Royal Vista San Gabriel

Allegation investigated: Staff overmedicated resident.

Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced subsequent complaint investigation visit regarding above allegations. LPA met with Assistant Clinical Administrator Ghea Guzman and explained the reason for the visit. The investigation consisted of the following: During the initial visit on 06/19/26 LPA requested a copy of resident roster and staff roster. LPA interviewed Administrator and staff 1(S1). LPA obtained the following documents: R1’s face sheet, active medication list, MD notes, request order for hospice care, medical assessment LIC 602, admission record for St. Vincent dated 06/13/26, and SIR report dated 06/10/26. During today’s visit LPA obtained medication destruction log, an updated physician report LIC 602, and caregiver notes. LPA interviewed staff #2- staff #6 (S2-S6), resident #2-residents #6 (R2-R6), phone interview with R1, W2, attempted interview with W1 and delivered findings. SEE LIC 9099C Unsubstantiated In regard to the allegation “Staff overmedicated resident”, it is alleged that staff gave R1 too much medication and that R1 would be asleep for most of the day. During interviews with Administrator and staff, six (6) out of six (6) stated that resident have never been overmedicated. S1 stated that R1 ‘s health is declining and that he/she takes a lot of medication that causes sleepiness. During record review LPA obtained documents listing R1’s health conditions and a full list of medications that did include medications that would cause sleepiness. R1 also receives palliative/hospice services due to progressive decline and increasing need for comfort focused care. During interviews with residents, four (4) out of five (5) stated that they have never had any problems with medication being given by staff. R1 was unable to answer LPA’s questions. LPA interviewed W1 over the telephone and could not get a clear answer to any questions asked. W1 did not know anything about the allegation listed above. 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.the state’s words, verbatim · CDSS document, Jul 21, 2026 · control 28-AS-20260618093053

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. LPA met with Executive Director Sarah Rafael. The Residential Care for Elderly (RCFE) facility serves residents ages 60 and over. There is a Memory Care Unit for cognitively impaired residents. The following were observed/inspected: Infection Control: The Infection Control Plan includes Environmental cleaning and disinfection activities. Operational Requirements: The facility has a hospice waiver for 20 residents. A fire clearance for 100 non-ambulatory residents; of which 10 may be bedridden is in place. Facility handles resident monies and has set up trust accounts. The Surety Bond is current. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 4/11/2027. However, the policy lists the wrong facility name and insured name. Therefore, a technical violation was issued regarding the liability insurance policy. Physical Plant/Environment Safety: The facility is comprised of a 3- story building that has 66 resident rooms, 2 activity rooms, TV room, Namaste room, 3 dining rooms, laundry room, 2 courtyard patio areas, and a Memory Care Unit. The interior and exterior physical plant was inspected. A total of 25 randomly selected resident rooms were inspected. The signal system was tested and is operational; residents use a pendant alert system. Beds have required bedding, linens, and mattress pads. The signal system was tested and is operational. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety. Cleaning supplies and toxic substances are inaccessible to residents. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has fire extinguishers. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Exit doors are free of any obstruction. There are surveillance cameras in common areas. The last fire inspection was conducted on 3/6/2026 by City of San Gabriel Fire Department. * The 2nd floor ceiling has multiple openings exposing wiring; the ceiling is not painted; wall paper is in disrepair and 3rd floor hallway ceiling has water damage that requires repair and painting. Staffing: A total of 59 staff members provide care and supervision of residents. Personnel Records/Staff Training: Administrator certificate expires 12/15/2026. Staff have criminal background clearance. 10 staff files were reviewed. They contained 1st Aid/CPR training, criminal background clearance, health/TB screenings, 1st Aid/CPR training, and training records. Resident Records/Incident Reports: Eight (8) resident files were reviewed. They contained Admission Agreements, Service Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, and centrally stored medication records. Planned Activities: Facility activity calendar was posted. Sufficient space to accommodate both indoor and outdoor activities was observed. RCFE & Ombudsman complaint posters are posted. Food Service: Food supply was checked in the kitchen and pantry storage areas, consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Residents have physician orders for modified diets. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Kitchen personnel have current food handling certificates. * The 3-door refrigerator temperature is above the maximum temperature requirement, and the food steamer ignition knobs are in disrepair, and as a result the steamer temperature is not able to be regulated. Incident Medical and Dental: Centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family or facility van. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed and is updated. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted in January 2026. Residents with Special Health Needs: There are currently 5 residents receiving hospice services, 9 residents receive home health services, and no residents have prohibited health conditions. Individual Service Plans, Appraisals, and postural support physician orders are on file. Pursuant to Title 22, deficiencies were observed and are cited. Exit interview was conducted with Sarah Rafael. A copy of report and appeal rights were issued.the state’s words, verbatim · CDSS document, Apr 9, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to Administrator Sarah Rafael. The Residential Care For Elderly (RCFE) facility serves residents ages 60 and over. The following were observed/inspected: Infection Control: The Infection Control Plan was reviewed. The facility has sufficient supply of Personal Protective Equipment (PPEs). Operational Requirements: The facility has a hospice waiver for 20 residents. A fire clearance for 100 non-ambulatory residents; of which 10 may be bedridden is in place. Facility handles resident monies and has set up trust accounts. The Surety Bond is current. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 11/1/2025. A technical advisory was issued regarding transportation van maintenance logs. Physical Plant/Environment Safety: The facility is comprised of a 3- story building that has 66 resident rooms, 2 activity rooms, TV room, Namaste room, 3 dining rooms, laundry room, 2 courtyard patio areas, and a Memory Care Unit. The interior and exterior physical plant was inspected. A total of 18 randomly selected resident rooms were inspected. Beds have required bedding, linens, and mattress pads. The signal system was tested and is operational. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Cleaning supplies and toxic substances are inaccessible to residents. Exit doors are free of any obstruction and there are no pools or large bodies of water. Delayed egress is in place in the 1st floor Memory Care unit. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has charged fire extinguishers. The last fire inspection was conducted on 1/24/2023 by City of San Gabriel Fire Department. Staffing: A total of 42 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 12/15/2026. Staff have criminal background clearance. Seven (7) staff files were reviewed. They contained 1st Aid/CPR training, criminal background clearance, health/TB screenings, 1st Aid/CPR training, and training records.. Administrator certificate expires 12/15/2026. Resident Records/Incident Reports: Ten (10) resident files were reviewed. They contained admission agreements, Service Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. Centrally stored medication records were reviewed. RCFE & Ombudsman complaint poster are posted in the main entrance hallway. Planned Activities: Facility activities are conducted in the AL dining room and 3rd floor activity room. Memory Care unit resident activities are held in the dining room area. Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted. The facility has a Resident Council. Food Service: Food supply was checked in the kitchen and pantry storage areas, consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Twenty eight (28) residents have physician orders for modified diets. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Dining Services Director's Food Handling Certificate is current. Incident Medical and Dental: Centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family or 3rd party transportation companies. The facility has a van with current insurance and registration. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 1/24/25. Residents with Special Health Needs: There are currently 3 residents receiving hospice services, 4 receive home health services, and no residents have prohibited health conditions. Individual Service Plans and Appraisals are on file. Postural support physician orders are on file. Half and full bed rails for mobility assistance were observed in some resident rooms. Resident (R10) had two half rails on one side, but is not enrolled in hospice. Therefore, a citation was issued. Per California Code of Regulations, Title 22, a deficiency was cited. Exit interview, copy of report/appeal rights was conducted with Administrator Sarah Rafael.the state’s words, verbatim · CDSS document, Apr 1, 2025

Allegation investigated: Staff hit resident. Staff restrained resident in care. Staff handles residents in a rough manner. Staff does not treat residents with dignity and respect.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegations. The purpose of the visit was explained to new Administrator Sarah Rafael. The investigation consisted of the following: On 3/26/2024, a physical plant tour of the facility, record review, and interviews of staff (S3- S8) and residents (R1-R4) were conducted. Staff (S1) is presently suspended and staff (S2) was terminated March 24, 2024, therefore, were not interviewed. Resident (R1 & R2's) and staff (S1 & S2) file records were obtained. On 3/27/2024, staff (S1, S9, S10) were interviewed telephonically. During today's visit, record review was completed, residents (R5- R9) and staff (S11) were interviewed, a collateral visit to the San Gabriel Police Department was conducted. NOTE: New Administrator began working at the facility on June 3, 2024. Licensee failed to notify CCL of Administrator change. Therefore, a CM visit was created. ***Report narrative continues next page. Substantiated Allegation: Staff hit resident. The complaint alleges that on 2/29/2024 four (4) elderly residents disclosed they were been hit "swatted" by caregiver staff (S1). On 3/26/2024, LPA interviewed with translation assistance four (4) Mandarin speaking residents (R1- R4). Three (3) out of the 4 residents allegedly hit denied the allegation. Residents (R1 & R2) were unable to recollect due to cognitive impairment due to Dementia diagnosis. A total of nine (9) residents were interviewed. Resident (R5) stated that caregiver (S1) slapped/hit their legs on numerous times during incontinence care if the resident commented or asked the staff a question. Another resident (R4) was not a victim of abuse, but overheard several residents on different occasions yell for help saying that staff hit them. A total of 9 staff were interviewed. Staff (S1) denied hitting residents. S1 stated that R2 was taken to bathroom to bathe in the middle of the night because the resident had smeared feces on themselves, but the resident pushed away staff and began screaming "Don't hit me". S1 stated that in regards to R5, while providing incontinence care R5 complained of pain in the genitalia area and then the resident moved and their cell phone hit the resident in the head. Staff (S1) denied hitting the resident in the head. The majority of staff reported having no knowledge that S1 was physically abusing residents. However, former Administrator Nelida Arlante conducted an internal investigation, and discovered that staff (S1) hit residents (R2 & R5). In addition, another caregiver (S2) was found to have been physically abusive towards residents. On 3/24/2024, staff (S2) was terminated. LPA attempted to interview S2, but no response was received. Per record review, Administrator immediately suspended staff (S1) on 3/1/2024 and reported it to all required agencies. The San Gabriel Police Department opened an investigation of elder abuse. As of today, Administration staff have not officially terminated staff (S1) because the police department has not provided a copy of the report, but visited the facility last week to inform staff that they closed the investigation. LPA requested investigation findings report from the San Gabriel Police Department, however, a copy of the report has not been furnished. There is sufficient evidence to corroborate the allegation. ***Narrative continues next page. Allegation: Staff restrained resident in care. Information obtained states that staff (S1) tied resident (R2) to their wheelchair with a blanket and told another staff not to untie the resident so that they do not put their hand in their incontinence diaper. A total of 9 residents were interviewed, of which none confirmed the allegation. The investigation revealed that resident (R2) is a Dementia resident whose room was located in the Assisted Living floor, and not the Memory Care Unit. The resident was incontinent and had behaviors such as, taking off their diaper and playing with bowel movements. According to staff interviews, R2 did not have any postural supports physician's orders, but was restrained in effort to prevent incontinence behaviors, and potential falls. Staff (S1) stated that the 2nd floor of the facility has a lot of residents that require total care, and only 2 night shift caregivers responsible for providing care incontinence care and other care as needed. Based on staff interviews conducted the findings indicate that staff (S2) found (R2) restrained to their wheelchair, after S1's night shift ended. Staff (S1) admitted that R2 was restrained because the resident played with their feces. Therefore, there is sufficient evidence to corroborate the allegation. Allegation: Staff handle residents in a rough manner. It is being alleged that staff (S1) handled resident (R5) harshly while providing incontinence care. A total of 9 residents were interviewed, of which 2 residents confirmed that staff (S1) was impatient and yelled at the residents while providing assistance, and often handled the residents very rough. A total of 9 staff were interviewed. Staff (S1) denied mishandling or mistreating the resident(s), and stated they assisted other staff fulfill their care assignments. Staff interviewed stated that the majority of staff treat residents kindly, but sometimes visible bruises were observed on the arms of some residents, which was then reported to supervisors. Based on staff interviews conducted, the findings indicate that staff (S1) handled residents (R1, R3, & R5) in a rough manner while providing incontinence and ADL care. Additionally, S2 was observed on surveillance lifting, shaking, and roughly sitting Memory Care resident (R10) down on their wheelchair. Based on interviews, record review, and photograph evidence it was discovered that staff (S1) has rough handled multiple residents as far back as December 2023. Therefore, there is sufficient evidence to corroborate the allegation. Allegation: Staff do not treat residents with dignity and respect. Concerns were reported that residents were being yelled at and treated in a rude manner. Information obtained revealed that staff (S1 & S2) verbally abused residents by yelling and calling the residents derogatory/teasing names. Staff interviews revealed that 2 regular staff (S1 & S2) and 2 agency staff failed to treat the residents with dignity and respect because sometimes when staff heard the residents screaming or yelling they would simply close the door and ignore the residents. Administrator stated that staff (S2) was terminated on 3/24/2024, due to employee-to-employee altercation, and not mistreatment of residents. Three (3) out of 9 residents reported instances of disrespect. Resident (R3) stated that staff (S1) would yell and spray water in their face or bathe the resident at 1:00 AM. Resident (R5) stated that S1 threw a plush teddy bear at the residents' face and felt "treated like a prisoner". Resident (R8) reported that a staff pushed a resident's wheelchair inappropriately because the resident was shouting. The investigation revealed Administration staff had knowledge of staff misconduct, but the staff in question were not disciplined until after this complaint was filed. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited. An exit interview was conducted and a copy of this report and appeal rights was provided to new facility Administrator Sarah Rafael.the state’s words, verbatim · CDSS document, Aug 27, 2024 · control 28-AS-20240322105813

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Sep 6, 2024

Personal Rihgts of Residents in All facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature............... ....sleeping, or elimination. This requirement was not met evidenced by: The findings indicate that caregiver staff (S1) physically abused residents while providing assistance. S1 was suspended on 3/1/24, and is pending termination. This poses a potential health and safety risk ro persons in care.the state’s words, verbatim · CDSS document, Aug 27, 2024

Plan of correction: Administrator shall ensure that residents are free of punishment, humilation, initmidation, abuse..etc. Administrator will retrain staff on personal rights. Submit plan of correction by due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(1) · Plan of correction due date: Sep 6, 2024

Postural Supports. Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. This requirement was not met as evidenced by: Based on interviews conducted, statements obtained corroborated with the allegation that S1 restrained R2 on their wheelchair by tying the reisdents hands in order to prevent the resident from putting their hands on diaper. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 27, 2024

Plan of correction: Administrator shall develop a written Plan of Correction (POC) to ensure compliance with California Code of Regulations Title 22, Section 87608. Written POC & proof of staff training must be submitted to CCL by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Sep 6, 2024

Additional Personal Rights of Residents in Privately Operated Facilities. (a) In addition to the rights listed in Section 87468.1, ....:(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met evidenced by: Based on interviews conducted the findings indicate that S1 handled R1, R3, & R5 in a rough manner while providing incontinence and ADL care. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 27, 2024

Plan of correction: Administrator agreed to retrain all staff on regulation 87468.2, and submit proof of staff in-service training.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1)(3) · Plan of correction due date: Sep 6, 2024

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:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met evidenced by: Based on investigation findings staff (S1 & S2) were found to be treating residents in a disrespectful manner by yelling and ignoring the residents. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 27, 2024

Plan of correction: A training regarding personal rights for residents will be provided to all staff prior to POC Due date. Executive Director Michael Forsgren will also provide training materials, agenda, and a log with staff signatures/initials proving they attened the training by POC due date. Administrator agreed to retrain staff on regulation 87468.1, submit training log with staff signatures, and provide training materials by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Galarza initiated a case management visit due to observations during complaint investigation control #: 28-AS-20240322105813 visit. The purpose of the visit was explained to Administrator Sarah Rafael. Upon arrival to the facility Corporate staff Jamie Toy and Steven Shulman stated that the facility hired a new Administrator. LPA informed staff that Licensee has not notified CCL of changes. Ms. Sarah Rafael began working at the facility on June 3, 2024. However, licensee did not notify CCL of change of Administrator and has not submitted required documents in order to process the change. Per Title 22, Title 22, Division 6 Chapter 8 Article 07. Personnel Administrator Recertification Requirements. 87407 (k)(1) Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to: (1) The local licensing office responsible for receiving information regarding personnel changes at the licensed facility with whom the certificate holder is or was associated. Deficiencies were cited. Exit interview was conducted with Sarah Rafael. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Aug 27, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87407(k)(1) · Plan of correction due date: Sep 6, 2024

Personnel Administrator Recertification Requirements. Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to: (1) The local licensing office ..... This requirement was not met evidenced by: Based on observation, the facility has a new Administrator. Licensee failed to report changes to CCL within 30 days. Administrator Sarah Rafael was hired on 6/3/24. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 27, 2024

Plan of correction: Licensee shall submit change of Administrator documents to CCL by POC due date.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Galarza conducted an unannounced Annual Continuation visit to provide a complete report of the annual visit dated 4/23/2024 and to issue citations on deficiencies observed on that date. The purpose of the visit was explained to Administrator Nelida Arlante. The facility serves elderly residents ages 60 and older. A hospice and Dementia waiver is in place. It consists of a 3- story with 66 resident rooms, 2 activity rooms, TV room, Namaste room, 3 dining rooms, laundry room, 2 courtyard patio areas, and a Memory Care Unit. The following were observed/inspected: Infection Control: The Infection Control Plan was reviewed. The facility has a supply of Personal Protective Equipment (PPEs). Operational Requirements: A hospice waiver for five (5) residents has been approved. A fire clearance for 100 non-ambulatory residents; of which 10 may be bedridden is in place. Facility handles resident monies and has set up trust accounts. The Surety Bond is current. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 11/1/2024. Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. On 4/20/2024, Fire Drill Service conducted an inspection. No violations were noted at the time of the inspection. The facility has fully charged fire extinguishers. The signal system was tested and is operational. Water temperature readings did not measured within the required 105 - 120 degrees Fahrenheit. A total 10 out 17 rooms inspected had water temperatures ranging from 83.8 DF - 125.0 Degrees Fahrenheit. *On 4/23/2024, a technical advisory was issued because the signal system wall pull-string in resident rooms is inaccessible to residents that are non-ambulatory. Physical Plant/Environment Safety: The facility has a Memory Care Unit located in the 1st floor. Facility is a 3-story building consisting of 66 resident rooms, 2 activity rooms, beauty salon, room, 2 dining rooms, laundry room, and a courtyard patio area in the Memory Care Unit. There are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. Beds had required bedding, linens, and mattress pads. On 4/20/2024, Fire Drill Service conducted an inspection. No violations were noted at the time of the inspection. The facility has fully charged fire extinguishers. The signal system was tested and is operational. However, a technical advisory was issued because the signal system in the resident rooms is inaccessible to residents that are non-ambulatory. The stairwell evacuation chairs are not kept in the stairwells. They were observed in the hallway. A technical violation was issued. Water temperature readings did not measured within the required 105 - 120 degrees Fahrenheit. A total 10 out 17 rooms inspected had water temperatures ranging from 83.8 DF - 125.0 Degrees Fahrenheit. Citation was issued. Staffing: A total of 45 staff members provide care and supervision to the clients. Fifteen (15) registry staff are still being used when there are staffing shortages. Personnel Records/Staff Training: Administrator certificate expired. Administrator provided proof that recertification training documents were submitted to CCL Recertification unit on March 20, 2023. Recertification process is pending. Staff have criminal background clearance and training. Nine (9) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training was observed. Resident Records/Incident Reports: A total of eight (8) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, Individual Service Plans, and medication records. RCFE complaint poster and Personal rights were observed posted. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted in the 2st floor hallway. The facility has a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. 18 residents are on modified diets. Physician orders are on file and special diet lists are kept in the kitchen area. On 4/23/2024, LPA observed the large freezers are not operating. Per Dietary Supervisor, licensee was notified of non-operable freezers in January 2024. The freezers were ordered on May 20, 2024. Incident Medical and Dental: Eight (8) centrally stored resident medications were reviewed. containing a 30-day supply of medications. Medical and dental transportation is provided. Facility has one (1) van for resident transport. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. There are no evacuation chairs in each stairway; one (1) stairway has an inoperable stair lift. A citation was issued. Facility has a First Aid Kit and Manual. Records of resident Appraisal and Needs services plans are part of Emergency training. Residents with Special Health Needs: Two (2) residents are receiving hospice services and four (4) residents receive home health services. Postural support physician orders are on file. Half bed rails for mobility assistance were observed in some resident rooms. No residents have prohibited health conditions. Individual Service Plans and Appraisals are on file. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Nelida Arlante. A copy of the report and appeal rights was issued.the state’s words, verbatim · CDSS document, May 30, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Nelida Arlante. The facility serves elderly residents 60 years and older. During today's visit 12 (CARE) tool domains were utilized during the inspection. The inspection, document review, and file review was completed. However, due to time constraints LPA will return at a later date to provide a complete report of today's visit and issue deficiencies. A technical advisory was issued addressing facility's signal system. Exit interview was conducted with Administrator Nelida Arlante. A copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 23, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Galarza conducted a Case Management- Incident visit to follow up on an SOC 341 Report of Suspected Dependent Elder Abuse incident report dated 3/1/2024. LPA met with Administrator Nelida Arlante. The purpose of today's visit is to check on the health & safety of residents in care and to obtain resident records. According to SOC 341, the facility reported suspected physical abuse of a resident. It is alleged that on 2/29/2024, during the resident council meeting three (3) residents reported that staff (S1) splashed water on resident (R1's) while sitting on the toilet, and two (2) other residents reported incidents involving care misconduct by staff (S1). On 2/29/2023, Administration staff opened an investigation. The investigation is pending. Staff (S1) was suspended on 3/1/2024, pending investigation findings. Facility Administrator does not have access to staff files. A staff person that works at the SNF next door, provided access to staff files. Staff (S1's) Personnel Record was obtained. A technical violation was issued. Exit interview conducted and a copy of the report was given to Administrator.the state’s words, verbatim · CDSS document, Mar 5, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Galarza conducted a Case Management- Incident visit to follow up on an incident report dated 12/6/2023, submitted via SOC 341 "Report of Suspected Dependent Adult/Elder Abuse". LPA met with Wellness Director Elizabeth Contreras. The purpose of today's visit is to check on the health & safety of residents in care and to obtain resident records. According to SOC 341, the facility reported suspected physical abuse of a resident. It is alleged that on 12/5/2023, 91 year old resident (R1's) family reported to Administration staff that they observed bruising on resident's arm and hands. The resident told family that caregiver staff (S1) hit the resident. Administration staff performed a body check and discoloration of R1’s left hand, left arm, and yellowish areas on left upper chest were observed in R1’s body. On 12/5/2023, Administration staff opened an investigation. According to report, staff (S1) stated that at approximately 2:40 PM, while showering the resident staff noticed bruising. On 12/5/2023, staff (S1) took the resident to the Wellness Department office. Resident (R1) was asked about the bruising, and allegedly denied being hit by staff (S1). The resident reported to staff that they fell. Resident (R1) was removed from staff (S1’s) care responsibilities pending investigation findings. LPA reviewed and obtained resident (R1's) file documents. Staff (S1's) file was locked. Therefore records were not obtained. Staff were instructed to email S1's Personnel record, proof of training, and disciplinary reports if applicable. LPA obtained a copy of incident report and SOC 341. NOTE: Law enforcement agency has not visited the facility as of yet. LPA interviewed staff (S1 - S2) and attempted to interview Dementia resident (R1). Administration staff were instructed to notify LPA once their investigation is complete and submit additional evidence if any to CCL. If warranted, LPA will return to the facility. During today’s visit, there were no deficiencies cited. Exit interview conducted and a copy of the report was given to Wellness Director Elizabeth Contreras.the state’s words, verbatim · CDSS document, Dec 11, 2023

Allegation investigated: Facility staff engaged in financial abuse of resident(s).

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to finalize complaint and deliver findings on the above allegation. The purpose of the visit was explained to Wellness Nurse Elizabeth Contreras. Administrator Nelida Arlante. The investigation consisted of: On 10/12/2021, staff (S2- S6) and residents (R1 - R3) were interviewed. Staff (S1) was not interviewed because staff (S1)/Resident Care Coordinator was placed on a suspension leave on 9/29/2021 pending investigation. The following documents were reviewed/obtained: Resident (R1's) Identification and Emergency Information, Physician Report, Admission Agreement, Assisted Living Waiver Individual Service Plan, and Client/Residential Personal Property and Valuables documents, copy of staff (S1's) job description and Employee Counseling Report, resident roster and LIC 500 Personnel Report. In addition, a total of 30 resident Authorization for Credit Card Use documents were obtained. On 10/26/2021, LPA interviewed four (4) resident authorized representatives. During today's visit, residents (R4 - R6) were interviewed. Substantiated Allegation: Facility staff engaged in financial abuse of resident. The complaint alleges that resident(s) were financially abused by Administration staff. It is alleged that former staff (S1)/Resident Care Coordinator used resident (R1's) debit card and charged approximately $800.00. The first fraudulent activity noted in R1's debit card was in July 2021. A new debit card was reordered. However, in August 2021 new fraudulent charges were caught by the bank. Based on record review and interviews conducted the findings indicate that staff (S1) had access to confidential credit card information via "Authorization for Credit Card Use" forms on file. In July 2021, resident (R1) asked staff (S1) to purchase a watch in the amount of $125.00 from Nordstram Rack. Staff (S1) used their own credit card and took R1's money. However, several weeks later R1 had not received the watch and asked S1 to cancel the order. Staff (S1) promised to return the money to R1, but did not. During July 2021- September 2021, R1's bank card was charged for items not purchased by the resident. Resident (R1) occasionally asked staff to assist with purchases. At least two (2) staff., staff (S1) and staff (S4) had access to R1's bank debit card. When the alleged financial abuse incident were occurring the facility did not have an Administrator. The Resident Care Coordinator was appointed by licensee to be in charge of the facility without being qualified as an Administrator. According to staff interviews, in September 2021 the facility received several phone calls from three (3) different resident's family members reporting fraudulent charges on the resident's debit bank cards. The Resident Care Coordinator (Staff 1) at that time was the only person responsible for charging the resident's monthly rent by accessing "Authorization for Credit Card Use" forms that have credit card information. A total of four (4) authorized representatives were interviewed. Two (2) out of the four (4) stated that their loved ones were overcharged rent fees in their bank cards. One resident was overcharged from January 2020- July 2020. The resident is part of the ALW program, and they confirmed the over charges were paid out from the resident's bank account. The Assisted Living Waiver program notified the authorized representative that facility staff were not billing correctly. Another resident was to be reimbursed money and the amount was not reimbursed as of 10/2021. ****Narrative continues next page.***** Staff (S1) was not interviewed because they were suspended and terminated after facility conducted an internal investigation. Staff (S2 - S6) denied engaging in financial abuse of residents. However, two (2) out of the five (5) staff interviewed stated they suspected staff (S1) engaged in financial abuse of residents. Resident (R1) stated that staff (S1) and other staff in the facility were given the bank card and PIN number to make a gas purchase and snack purchases at 7 eleven, but never for Chipotle, Uber rides, Amazon, or Instacart. R1 stated that fraudulent charges were noted after giving the bank card PIN to staff. A total of six (6) residents were interviewed. Resident (R2) stated that in September 2021 their monthly rent was charged twice, and they notified staff (S1). Resident (R4) stated that concert tickets were purchased with the credit card on file, and the only staff that had access to their credit card was staff (S1). There is sufficient evidence to corroborate the allegation. Licensee is to furnish a plan to the Regional Office on staff responsibilities and protocols for handling resident's money and accessing confidential credit card information. In addition, all staff shall be retrained on facility policy in reference to taking money and bank cards/PINs from residents. Based on record review and interviews 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, Chapter 8, Article 08 is being cited. See attached LIC 9099D. Exit interview was conducted with Nelida Arlante. A copy of the appeal rights and report was issued.the state’s words, verbatim · CDSS document, Nov 13, 2023 · control 28-AS-20211005163109

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Nov 20, 2023

Additional Personal Rights of Residents in Privately Operated Facilities: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met evidenced by: Based on record review and interviews conducted, the findings indicate that S1 made unauthorized charges totaling approximately $800.00 by using R1's bank card/PIN for online purchases that were never received by R1, and charging concert tickets on R4's card. This poses an immediate and health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 13, 2023

Plan of correction: Facility shall submit proof of: 1. Written POC that includes the job description of staff that are responsible for handling resident's money and accessing confidential credit card information. 2. Proof of staff retraining on facility policy against taking money, bank cards/PINs from residents and regulation 87468.2.