Roxbury Elderly Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Licensee (LCN) Tingxiu Li. LPA toured the facility inside and out with LCN. License, Administrator Certificate, and personal rights posters were observed in the facility. The facility has no residents yet. The facility is waiting for SARC to vendorize. Living room, kitchen, dining area, 2 restrooms, and garage were inspected. 4 resident bedrooms and a staff room were observed. The temperature of the freezer was observed at 0 degree F, and the temperature of the refrigerator was observed at 36 degree F. Medication closet, knives closet, and chemical closet were observed locked. Room temperature was at 72 degree F, and hot water temperature was at 105 degree F in facility. Fire extinguisher was observed without expiration date, LCN stated it is within one year. LCN stated he/she will buy a new one today. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Carbon monoxide detectors were tested by ADM, and were working. First aid box, night lights, and flash lights were observed in the facility. Front yard and backyard were inspected. A pond was observed closed with cover in the front yard. A storage room was observed unlocked at backyard. LCN locked it before LPA completed the inspection. Exit interview was conducted with LCN. This report was provided to LCN for signature. A copy of the report was provided to LCN.the state’s words, verbatim · CDSS document, Sep 14, 2026

Allegation investigated: Staff forced a resident in care to stay in a room. Staff did not ensure that resident was provided an adequate amount of toiletries. Staff made an inappropriate comment towards a resident in care.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with facility staff Noemi Velasquez (S1). On 02/10/2026, the Department received a complaint with the above 3 allegations. On 02/20/2026, the Department conducted an initial investigation visit. LPA interviewed staff S1 and Administrator (ADM). LPA toured the facility and R1's bedroom. LPA requested resident R1's physician report and appraisal needs and service plan. Continue on LIC9099-C. Page 1 of 3. Unfounded Staff forced a resident in care to stay in a room: Staff did not ensure that resident was provided an adequate amount of toiletries: Staff made an inappropriate comment towards a resident in care: On 02/20/2026, LPA interviewed staff S1. S1 stated resident R1 was not forced to stay in his/her room. S1 stated R1 was provided necessary and enough toilet paper. S1 stated he/she did not hear Administrator making any comment on R1. S1 stated R1 was provided a commode in his/her room because R1 played with toilet paper with water for long time when R1 used restroom, and caused toilet pipe clogged. S1 stated R1 used restroom for showering and brushing teeth. S1 stated R1 can walk in the facility by himself/herself. LPA interviewed Administrator (ADM) Tingxiu Li. ADM denied all the allegations. ADM stated the facility has the approval from R1's POA to place a commode in R1's room for R1's toileting. ADM stated R1 was provided enough toilet paper for his/her needs. ADM stated R1 played water and toilet paper in the restroom and caused the facility pipe clogged. ADM stated R1 has severe mental disorders. ADM stated he/she did not make any comment on R1. LPA interviewed R1's Power of Attorney (POA). POA stated R1 had lived with him/her before for 25 years. POA stated R1 has severe mental disorders. POA stated R1 is unable to describe well on what he/she wants to express. POA stated R1 had some behaviors in the facility and caused serious problem to the facility. POA stated he/she agrees the facility to put a commode in R1's room for R1's toileting. POA stated all the allegations are not true. POA stated he/she took R1 to psychiatry doctor and to transfer R1 to a bigger facility which he/she thinks is better for R1. POA stated the facility did not have any physical abuse or mental abuse to R1. POA stated the facility does not have any problem. Based on review of R1's appraisal/needs and service plan dated 11/3/2025 and 11/04/2025, R1 has severe mental illness, severe emotional problems, behavior of attention seeking, and has been in institutionalized care since the age of 4. Continue on LIC9099-C. Page 2 of 3. The Department has investigated the above allegations. Based on the investigation, observation, records reviewed, and interviews conducted, the Department found that the above allegations are UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citations noted at today’s compliant investigation visit. Exit interview conducted with S1. This report was provided to review and for signature. A copy of this report was provided to S1. Page 3 of 3.the state’s words, verbatim · CDSS document, Mar 12, 2026 · control 26-AS-20260210093456

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Tingxiu Li. LPA toured the facility inside and out with ADM. License, Administrator Certificate, and personal rights posters were observed in the facility. 3 residents and 1 staff were observed in the facility. LPA reviewed 2 resident file and 1 staff files. Living room, kitchen, dining area, 2 restrooms, and garage were inspected. LPA observed a bed in garage, ADM stated the bed will be removed this week. 4 resident bedrooms and a staff room were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. The temperature of the freezer was observed at -1 degree F, and the temperature of the refrigerator was observed at 37 degree F. Medication closet, knives closet, and chemical closet were observed locked. Room temperature was at 78 degree F, and hot water temperature was at 116 degree F in facility. Fire extinguisher was serviced on 6/24/2025. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Carbon monoxide detectors were tested by ADM, and were working. First aid box, night lights, and flash lights were observed in the facility. Front yard and backyard were inspected. The branches of a tree was observed hanging out but people still can walk through to the exit gate. ADM stated the facility will trim the branches by end of this week. A pond was observed closed in the front yard. A storage room was observed at backyard. The last time the facility conducted the emergency and fire drill was on 6/1/2025. Deficiency noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Jul 10, 2025

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Christine Dolores, Marcela Yanez, and Kiran Jain arrived announced to conduct the pre-licensing inspection. LPA met with Tingxiu Li. The facility has an approved fire clearance for (6) non-ambulatory with a hospice waiver granted for (6) residents. During visit, LPAs toured the interior to include 4 resident bedrooms, 1 staff bedroom, 2 bathrooms, living room, kitchen, garage, backyard, and front yard. All fire exit routes are free and clear of obstruction. Fire extinguisher, carbon monoxide detector, and complete first aid kit observed present. No emergency lighting present at the facility during inspection. Ting ordered the emergency lighting during visit. The backyard contains a shed and observed with storage items. Hot tub observed filled with water and observed covered and locked. Front porch observed with a pond that is drained and contains wood that fills the inside. Interior temperature maintained between 74 - 76 degrees Fahrenheit. Kitchen is equipped with cabinets that has child locks to store items that will be kept inaccessible to residents. Ting was advised to ensure the cabinets contains more secure locks. Sufficient cups, plates, bowls, and utensils observed. Refrigerator temperature maintained at 32 degrees Fahrenheit. Freezer temperature maintained at 0 degrees Fahrenheit. Bedrooms equipped with beds, linens, adequate lighting, chair, night-stand, and dresser. All beds contains half rails and 1 bed observed with full rails. Ting states the residents who will be admitted to the facility will contain a physician's report for half or full rails. SEE LIC809-C. Hot water temperature in the bathroom maintained at 106 degrees Fahrenheit. Bathroom shower does not contain a non-slip mat. Ting purchased the non-slip mat during visit. Bathroom toilet does not contain grab bars. Ting states a plan to input a handicap rising toilet that contains grab bars. Garage observed with laundry appliances and supplies. Facility has an area to lock medications and records. Posters observed to include the licensing complaint poster, personal rights and rights of resident council. Ting was advised to ensure the emergency disaster plan and theft and loss policy is posted. COMP III was waived as the applicant is the licensee/administrator of another care facility. No issues noted during the pre-licensing inspection. LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required. This report was reviewed with Tingxiu Li and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 7, 2024

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: INITIAL Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Name - TingXiu Li CEO/Administrator Interview Method: Telephone interview On July 24, 2024, Applicant/Administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of the following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-Licensing Readinessthe state’s words, verbatim · CDSS document, Jul 24, 2024