Polly's Place

Allegation investigated: Staff handles residents in a rough manner. Staff spoke in an inappropriate manner to resident.

On March 2, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Licensee Polly Valencia was notified via telephone and later arrived to assist with the inspection. During the course of the investigation, the Department interviewed residents, interviewed staff, reviewed and collected pertinent documents to this complaint. Regarding the allegation, staff handles residents in a rough manner, the following has been concluded: It was alleged that staff handle Resident #8 (R8) in a rough manner. The Department was unable to conduct an interview with R8 for this allegation, due to R8 passing away on July 7, 2024. The Department conducted seven resident interviews. Four out of the seven residents were unable to qualify for an interview. However, three out of the seven residents denied the allegation. The Department conducted seven staff interviews, including an interview with Licensee Polly Valencia. Seven out of the seven staff interviewed denied the allegation. CONTINUED ON LIC9099-C Substantiated However, the Department was able to obtain a video recording of an incident involving R8 and Licensee Polly Valencia, which was captured in R8’s bedroom. In the video recording, R8 appears to be adjusting herself to lay down on her bed. Licensee Polly Valencia is then seen wrapping both of her arms around R8 and tossing her down on the bed in an aggressive manner. R8 is then heard groining, which suggests this action may have caused her discomfort. At this point, R8's back is on the bed, however, her legs are still hanging on the side of the bed. Licensee Polly Valencia is then seen grabbing R8's legs with both arms, and tossing them onto the bed in an aggressive manner. R8 is seen saying something to Licensee Polly Valencia after this action, however, it is unclear of what was said. Regarding the allegation, staff spoke in an inappropriate manner to resident, the following has been concluded: It was alleged that staff spoke in an inappropriate manner to R8. The Department was unable to conduct an interview with R8 for this allegation, due to R8 passing away on July 7, 2024. The Department conducted seven resident interviews. Four out of the seven residents were unable to qualify for an interview. However, three out of the seven residents denied the allegation. The Department conducted seven staff interviews, including an interview with Licensee Polly Valencia. Seven out of the seven staff interviewed denied the allegation. However, the Department was able to obtain a video recording of an incident involving R8 and Licensee Polly Valencia, which was captured in R8’s bedroom. In the video recording, Licensee Polly Valencia is seen speaking to R8 in an inappropriate manner multiple times. Licensee Polly Valencia is heard telling R8, "I am disgusted with you". Licensee Polly Valencia is heard telling R8, "I am absolutely disgusted with you". Licensee Polly Valencia is also heard telling R8, "Shame on you". Licensee Polly Valencia is heard making a fourth statement to R8, however, the video recording ends before the full statement is captured. Based on the evidence gathered during this investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D page. An exit interview was conducted with Licensee Polly Valencia. A copy of the report and Appeal Rights were provided. The Department conducted seven staff interviews, including an interview with Licensee Polly Valencia. Seven out of the seven staff interviewed denied the allegation. The Department obtained a video recording from a camera that was placed in Resident #8 (R8) bedroom. The Department reviewed R8’s file. The Department observed that there was a consent form which authorized a camera to be placed in R8’s bedroom for safety reasons. The consent form was signed by R8’s Responsible Party and by Licensee Polly Valencia. However, the consent form was not signed by R8 and the Department was unable to conduct an interview with R8 for this allegation, due to R8 passing away on July 7, 2024. Regarding the allegation, staff forced resident to eat, the following has been concluded: It was alleged that staff forced R8 to eat. The Department was unable to conduct an interview with R8 for this allegation, due to R8 passing away on July 7, 2024. The Department conducted seven resident interviews. Four out of the seven residents were unable to qualify for an interview. However, three out of the seven residents denied the allegation. The Department conducted seven staff interviews, including an interview with Licensee Polly Valencia. Seven out of the seven staff interviewed denied the allegation. Regarding the allegation, staff hit resident, the following has been concluded: It was alleged that staff hit R8. The Department was unable to conduct an interview with R8 for this allegation, due to R8 passing away on July 7, 2024. The Department conducted seven resident interviews. Four out of the seven residents were unable to qualify for an interview. However, three out of the seven residents denied the allegation. The Department conducted seven staff interviews, including an interview with Licensee Polly Valencia. Seven out of the seven staff interviewed denied the allegation. Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the three allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Licensee Polly Valencia and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 2, 2026 · control 22-AS-20240227123453

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Mar 3, 2026

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not evidenced by: Based on evidence gathered, the Licensee did not ensure Resident #8 was treated with dignity. LPA observed a video recording in which the Licensee spoke to R8 in an inappropriate manner. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: The Licensee stated that she will complete a statement and conduct an in service training with all staff regarding this regulation. The Licensee agreed to provide LPA the statement and proof of training via email or fax by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Mar 3, 2026

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall ...:(3) ...be free from punishment, humiliation, intimidation, abuse... This requirement was not evidenced by: Based on evidence gathered, the Licensee did not ensure Resident #8 was free from intimidation and abuse. LPA observed a video recording in which the Licensee handled R8 in a rough manner. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: The Licensee stated that she will complete a statement and conduct an in service training with all staff regarding this regulation. The Licensee agreed to provide LPA the statement and proof of training via email or fax by POC date.

Type of visit: Case Management - Other

On March 2, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management inspection. Licensee Polly Valencia was notified via telephone and later arrived to assist with the inspection. This visit is being conducted in conjunction with complaint #22-AS-20240227123453. During the complaint investigation, Licensee Polly Valencia was interviewed on two separate occasions, regarding the complaint allegations of staff handles residents in a rough manner, and staff spoke in an inappropriate manner to resident. During both interviews, Licensee Polly Valencia denied the complaint allegations and stated that she has not handled a resident in a rough manner and has not spoken to a resident in an inappropriate manner. However, during the complaint investigation, the Department obtained a video recording, which contradicted Licensee Polly Valencia’s statements. In the video recording, Licensee Polly Valencia is observed to be handling a resident in a rough manner when transferring a resident into her bed. The resident is heard groining in the video recording, which suggests it may have caused them a level of discomfort. Licensee Polly Valencia is also heard speaking to the resident in an inappropriate manner. Licensee Polly Valencia is heard telling the resident, "I am disgusted with you", "I am absolutely disgusted with you", and "Shame on you". The video recording directly contradicts the statements that Licensee Polly Valencia made to the Department during two separate interviews. Additionally the actions on the video recording by Licensee Polly Valencia were in itself, inimical to the health and safety of the resident in care. Based on the information gathered, a deficiency is being cited on the attached LIC809-D page. An exit interview was conducted with Licensee Polly Valencia. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Mar 2, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87408(a)(6) · Plan of correction due date: Mar 9, 2026

87408 Denial or Revocation of a Certificate: (a) The Department may deny or revoke any administrator certificate ... (6) The certificate holder engaged in conduct which is inimical to the health, morals, welfare, or safety of ... an individual ... This requirement was not evidenced by: Based on evidence gathered, the Licensee engaged in conduct inimical to the health and safety of a resident in care. The Licensee also provide false statements on two occasions to the Department. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: The Licensee stated that she will complete a statement of understanding regarding this regulation. The Licensee agreed to provide the statement to LPA via email or fax by POC date.

Allegation investigated: Facility failed to ensure a resident's visitation rights Facility staff failed to report a fall incident to a resident's reporting party in a timely manner Facility staff failed to notify a resident's responsible party of a change in condition requiring an admission onto hospice care Facility staff did not provide a responsible party with a list of the prescribed medication for a resident

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator Polly Valencia and explained the reason for the visit. The investigation into the allegation, facility failed to ensure resident's visitation rights, revealed the following. It was reported that on two occasions facility staff told Resident 1's (R1) family members not to visit because R1 was asleep or was overwhelmed. The Administrator reported they never told any possible visitor not to visit. 4 out of 4 staff interviewed reported they have never told anyone not to visit a resident. No specific details were provided as to who informed possible visitors they could not visit or the dates that it occurred. LPA attempted to contact R1's responsible party but never received a response so they were not interviewed. R1's whereabouts are unknown so they could not be interviewed. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. Unsubstantiated The investigation into the allegation, facility staff failed to report a fall incident to a resident's reporting party in a timely manner, revealed the following. It was reported that in September 2023, R1 suffered a fall and the responsible party was not notified in a timely manner. No specific date was provided for R1's fall. The Administrator reported that R1 did have a fall in September 2023 but could not remember the exact date. Staff 1 reported that R1 started to fall out of their wheelchair and Staff 1 broke their fall but R1 still bumped their head on the ground. At that time R1's hospice nurse was present and assessed R1. R1's hospice nurse assessed R1 and determined R1 did not need emergency services. First aid was applied and R1 was taken to her room. R1' hospice nurse verified this information. The Administrator reported they contacted R1's responsible party and reported the incident. LPA attempted to contact R1's responsible party but never received a response so they were not interviewed. R1's whereabouts are unknown so they could not be interviewed. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, facility staff failed to notify a resident's responsible party of a change in condition requiring an admission onto hospice care, revealed the following. Resident 1 (R1) moved into the facility May 15, 2023 and moved out November 30, 2023. A review of records shows R1 was put on hospice on September 9, 2023. The Administrator reported that R1 appeared to be losing weight and wanted R1 to be evaluated by hospice. The Administrator reported that R1 agreed. The Administrator reported that they informed the responsible party and they agreed. R1 was assessed and hospice was approved. R1 was admitted to hospice for unspecified protein/calorie malnutrition. The Administrator reported that the responsible party was notified and kept informed of all of R1's changes. LPA attempted to contact R1's responsible party but never received a response so they were not interviewed. R1's whereabouts are unknown so they could not be interviewed. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, facility staff did not provide a responsible party with a list of the prescribed medication for a resident, revealed the following. It was reported that after R1 moved out the responsible party requested a list of medications for R1. It was reported that the facility was taking R1 to medical appointments without notifying the responsible party. The Administrator reported that R1's appointments were at the facility and the responsible party was notified about each appointment. therefore the allegation is substantiated. Deficiencies are being cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted and a copy of the report provided. The Administrator reported that any issues with medication should have been communicated with the physician because the facility only administers medications as prescribed and doesn't decide what medications are prescribed. The Administrator reported that the responsible party was provided with R1's medications and a list of their medications when R1 moved out. LPA attempted to contact R1's responsible party but never received a response so they were not interviewed. R1's whereabouts are unknown so they could not be interviewed. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 22-AS-20240416125427

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Dec 26, 2025

A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...This requirement was not met as evidenced by The facility verified R1 suffered a fall in September 2023 but did not report it to the Department, this poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 17, 2025

Plan of correction: Licensee agrees to sign a statement of understanding for CCR 87211 and to train staff on CCR 87211. Licensee to submit proof to LPA by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sam Haddadin conducted an unannounced Required One-Year Inspection. Upon arrival, LPA met with Administrator Polly Valencia and explained the purpose of the visit. The facility is licensed to operate as a Residential Care Facility for the Elderly (RCFE) serving six (6) residents, ages 60 and above. At the time of the visit, six residents were present in care. The facility is a one-story residence consisting of six bedrooms, seven bathrooms, and a detached garage used for storage. LPA inspected all resident bedrooms, which were observed to be clean, well-furnished with a bed, chair, and linens in good condition. Adequate storage space was available, and no tripping hazards were observed. The kitchen was clean and well-maintained, with all major appliances functioning properly. Knives and sharps were stored securely and were inaccessible to residents in care.The exterior grounds were observed to be clean, safe, and well-maintained. Outdoor pathways were unobstructed, and a shaded seating area was available for residents’ use. The fire extinguisher was fully charged, with the gauge indicator in the green zone. Hot water temperature was measured at 108.6 degrees Fahrenheit, which is within the regulatory range. Facility records indicated that the most recent emergency drill was conducted on October 1, 2025. {***CONTINUE***} The facility maintained an adequate food supply consisting of at least two (2) days of perishable and seven (7) days of non-perishable items. A review of resident and staff records revealed no discrepancies; all documentation was complete and met Title 22 requirements. Based on observations made during today’s inspection, no deficiencies were cited in accordance with Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 10, 2025

Type of visit: Annual/Random

This LIC809 is generated to update the LIC9099 D page for the previous annual done on 11/23/2024.the state’s words, verbatim · CDSS document, Dec 7, 2024

Type of visit: Required - 1 Year

On 11/23/2024 at 11:30 AM, Licensing Program Analyst LPA) Jose Calderon conducted an unannounced annual inspection visit at the Polly’s Place Facility. LPA Calderon was allowed entry into the facility by Administrator Polly Valencia. Administrator Valencia asked infection control questions and took LPA Calderon temperature prior to entrance into the facility. Facility is to operate a Residential Care Facility for 6 Elderly residents 60 years or older. Currently, there are six (6) residents residing in the facility, 60 and older. LPA Calderon explained to Administrator Valencia, the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Six (6) client service records, six (6) client medication records (MAR), three (3) staff records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 10/01/2024. The one-story residential home consists of six (6) client bedrooms, seven (7) client bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the garage and kitchen area. LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of client’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 115 degrees Fahrenheit, bathroom #2 hot water temperature properly measured at 113 degrees Fahrenheit, and bathroom #3 hot water temperature properly measured at 112 degrees Fahrenheit. Kitchen hot water temperature properly measured at 118 degrees Fahrenheit. Facility (14) Carbon Monoxide and (14) Smoke Detectors hard wired operated and connected were tested and are working properly. The facility one (1) Fire Extinguishers was checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. The facility has a working landline telephone. All toxins and knifes are locked/secured and inaccessible to clients. Medications are centrally stored and in a locked storage cabinet. Facility 2 first aid kit is fully stocked with manuals was checked and in order. Outside grounds were toured and there is a pool observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to clients. Six (6) client files were reviewed and found to be complete. LPA Calderon reviewed six (6) resident medications (MAR) and they were all found to be administered according to doctor's orders. Three (3) staff files were checked and have the required documents. LPA Calderon noted the Administrator Polly Valencia Certification # 6061671740 expiration date of 1/5/2024 was NOT valid at time of inspection. The facility does not handle client's money/cash resources and no surety bond is needed. Commercial General Liability Policy #CFP3411281 policy period from 02/01/2024 to 02/01/2025 underwritten by Seneca Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. Administrator Valencia to email LPA Calderon a full copy of the commercial insurance policy including all endorsements no later than 12/10/2024. All the required documents are posted in the facility in a clearly visible area. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and clients, sanitizing stations (Located in common areas and restrooms). LPA observed staff and clients were NOT wearing face coverings. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA Calderon advised the Administrator Valencia to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did observe deficiencies therefore citations were issued at this time. Annual Licensing Fee is CURRENT. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Polly Valencia.the state’s words, verbatim · CDSS document, Nov 23, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joseph Alejandre conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20240416125427. LPA met with Administrator Polly Valencia. LPA explained the reason for the visit. During the visit LPA observed the following. The smoke detectors in the kitchen and TV room next to the kitchen that both smoke detectors have been removed. LPA observed that the base plates are attached with the wires to connect the smoke detectors hanging freely from the ceiling/wall. LPA toured the facility. LPA observed the bathroom next to the living room does not have a screen in the window. Deficiencies are being cited per Title 22, Division 6 of the California Code of regulations. An exit interview was conducted and a copy of the report along with the LIC 809D, LIC 421IM and appeal rights was provided.the state’s words, verbatim · CDSS document, Apr 24, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Apr 25, 2024

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not being met as evidenced by: LPA observed the smoke detectors in the kitchen and TV room have been removed. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Apr 24, 2024

Plan of correction: Licensee agrees to install smoke detectors in the kitchen and TV room next to the kitchen and to forward proof to LPA by POC due date.

Allegation investigated: Facility refused to return resident’s medications

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility and to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by facility administrator (AD) Polly Valencia. During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that facility refused to return resident's medications. LPA De Perio conducted 5 interviews that consisted of staff and residents. 4 out of the 4 resident interviews, and the 1 staff interview did not corroborate with the allegation. An interview was conducted with the resident's (R1) social worker, who stated that R1's responsible party requested for the facility to return R1's medication on December 15, 2023, and that R1's responsible party confirmed to the social worker via text message that the facility had returned R1's medication the following day on December 16, 2023. Unsubstantiated R1's social worker listed the medications that R1's responsible party had received from the facility, and per documentation review, 8 out of the 8 medications that R1 was prescribed, was given to the responsible party. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with AD Valencia. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Dec 26, 2023 · control 22-AS-20231218142300