Queens Home 3

Allegation investigated: Staff verbally abused a resident while in care Staff denied a resident from eating while in care Staff did not follow general food service requirements Resident sustained unexplained injuries while in care Staff did not properly report incidents involving a resident

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. The Department received a complaint on March 14 2025 and the initial visit was conducted on March 24th 2025. LPA Mendivil interviewed staff and residents and obtained copies of staff training records and resident physician reports. Regarding the allegations Staff verbally abused a resident while in care, Staff denied a resident from eating while in care, Staff did not follow general food service requirements , Resident sustained unexplained injuries while in care and Staff did not properly report incidents involving a resident the investigation revealed the following: The facility consists of 2 homes sharing lot. The facility capacity is 15 and the current census is 12 residents. Unsubstantiated It was alleged that staff verbally abused resident while in care, per interviews with 6 out of 6 staff stated they have never verbally abused any resident in care. Based on interviews with 6 out of 6 residents interviewed stated no one has yelled at them. The remaining 6 residents were not available for interviews or not oriented to time and space. It was alleged that staff denied a resident eating, per interviews with staff, 6 out of 6 staff stated they have never denied a resident food. Per interviews with 6 out of 12 residents stated they have never been denied food. 6 out of 6 residents interviewed stated the food is good and they have snacks available. It was alleged that staff did not follow general food service requirements, per interview with Administrator Arya stated the facility has designated staff for cooking. LPA interviewed 6 out of 6 staff, staff stated they have never witnessed any issues with sanitation in the kitchen. Per LPA’s observation the kitchens are clean and free of debris and without odors. It was alleged that resident sustained unexplained injuries while in care . Per review of Resident 1 (R1) physician report dated December 22 2024, R1 is diagnosed with dementia and has a history of skin breakdown. No photographs, medical records or documentation could be found to verify the presence of an injury for any resident in care. Interviews with 6 out of 6 staff, staff stated they have not been rough when handling any residents. Per interview with Administrator Arya, AD stated that R1 would rattle their bed rails and would hit against the bed rails. Based on 6 out of 6 residents interviewed, they stated that all the staff is kind and gentle and no one has been aggressive. It was alleged that staff did not properly report incident involving residents. Per review of LIC 624 Unusual Incident/Serious Injury reports facility reported various incidents. Per staff interviewed, incidents were reported to facility Administrator. No further documentation of incidents was obtained to suggest incidents were not being reported as required. Therefore based on the preponderance of evidence through records reviewed, interviews and observations the allegations Staff verbally abused a resident while in care, Staff denied a resident from eating while in care, Staff did not follow general food service requirements , Resident sustained unexplained injuries while in care and Staff did not properly report incidents involving a resident are determined to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies are being cited in today's visit. An exit interview was conducted and a copy of this report was provided. Therefore based on the preponderance of evidence through interviews the allegation that staff left residents unattended is determined to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 19, 2026 · control 22-AS-20250314094920

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a required annual. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. The facility is licensed for 15 non ambulatory residents. The facility has a hospice waiver for 8 residents. The facility is a two-unit one-story house each as unit A and Unit B. Unit A has 4 resident bedrooms, 1 staff bedroom, 2 full bathrooms, a living room, a dining room, and a kitchen. Unit B has 6 resident bedrooms, 1 staff bedroom, 3 full bathrooms, a living room, a dining room, and a kitchen. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors and testing hot water temperature in the bathrooms. The hot water temperature in Unit A measured 114.4 and 115.7 degrees Fahrenheit and all smoke detectors were operational. The water temperature in Unit B measured between 117.9 to 133.5 degrees Farenheit. The facility conducted an emergency drill on June 2025. LPA inspected the facility food supply for both Unit A and Unit B and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed seasonings that were expired in Unit A's kitchen. LPA observed secured medication storage in a secured cabinet for both untis. LPA observed emergency food and water in facility laundry room. LPA observed Resident 9 (R9) had full bed rails without hospice. LPA observed R9 LIC 602 Physician's Report that is out of date. LPA reviewed six out of six staff training and fingerprint records and conducted a complete review of 12 out of 12 residents files. Administrator has a current administrator certificate which expires on 08/24/2027. LPA Mendivil observed staff training to be certificates without times listed for the trainings. LPA observed no trainings for restricted health conditions or postural supports. Based on observations made during today's visit citations are being cited. An exit interview was conducted a copy of this report, LIC 809-D, LIC 858 Resident Records Reviewed, and appeals rights were provided.the state’s words, verbatim · CDSS document, Dec 17, 2025

Allegation investigated: Resident sustained unexplained injuries Staff handled resident in a rough manner The facility did not accurately report resident's injuries

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to deliver findings on the allegations listed above. LPA was greeted and granted entry by staff after an introduction and stating the purpose of the visit. The complaint investigation was initiated by LPA Jerome Haley on April 17, 2024, regarding complaint allegations filed on April 16, 2024. The complaint was investigated by the Department and consisted of the following: a tour of the physical plant, record review (resident & staff), and interviews with facility staff including Licensee/Administrator Kathy Maghbouleh, medical professionals, and a witness. Documents and photos were provided and reviewed including hospice records from Golden Coast Hospice and Palliative Care, and photos of Resident 1’s (R1) injuries. During the investigation 7 of 7 individuals interviewed, including facility staff and medical professionals, Continued on LIC9099C page 1 of 3 Substantiated provided information that supports the complaint allegations. During interviews, Registered Nurse 1 (RN1) confirmed they were notified on April 11, 2024, regarding a small skin tear on the right arm of R1. After responding to the facility, RN1 observed the smaller skin tear to the right arm, and an additional larger skin tear on R1’s left arm. RN1 explained, R1 sustained small skin tears before, but not to the degree of what R1 sustained on April 11, 2024. RN1’s medical opinion is that both skin tears occurred at the same time and were fresh. RN1 stated, it’s reasonable to believe the bruise observed on R1’s forehead was also sustained at the same time of the skin tears. Per information gathered from Licensee – Kathy Maghbouleh (S10), on April 11, 2024, S1 was present in the facility when R1 sustained a small cut to the right arm. According to Licensee Maghbouleh, they helped put a bandage on the smaller cut to R1’s right arm. Licensee Maghbouleh claimed an unidentified caregiver told S1 the skin tear occurred during a transfer. The unidentified caregiver explained to Licensee Maghbouleh, that R1 has no muscle control and can easily lean forward while in the wheelchair and hit their head. Licensee Maghbouleh claims this is probably how R1 sustained the bruise on the forehead. The unidentified caregiver told Licensee Maghbouleh, they did not see the larger cut on the left arm, and suggested, maybe the hospice nurse who responded to the facility caused the cut on the left arm. Per the information gathered from Witness 1 (W1), after R1 sustained unexplained cuts and bruises on April 11, 2024, W1 and Licensee Maghbouleh came to a verbal agreement. Licensee Maghbouleh allowed W1 to place a camera in R1’s room after the resident sustained “unexplained injuries.” Shortly after the camera was placed in the resident’s room, on April 14, 2024, a video was recorded that showed a caregiver handling R1 in an aggressive manner while changing the resident. The video recording of the caregiver (now Former Caregiver 1 – FC1) handling R1 was provided for review. Per information provided by Staff 5 (S5), FC1 was unaware a surveillance camera was installed in R1’s room. FC1 was recorded changing R1’s diaper and flipped R1 like a piece of paper. Licensee Maghbouleh confirmed the verbal agreement with W1 for a camera to be placed in R1’s room after R1 sustained injuries on April 11, 2024; furthermore, S1 (licensee) confirmed FC1 was terminated after the video recording that shows the former caregiver handling R1 in a rough manner. Continued on LIC812C page 2 of 3 During subsequent interviews to clear up discrepancies discovered during the investigation, three facility staff members including Licensee Maghbouleh admitted to providing false statements regarding the details of the fall that occurred on April 11, 2024. Licensee Maghbouleh, S3, and S6, all admitted R1 was found on the floor with a skin tear after being left alone in their wheelchair. Licensee Maghbouleh, S3, and S6, all admitted to providing false statements during previous interviews. It was confirmed, not only were false statements provided to the department during the course of a complaint investigation, but a hospice nurse was falsely accused or "suggested" to be responsible for causing the larger skin tear to R1 when Licensee Maghbouleh, S3, and S6 all knew the statement and/or suggestion that the hospice nurse was responsible for the large skin tear was false. Based on the evidence gathered through interview confirmation, document review, staff’s own admissions, and video review, the preponderance of evidence standard has been met, therefore, all three allegations listed above are found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6. An immediate Civil Penalty is being assessed today in the amount of five hundred dollars ($500). An additional Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f). An exit interview was conducted, and a copy of this report and appeal rights were provided. Page 3 of 3the state’s words, verbatim · CDSS document, Sep 3, 2025 · control 22-AS-20240416145514

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 4, 2025

Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). Health and Safety Code section 1569.2(c) provides: (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with.., or personal care. This requirement was not met as evidenced by: Three staff members including Licensee Maghbouleh, confirmed R1 was left unattended, resulting in the resident falling and sustaining skin tears to both arms and bruising to the forehead. This poses a threat to the health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Administrator Maghbouleh stated the regulation will be reviewed by all Administrators and the Licensee. A signed statement of acknowledgement and understanding will be provided for each Administrator and the Licensee, for a total of four statements of acknowledgement. POC is by 4:00pm on the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Sep 4, 2025

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 met as evidenced by: On April 14, 2024, a caregiver was recorded on video handling R1 in a rough manner. While being changed, R1 was carelessly flipped over by one of the caregivers. Multiple individuals, including Licensee Maghbouleh confirmed the now former caregiver’s actions captured on video. This poses a threat to the health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Administrator Maghbouleh stated the regulation will be reviewed by himself, and all primary caregivers. A signed statement of acknowledgement and understanding will be provided for each primary caregiver.If all staff can not review the regulation with the licensee and sign a statement of acknowledgement and understanding. Licensee will be given no more than three business days to submit all signed statements.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Sep 5, 2025

Reporting Requirements (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. This requirement was not met as evidenced by: The facility failed to accurately report R1’s falls and injuries to R1’s responsible person. The facility also failed to accurately report R1’s fall and injuries to the department. The incident report with no date contains false information and there’s no incident report for R1 from Queens Home 3 in the departments data base for all incident and death reports. This poses a potential threat to the health, safety, and personal rights of residentsthe state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Administrator Maghbouleh stated himself, and the other Administrator(s) and the licensee will read and review the regulation section on Reporting Requirements and send a signed statement of acknowledgement and understanding for each administrator and the licensee. AD Maghbouleh will conduct and in-service training for all staff members on reporting requirements and email the sign in sheet for all staff in attendance, and share with the department who the primary person and a secondary person responsible for sending all incident reports to the department in a timely fashion. POC is due Friday, September 5, 2025, by 1:00pm.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management regarding information discovered during a complaint investigation. While investigating complaint control number 22-AS-20240416145514, it was discovered Licensee Kathy Maghbouleh, and two caregivers all made false statements during the complaint investigation into the complaint control number mentioned above. During the investigation, three staff members including Licensee Kathy Maghbouleh admitted to making false statements during the complaint investigation. As a result of today’s case management visit, a deficiency will be cited. An exit interview was conducted, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 3, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: Sep 4, 2025

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not being met as evidenced by: Three staff members, including AD, admitted to making false claims to the department during the course of a complaint investigation. This a potential threat to the health, safety, and personal rights of residentsthe state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Administrator Maghbouleh stated all administrators, the licensee, and all primary caregivers will read and review regulation section 87207 False Claims. Administrator Maghbouleh stated everyone will sign their statement of acknowledgment and understanding once completed. POC will be emailed to LPA Haley by 4:00pm on the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA Samer Haddadin made an announced visit to the facility for purpose of conducting a required annual inspection. LPA arrived at the facility and was greeted and granted entry by Administrator AD Kathy Maghbouleh. The facility is a two-unit one-story house each as unit A and Unit B. Unit A has 4 resident bedrooms, 1 staff bedroom, 2 full bathrooms, a living room, a dining room, and a kitchen. Unit B has 6 resident bedrooms, 1 staff bedroom, 3 full bathrooms, a living room, a dining room, and a kitchen. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with an exit walkway on one side of the house with 2 covered seating patios for the residents. Facility appears clean, safe, and sanitary. All residents’ rooms had required elements, including bed, chair, closet space, and ample lighting. Facility had extra linens and hygiene supplies for residents in care. Restrooms were stocked with soap and paper towels. Hot water measured at 115.6 degrees Fahrenheit in all bathrooms. LPAs observed the facility had a two-day supply of perishables and a seven-day supply of non-perishable food. LPAs observed hallways and walkways were free of obstruction. LPAs observed the fire extinguisher was charged based on the arrow on the extinguisher's meter pointing into the green zone. The service tag indicates the extinguisher was last serviced on November 27, 2024. LPA tested smoke and carbon monoxide detectors LPAs observed the detectors to be operational. Chemicals and toxins are locked up in the kitchen closet. LPAs noted the facility's knives and sharps are in the kitchen secured and locked. Medication for each resident is kept locked in the staff office as well as staff and residents files. The backyard has one shaded seating area, and the exit gate is unlocked and unobstructed. No bodies of water observed. No deficiencies were noted during today's inspection visit. An exit interview was conducted, and a copy of this report was provided to the facility staff.the state’s words, verbatim · CDSS document, Dec 17, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to follow up on an Incident Report received in our office on October 21, 2024. LPA was greeted and granted entry into the facility by staff at 1 PM and met with Arya Maghbouleh, Administrator and explained the reason for the visit. The purpose of the visit is to investigate the allegation that a caregiver slapped the resident. The facility reported recurring incidents where resident was found on the floor next to the bed. On October 14, 2024 resident reported to staff that a caregiver slapped the resident's forehead after resident was assisted back into the bed that night. Facility Administrator Kathy Maghbouleh and Facility Director Arlene Murray met with resident's conservator regarding the allegation and the Long Term Care Ombudsman also spoke with resident regarding the incident on October 21, 2024. On October 26. 2024 at 8:30 PM resident was found on the floor next to her bed. Physician's orders were written for full bedrails. LPA interviewed two of two staff members who were involved with the incident and explained what occurred on October 14, 2024. At 2:15 PM Resident returned to the facility and was eating lunch when LPA was introduced. LPA interviewed resident at 2:45 PM regarding the incidents that occurred in resident's bedroom. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Arya and Kathy Maghbouleh, Administrators and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Nov 8, 2024

Allegation investigated: Facility did not provide resident records to legal representative.

This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by facility staff. LPA met with Arya , Administrator and explained the nature of the inspection. The department received a complaint on 8/13/2024 stating Facility did not provide resident redcords to legal representative. During the investigation, the department interviewed the Administrator (AD) and staff. On 8/23/2024 LPA conducted a visit to the facility. LPA obtained copies of the staff roster dated May 2024, resident roster dated 7/24/24, HIPAA complaint release letter dated August 8, 2024, FedEx Delivery shipping slip dated August 13, 2024 and electronic copies of all the records the facility has on file for R1 and a forwarded email containing a record request fulfilled by the facility. (continued on LIC9099-C) Substantiated (continued from LIC9099) Based on review of FedEx shipping/delivery labels, LPA determined the HIPAA letter was sent to the facility from R1's legal representative's office on 8/8/24 and that it was delivered to the facility on Saturday, 8/10/24. LPA conducted interviews with one staff (S1), Licensee(L1) and Administrator(AD). AD, and L stated the request was received on 8/13/2024, they communicated with LR's office on 8/14/24 and the request was fulfilled on 8/16/2024. AD, L1 and S1 stated AD and L1 would have been the only staff to open the package sent from R1's legal representative. AD, L1 and S1 also stated, AD and L don't work in the facility over the weekends. LPA reviewed an email sent to R1's legal representative's office. The email was dated 8/16/2024 with a 55-page pdf attachment with the documents requested for R1. LPA determined the facility fulfilled R1's legal representative's request on 8/16/2024. Per Health and Safety Code 1569.269(a) "Residents of residential care facilities for the elderly shall have all of the following rights: (21) To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies." Based on interviews conducted and records reviewed, the facility did not comply with the regulation stated above due to the facility exceeding two business days to fulfill the request. The preponderance of evidence standard has been met. The allegation is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Oct 30, 2024 · control 22-AS-20240813114923

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a) · Plan of correction due date: Oct 31, 2024

1569.269(a) Residents of residential care facilities for the elderly shall have all of the following rights: (21) To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. The licensee did not comply with the section cited above because the investigation revealed, the facility exceeded two days to get the requested documents sent out.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: The facility fulfilled the request on August 16, 2024, therefore the plan of correction has been fulfilled before the time of this visit. LPA provided a clear letter with this deficiency.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at the facility and was greeted and granted entry by staff. LPA met with Kathy Maghbouleh, Director/Administrator. A change of ownership application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (15) capacity, (0) ambulatory, (15) non-ambulatory, and (0) bedridden residents was submitted to CCL on 05/22/2023. Structure: The facility is a two unit one-story house each as unit A and Unit B. Unit A has 4 resident bedrooms, 1 staff bedroom, 2 full bathrooms, a living room, a dining room, and a kitchen. Unit B has 6 resident bedrooms, 1 staff bedroom, 3 full bathrooms, a living room, a dining room, and a kitchen. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with an exit walkway on one side of the house with 2 covered seating patios for the residents. Air/Heating: Central air/heating system installed with a central panel to control entire house in each unit. Bedrooms Residents: Bedrooms will accommodate 15 residents combined in both units. Unit A will accommodate 6 residents with 2 private and 2 shared bedrooms. Unit B will accommodate 9 residents with 3 private and 3 shared bedrooms. Bedrooms Staff: Unit A bedroom #1 designated for awake-staff and unit B bedroom #7 designated for awake-staff. Bathrooms: All bathrooms have a working toilet, wash basin, and walk-in shower. Linens & Hygiene Supplies: Adequate supply of linen stored in bedroom hallway storage in both units. Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Continued on LIC809-C Menus prepared one week prior and listed for food serve for one week. Food Service: Adequate supply of 7-day non-perishable and 2-day perishables are stored in the kitchen. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested, and found operational. Appliances: Unit a has 5 gas burner stove, single oven, 1 refrigerator, microwave, washer, and dryer, unit B has a 4 gas burner stove, single oven, 2 refrigerators, microwave, washer and dryer. All were noted to be clean and operational. Toxins: All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked underneath kitchen sink and locked storage in both units. Water Temperature: Tested and recorded maintained at a comfortable temperature and the water temperature measures 119.8 Fahrenheit degrees in unit A and 108.9 Fahrenheit degrees in unit B in facility bathrooms. Medications, First-Aid Kit & Book: Medication and first aid kit/book are stored and locked in a storage cabinet located in kitchen in both units. Resident & Staff Files: Records will be kept locked in office space in both units. Each unit has an office space. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the resident’s use, commensurate with the plan of operation. Fire clearance: Was approved on August 29, 2023. Component III: Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities. The applicant has met all pre-licensing requirements. LPA will submit notification to CAB in Sacramento for final review prior to license being issued. Exit interview was conducted and a copy of this report was left with the applicant.the state’s words, verbatim · CDSS document, Dec 4, 2023