024 and is located on the kitchen wall. A tour of the physical plant was initiated at approximately 10:15am and the following was observed: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, gas stove, microwave oven and sink. LPA observed adequate supplies of emergency and nonperishable food properly stored inside the kitchen cabinets. Perishable food items are not required at this time as there are no residents in the facility. Licensee will supply sufficient amount of perishable food upon arrival of the residents. dining ware to accommodate a maximum capacity of six (6) residents. Knives and other sharps were observed locked inside the kitchen cabinet and chemicals observed stored inside locked cabinet under the kitchen sink. BEDROOMS: The facility has four (4) bedrooms and all bedrooms are designated for residents' use. All residents' bedrooms observed to be nicely furnished with beds, night stands, lamps, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and a closet space. Additional linen is available inside each bedroom’s closet. Continue on LIC809-C BATHROOMS: The facility has three (3) bathrooms, both designated for residents’ and staff use. All bathrooms were observed to have the proper fixtures, grab bars, non-skid mats, trash cans with closed lids, paper towels and washing hands signs. The hot water delivered in the bathrooms measured at 10:15am to be at 117.7 degrees F. COMMON AREAS: These includes living room and a dining room. The living room was equipped with new furniture, a television, and television stand. The dining area has a dining table to accommodate six (6) clients. There were no visible immediate hazards. The facility has comfortable temperature which was measured at 10:45am to be at 70 degrees F. LPA observed various activity supplies nicely stored inside the TV stand and ready for residents' use. LAUNDRY ROOM: The washer and dryer is located in a laundry area located in the hallway across from the kitchen. Laundry chemicals will be stored inside the separate storage area, which will always be locked and under supervision. MEDICATIONS/ Client/Staff Files: Medications and facility files will be kept inside the locked storage cabinet next to the facility entrance door. First Aid and the new manual is also locked inside the same cabinet. LPA observed the First-aid has all proper items and is current. SURROUNDING GROUNDS: The driveway, passageways and entrance to the home were clear of obstruction. The backyard of the facility is properly fenced, has a patio and backyard furniture to accommodate six (6) clients. Facility is sharing the area with another house located in the same property. Both houses are separated with proper fencing, have no access to each other’s space and have separate addresses. GARAGE: There is no garage in the property. Continue on LIC809-C LPA observed the facility is clean, safe and sanitary. All window screens were in good repair. Auditory signals were installed on exit doors. All passageways were free of obstruction. In addition to the Pre-Licensing inspection, a Component III power point presentation was also held. Pursuant to Title 22, CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised. An emergency exit plan/sketch along with other posting requirements were available and posted on the wall. No deficiency cited on today’s visit. Exit interview conducted and copy of this report signed and delivered to the Administrator.the state’s words, verbatim · CDSS document, May 1, 2025