Promise Assisted Living

Type of visit: Case Management - Other

Licensing Program Analysts (LPA) Luis De Leon conducted an initial unannounced Case Management Visit. LPA met with the Assistant Administrator Theressa Resendez and explained the reason for the visit. Ms. Resendez informed Administrator Gregory Restum of today’s visit. Administrator Gregroy Restum joined visit some time after. On today's visit, LPA observed from property doors leading to street to have the double-bolt lock in disrepair and LPA learned that staff was using chains with lock pad to secure front property door during the 10 PM-6AM hours. Administrator Restum stated that Administrator was not aware that the door lock was in disrepair and that Administrator was not aware that chains with lock pad was being used by staff to secured the front entrance door. Administrator Restum removed the broke double-bolt lock from the front entrance door and discarded chains being used to lock front entrance door. Administrator stated that new lock was going to be install at front door entrance. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. A technical Assistance was issue to ensure that facility is maintain in good repair at all time. Exit interview was held and a copy of the report was provided to the Manager Roxana Aparicio.the state’s words, verbatim · CDSS document, Aug 24, 2026

Allegation investigated: Staff are not providing resident with their medication as prescribed.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the allegations listed above. LPA met with Theresa Resendez and explained the reason for the visit. The investigation consisted of the following: LPA obtained copies of staff and residents, conducted medication review, toured facility, and conducted interviews with 3 staff and 6 residents. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff are not providing resident with their medication as prescribed. It is alleged that for the past four months S1 has refused to assist R1 with medication. LPA interviewed 6 Residents and 5 out of 6 residents denied the allegation, R1 stated that MedTechs/Caregivers assist with medication, however, their doctor is not signing off on a new order. LPA interviewed 3 staff and each denied the allegation and stated they always assist resident with medication upon request and hav never witnessed other staff refuse to assist residents with medication. S1 stated that they do not administer medication but do help the residents with doctor appointments and reordering medication, however, sometimes certain medication need a new doctors order or sometimes are waiting for the insurance to pay for the mediation therefore a delay may happen in these situations. LPA conducted a medication review and did not observe any issues with medication. Based on statements and interviews conducted with Staff/Residents, and review of medication, there was not enough supportive evidence to concur with the reported allegation. 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. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 6, 2026 · control 28-AS-20260803175403

Allegation investigated: Staff neglect resulted in a resident sustaining multiple pressure injuries Staff did not prevent a resident from physically assaulting other residents

On todays visit, Licensing Program Analyst (LPA) Luis De Leon conducted a subsequent unannounced complaint investigation visit for the allegations listed above and to deliver findings. LPA met with Administrator Gregory Restum and explained the reason for the visit. On 12/24/25, LPA DeLeon conducted the initial complaint visit, during visit, LPA toured the physical plant with S1, obtained the current resident and staff roster, relevant documents pertaining to residents 1 (R1). On 04/09/2026, LPA DeLeon conducted a subsequent complaint visit and obtained additional documents including staff and resident roster, facility’s hospice care policy, R1’s hospice care plan and R1’s hospice care notes. On 05/01/2026, LPA DeLeon conducted a subsequent compliant visit and obtained additional documents, R1’s hospice treatment instructions for hospice visit on 12/16/2025 and facility R1’s Medication Administration Record (MAR). LPA interviewed seven (7) residents and six (6) staff. (Report continues on page LIC-9099C...) Unsubstantiated Regarding allegation: Staff neglect resulted in a resident sustaining multiple pressure injuries. It is alleged that staff did not provide a resident with adequate care, which led to the resident developing several pressure injuries. The investigation consisted of interviews with staff, residents, and review of R1 facility files including discharge hospital records and hospice care plan. The investigation reveals the following: R1 was admitted to the facility on 08/20/2025 with no wounds and R1 was admitted to Hospice on 08/21/2025. Review of R1s facility records revealed that R1 had a hospital visit on 12/05/2026, and there are no documents indicating that R1 had developed a pressure injury on 12/05/2026. On 12/16/25, R1s hospice records revealed that R1’s hospice attending nurse documented it was observed that R1 had a new onset Stage II to Upper Coccyx. Hospice Nurse provided staff with instructions to staff to care for R1’s wounds, which included cleaning, medication, and re-positioning. On 12/21/2025, R1 was sent to the hospital for shortness of breath. R1’s hospital discharge records dated 12/23/26 indicated that R1 had developed lower back unstageable pressure injury to lower back. R1s Facility Medication Administration Record (MARs) for the month of December 2025 revealed that the facility implemented and followed R1s hospice wound care plan beginning December 16, 2025, which included staff repositioning R1 every two (2) hours, cleaning wound, and applying medication. The facility MARs indicated that staff provided followed R1’s wound care until R1 was sent to the hospital on 12/20/2025. Interview with residents revealed that six (6) out of eight (8) residents were not aware of any resident bedbound to have developed any wounds from being in bed or on wheelchair. Interviews with staff revealed that six (6) out of six (6) staff were not aware of the above allegation. Staff indicated that R1 spent most of the day in the wheelchair. Staff stated that staff assisted R1 with repositioning in wheelchair and at bed when R1 was awake. Staff assisted R1 with transferring from bed to wheelchair whenever R1 requested transfer assistance. Based upon the investigation, resident and staff interviews, document review, and LPA observations, there is no evidence to support the allegation that facility’s neglect caused R1 developing pressure injuries. Regarding allegation: Staff did not prevent a resident from physically assaulting other residents. It is alleged that facility staff did not take action to prevent a resident assaulting another resident in care. Investigation consisted of interviews with staff, residents, and review of resident #1 (R1) and resident #7 (R7) facility files, including admission agreement and physician’s report. The investigation revealed the following: Interviews with six (6) out eight (8) residents revealed that residents denied being assaulted at facility and residents denied knowing of other residents being assaulted at the facility. (Report continues on page LIC-9099C...) Residents stated that residents have not witnessed any residents arguing with each other and that residents get along with one another. LPA interviewed resident #1 (R1), R1 stated that staff do not take action to prevent R7 from verbally or physically assaulting other residents. R1 stated that R7 has assaulted R1 and that R7 has threatened to hurt other residents. R1 stated that R7 has hit R1 with close fist on the face. However, R1 later stated that R7 didn’t hurt bad but would strike using his knuckles closed fist. Interview with R7 revealed that R7 denied assaulting R1. Staff did not intervene since there was no incident between R1 and R7. Interview with five (5) out of six (6) staff revealed that staff are not aware of any residents assaulting other residents in care. One (1) out of six (6) staff stated to be aware of a resident attempting to assault another resident. Staff intervened, reported the incident to local law enforcement and the resident is no longer residing at the facility, after said incident. Staff interviewed described R7 as being calm and as peacekeepers when conflicts between residents arise. Staff stated that R7 personality is loud, but staff are not aware of R7 assaulting any facility residents. S1 indicated that staff re-direct residents before any conversation may escalate to assault. Staff separates residents and discusses with residents the matter that caused the residents’ disagreement. S1 stated that no resident has touched or put a finger on other residents at the facility. The investigation did not reveal that residents are assaulting other residents and revealed that staff take action to prevent residents from assaulting other residents. Based upon the investigation, resident and staff interviews, document review, and LPA observations, there is no evidence to support the allegation that staff is not preventing residents from assaulting other residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held with Administrator Gregory Restum. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 18, 2026 · control 28-AS-20251223110449

Allegation investigated: Staff did not intervene when a resident threatened another resident. Staff retaliate against resident for filing a complaint

On 05/12/26, Licensing Programming Analyst (LPA) Jewel Baptiste conducted a complaint visit to the facility listed above. Upon arrival, LPA met with Roxana Aparicio (Supervisor), who contacted Gregory Restum (Administrator), and LPA Baptiste explained the purpose of the visit via phone. During the visit, LPA obtained the resident roster, staff roster, two (2) incident reports dated 5/1/2026 and 5/3/2026, physician reports for R1 and R2, Admissions agreements for R1 and R2, R1 and R2 house rules, and R2 Face Sheet. LPA toured the facility with the supervisor, reviewed R1 and R2 files, and the plan of operation. LPA interviewed the administrator and four (4) staff members, who shall be referred to as Staff #1 through Staff #4 (S1-S4). LPA attempted to interview S5 and S6. LPA also interviewed a total of 5 residents, who shall be referred to as residents #2 through #6 (R2-R6). R1 was interviewed prior to the visit. LPA Luis De Leon was present for part of an incident involving R1 and R2. Report Continued on 9099C Unsubstantiated The investigation reveals the following: Regarding "Staff did not intervene when a resident threatened another resident," it is alleged that the facility allowed R2 to threaten R1 in the presence of staff. The administrator and all staff denied the allegation, stating they have never witnessed residents threatening each other. They further stated that, when they were present, R1 was the instigator and that there was no knife. According to the administrator, R1 called the police, and the case was dropped. R1 stated that R2 verbally threatened them and also threatened them with a knife. R2 denied the allegation, stating that R1 has been picking on staff and other residents. R2 further stated that R1 likes to touch them in an uncomfortable manner and that they told R1 to stop. R2 also denied having a knife. The other four (4) residents stated that they either did not know R1 and R2 or had not seen the residents threaten each other. They also stated that if residents were threatening each other, they believed that staff would intervene. R3 stated that in the past, their ex-roommate was threatening, and staff intervened; they no longer reside at the facility. The investigation reveals the following: Regarding "Staff retaliates against residents for filing a complaint," it is alleged that the facility is using R2 as an enforcer to retaliate against anyone who complains to keep other residents compliant and discourage them from complaining. The Administrator and all staff denied the allegation. They further stated that the former employee, whom R1 believes was fired due to a prior complaint, was not fired but retired of their own accord. They further denied any biological relationship between the former staff and S1. R1 stated they believe staff is allowing R2 to retaliate against them because of a complaint they made that led to the firing of a former staff member. R2 denied the allegation, stating the facility has never told them to threaten other residents. R2 further stated they do not work for the facility. 4 of the 6 residents stated they had not heard R2 threaten other residents, nor had they been threatened by R2. Based on LPA observations, interviews, and file review, the preponderance-of-the-evidence standard has not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. Exit Interview Conducted with the Superviser Roxana Aparico/ A Copy of the Report Issued.the state’s words, verbatim · CDSS document, May 12, 2026 · control 28-AS-20260504092247

Allegation investigated: Staff does not ensure the facility is kept free of pests Licensee does not ensure all the staff can adequately communicate with residents Staff don't ensure residents room is kept clean and sanitary at all times Staff do not ensure residents receive their mail correspondence

***This is an ammended report of original report dated 3/10/2026. The reason it is being ammended is to remove confidential information from the original report.*** Licensing Program Analyst (LPA) Erik Zaragoza conducted an initial unannounced complaint visit to address the allegations listed above. LPA met with Roxanne Aparicio, supervisor for the facility, and explained the purpose of the visit. Administrator Gregory Restum was notified of the visit by phone call. The investigation consisted of the following: LPA obtained a copy of the staff and resident rosters, conducted a tour of the facility including resident bedrooms, interviewed Residents #1 - 7 (R1 - R7), Staff #1 - 5 (S1 - S5), and also obtained the physician's report and appraisal of R1. The investigation revealed the following: In regards to the allegation that "Staff does not ensure the facility is kept free of pests," it is alleged that bed bugs, roaches, and spiders have been present inside the resident bedrooms and that staff are not addressing the issue. Unsubstantiated Based on interviews with the residents, five (5) out of seven (7) did not corroborate the allegation. One of the residents interviewed stated that there have been bedbugs and roaches present in their room in the past, however the staff are treating them with a pest control company. Another resident interviewed stated that they have not had any problems with bedbugs or other pests in their room. During interviews with the staff, none of them corroborated the allegation. One staff interviewed stated that they do receive services from a pest control company to treat and prevent bedbugs. Another staff member interviewed also stated that pest control frequently come to perform treatment for bedbugs and roaches. During record review of the last invoice from the facility's pest control company dated 3/5/2026, it is detailed that all rooms were treated for bedbugs. In regards to the allegation that "Licensee does not ensure all the staff can adequately communicate with residents," it is alleged that S6 has difficulty communicating with residents by speaking too quickly and in Spanish. During interviews with the residents, five (5) out of seven (7) did not corroborate the allegation. One of the residents interviewed stated that S6 does their best to assist residents to the best of their ability despite a language barrier. Another resident stated that all staff communicate with them effectively and treat them with dignity and respect. During interviews with the staff, none of them corroborated the allegation. One of the staff interviewed stated that S6 does not have bad communication with the residents and is able to assist them with their daily needs. Another staff interviewed also stated S6 communicates effectively with the residents of the home. All staff present during the visit were capable of speaking English and did not have difficulties communicating with the residents. In regards to the allegation that "Staff don't ensure residents room is kept clean and sanitary at all times," it is alleged that staff are not cleaning resident bedrooms and are allowing trash to accumulate in their bedrooms. During interviews with the residents, six (6) out of seven (7) did not corroborate the allegation. One resident interviewed stated that staff clean their room all the time and they never leave it dirty. Another resident interviewed stated that their room is cleaned twice per day and this is not an issue. During interviews with the staff, none of them corroborated the allegation. One of the staff interviewed stated that staff do ensure that they clean resident bedrooms and do not refuse to clean any resident room. Another staff member also stated that staff ensure to clean resident rooms multiple times per day. During a tour of the resident bedrooms, LPA observed that all rooms were cleaned and there was no trash overflowing in any of the resident bedrooms. In regards to the allegation that "Staff do not ensure residents receive their mail correspondence," it is alleged that staff are opening residents mail before deliver it to them and also deliberately refusing to provide residents their mail. Based on interviews with the residents, six (6) out of seven (7) did not corroborate the allegation. One resident interviewed stated that this never occurs and they always receive their mail unopened. Another resident also stated they have not had any issues with having their mail opened by staff. During interviews with the staff, none of them corroborated the allegation. One staff interviewed stated that the mail box is locked so that only the owner of the facility can open it, and once it is opened they distribute all mail to residents unopened. Another staff member stated that they do not open the residents' mail and always hand it directly to the residents after they receive it. LPA observed the mailbox for the facility locked at the time of the visit. Based on statements and interviews conducted with staff/residents, review of facility file records, and LPA's observations, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided. During interviews with the residents, three (3) out of seven (7) corroborated the allegation. All three (3) residents interviewed who require insulin stated that staff have assisted them with their insulin injections. One of the residents stated that the majority of the time staff inject their insulin for them, and that they believe they are doing it effectively. During interviews with the staff, four (4) out of five (5) corroborated the allegation. One of the caregivers interviewed stated that they assist some residents with their insulin injections directly, and that they are not a registered nurse or licensed vocational nurse. Another caregiver interviewed also corroborated that they assist residents by administering their insulin injections. According to Title 22 regulations, residents of residential care facilities for the elderly (RCFEs) must either administer insulin themselves, or must be assisted by an appropriately skilled professional. Based on LPAs observations and interviews which were conducted , the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 is being cited on the attached LIC9099D. Exit interview held, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 28-AS-20260302154316

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87629(a) · Plan of correction due date: Mar 11, 2026

(a) The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. This regulation is not met as evidenced by: Based on interviews, LPA determined that the facility did not meet the above requirement in three (3) out of twenty-two (22) residents, as staff and resident interviews revealed caregivers are assisting R1, R2, and R3 with insulin injections, which poses an immediate health and safety risk to residents.the state’s words, verbatim · CDSS document, Mar 10, 2026

Plan of correction: Licensee/Administrator is to ensure that insulin injections are performed either by the residents themselves or a an appropriately skilled professional at all times. Administrator is to submit the facility's plan to LPA by email on how this requirement will be met by the POC due date.

Type of visit: Required - 1 Year

License Program Analysts (LPA) Luis De Leon conducted an unannounced annual required visit. LPA met with Supervisor Roxana Aparicio. Administrator Gregory Restum was informed via phone about today’s visit; Administrator joined visit some time after. The purpose of today’s visit was explained to supervisor Roxana Aparicio. The facility is licensed to serve 22 residents over the age of 60, of which (12) may be non-ambulatory of which 12 can be bedridden on the 1st floor only, with a hospice waiver approved for 12 residents. The LPA use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. The visit consisted of the following: FACILITY PHYSICAL PLANT The facility is in a commercial area and is made up of a two-story building. The facility consists of the following: first floor has 10 bedrooms, 3 bathrooms, 2 closets, office space, and the kitchen; second floor has 6 bedrooms and 2 bathrooms, a front yard, a back yard, parking, and a laundry in the basement. The facility has a shaded area for residents to enjoy. There is not body of water on property. REVIEW OF FILES Client record review consisted of Admission Agreements, Identification and Emergency Info, Physicians Report, Consent Report, Needs and Service Plan, Personal Rights, Hospice care plan, and Centrally Store Medication. Staff record review consisted of Personnel Report, Health Screening, Criminal Record Statements, Fingerprint Clearance, Training, First Aid and CPR. Operation plan, disaster and emergency plan, and infection control plan. (Report continues on page LIC-809C...) Observations during facility tour: Bedrooms were furnished with a bedframe, dresser, lamps, and chairs. LPA observed that there was clean linen, bath towels, and personal hygiene with reasonable closet space available for residents. Wall and floors are in good repair. Hallways were clean and free of obstructions. Kitchen appliances were in working order and clean. There is sufficient two (2) days of perishables and seven (7) day supply of non-perishable food. Dining room has sufficient seating area. Weekly food menu is posted at facility. Toilets, showers, and water faucets are found in compliance with Title 22 regulations for temperature and function. Restrooms were stocked and clean. The water temperature was tested and measured. The temperature in five (5) bathrooms were not in compliance with Title 22 regulations between 105º and 120º F degrees. The bathrooms measure in the range of 129-153 degrees F. A deficiency is noted. Sharps are locked inside the kitchen room and inaccessible to residents. Also, disinfectants and cleaning supplies are locked and secured inaccessible to residents. Smoke detectors were observed in all bedrooms and carbon monoxide detectors were observed in hallway area. Five (5) fire extinguishers were observed and were fully charged with last inspection on March 2025. Last fire drill and earthquake drill were conducted on 01/19/2026. The medications are centrally stored and locked in the staff room. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all five (5) residents. LPA observed that four (4) out of five (5) resident medication was not properly recorded for residents R1-R3, and R5. Medication was observed that appear that had not been administered or pills on packages did not match the MAR records. Interviews with staff were not able to provide proof of destruction of missing pills or extra pills were missed or refused by residents. Staff stated that medication was distributed, but not properly documented. A deficiency is noted. LPA conducted interviews with three staff and three residents. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC-809D page. Exit interview was held and copies of reports LIC-809, LIC-809C, LIC 809D, and Appeal Rights were discussed and provided to Administrator Gregory Restum.the state’s words, verbatim · CDSS document, Mar 9, 2026

Allegation investigated: Facility is in disrepair.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegations. LPA met with Assistant Administrator Darolyn Azevedo and explained the purpose of today's visit. The investigation consisted of the following: LPA obtained copies of Staff and Residnt Rosters, copies of pest control contract and most recent service date invoices, LPA toured facility, interviewed 4 Staff (S1-S4) and 5 Residents (R1-R5). (Continued on LIC9099-C) Substantiated The investigation revealed the following: Allegation: Licensee did not ensure that facility is free of pests. It is alleged that there were cockroaches observed at the facility. LPA toured facility, a total of 8 resident bedrooms, 4 restrooms, kitchen and dining area was toured and LPA did not observe any signs of roaches. Interviews with 4 staff denied the allegation, each stated they haven’t seen any roaches and confirmed that there is a pest control treatment done weekly. LPA interviewed 5 residents and each stated they haven’t seen any roaches but do notice the facility being sprayed/fumigated often. LPA obtained copies of pest control contract and most recent visits, contract was created 7/21/21 and indicated that both interior and exterior perimeter, common areas, planters, trash and all entry points would be treated monthly, upon reviewing the invoices, it appears that this service is now weekly with most recent visits dated 3/4/26, 2/18/26, 2/4/26, 1/28/26, 1/21/26,1/14/26, 1/7/26, there were no indications of roach activity on these invoices, only the routine treatments. Allegation: Facility is unsanitary. It is alleged that there is grease and food debris on the countertops and there is accumulation of trash in the bathrooms. LPA toured facility, kitchen was inspected, staff were cleaning the kitchen, there were no signs of grease or food debris on the countertops, there is a door that blocks access to the kitchen and staff stated residents do not enter the kitchen area. LPA inspected client room and bathrooms there was no observations of accumulated trash. LPA interviewed 4 staff and each denied the allegation and stated that the trash is taken out at least two times daily. LPA interviewed 5 residents and each denied the allegation, residents each stated their trash is taken out twice daily and have never seen accumulation of trash in the bathrooms. Based on statements and interviews conducted with staff/residents, review of facility file records, and LPA's observations, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided. The investigation revealed the following: Allegation: Facility is in disrepair. It is alleged that there are multiple window screens missing and laundry room window is in disrepair. LPA toured facility and observe window screens missing in dining area, the following resident bedrooms were missing window screens: room #’s 8, 9/10, and 17/18. Interview with S1 confirmed that they are repairing window screens as there was a visit by the housing department where this was mentioned, S1 took immediate action and is currently making all the necessary repairs. Based on LPAs observations and interviews which were conducted , the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC9099D. Exit interview held, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 6, 2026 · control 28-AS-20260228121123

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(c) · Plan of correction due date: Mar 20, 2026

87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair. This requirement was not met as evidence by: During tour LPA observed multiple window screens missing throughout the facility, specifially in dining room and the following resident bedrooms: room #’s 8, 9/10, and 17/18.the state’s words, verbatim · CDSS document, Mar 6, 2026

Plan of correction: Licensee/Administrator to ensure all windows have window screens and add window screens to the areas mentioned in report. Photos of the windows with screens shall be emailed to LPA by POC due date. tena.herrera@dss.ca.gov

Type of visit: Required - 1 Year

Licensing Program Analyst’s (LPA’s) Christian Gutierrez and Gaby Castro conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA’s met Caregiver Yerele Fuentes at approximately 8:30 AM and explained reason for visit. Administrator Gregory Restum was notified by telephone. The facility is licensed to serve 22 residents over the age of 60, of which (12) may be non-ambulatory and/or 12 may be bedridden on the 1st floor only, with a hospice waiver approved for 12 residents. The home is a two-story building located in residential/commercial area and consist of the following: first floor has 10 bedrooms, 3 bathrooms, 2 closets, office space, and the kitchen; second floor has 6 bedrooms and 2 bathrooms, a front yard, a back yard, parking, and a laundry in the basement. LPA’s observed random resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. Resident bathrooms and shower rooms are equipped with required grab bars and non-skid mats. The hot water temperature in the bathrooms were not measured between the required range of 105-120 degrees F. downstairs bathroom #1 140 degrees, bathroom #2 127.2 degrees, and upstairs bathroom #1 68.1 degrees. The facility has a commercial kitchen. LPA's observed the floors to be dirty. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Fire extinguishers were observed throughout, with current inspections and were fully charged. Cleaning supplies/toxins were observed to be accessible to residents in care in downstairs laundry room. The carbon monoxide devices both upstairs and downstairs did not work. Auditory devices on two doors did not work. The facility is equipped with surveillance cameras in common areas. The facility does not have any swimming pools or large bodies of water. There is a shaded seating area for the residents outside. Passageways and exits are free of obstruction. SEE LIC 809c Five (5) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Five (5) residents files were reviewed and included physicians report, TB clearance, and appraisal needs and service plan. Last fire/earthquake drill was conducted in April of 2025. Infectious control plan was reviewed. Two (2) staff and four (4) residents were interviewed. Random resident medications were reviewed. Medications are centrally stored and locked MAR log is used. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 25, 2025

Allegation investigated: Licensee is preventing resident from seeing a doctor of their choice Staff are not adequately trained Staff did not keep the facility free of cockroaches Staff did not keep the facility free of bedbugs Staff exposed residents to chemicals that are hazardou

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Supervisor Roxana Aparicio and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 02/27/2025, LPA interviewed Staff #1 - Staff #5, Resident #1- Resident #5.LPA obtained copies of the following documents: Staff roster, Resident roster, CPR/FIRST AID for S1-S5, R1’s LIC 601 Identification and emergency information, appraisal information, and Physicians reports. LPA toured the facility and obtained copies of invoices for rodent and pest services. During today’s visit LPA Gutierrez delivered findings. SEE 9099C Unsubstantiated In regard to the allegation “Licensee is preventing resident from seeing a doctor of their choice”, it is alleged that staff is forcing residents to be seen by the facility house doctor. During interviews with staff five (5) out of five (5) staff stated that all residents had a choice of to what doctor residents want to see. S2 states they have residents that see their own doctors. During interviews with residents four (4) out of five (5) residents stated they can pick their own doctors. R1 stated he/she has their own doctor and does not see house doctor. In regard to the allegation “Staff are not adequately trained”, It is alleged that a resident was choking, and staff did not know how to perform the Heimlich maneuver. During interviews with staff five (5) out of five (5) staff stated that all employees are CPR/FIRST AID trained and that they have never witnessed a resident preforming Heimlich on another resident. LPA obtained copies of CPR training for five (5) staff members. During interviews with residents four (4) out of five (5) residents felt staff is properly trained. In regard to the allegation “Staff did not keep the facility free of cockroaches and Staff did not keep the facility free of bedbugs”, it is alleged that facility has cockroaches and bedbugs. During interviews with staff four (4) out of five (5) stated they are aware of the bed bug/cockroach problem, but the facility has been addressing the issues with rodent and pest services monthly for the last six months. LPA obtained all invoices for last six months. During interviews with residents five (5) out of five (5) all confirmed that they spray the facility every month. In regard to the allegation “Staff exposed residents to chemicals that are hazardous”, it is alleged that when the exterminator comes to spray residents are moved to another room that had just been sprayed. During interviews with staff five (5) out of five (5) stated that residents need to go outside on the patio area or in the dining room that was treated hours before. Staff stated some residents are mad because they want to go back to their bedrooms right away. During interviews with residents three (3) out of five (5) residents don’t feel that that they are being exposed to hazardous chemicals. R2 stated that he/she had only been at facility for a month and was unaware of spraying. R1 stated that it made no sense to not let them back in to their bedrooms. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Supervisor Roxana Aparicio.the state’s words, verbatim · CDSS document, Mar 1, 2025 · control 28-AS-20250226130647

Allegation investigated: Staff member physically assaulted resident which resulted in an injury

Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegation. On today's visit, LPA met with Assistant Administrator, Darolyn Azevedo who assisted with the visit. Regarding the allegation that : Staff member physically assaulted resident which resulted in an injury. The investigation consisted of interview(s) with Staff #1 - Staff #3, and resident #1 - resident #4. LPA also reviewed resident #5's file. The investigation revealed that former resident, (resident #5) alleged that staff #4 hit her. Staff interviewed stated that resident #5 made this allegation sometime in December of 2023. Three out of three staff interviewed denied that they have observed any staff assault any residents in care. Staff interviewed stated that the facility conducted an internal investigation, and staff #4 denied the allegation. Staff interviewed stated that there were no witnesses to resident #5's allegation. Staff #4 is no longer working at the facility, therefore LPA was unable to interview Staff #4. Unsubstantiated Resident #5 is no longer living at the facility, and was not interviewed. Residents interviewed were unable to corroborate the allegation. Resident #1 - Resident #4 stated that they have not observed any staff assault any residents in care. 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. Exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 8, 2024 · control 28-AS-20240606093952

Allegation investigated: Staff are not accepting resident back after hospital stay.

Licensing Program Analyst (LPA) Tao conducted an unannounced complaint investigation for the allegation listed above. LPA met with Darolyn Azevedo, administrative assistant and explained the purpose of today's complaint investigation visit. The investigation consisted of the following: during the investigation visit, LPA obtained staff/resident roster, reviewed/obtained resident#1’s (R1) records, interviewed residents from resident#2 (R2) to resident#6 (R6), attempted but unable to reach resident#1 (R1) for interview, interviewed staff from staff#1 (S1) to staff #6 (S6), and conducted a physical plant. The investigation revealed the following: In regard of allegation, staff are not accepting resident back after hospital stay, it was alleged that the facility did not take resident back after the hospital stay. (-continued in LIC9099C-) Unsubstantiated LPA interviewed residents, five (5) out of five (5) residents stated residents could not corroborate the allegation. Resident interviews revealed the facility would take residents back from hospital stay. All six (6) staff interviewed denied the allegation. Staff interviews revealed staff would take residents back when residents were discharged from hospitals. It was resident#1's (R1) own will of not returning to the facility. Resident had admitted to another facility. Per record review, resident’s records indicated resident did not want to return to the facility by resident's own will. Thus, staff did not fail to accept resident back after hospital stay. Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Darolyn Administrator assistant and findings were discussed. A copy this report was provided to Administrator at time of visit.the state’s words, verbatim · CDSS document, Jun 18, 2024 · control 28-AS-20240611142720

Type of visit: Required - 1 Year

Licensing Program Analyst(LPA) Sanjay Vaid conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Roxana Aparicio supervisor/caregiver and explained the reason for the visit. D'arolyn Acevedo administrative assistant, arrived 10 minutes later. The facility is licensed to serve 22 residents over the age of 60, of which (12) may be non-ambulatory and/or 12 may be bedridden on the 1st floor only, with a hospice waiver approved for 12 residents. The home is a two story building located in residential/commercial area and consist of the following: first floor has 10 bedrooms, 3 bathrooms, 2 closets, office space, and the kitchen; second floor has 8 bedrooms and 2 bathrooms, a front yard, a back yard, parking, and a laundry in the basement. LPA conducted a tour with Roxana Aparicio and observed the following: Kitchen consists of a commercial stove/grill, sink, a pantry, refrigerator, and freezer inaccessible to the residents. LPA observed sufficient food. Kitchen and pantry floors were observed clean during the visit. Each bathroom was observed with skid mats and grab bars and water temperature was tested as follow; bathroom #1(B1) tested at 115.7 degrees F., bathroom #2(B2) tested at 107.9 degrees F., bathroom #3(B3) tested at 109.4 degrees F., bathroom #4(B4) tested at 110.2 degrees F., and bathroom #5(B5) tested at 112.7 degrees F., which is within the required 105-120 degrees F. LPA observed 6 resident rooms (room #4, #7, #14, #18, #20 and #22) and observed required furniture, bedding supplies, and sufficient lighting. Resident in room #1 and #10 was observed to have full bed rails and has a hospice plan and bed rail request on file. Front and back yard have shaded sitting area. No large bodies of water were observed. LPA reviewed medication and files for 6 residents and 4 staff files. Fire drill is done quarterly. Facility has fire sprinkler system and smoke/carbon monoxide detectors throughout. Fire extinguishers were observed and last checked in Jan 2024 and are fully charged. No deficiencies were noted on today’s annual inspection. Exit interview was conducted with Roxanne Aparicio and a copy of this report.the state’s words, verbatim · CDSS document, Apr 11, 2024

Allegation investigated: Staff caused a resident to fall while in care

Licensing Program Analysts (LPA's) Angelica Rea and Christian Gutierrez conducted an unnannounced visit. LPA's met with supervisor caregiver, Roxanne Aparicio, who assisted with today's visit. The reason for the visit is to correct the date from 2/21/24 to 2/22/24 and that the findings and all other information remain the same. Regarding the allegation that Staff #1 caused resident #1 to fall while in care. An initial visit was conducted on 6/29/22. The investigation consisted of Interview(s) with Administrator, Staff #1 - Staff #4, and Resident #1 - Resident #5. Administrator and staff interviewed stated that they were not aware of the incident. Residents interviewed were not able to corroborate the allegation. Resident #1 denied that Staff #1 caused her to fall. 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. Unsubstantiated Resident #1 stated that she was not dressed at the time of the incident. Residents interviewed corroborated the allegation(s). Resident #2 stated that he did assist resident #1 on 6/21/22. Resident #3 stated that he witnessed the incident. Resident #4 and Resident #5 were not aware of the incident. Staff interviewed stated that they were not present at the time of the incident, and did not know if it happened. Regarding the allegation that : Staff did not seek timely medical attention for a resident, Resident #1 stated that she did not receive medical attention following the incident. Resident #1 stated that staff #1 stated that resident did not need medical assistance. Staff interviewed stated that they were not present at the time of the incident, or stated that they were not aware of the incident occurring. Staff #1 stated that she did not recall the incident. Residents interviewed were able to corroborate the allegation. Three out of five residents interviewed stated that resident #1 did not receive medical attention after the fall. Regarding the allegation that : Facility did not report the incident to Community Care Licensing as required. LPA observed that the facility did not have an incident report regarding the incident that occurred on 6/21/22, and did not send a report to Community Care Licensing as required. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 7, 2024 · control 28-AS-20220623160200

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Mar 8, 2024

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 is not being met as evidenced by: LPA learned that resident #1 was assisted by resident #2 in the bathroom while resident #1 was not dressed.the state’s words, verbatim · CDSS document, Mar 7, 2024

Plan of correction: Administrator will ensure that Title 22 regulations are being adhered to, and will ensure that residents personal rights are not being violated. Administrator will conduct an in service training with all staff on resident personal rights and will send proof of staff training to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 8, 2024

a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental car This requirement is not being met as evidenced by: LPA learned that resident #1 was not sent out to be medically assessed after falling on 6/21/22.the state’s words, verbatim · CDSS document, Mar 7, 2024

Plan of correction: Administrator will ensure that Title 22 regulations are being adhered to, and will ensure that residents who require a medical assessment receive it as required. Administrator will send LPA facility plan on incidental medical and dental care, and proof of staff training on plan by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Mar 8, 2024

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) 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 report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not being met as evidenced by : LPA observed that facility did not submit a special incident report for resident #1's fall on 6/21/22.the state’s words, verbatim · CDSS document, Mar 7, 2024

Plan of correction: Administrator will ensure that Title 22 regulations are being adhered to as required. Administrator will conduct an inservice training with all staff on reporting requirements and will send proof of training to LPA by POC due date.

Allegation investigated: Staff caused a resident to fall while in care

Licensing Program Analysts (LPAs) Angelica Rea and Sanjay Vaid conducted another visit to deliver the final results of the investigation. LPAs met with supervisor caregiver, Roxanne Aparicio, who assisted with today's visit. Regarding the allegation that Staff #1 caused resident #1 to fall while in care. An initital visit was conducted on 6/29/22. The investigation consisted of Interview(s) with Administrator, Staff #1 - Staff #4, and Resident #1 - Resident #5. Administrator and staff interviewed stated that they were not aware of the incident. Residents interviewed were not able to corroborate the allegation. Resident #1 denied that Staff #1 caused her to fall. 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. Unsubstantiated Resident #1 stated that she was not dressed at the time of the incident. Residents interviewed corroborated the allegation(s). Resident #2 stated that he did assist resident #1 on 6/21/22. Resident #3 stated that he witnessed the incident. Resident #4 and Resident #5 were not aware of the incident. Staff interviewed stated that they were not present at the time of the incident, and did not know if it happened. Regarding the allegation that : Staff did not seek timely medical attention for a resident, Resident #1 stated that she did not receive medical attention following the incident. Resident #1 stated that staff #1 stated that resident did not need medical assistance. Staff interviewed stated that they were not present at the time of the incident, or stated that they were not aware of the incident occurring. Staff #1 stated that she did not recall the incident. Residents interviewed were able to corroborate the allegation. Three out of five residents interviewed stated that resident #1 did not receive medical attention after the fall. Regarding the allegation that : Facility did not report the incident to Community Care Licensing as required. LPA observed that the facility did not have an incident report regarding the incident that occurred on 6/21/22, and did not send a report to Community Care Licensing as required. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 21, 2024 · control 28-AS-20220623160200

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Mar 1, 2024

(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 is not being met as evidenced by: LPA learned that resident #1 was assisted by resident #2 in the bathroom while resident #1 was not dressed.the state’s words, verbatim · CDSS document, Feb 21, 2024

Plan of correction: Administrator will ensure that Title 22 regulations are being adhered to, and will ensure that residents personal rights are not being violated. Administrator will conduct an in service training with all staff on resident personal rights and will send proof of staff training to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 1, 2024

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not being met as evidenced by: LPA learned that resident #1 was not sent out to be medically assessed after falling on 6/21/22.the state’s words, verbatim · CDSS document, Feb 21, 2024

Plan of correction: Administrator will ensure that Title 22 regulations are being adhered to, and will ensure that residents who require a medical assessment receive it as required. Administrator will send LPA facility plan on incidental medical and dental care, and proof of staff training on plan by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Feb 23, 2024

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) 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 report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not being met as evidenced by : LPA observed that facility did not submit a special incident report for resident #1's fall on 6/21/22.the state’s words, verbatim · CDSS document, Feb 21, 2024

Plan of correction: Administrator will ensure that Title 22 regulations are being adhered to as required. Administrator will conduct an inservice training with all staff on reporting requirements and will send proof of training to LPA by POC due date.

Allegation investigated: Resident was sexually assaulted while in care. Residents are being mentally and physically abused by staff. Residents needs are not being met by the facility.

Licensing Program Analyst (LPA) Galarza conducted a subsequent visit to deliver findings on the investigation conducted by DSS Investigation Branch (IB) Investigator Laura Garcia. LPA explained the purpose of the visit to Supervisor Roxana Aparicio. The investigation consisted of: On 9/28/22, LPA Galarza conducted a physical plant tour of the facility, obtained file documents, and reviewed staff and resident files. Staff (S1)/Administrator and staff (S5 & S6) were interviewed. Copies of resident (R1-R3) and staff (S2- S3) file documents were obtained, as well as LIC 500 Personnel Report, Register of Facility Clients/Residents, incident reports, and a list of staff phone numbers. IB investigator interviewed staff (S1-S4) and residents (R2-R3), and conducted a law enforcement inquiry. LPA inter During today's visit, LPA conducted a physical plant tour and interviewed non-ambulatory residents R4- R6. ***Narrative continues next page.***** Unsubstantiated Allegation: Resident was sexually assaulted while in care. It is alleged that resident (R1) was raped at the facility by an unknown perpetrator. Investigations Branch (IB) investigator L. Garcia conducted the investigation. Resident (R1) only resided at the facility a total of four (4) days [6/10/22 - 6/14/22], and there were no complaints reported to staff of alleged sexual abuse. A total of six (6) staff were interviewed, of which all denied having knowledge of alleged rape/alleged sexual abuse of resident (s). Staff revealed that there are some residents that are intimate with each other and in a relationship. It is assumed their relationship is consensual because no reports of rape or sexual abuse have been report. Per file review, R1 has history of schizophrenia and paranoia. Staff (S3) stated that on one occasion they witnessed resident (R1) saying that a man was behind trying to kill the resident, but there was no one around. Resident (R1) was not interviewed because they moved out, and after several attempts to contact R1, and interview was not possible. IB investigator interviewed residents (R2 & R3); both denied sexual abuse or knowledge of sexual abuse incidents. A law enforcement search inquiry was made, however, no relevant information or current address location was obtained for resident (R1). Based on interviews conducted and record review, the findings indicate that there is insufficient evidence to corroborate the allegation. Allegation: Residents are being mentally and physically abused by staff. It is alleged that staff hit residents and are verbally abusive to residents. It was reported that in the past one (1) staff (S7) fought with a resident (unknown name) with their fist. It is also alleged that supervisor/staff (S3) has been overheard calling resident(s) "bitch". It was also reported that a night shift staff (S8) accidentally dropped resident (R2), and that supervisor/staff (S3) and S8 told R2 to say they were hit and not dropped. Three (3) staff, [staff S2, S3, and S7] were reported to be verbally and physically abusive to residents. Staff (S2 & S3) denied the witnessing or engaging in abuse. Administrator/staff (S1) stated that two (2) staff were fired the week prior to this complaint being filed, and they told Administrator they were going to file a complaint. A copy of Employee Disciplinary Action Form was provided to investigator, stating that staff (5) was fired due to threats and harassment of residents. A total of two (2) residents were interviewed, both R2 & R3 stated that they have not been victims of mental or physical abuse. Resident (R2) denied sustaining injuries from either neglect or abuse by any of the staff members, and also denied ever witnessing any type of abuse by any of the staff or residents or hearing any rumors of abuse. One (1) out of six (6) staff interviewed stated that staff are verbally and physically abuse. However, there is insufficient evidence to prove the allegation. *See next page. Allegation: Residents needs are not being met by the facility. It is alleged that residents are not being provided feeding assistance, receiving incontinence care as directed, staff do not wash the resident's clothes, and are not being provided transfer assistance into their wheelchairs. A total of six (6) staff were interviewed, of which all denied neglect of care and supervision. According to staff, non-ambulatory residents are assisted with incontinence care, bathing, and basic needs. A total of six (6) residents were interviewed. Resident interviews revealed that staff assist with Activities of Daily Living (ADL's) as required, and that they are satisfied with the level of care provided by staff. Based on interviews conducted and record(s) review, there was insufficient evidence to prove the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted with Roxana Aparicio. *Only the 1st page of the report was printed. There were printing technical issues. The entire report will be emailed & mailed.the state’s words, verbatim · CDSS document, Jan 23, 2024 · control 28-AS-20220927115755

Allegation investigated: Staff are not adequately supervising resident resulting in resident sustaining multiple fractures.

Licensing Program Analyst (LPA) Galarza conducted a subsequent visit to deliver findings on the investigation conducted by DSS Investigation Branch (IB) Investigator Laura Garcia. LPA explained the purpose of the visit to Supervisor Roxana Aparicio. The investigation consisted of: On 9/4/22, LPA Galarza conducted a physical tour of the facility and file review was conducted. No staff or residents were interviewed. Resident (R1's) file documents [Identification and Emergency Information, Admission Agreement, Physician's Report (3/19/2021), incomplete Oceanside Home Health Services, Inc documents (7/27/22), Preplacement Appraisal Information, Resident Appraisal, Centrally Stored Medication Record/Medication Administration Recors (Aug. 2022- Sep. 2022), three (3) incident reports dated 7/8/22, 9/4/22, 9/8/22, Admission Policies, Procedure & Care of Persons with Dementia, LIC 500 Personnel Report, and Register of Facility Residents were obtained. IB investigator obtained medical records, and conducted interviews. ***Narrative continues next page.***** Unsubstantiated Allegation: Staff are not adequately supervising resident resulting in resident sustaining multiple fractures. It is alleged that resident (R1) has had repeated falls at the facility resulting in multiple fractures. Per record review, on June 8, 2022, resident (R1) fell on their face when getting out of bed. The facility called R1's physician and 911. The resident was transported to Good Samaritan Hospital, and was admitted with a nasal fracture. On 9/4/2022, R1 fell as they were trying to get up. The resident was examined that evening by Primary Care Physician, who determined that the resident did not need to go to the hospital. Staff were instructed to monitor the resident. Home health services were already being provided R1 to address General Muscle Weakness. The resident is ambulatory, uses a wheelchair to ambulate around the facility, and does not require one-to-one assist. On 9/8/2022, the resident reported to staff that they were having pain on the side of the body they fell on. Facility staff notified R1's Primary Care Physician, and per MD note it states that staff were informed that the physician would exam the resident that evening, but staff called 911. According to staff interviews, facility protocol is to to immediately send out residents to the hospital for an evaluation when they sustain a fall, or get injured. On 9/8/2022, R1 was admitted to LAC/USC Medical Center with a left hip fracture. Based on interviews conducted, all staff, residents, and 3rd party providers interviewed denied the allegation. Resident (R1's) physician's office stated that the facility has great communication, and appear to be attentive to residents' needs. Based on the above information and documentation provided there is insufficient evidence to corroborate negligence or lack of care on behalf of facility staff. Based on interviews conducted and record(s) review, there was insufficient evidence to prove the allegation. 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. Exit interview was conducted with Roxana Aparicio. A copy of the report will be emailed due to printing issues.the state’s words, verbatim · CDSS document, Jan 16, 2024 · control 28-AS-20220913140148

Allegation investigated: Facility does not have adequate staff to meet the needs of the residents. Facility is in disrepair. Facility staff did not ensure that residents had hot water. Facility staff did not meet resident's diapering needs. Facility staff did not ensure that residents received showers.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Darolyn Azevedo (Administrative Assistant) and explained the reason for the visit. The investigation consisted of the following: On 03/27/23, LPA obtained copies of the resident and staff rosters, interviewed Administrative Assistant, Resident 1 - Resident 3 (R1 - R3) and toured the facility. LPA also obtained copies of estimate documents for roof and bathroom ceiling repair. Today's visit, LPA obtained copies of resident and staff rosters,and interviewed Administrative Assistant, Staff 1 - Staff 3 (S1 - S3), Resident 4 - Resident 7 (R4 - R7) and toured the facility. The investigation revealed the following: regarding the allegation "facility does not have adequate staff to meet the needs of the residents", it is alleged that on 03/18/23 during the night shift, there was a storm flood inside the facility and a staff was working alone and had to clean up the flood while also having to care for the 22 residents. (Continued to LIC 9099-C) Unsubstantiated Review of facility's clock in time sheet, on 03/18/23 there were 2 staff working during the night shift (2pm-10pm) and 1 staff working the graveyard shift (10pm-6am). Per Title 22 Section 87415(a)(3), the following persons providing night supervision from l0:00 p.m. to 6:00 a.m....shall be available as indicated below to assist in caring for residents in the event of an emergency: In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes. Staff 1 (S1) is the supervisor and the staff on call. Administrative Assistant and staff interviewed denied the allegation. They stated there was no flood and that they have adequate staff to meet the residents' needs. Residents interviewed could not corroborate the allegation and stated their needs are being met. Regarding the allegations "facility is in disrepair", "facility staff did not ensure that residents had hot water", and "facility staff did not ensure that residents received showers", it is alleged that the storm caused damage to the water heaters and therefore there was no hot water for the residents to shower for a couple of days (03/18/23 - 03/21/23). Administrative Assistant and staff interviewed denied the allegation. They stated that there was no flood. According to the Administrative Assistant the water heaters were replaced due to wear and tear and not because they were damaged. They replaced them 1 at a time between 03/19/23 and 03/20/23. Residents interviewed could not corroborate the allegations. They expressed no issues with showering or not having hot water during the dates above. During the facility tour on 03/27/23, LPA observed new water heaters and LPA measured the water temperature and it measured within the required 105-120 degrees F. Regarding the allegations "facility staff did not meet resident's diapering needs", it is alleged that a resident obtained an infection due to not having their diaper changed. No information of this resident was provided to the LPA. Administrative Assistant and staff interviewed denied the allegation. They stated that there was no resident that got an infection. Residents interviewed could not corroborate the allegation. The residents that get assistance with diaper change expressed no issues. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Nov 2, 2023 · control 28-AS-20230322120637