Royal Palms

Allegation investigated: Staff falsified documents

At 1:00pm, Licensing Program Analysts (LPAs), Angela Panushkina and Huma Rahimi conducted an unannounced visit in response to the above-mentioned allegation. LPAs met with the Staff #1 (S1), who granted access to the facility. Administrator was contacted and LPAs explained the reason for the visit. LPAs were informed that the Administrator is not able to come and designated S1 to sign the report. At 1:10pm, LPAs requested resident and staff roster. Between 1:30pm – 2:30pm, LPAs conducted an interview with the Administrator and two (2) staff members. It was alleged that Resident 1 (R1) fell on 10/28/25, Staff 1 (S1) failed to call 911, and Administrator, John Mallon, forged S1’s signature on the incident report to avoid a citation from Community Care Licensing Division (CCLD). To investigate this allegation, LPA interviewed the Administrator who denied any forgery and stated he himself signed the report. Continue on LIC9099-C Unsubstantiated The Administrator acknowledged the fall occurred and stated that after reviewing video footage on 10/30/25, R1’s responsible party was notified and 911 was called. Two (2) staff interviewed informed LPAs they had not seen any signature forging and stated that when incidents occur, they call 911, notify the Administrator, and record detailed notes in the log. The log does not require staff signatures. LPAs reviewed facility’s incident log and confirmed that staff signatures are not required. Additionally, review of an incident report (submitted to CCLD on 11/03/25) showed only the Administrator’s typed name in both signature sections - no signatures from any staff were observed. Therefore, based on interviews and document review this allegation is deemed Unsubstantiated at this time. No deficiency issued during today's visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 31-AS-20260622125413

Allegation investigated: Staff dispensed medication that was not prescribed to resident. Staff are confining resident to room.

At 11:00am, Licensing Program Analysts (LPAs), Angela Panushkina and Huma Rahimi conducted a subsequent visit to deliver final findings. LPAs met with the Staff #1 (S1), who granted access to the facility. Administrator arrived shortly after and LPAs explained the reason for the visit. During the initial visit, conducted on 12/08/25, LPA requested resident and staff roster. At 08:10am, requested copies of pertinent information which include, but not limited to Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, Staff Training, Medication Policy, Dementia Plan of Operation, Emergency Procedure Policy, Reporting Policy, relevant to the investigation. At approximately 08:15am, LPA conducted a physical plant tour. Between 08:20am - 9:30am, LPA conducted an interview with the Administrator, two (2) staff, four (4) residents and one witness. On multiple occasions, LPA attempted to contact R1's Power of Attorney (POA) to discuss the above allegations. LPA left voicemails requesting a call back. Continue on LIC9099-C Substantiated Allegation: Staff dispensed medication that was not prescribed to resident. It was alleged that the staff has been administering L-Tryptophan to R1 at night without physician’s order. To investigate this allegation, LPAs conducted an interview with the Administrator who confirmed that R1 is taking L-Tryptophan (2tab x bedtime). The Administrator stated that staff are required to dispense medications only according to the physician’s orders and to verify orders before administration. However, The Administrator acknowledged that no physician’s order was available for the medication that had been given to Resident (R1) nor was it recorded on Centrally Stored Medications and Destruction Record (CSMDR). The Administrator also confirmed that the centrally stored medication record had not been updated or completed properly for this medication. Staff interviewed also confirmed that medication was administered to R1, for almost six (6) months, without a valid and current physician’s order. Staff further confirmed that the medication was not documented in the CSMDR. However, it’s recorded on Medication Administration Record. Lastly, LPAs reviewed R1’s medication records, physician’s orders, and centrally stored medication logs. LPA did not observe a physician’s order for the medication in question. Additionally, LPA observed that the medication was not recorded in the Centrally Stored Medication and Destruction Record consistent with regulatory requirements. Photographs taken by LPA showing the missing entries in the centrally stored log and the absence of corresponding documentation in R1’s file. Therefore, based on interviews and LPAs record reviews this allegation is Substantiated. Allegation: Staff are confining resident to room. It was alleged that the staff installed a child safety cover on R1’s bathroom and bedroom doors to prevent R1 from eloping at night. To investigate this allegation, LPAs conducted an interview with the Administrator who denied instructing staff to confine any residents to their room. The Administrator also disclosed that R1 has diabetes and, for R1’s safety, staff placed a child-proof lock on R1’s bedroom door. When LPA requested R1’s care plan, physician’s orders, and any behavioral plan related to the use of the child-lock or to R1’s medical conditions, the Administrator was unable to provide any of these documents. LPA conducted review of facility records and did not observe an exception request being submitted to the Department. During the initial (12/08/25) visit and today’s visit (06/03/26) LPAs observed child-proof lock placed on R1’s bedroom door. Lastly, a credible witness, who visited this facility on 12/13/25, reported observing staff confining R1 to their room on several occasions. The witness stated they saw staff physically blocking the doorway and instructing R1 to remain inside. The witness provided consistent, detailed information supporting the allegation. Therefore, based on interviews and LPAs/credible witness’ observations this allegation is Substantiated. Deficiency issued on LIC9099-D. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered. Allegation: Staff did not communicate with residents authorized representative about providing medications. To investigate this allegation, LPA conducted an interview with the Administrator who denied the allegation and informed LPA that the R1’s Power of Attorney (POA) was notified about the bedtime medication administration, and R1’s POA expressed no concerns at that time. LPA attempted multiple times to contact the R1’s authorized representative/POA to obtain additional information and clarify the allegation. Attempts were made on the following dates/times: · On 12/05/25 at 3:45pm – phone call, message left · On 12/08/25 at 2:10pm – phone call, message left · On 02/16/26 at 10:30am – phone call, message left · On 04/17/26, at 3:45pm – phone call, message left · On 05/04/26, at 9:00am – phone call, message left · On 05/27/26, at 2:50pm – phone call, message left Despite repeated attempts, the authorized representative could not be reached for confirmation or additional details. Based on interviews, record review, and unsuccessful attempts to gather additional information from the authorized representative/POA, there is insufficient evidence to determine that staff failed to communicate with the R1’s authorized representative/POA regarding medications. Therefore, this allegation is deemed Unsubstantiated, at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jun 3, 2026 · control 31-AS-20251203143852

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(6) · Plan of correction due date: Jun 5, 2026

Incidental Medical and Dental Care: (a) ...Each facility must be in compliance with the following: (6) When requested by the prescribing physician... a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by failing to obtain Dr's order for R1's L-Tryptophan medication and properly documenting on CSMDR for accountability. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 3, 2026

Plan of correction: Administrator agreed to schedule vendorized training for all staff and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(6) · Plan of correction due date: Jun 5, 2026

Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights... the following personal rights: (6) To make choices concerning their daily lives in the facility. This requirement is not met as evidenced by: Based on interviews, LPAs/witness observation, licensee did not comply with the section cited above by allowing the staff to confined R1 in their room by placing a child-proof lock on a door knob. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 3, 2026

Plan of correction: R1’s care plan will be updated to ensure behavior support strategies comply with Title 22. Administrator agreed to retrain all staff on resident personal rights and proper redirection techniques. Proof of training will be submitted to LPA by POC date.

Allegation investigated: Resident sustained an injury due to staff neglect. Staff did not provide medical attention to resident in a timely manner Staff did not follow reporting requirements.

At 11:00am, Licensing Program Analyst (LPA), Angela Panushkina and Huma Rahimi conducted a subsequent visit to deliver final findings. LPA met with the Staff #1 (S1), who granted access to the facility. Administrator arrived shortly after and LPA explained the reason for the visit. During the initial visit, conducted on 12/08/25, LPA requested resident and staff roster. At 08:10am, requested copies of pertinent information which include, but not limited to Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, Staff Training, Medication Policy, Dementia Plan of Operation, Emergency Procedure Policy, Reporting Policy, relevant to the investigation. At approximately 08:15am, LPA conducted a physical plant tour. Between 08:20am - 9:30am, LPA conducted an interview with the Administrator, two (2) staff, four (4) residents and one witness. On multiple occasions, LPA attempted to contact R1's Power of Attorney (POA) to discuss the above allegations. LPA left voicemails requesting a call back. Continue on LIC9099-C Unsubstantiated Allegation: Resident sustained an injury due to staff neglect. It was alleged that on October 26th 2025, Resident #1 (R1) disclosed that his/her hand was injured. R1 was unable to move it normally and experienced pain when attempting to do so. To investigate this allegation LPA conducted an interview with the Administrator and was informed that staff conduct regular resident checks and respond promptly to resident needs. The Administrator reported no incidents where staff failed to provide required care leading to resident injury. Two (2) staff members interviewed denied the above allegation and informed LPA that they did not witness any incident involving R1 injury caused by staff neglect. Both staff also reported that they are trained to assist residents safely and document required care appropriately. Furthermore, four (4) residents interviewed expressed no concern regarding this allegation. Residents stated that staff assist them appropriately, respond to calls and provide care as needed. No resident reported witnessing or experiencing neglect resulting in injury. During the initial and today’s facility tour, LPA observed residents resting, ambulating, and interacting with staff. Staff were observed providing care, supervision, and assistance appropriately. Based on interviews and LPA observations, there was not enough evidence to support the allegation that a resident sustained an injury due to staff neglect. Therefore, the allegation is Unsubstantiated, at this time. Allegation: Staff did not provide medical attention to resident in a timely manner It was alleged that on October 26th 2025, Resident #1 (R1) disclosed that his/her hand was injured and no medical attention was provided. The Administrator denied the allegation and stated that staff follow facility protocols regarding medical attention. According to the Administrator, residents are assessed promptly and emergency services are contacted when needed. LPA was also informed that he received a text message from the “former staff” (FS) who observed R1’s left hand being swollen, however, R1 did not feel any pain, unless it was pressed. FS examined the rest of R1’s body and observed no other markings that may indicate injury. After applying ice to R1’s hand the swelling reduced and R1 did not complain of any pain. Both staff members interviewed denied the allegation. They stated that they have not witnessed any delays in providing medical attention to residents. Staff reported that they respond immediately when residents report discomfort, injuries, or medical concerns. Residents interviewed denied having experienced or observed any delays in receiving medical care. Residents reported that staff are responsive and check in regularly. LPA conducted review of incident report faxed to the Regional Office on 10/29/2025 at 9:41pm, which confirmed the statement provided by the Administrator. Therefore, based interviews and record reviews this allegation is deemed Unsubstantiated, at this time. Continue on LIC9099-C Allegation: Staff did not follow reporting requirements. It was alleged that on October 26th 2025, Resident #1 (R1) disclosed that his/her hand was injured and the staff did not follow reporting requirements. To investigate this allegation, LPA conducted an interview with the Administrator and was informed that all required incident reports are submitted according to regulation. Both staff interviewed reported they are trained in reporting requirements and confirmed that the incident referenced in the complaint was communicated to management promptly and documented according to procedure. LPA conducted review of the incident report referenced in the complaint. The report was received by Community Care Licensing within the required timeframe (on 10/29/25 at 9:41pm). Documentation showed the report was submitted accurately and in accordance with Title 22 reporting requirements. Therefore, based on interviews and records review this allegation is deemed Unsubstantiated, at this time. No deficiencies issued during today’s visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jun 3, 2026 · control 31-AS-20251205102316

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Huma Rahimi and Angela Panushkina conducted an unannounced visit to the facility in conjunction with complaint control numbers 31-AS-20251205102316 and 31-AS-20251203143852. LPAs met with Staff #2 (S2), who granted access to the facility. The Administrator was contacted, and LPAs explained the purpose of the visit. During the visit, LPAs conducted a tour of the facility and observed the following items unlocked and accessible to residents in care: One Lysol disinfectant spray in Resident #2's (R2) room; One pair of scissors in a countertop stand; One knife in the dishwasher; One container of Lysol disinfectant wipes in the staff room; One Lysol disinfectant spray in Resident #3's (R3) room; and Laundry detergents stored in the facility garage. Additionally, LPAs conducted a review of Resident #2's (R2) records and observed a Physician's Report dated 04/06/2026 indicating that R2 was bedridden. The facility is not approved or fire-cleared to retain bedridden residents. Based on observations and record review, deficiencies were cited pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 8. The deficiencies are documented on the LIC 809-D. An exit interview was conducted. Appeal rights were discussed. Copy this report signed and delivered.the state’s words, verbatim · CDSS document, Jun 3, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Jun 5, 2026

Fire Clearance: (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department...., or the State Fire Marshal. Prior to accepting ...: (2) Bedridden persons. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by accepting a bedridden resident (R2) without having a proper fire clearance, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2026

Plan of correction: Licensee must submit LIC200 along with the facility sketch or re-locate R2 by POC date and provide relocation information to LPA. This is zero tolerance and an immediate civil penalty of $500.00 will be assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(1) · Plan of correction due date: Jun 5, 2026

87705-Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by one knife, one pair of scissors, two Lysol disinfectant sprays, one container of disinfectant wipes, and laundrythe state’s words, verbatim · CDSS document, Jun 3, 2026

Plan of correction: Administrator agreed to provide in service training to their staff and provide LPA with a proof by the due date. detergent being unlocked and accessible to residents, which poses an immediate health and safety risk to persons in care.

Type of visit: Required - 1 Year

At 12:00pm, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with the Staff #1 who granted access to the facility. Administrator arrived shortly after, and LPA explained the reason for the visit. At 12:05pm LPA conducted a tour of the physical plant and observed the following: Facility is licensed for capacity of six (6) Non-Ambulatory residents. Facility also has a hospice waiver for one (1) resident. LPA observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. All knives were observed to be locked in the kitchen drawer. The fire extinguisher is located in the kitchen area and was last serviced on 6/24/2024. Medications and resident/staff files are kept in a kitchen cabinet and observed to be locked and inaccessible to residents in care. The first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual. Facility is a single-story home consisting of seven (7) bedrooms and three (3) full bathrooms. There are six (6) private bedrooms designated for residents use. Only master bedroom has a private bathroom. Live-in staff bedroom is located by the kitchen area. LPA observed that all bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. At 12:20pm LPA observed all bathrooms are clean and in good repair. All three (3) bathrooms have a working Continue on LIC809-C toilet, wash basin, and a shower/bathtub. Properly supplied with toilet papers, soap and paper towels. At 12:30pm, the hot water temperature measured at 116.7°F. All trash cans in bathrooms had fitted lids to protect from cross contamination. Laundry is located in the garage. The washer/dryer appear to be in good condition. Laundry supplies, chemicals and detergents are kept in the garage and inaccessible to residents in care. Smoke detectors and carbon monoxide monitors were tested at 12:40pm and observed to be functional. At 12:50pm, LPA observed sufficient yard space with fenced backyard. The outdoor area was free of visible immediate hazards. There is a swimming pool that is fenced to keep clients out of the swimming pool area. The fence is approximately 5 feet high throughout the parameters. You will need a key to unlock the padlock to gain entry to the swimming pool as it is kept locked at all times. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. Between 1:00pm to 2:30pm, LPA reviewed records of six (6) residents and three (3) staff. Resident and staff records appeared to be complete and updated. Resident’s files contain signed admission agreements and a medical assessment, and all other required documentarians. LPA collected Certificate of Liability Insurance, Administrator Certificate (exp. 11/04/2025) and LIC500. No citations issued during this visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 15, 2025

Type of visit: Required - 1 Year

At 09:15am, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with Staff #1, who granted access to the facility. Administrator arrived shortly after, and LPA explained the reason for the visit. At 09:20am LPA conducted a tour of the physical plant and observed the following: Facility is licensed for capacity of six (6) Non-Ambulatory residents. Facility also has a hospice waiver for one (1) resident. There are four (4) bedrooms designated for residents’ use, and one (1) bedroom, by the kitchen, is designated for a live-in caregivers. Bedrooms are appropriately furnished and have appropriate lighting. The hot water temperature measured at 120.0°F. Extra towels and linens were readily available. Bathrooms have soap, paper towels and hand washing signs were observed. Extra towels and linens were readily available. Facility maintains a temperature of 73°F. LPA observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. The fire extinguisher is located in the kitchen and was last serviced on 07/23/23. Laundry is located in a hallway, and LPA observed all chemicals and detergents are kept locked and inaccessible to residents in care. LPA observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Smoke detectors and carbon monoxide monitors were tested at 10:30am and observed to be functional. Between 10:30am to 11:30am, LPA reviewed records of six (6) clients and two (2) staff. Resident and staff records appeared to be complete and updated. LPA collected Certificate of Liability Insurance and LIC500. No citations issued during this visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 17, 2024

Allegation investigated: Staff are not providing night time supervision to the residents

This is an ammended report to the complaint investigation conducted by Licensing Program Analyst (LPA) Abeye Duguma pertaining to the above allegation. The findings were unsubstantiated but erroneously marked substantiated. Licensee, John Mallon, designated staff Astrid Bautista to sign and accept the report. LPA Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegation. LPA met with caregiver, John Mallon, and explained the reason for the visit. --- Staff are not providing night time supervision to the residents. It was alleged that the facility does not have awake staff member 24/7. To investigate the allegation, on 12/14/2022 at around 3:15 PM, LPA Martinez interviewed two (02) staff and on 01/05/2024, LPA Duguma interviewed two (02) staff from 10:30 AM – 11:30 AM and three (03) out of six (06) residents from 3:30 PM – 4:30 PM. During interviews with staff, Staff #1 (S1) stated they are live-in staff, work one twelve (12) hour shift per day from 7:30 AM - 7:30 PM and on-call should any residents need assistance overnight. (CONT. on LIC9099-C) Unsubstantiated Staff #1 (S1) added that they check on the residents every two (02) hours. Staff #2 (S2) stated S1 is the staff that works at night and is a wake staff. S2 added that S1 usually works from 9:00 PM to 7:00 AM. Staff #3 (S3) stated that they work from 7:30 AM - 7:30 PM but are on-call to tend to any residents that need assistance overnight and check on residents every two hours. During interviews with residents, all residents stated staff are available overnight, should they need assistance. LPA was unable to interview three (03) out of (06) six residents. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No other health and safety hazards were noted during the visit. An exit interview was conducted, and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 5, 2024 · control 31-AS-20221205172017