Santa Anita Assisted Living

Type of visit: Office

An informal meeting was held today at the Monterey Park Adult and Senior Care Licensing office. Adeline Ho, Licensing Program Manager (LPM), Mayra Cota, Licensing Program Analyst (LPA) and Nune Margaryan Licensing Program Analyst (LPA) met with Alisa Dean, Executive Director, Randy Herzig, Regional Program Manager, Adrianne Hurd, Regional Wellness Director, Chantelle Hudson, Corporate Director of Wellness and Leslie Quintanar, Chief Operating Officer. The reason for the meeting was explained to the participants. The purpose of the meeting was to discuss the number of complaints the department has been receiving for the past two years. The department has noted a significant increase in complaints and has deemed it necessary for the facility to develop a mediation plan to address concerns and resolve underlying issues. The following was discussed during the office meeting: Complaint numbers for January 2024 – September 2026. · Year 2024 – 12 complaints · Year 2025 - 37 complaints · January to September 2026 – 38 complaints Updates regarding facility staff changes: · Alisa Dean took over as Executive Director in May 2026. · Wellness Director vacancy has been filled as of September 2026. · New position created: Resident Relations Coordinator was hired June 2026. ***Continues on LIC 809-C*** Reviewed facility’s compliance for past substantiated complaints and citations issued during past two annual visits (main areas of concern). · Medication mismanagement has been noted during complaint investigations and annual visits. Citations have been issued and Civil Penalties assessed. · Facility being short-staffed and retention challenges. Addressing residents’ concerns: · Resident voice and families’ feedback. · Resident Relations Coordinator position created and address resident issues and concerns. Position brought in for additional support by creating a liaison between facility staff and residents. · Additional psychological services for residents are provided monthly and as needed. · Monthly in-service training for caregivers to address challenging behaviors has been implemented this month. · Staff conduct Town Hall meetings with residents to provide a platform in which they can share suggestions and voice their concerns. · Executive Director has an open-door policy in which residents can discuss any issues they feel need to be addressed. · Clinical nurses will be visiting the facility to provide additional services to residents who may be experiencing health declination. · Ombudsman is visiting facility two times a week to talk to residents openly. Licensee agreed to the following: Plan of Action · Facility has acknowledged concerns and has committed to finding resolutions to those concerns. Addressing resident concerns through a validation process. · Resident Council communication to mitigate resident issues. · Assistant ED has been hired to assist Alisa Dean, Executive Director, to help with follow ups, quality assurance and also provide additional structure. · Facility’s partnered pharmacy will be coming in to consolidate residents’ medication. · Participation in Technical Support Program and in-service training for med-techs to ensure proper medication management. · Executive Director has agreed to conduct spot checks. · For frequent callers, facility will provide time to talk to staff individually regarding their concerns. ***Continues on LIC 809-C page 2*** Department recommendation: · Continued partnership with CCL. · Conduct spot-checks in areas which need additional monitoring. · Conduct reassessments in a timely manner and reach out to primary care physicians when there is a change of condition. Note: Facility stated that the newly installed Wonderguard does not include delay egress. They will continue to comply with Tittle 22 Regulations. Facility was advised to continue making improvements, follow facility policies and procedures and adhere to regulations to maintain compliance. If operations do not improve, it could lead to a Non-Compliance Conference (NCC). Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 2, 2026

Allegation investigated: Neglect/Lack of Care and Supervision

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced complaint investigation visit regarding the above allegation. LPA Gonzalez was greeted by staff, and the purpose of the visit was explained. Executive Director Alisa Dean arrived shortly after. The investigation consisted of the following: LPA obtained and reviewed copies of resident rosters and discharge forms. LPA interviewed staff #1-11 (S1- S11) and residents #2-12 (R2-R12). The investigation revealed the following: Regarding allegation “Neglect/Lack of Care and Supervision,” it was reported that R1 sustained serious injuries and was hospitalized after being dropped from a Hoyer. Per record review, LPA observed that R1 was not a resident at this facility. Interviews with S1-S11 and R2-R11 confirmed that there was not a resident by that name at the facility. The department has investigated the complaint alleging Neglect/Lack of Care and Supervision. We have found that the complaint was unfounded, meaning that the allegation was 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 to Executive Director Alisa Dean. Unfoundedthe state’s words, verbatim · CDSS document, Aug 27, 2026 · control 28-AS-20260825125213

Allegation investigated: Staff do not ensure the dining room is clean. Staff do not clean feces, blood, or urine off of common area surfaces. Staff retains residents whose presence poses a health and safety risk to other residents.

Licensing Program Analyst (LPA), Mayra Cota, conducted a subsequent complaint visit to investigate and deliver findings regarding the above-mentioned allegations. LPA met with Alisa Dean, Executive Director, and the reason for the visit was explained. During initial visit conducted on 6/11/2026, LPA obtained copies of staff and resident rosters, toured the common areas of the facility with a focus on inspecting the (2) resident dining rooms and kitchen, interviewed Staff 1 – Staff 11 (S1-S11) and Resident 1 – Resident 4 (R1-R4). LPA also reviewed and obtained copies of Server Duties log and facility file documents for (1) resident. During the span of the investigation, LPA interviewed Resident 5 – Resident 12 (R5-R12) and R1’s Hospice Nurse (HN). LPA attempted to interview staff person (SP); however, SP no longer works at the facility. The investigation revealed the following: ***Conitnues LIC 9099-C*** Unsubstantiated Regarding: Staff do not ensure the dining room is clean. It is alleged that the dining room chairs, tables, floors and walls are dirty and have been for weeks. It is also alleged that staff are supposed to mop and have the tables and floors clean and ready for the next mealtime but are not doing so and that dirty dishes are mixed with clean dishes. Staff deny the allegation. Five (5) staff who oversee and work directly in the kitchen’s operations indicated that chairs, tables, floors and walls in the dining room are cleaned daily and have not remained dirty for weeks. Chairs, tables, floors and walls are cleaned after each meal service and as needed. Clean and dirty dishes are not mixed. Procedures are in place to properly store clean and dirty dishes. Staff further indicated that the floors are mopped after lunch and dinner meal services or as needed. Eleven (11) out of (12) residents indicated that they are not concerned about the facility’s cleanliness because they consider the facility to be clean and sanitary, including the dining room. During inspection of the dining rooms, LPA observed. chairs, tables, floors and walls to be clean and sanitary. LPA also monitored the breakfast and lunch meal services and observed that staff cleaning and sanitizing high traffic areas. Furthermore, a review of the facility’s Server Duties Logs for May – June 2026, was conducted. It was observed that chairs, tables, floors and walls are part of the routine cleaning tasks executed throughout the day. An audit of the facility’s cleaning supplies was also conducted during the visit. LPA observed that the facility has sufficient cleaning supplies readily available for use. Interviews, observations and record review do not corroborate the allegation that staff do not ensure the dining room is clean. Regarding: Staff do not clean feces, blood, or urine off of common area surfaces. It is alleged that fecal matter has been on the walls in and outside of the dining rooms for weeks. It is also alleged that there is a presence of urine, blood and feces in the common areas which are not cleaned by staff. Staff deny the allegation. Interviews with (11) out of (11) staff indicated that the walls in and outside of the dining rooms do not have fecal matter, urine or blood. Staff stated that there is no presence of urine, blood or feces in the facility’s common areas. Staff also indicated that the walls around the facility are not left without being cleaned for weeks. Interviews with (6) staff who oversee and work within the facility’s food service department indicated that the dining rooms are cleaned after every meal service, which includes wiping down the walls. ***Continues on LIC 9099-C page 2*** Staff stated that staff routinely do spot checks to ensure that the walls and floors are clean, and if areas are observed in need of cleaning, they are cleaned in a timely manner. Staff further indicated that at times, residents lose bladder control while they are having their meal in the dining rooms; however, staff follow protocol to ensure that residents are removed from the dining area momentarily to be provided with personal hygiene care. Staff who oversee cleaning bodily accidents are then called in to properly clean and disinfect the soiled surfaces. Interviews with (8) out (12) residents indicated that they have not observed fecal matter or blood on the walls of the facility. Three (3) residents indicated that they do not eat in the dining areas but have not observed feces or blood on the walls of the facility. Eleven (11) out of (12) residents indicated that they are not concerned about the facility’s cleanliness because they consider the facility to be clean and sanitary. During inspection of common areas and dining rooms, LPA found all wall surfaces clean and free of dust, dirt, or biohazards. LPA also monitored the breakfast and lunch operations, observing that staff maintained proper cleaning protocols between services and routinely sanitized high-traffic areas. LPA also observed that staff are on hand to assist residents with their incontinent care needs during meal services if needed. Furthermore, a review of the facility’s Server Duties Logs for May – June 2026, was conducted. It was observed that the cleaning of walls is included as part of the routine cleaning tasks executed throughout the day. An audit of the facility’s cleaning supplies was also conducted during the visit. LPA observed that the facility utilizes commercial-grade cleaning products formulated to mitigate infection, eliminate pathogens, and prevent cross-contamination in food service and resident care areas. Interviews, observations and record reviews do not corroborate the allegation that staff do not clean feces, blood, or urine on common area surfaces. Regarding: Staff retains residents whose presence poses a health and safety risk to other residents. It is alleged that a resident has been physically abusive toward another resident and staff are not doing anything about it. Interviews with (6) staff revealed that staff provide care and supervision to residents who live in the facility, including behavioral intervention when necessary. Staff indicated that they are trained to respond to aggression between residents by re-directing and de-escalating. ***Continues on LIC 9099-C page 3*** Interview with S1 and S2 revealed that on 5/15/2026, R1 pushed R2 by the med-tech room after a verbal altercation ensued between both residents. S1 and S2 indicated that staff person (SP) reported to them that SP was able to prevent R2 from falling by placing space between both residents. S1 and S2 stated that the incident was reported to the proper authorities and R1’s Hospice Nurse (HN). S1 and S2 further indicated that staff are monitoring both residents to prevent further altercations and no other incidents have been reported. Interview with HN revealed that R1 experienced health changes which altered their behavior. RN stated that RN discussed a protocol with facility staff to monitor R1 for UTI and to continue to encourage R1 to take their medication to help prevent agitation. RN stated that they do not feel that R1 is a danger to other residents; however, RN has had 1:1 discussion with medtechs and caregivers to educate them about R1’s behavioral changes to prevent recurrences. SP, who provided intervention during the incident between R1 and R2 no longer works at the facility and was unable to be interviewed; however, interview with R2 revealed that SP intervened by preventing R2 from being hurt by R1. R2 stated that R1 pushed them but R2 did not fall because SP stepped in and de-escalated the situation. LPA interviewed R1; however, R1 did not provide information regarding the incident. Interviews with (5) out of (12) residents stated that they are aware that R1 is verbally aggressive sometimes, but do not feel unsafe around R1. Nine (9) out of (12) residents indicated that they feel safe living at the facility and that staff intervene appropriately when residents exhibit “aggressive” behaviors. Review of R1’s records revealed that R1 has been receiving Hospice services and has consistent care and monitoring since September 25, 2025, to present. Interviews and record review do not corroborate the allegation that staff retains residents whose presence poses a health and safety risk to other residents. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Alisa Dean, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 27, 2026 · control 28-AS-20260605145711

Type of visit: Case Management - Other

***This is a corrected version of the original report. The purpose of the report is to re-issue citation issued on 7/9/2026 which was dismissed by the department. On today's visit LPA is issuing a new citation for section 87303(a). Also, missing information on the narrative of LIC 809 has been added regarding details of why citations were issued on 7/9/2026. LPA met with Alisa Dean, Executive Director, and the reason for the visit was explained. Licensing Program Analysts (LPAs), Mayra Cota and Nune Margaryan, conducted an unannounced annual continuation visit on 7/9/2026. The following observations were made on 7/9/2026. The facility is licensed for 150 non-ambulatory residents, ages 60 and over, of which (20) may be bedridden. There is a hospice waiver approved for (20) residents. Currently, there are (12) residents receiving Hospice services. Facility is operating within the scope of its license. The facility is in a residential area of Temple City and consists of (89) resident rooms with bathroom included in each room, main entry lobby/lounge, (5) administrative office, medication room, kitchen, (2) dining rooms, (2) patios/courtyards, movie theater room, activities room, (6) staff/visitor restrooms, garden room/TV room, beauty parlor, staff break room, (2) maintenance/housekeeping storage rooms, laundry room, record room and parking lot. Furniture throughout the facility was observed clean and in good condition. Facility ramps were free of obstruction; however, stacked boxes with incontinent care and cleaning supplies were observed in front of the west doorway/exit unattended and obstructing the exit/entry way. Also, outdoor areas accessible through residents' rooms around the facility and back lot had broken furniture, piles of old mattresses, broken bedframes, wheelchairs, walkers, commodes/toilets, wooden pallets, cardboard boxes and AC filters. Shaded areas are available in the courtyard and smoking section in the secondary patio is kept clean. Outdoor furniture was observed to be in good repair and sufficient seating is available. ***Continues on LIC 809-C*** LPAs observed signal/auditory devices on (4) exit doors. Staff indicated that the facility recently installed the auditory devices; however, they are non-operational. LPAs observed the auditory devices to be non-operational during visit. R9's room was observed to have scissors and tweezers and outdoor passageway in their room had gardening tools, insect repellant and aerosol paint cans. LPAs also observed Tylenol (Acetaminophen) 500 mg. tablets, Vitamin C 500 mg tablets, and Allergy Relief nasal spray in the room of R1 who cannot manage their own medication, according to staff input. Kitchen was inspected and observed to have sufficient 2-day perishable and 7-day non-perishable supply of food. Food was observed to be kept properly stored and within expiration limits. Refrigerators and freezers maintain proper temperatures. Extra supply of food and water is kept in a secondary pantry. Serving trays were observed with cracks on the edges and baking trays had layers of burnt grease. Also, dishwashing area and equipment were observed unclean and hot water in the faucet was observed running and not fixed. Appliances in the laundry room were observed operational; however, the laundry room was observed unlocked and bleach and laundry detergent were kept accessible to residents. LPAs conducted inspection of the medication room during visit. Medication was observed centrally stored. During review of medication, LPAs observed that Resident 4 (R4) had a prescription for Acetaminophen 500 mg tablets (PRN), quantity 180, prescribed on 5/4/2026. LPAs observed that 60 tablets were missing from the medication supply. Staff indicated that R4 had recently left the facility for an extended period and took the Acetaminophen 500 mg tablets (PRN) and returned with the number of tablets observed by LPAs during medication review. Staff were not able to provide proof that inventory of the medication was conducted before and after R4 returned from extended leave to account for the missing (60) tablets. Staff were unable to determine the amount of tablets that were used by R4 during their leave. LPAs reviewed (6) staff and (10) resident files. Staff files contain background clearances, health screenings and training documents. Physician orders for half bedrails for (2) residents whose room was inspected during visit, were not present in the file. Staff were unable to provide them during visit. Above deficiencies were observed and noted on LIC 809Ds on 7/9/2026. Exit interview was conducted with Alisa Dean, Executive Director, and a copy of this report,new citation on LIC 809D and Appeal Rights, was provided.the state’s words, verbatim · CDSS document, Aug 27, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 4, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: LPAs observed signal/auditory devices on (4) exit doors. Staff indicated that the facility recently installed the auditory devices; however, they are non-operational. LPAs observed the auditory devices to be non-operational during visit.the state’s words, verbatim · CDSS document, Aug 27, 2026

Plan of correction: Licensee/Administrator will ensure that the auditory/signal system is working at all times. Licensee/Administrator will email proof of staff in-service and proof that the entire building's auditory/signal system and pendants were tested and are receiving the page within facility protocols response time by POC due date.

Allegation investigated: Staff do not provide a safe environment for resident.

Licensing Program Analyst (LPA) Alberto Lopez made initial 10 day unannounced visit to investigate the above allegation. LPA met with Destinee Yepez, receptionist and discussed the purpose of the visit. Administrator Alisa Dean met with LPA a short time later and assisted with the visit. The investigation consisted of LPA taking a tour of facility, reviewing and obtaining copy of staff and resident rosters, resident face sheet, physician's report, interviewing ten (10) Residents and four (4) staff. The investigation revealed regarding allegation Staff do not provide a safe environment for resident. It is alleged that staff do not provide safe environment for resident. LPA interviewed four (4) staff S#1 - S#4 and all four staff denied the allegation. Several staff stated that resident makes up allegations about roommates to be able to have the room without a roommate. LPA interviewed ten (10) residents and nine (9) of ten (10) residents did could not corroborate the allegation. Most residents feel safe at facility and LPA did not observe any health or safety concerns during the visit. (CONTINUED ON 9099C) Unsubstantiated (Continued from 9099) Resident stated to LPA that resident feels safe at facility. Resident stated that a staff was a witness to threat from another resident. LPA interviewed that staff and staff denied ever hearing any resident threaten that resident or any other resident at facility. Based on statements and interviews conducted with staff/residents, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 11, 2026 · control 28-AS-20260806082541

Allegation investigated: Staff speaks inappropriately to resident Staff withhold pain medication from resident Staff do not safeguard resident's belongings

Licensing Program Analysts (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegations. LPA met with Administrator Alisa Dean and explained the purpose of today's visit. The investigation consisted of the following: LPA obtained copies of Staff and Residnet Rosters, Conducted and Medication Review and Interviewed 5 Staff (S1-S5) and 10 Residents (R1-R10). (Continued on LIC9099-C) Unsubstantiated Allegation: Staff speaks inappropriately to resident It is alleged that S1 often speaks to residents disrespectfully, mocking, belittling, and dismissing requests for help. LPA interviewed 5 staff and each denied the allegation, stating that they have never spoken to residents inappropriately and have not seen other staff speak to them inappropriately, disrespectfully or being dismissive towards residents. Interviews with S1 and S2 revealed that S1 has a stronger voice that carries a louder tone but that S1 is not disrespectful or dismissive when speaking to the residents. LPA interviewed 10 residents and 9 out of 10 residents denied the allegation and stated they have never been spoken to inappropriately by staff and have not seen staff do this to other residents. Allegation: Staff withhold pain medication from resident It is alleged that S1 makes residents wait extra time, often one or two hours, for pain medication. LPA conducted a medication review and all medications for R1 including pain medication were accounted for and no issues were observed. LPA interviewed 5 Staff and each denied the allegation and stated that they do not hold medication for residents, interviews with S1 and S4 revealed that if medication is held it is because it is a PRN that has specific instructions where they cannot administer another dose within a certain timeframe, if resident’s ask for their medication prior to when they are able to administer they hold the medication and let the resident know they must wait and with what time they will be able to administer more medication, if pain is persistent they are offered to be transported to the hospital for further assessment . LPA interviewed 10 Residents and 8 out of 10 residents denied the allegation and stated they receive all their medication in a timely manner, and PRN is given rather quickly after asking for it. Allegation: Staff do not safeguard resident's belongings It is alleged that residents’ personal belongings go missing and S1 dismisses their concerns, stating they are just imagining things. LPA interviewed 5 Staff and each denied the allegation, staff stated that sometimes residents will make claims that belongings are missing and they will help the resident find their belongings, most times it is misplaced in their room or left in a common area and returned to the resident. S1 stated they do not dismiss these concerns and assist in finding, will look in common areas that the resident was previously at and search the lost and found, typically the item is found and returned to the resident. LPA interviewed 10 Residents and 8 out of 10 residents denied the allegation and stated they have never had items missing, residents stated at times they may misplace an item but staff will assist in finding their missing item. Based on statements and interviews conducted with staff/residents, and review of resident files, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 4, 2026 · control 28-AS-20260730090302

Allegation investigated: Staff do not respond to resident’s call button. Staff are not ensuring the residents are taking medication as prescribed.

Licensing Program Analyst (LPA), Mayra Cota, conducted a 10-day complaint visit to investigate the above-mentioned allegations. LPA met with Kim Griffin, Wellness Director, and the reason for the visit was explained. The investigation consisted of the following: During today’s visit, LPA obtained copies of staff and resident rosters, toured the facility including the medication room, reviewed medication for (1) resident, and interviewed (6) staff and (10) residents. LPA also obtained a copy of R1’s Physician Report and Care Plan and SIR dated 6/25/2026. The investigation revealed the following: ***Continues on LIC 9099-C*** Unsubstantiated Regarding: Staff do not respond to resident’s call button. It is alleged that resident pushed their call button two times and had to wait 30 minutes for staff to respond. It is also alleged that resident is being punished by staff by not answering to calls from resident due to praising a caregiver for assisting resident. Staff deny the allegation. Interviews with (6) out of (6) staff revealed that calls from residents get answered by staff. Staff indicated that staff do not make residents wait 30 minutes to respond when they request assistance from staff. Staff indicated that they respond to residents’ calls within five to ten minutes after a call is made. Staff stated that they do not use retaliatory punishment toward residents by not answering their calls when requesting assistance. Staff further indicated that calls from R1 are answered in a timely manner. Staff stated that they are properly trained in care, supervision, and resident rights and also, facility policy mandates that any form of resident punishment violates these rights and must be reported to the proper authorities. Interviews conducted with (9) out of (10) residents revealed that their calls to staff are answered within ten minutes. Residents also indicated that staff do not make them wait 30 minutes to receive assistance. Interviews conducted could not corroborate the allegation that staff do not respond to resident’s call button. Regarding: Staff are not ensuring the residents are taking medication as prescribed. It is alleged that resident has not been provided with their medication for approximately six hours. Staff deny the allegation. Interviews conducted with (4) staff revealed that staff are giving R1 their medication as prescribed. Staff stated that R1 was prescribed "as-needed" (PRN) pain medication following a fall on June 25, 2026. According to physician orders, this medication can only be administered every six hours as needed. Staff indicated that R1 is frequently requesting medication before the safety window closes and staff have to remind R1 that the pain medication is not part of their ongoing routine regimen and can only be taken “as needed.” Staff also indicated that R1’s doctor has prescribed the same PRN in a slightly higher dose so that R1 can take when pain may be more difficult to manage. Staff stated that R1 is given their PRN medication when they request it, but also, staff offer it during medication pass if time indicates that it is appropriate to be administered. LPA reviewed R1’s PRN medication and was observed to be given according to physician’s orders. Interviews with (9) out of (10) residents indicated that staff provide them with their medication as prescribed. Residents also stated that medication is provided by staff in a timely manner. Interviews and record review could not corroborate the allegation that staff are not ensuring resident is taking their medication as prescribed. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Kim Griffin, Wellness Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 23, 2026 · control 28-AS-20260721102329

Allegation investigated: Staff slammed resident's foot in door.

Licensing Program Analyst (LPA), Mayra Cota, conducted a subsequent complaint visit to deliver findings regarding the above-mentioned allegation. LPA met with Alisa Dean, Executive Director, and the reason for the visit explained. The investigation consisted fo the following: On 6/19/2026, LPA conducted an intial investigation visit and interviewed Staff 1 (S1) and obtained charting notes for R1. During today's visit, LPA toured the common areas of the facility, obtained staff and resident rosters, and during the course of the investigation, LPA interviewed Staff 2 - Staff 3 (S2-S3) and attempted to conduct interview R1 and Person 1 (P1). ***Continues on LIC 9099-C*** Unsubstantiated Regarding: Staff slammed resident's foot in door. It is alleged that staff slammed door on resident's food and resident does not feel safe around staff. Interview with S1 revealed that R1 was admitted to the facility on 11/14/2025; however, R1 had to be sent out to hospital on the same day they were admitted. S1 indicated that R1 was at the facility less than a day after being admitted to the facility. S1 further indicated that R1 remained in the hospital until 12/22/2025 and returned to the facility on 12/27/2025 but was then sent out to hospital again and did not come back to the facility due to serious illness. S1 indicated that during the initial day of admission and the four days R1 was at the facility, thereafter, R1 did not complain about staff slamming a door on their foot nor observed any injuries on R1. Interview with (2) out of (4) staff who were on shift when R1 resided at the facility indicated that R1 was not hurt by staff by a slammed door on their food or in any other way because residents are treated with care and dignity. Two (2) out of (4) staff indicated that they do not recall meeting R1 during their shift on 11/14/2025 and days between 12/22/2025 through 12/27/2025. Four (4) out of (4) staff stated that they do not slam doors on residents. Staff further indicated that they treat all residents with dignity and respect and any sign of resident abuse is reported immediately to the proper authorities. Interviews with (10) out of (10) residents indicated that they are treated with dignity and respect by staff and feel safe living at the facility. LPA attempted to conduct interviews with R1 and P1; however, call attempts were unsuccessful. Charting notes for R1 confirmed the days R1 lived at the facility; however, notes do not indicate noted injuries on R1 or complaint regarding an incident in which R1 had a door slammed on their foot by anyone. Based on interviews and record review, there is not enough evidence to corroborate with this allegation that staff slammed a door on resident's foot. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 28-AS-20260615091158

Type of visit: POC

Licensing Program Analyst (LPA), Mayra Cota, conducted a Plan of Correction Visit (POC) to follow up on deficiencies cited during annual continuation visit conducted on 7/9/2026. Upon arriving at the facility, LPA met Alisa Dean, Executive Director and explained the purpose of this visit. LPA was provided with copies of staff and resident rosters and a physical plant inspection was facilitated by Executive Director. The purpose of today’s visit is to follow up on the POCs that were due on 7/10/2026 and and also on 7/17/2026. The following citations were cleared today: CCR Section 87705(d) - Care of Persons with Dementia - staff provided proof of scheduled training for staff and date of completion of installation of the door auditory system which was sent to the Director by the Licensee. CCR Section 87309(a) - Storage Space and Access - LPA inspected the areas of concern and observed the them to be clean and free of obstruction. Director provided a copy of proof of purchase of a tool shed with the ability to be locked. CCR Section 87465(h)(2) - Incidental Medical and Dental Care Services - LPA inspected resident room and did not observe any unauthorized medication. Director also provided proof of in-service training and review of the regulation with staff. CCR Section 87307(d)(6)- Personal Accommodations and Services - LPA inspected the areas of concern and observed that the back lot and areas around the outdoor perimeter of the facility have been cleared of debris and obstructions. CCR Section 87555(b)(29) - General Food Service Requirements - LPA, inspected the kitchen and observed the areas of concern to be clean. LPA also observed that the cooking tools have been cleaned and tray cart has been ordered per proof of purchase receipt provided during today's visit. Exit interview was conducted with Alisa Dean, and a copy of the report and POC letters was provided.the state’s words, verbatim · CDSS document, Jul 16, 2026

Allegation investigated: Staff do not ensure facility vehicle is in good repair.

***This report supersedes the report dated 05/28/26. The superseded report was created to revise the regulation cited on the deficiency page LIC9099 D. The finding of the allegation remains as substantiated. *** Licensing Program Analyst (LPA) Tao conducted an unannounced subsequent visit on 07/02/2026 due to the revised citation. The initial visit was conducted by LPA Tao on 05/28/2026. Upon arriving at the facility, LPA met with Business Office Manger, Kuliema Blueford. LPA explained the purpose of today’s visit and discussed the allegation mentioned above to Administrator. The investigation consisted of residents/staff interviews, physical plant tour and facility records review. LPA obtained residents/staff roster, and residents’ facility files. (-continued on LIC 9099C-) Substantiated ***This report supersedes the report dated 05/28/26. The superseded report was created to revise the regulation cited on the deficiency page LIC9099 D. The finding of the allegation remains as substantiated. *** The investigation revealed that, in regard of facility staff do not ensure facility vehicle is in good repair, it is alleged that facility van sliding door is not working. Per resident interviews, one (1) out of twelve (12) residents interviewed was unable to comprehend the interview questions. Two (2) out of twelve (12) residents interviewed stated the facility van's sliding door was jammed. The rest of the nine (9) residents could not corroborate with the allegation. It was revealed that they were not aware of the facility van's sliding door is not working. Per staff interviews, all five (5) out of five (5) staff interviewed could not corroborate with the allegation. Per observation during the physical plant tour with the Administrator, the facility van's door was jammed, the door handle was missing which required a tool to unlatch the door when opening it. Therefore, the facility vehicle is not in good repair. Based on record review, observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Kuliema Blueford, Business Office Manager. The findings were discussed. Copies of LIC 9099s report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 28-AS-20260526115258

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87312 · Plan of correction due date: Jul 3, 2026

...Any vehicle used by the facility to transport residents shall be maintained in a safe operating condition. This requirement was not met as evidenced by: The facility van's sliding door is jammed and not operable. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Administrator agreed to repair the facility van's sliding door and submit the proof of repair to licensing by the POC due date. POC was cleared on 06/10/26.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual visit today. LPA met with Alisa Dean, Executive Director, and the reason for the visit was explained. The facility is licensed to serve adults age range 60 and over; approved for 150 non-ambulatory of which 20 can be bedridden; Hospice waiver approved for 20 residents. The facility is operating within the scope of its license. The facility is in a residential area of Temple City and consists of (89) resident rooms with bathroom included in each room, main entry lobby/lounge, (5) administrative office, medication room, kitchen, (2) dining rooms, (2) patios/courtyards, movie theater room, activities room, (6) staff/visitor restrooms, garden room/TV room, beauty parlor, staff break room, (2) maintenance/housekeeping storage rooms, laundry room, record room and parking lot. During today’s visit, LPA toured the physical plant. Facility was observed clean throughout. Hallways, walkways and exits are kept free of debris and obstructions. LPA inspected the common areas and randomly checked (10) resident rooms. Resident rooms have the required furniture, bedding, closet space and lighting. Bathrooms were observed clean and sanitary. Water temperature was tested in each bathroom and measured between 105.3 – 115.5 degrees F. which is within compliance range. Bathrooms have anti-slip mats and grab bars; however, shower side grab bar in room #143 and shower grab bar above faucet in room #112 are loose. Grabs bars were observed not properly bolted to the wall in both rooms. Call buttons in resident rooms were tested and working properly. Common areas have sufficient seating, and furniture is in good repair. There are no swimming pools or other bodies of water on the premises. Fire extinguishers were observed throughout the facility and are kept charged and operational. Fire extinguishers were last serviced on 8/21/2025. Laundry room is clean and appliances are operational. LPA also conducted interviews with (9) residents during the tour. Due to time constraints, LPA Cota will return to complete the annual inspection. Deficiency noted during today’s visit and a Civil Penalty was assessed for $250 for Repeat Violation. Exit interview was conducted with Alisa Dean, Executive Director, and a copy of this report, 809-D, Appeal Rights and LIC 421FC was provided.the state’s words, verbatim · CDSS document, Jun 30, 2026

Allegation investigated: Staff do not ensure that residents' incontinence needs are met. Staff do not maintain facility in good repair. Staff do not maintain facility sanitary. Staff do not allow residents to visit privately with licensing. Facility smells malodorous. Staff do not provide a safe environment for residents in care.

Licensing Program Analyst (LPA), Mayra Cota, conducted a 10-day complaint investigation visit regarding the above-mentioned allegations. LPA met with Alisa Dean, Executive Director, and the reason for the visit was explained. The investigation consisted of the following: During today’s visit, LPA obtained copies of staff and resident rosters, toured the facility, inspected the common areas of the facility including the television room and inspected (10) resident bathrooms. LPA, also conducted interviews with Staff 1 – Staff 8 (S1-S8) and Resident 1 – Resident 10 (R1-R10). The investigation revealed the following: ***Continues on LIC 9099-C*** Unsubstantiated Regarding: Staff do not ensure that residents' incontinence needs are met. It is alleged that staff leave residents in soiled diapers for extended periods of time. It is also alleged that resident sits in a soiled diaper in the dining room and staff leave resident there. Staff deny the allegation. Interviews with Staff 1 – Staff 7 (S1-S7) revealed that staff do not leave residents in soiled diapers for extended periods of time. Staff indicated that residents who require full incontinent care are checked routinely, every two hours or more if needed. Staff indicated that residents who are taken to the dining room by staff ensure residents’ diapers are checked and changed before taking them to eat. Staff stated that R2 has soiled their diaper while eating in the dining room; however, staff immediately return resident to their room and proceed to get them cleaned up. Interviews with (9) out of (10) residents indicated that staff assist with incontinent care in a timely manner and do not have concerns about how staff are conducting their checks. Interview with R2 revealed that staff change their diaper as soon as it is needed. LPA observed the breakfast and lunch meal services and noted caregivers doing wellness checks on residents in the dining rooms. Interviews and observations do not corroborate the allegation that staff do not ensure that residents’ incontinent needs are met. Staff do not maintain facility in good repair. It is alleged that toilet in resident room does not flush and resident has to lift up the toilet top and manually flush it. It is also alleged that many other residents’ toilets are in disrepair. Staff deny the allegation. Interviews with (7) out of (8) staff indicated that resident toilets are not in disrepair. Staff indicated that residents have not reported having toilets in disrepair. Staff stated that maintenance staff conduct regular monitoring of the physical plant and if a disrepair is observed, staff inform maintenance personnel as soon as possible to ensure repairs are conducted in a timely manner. LPA toured the facility and inspected (10) resident and (2) staff bathrooms and found the toilets to be operational. LPA inspected the toilet in the room mentioned in the report and found it to be operational. When LPA interviewed the (2) residents who live in the room with the toilet allegedly in disrepair, they indicated that the toilet has always been operational and has not presented any issues to the residents. Further interviews with (9) out of (10) residents indicated that their toilets are operational and have not caused any issues. Interviews and observations could not corroborate the allegation that staff do not maintain the facility in good repair. ***Continues on LIC 9099-C page 2*** Regarding: Staff do not maintain facility sanitary. It is alleged that resident urinate in the television room and the room smells like urine. Staff deny the allegation. Interviews with (8) out of (8) staff revealed that residents do not urine in the television room nor does it smell like urine. Staff indicated that the physical plant is regularly monitored to ensure cleanliness. Staff stated that the television room is cleaned daily and that residents have not reported smelling urine. Interviews with (9) out of (10) residents indicated that they have not observed residents urinating in the television room. Interview with R3 indicated that they have never urinated in the television room. Residents also indicated that they have not smelled urine in the television room. LPA inspected the television room and did not smell urine or any other foul odors. The television room was observed clean, and seating was free of odors and stains. LPA also observed throughout the facility, odor neutralizing spays which were working properly. Interviews and observations could not corroborate the allegation that staff do not maintain the facility sanitary. Regarding: Staff do not allow residents to visit privately with licensing. It is alleged that when licensing staff visit the facility, staff follow the licensing analysts around to prevent residents from speaking to licensing. Staff deny the allegation. Interview with (8) out of (8) staff indicated that staff do not follow licensing analysts around to prevent residents from speaking to them. Interview with S1 who facilitates visits from licensing analysts indicated that analysts are accorded privacy with residents during their visits. S1 indicated that analysts are provided with access to the facility’s conference room to conduct their interviews in private. S1 indicated that a resident reported recently that a staff member was standing too close to the door of the room, which was closed, and in which an analyst was conducting interviews on 6/18/2026. S1 stated that a staff member was observing a small crowd that gathered outside of the conference room as they waited to talk to licensing, only to provide care and supervision of the residents and to ensure that the hallway had clearance for other residents to walk safely around the crowd. During today’s visit, LPA conducted interviews by visiting residents in their rooms and staff did not impede LPA from talking privately to staff and residents. LPA also worked in the conference room and staff knocked before entering. Interviews with (9) out of (10) residents indicated that staff do not prevent them from talking to licensing or other agencies privately. Residents further indicated that they have no concerns about being able to talk privately to fellow residents, staff or other agency representatives. Interviews and observations do not corroborate the allegation that staff do not allow residents to visit privately with licensing. ***Continues on LIC 9099-C page 3*** Regarding: Facility smells malodorous. It is alleged that the TV room smells like urine which is not cleaned up by staff. Staff deny the allegation. Interviews with (8) out of (8) staff indicated that the TV room does not smell like urine. Staff indicated that the physical plant is regularly monitored to ensure cleanliness. Staff stated that the television room is cleaned daily and that residents have not reported smelling urine. Interviews with (9) out of (10) residents indicated that they have not observed residents urinating in the television room. Staff also indicated that they have not smelled urine in the television room. LPA inspected the television room and did not smell urine. The television room was observed clean, and seating was free of odors and stains. LPA also observed throughout the facility, odor neutralizing spays which were working properly. Interviews and observations could not corroborate the allegation that the facility is malodorous. Regarding: Staff do not provide a safe environment for residents in care. It is alleged that sometimes the television room has a specific capacity; however, staff allows too many residents to be in the room at one time, resulting in in overcrowding. Staff deny the allegation. Interviews with (8) out of (8) staff indicated that the television room is never overcrowded. Staff indicated that overcrowding has never been a concern due to only small number of people who visiting the television room. Staff stated that the room is typically observed to be used by five residents or less at a given time. Staff stated that the room is used more frequently in the evenings; however, crowds are always small and have not posed a safety concern. Interviews with (9) out of (10) residents indicated that the television room is never crowded and that they can safely spend time watching television. During today’s visit, three people were observed reading in the television room at different times by LPA. The television room has three doors and exits signs are clearly visible. No overcrowding was observed and exits were free of obstruction. Wheelchair access is available and there is sufficient space to house a crowd of about 10-12 people. Interviews and observations do not corroborate the allegation that staff do not provide a safe environment for residents in care. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Alisa Dean, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 19, 2026 · control 28-AS-20260616135038

Allegation investigated: Staff is not assisting residents with resident council.

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced subsequent visit to deliver findings regarding the above-mentioned allegation. LPA met with Alisa Dean, Executive Director, and the reason for the visit was explained. The investigation consisted of the following: On 4/21/2026, LPA Cota conducted initial complaint investigation visit and obtained copies of staff and resident rosters, toured the facility and conducted interviews with Staff 1 (S1) and Resident 1 – Resident 2 (R1-R2). LPA also obtained copies of Resident Council Meeting Minutes for 3/4/2026. During the investigation, LPA interviewed Staff 2 – Staff 4 (S2-S4) and Resident 3 – Resident 13 (R3-R13). LPA, reviewed and obtained copies of Resident Council Minutes, Election Results and Meeting Announcements flyers. The investigation revealed the following: ***Continues on LIC 9099-C*** Unsubstantiated Regarding: Staff is not assisting residents with resident council. It is alleged that facility staff were supposed to bring a box around the facility so that people can vote during resident council elections, but staff refused to do so. It is also alleged that staff refused to ask residents if they wanted to vote in the election. Interview with S1-S4 deny the allegation. Staff interviews revealed that staff assist residents with resident council. Staff indicated that resident council is a resident guided activity; however, staff assist when help is requested by residents. Staff stated that they assist with typing the Resident Council Minutes after approval from residents is provided, print and post the monthly meeting announcements and hand out flyers to residents in the common areas. During the week of resident council elections which took place on 4/15/2026, staff’s help was requested by residents to assist in creating the voting ballots, printing and posting flyers around the facility announcing the elections, and handing the flyers out to residents. Staff stated that they did not refuse to ask residents if they wanted to vote. Staff indicated that S2 and S3 walked room to room with a box and took the votes from residents who wanted to participate. Residents who did not want to participate in voting were reminded that the box was going to be in the front office so that they could cast their vote before 4/15/2026 in case they change their mind. Staff further indicated that announcements were made prior to the election, starting on 3/9/2026 during the monthly resident council meeting. Interviews with (8) out of (13) residents indicated that staff assisted them with voting in the resident council election. Four (4) residents indicated that staff walked around the facility with the ballot box and collected their votes in their room. Four (4) residents indicated that they placed their vote in the box that was in the front office. Three (3) residents indicated that they did not participate in the election but were offered by staff if they wanted to vote. Interviews with staff and residents could not corroborate the allegation that the facility is not assisting with resident council. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 19, 2026 · control 28-AS-20260417112412

Allegation investigated: Staff does not ensure residents special dietary plan is followed. Staff does not ensure residents care plan is being followed. Facility is not posting the resident council meetings notice for residents to view.

Licensing Program Analyst (LPA), Mayra Cota, conducted subsequent visit to deliver findings regarding the above-mentioned allegations. LPA met with Alisa Dean, Executive Director, and the reason for the visit was explained. The investigation revealed the following: During initial visit, LPA obtained copies of staff and resident rosters and toured the common areas of the facility with a focus on observing the lobby and the activities room. LPA also obtained a copy of Resident Council Minutes for 2/4/2026. During the span of the investigation, LPA toured the facility with a focus on observing the kitchen, bistro and lobby, conducted interviews with Staff 1 – Staff 13 (S1-S13) and Resident 1 – Resident (13), and reviewed and obtained copies of 3/4/26 Resident Council Minutes, election result and meeting announcement flyers. LPA also reviewed Care Plan and Physician’s Report for R1. The investigation revealed the following: ***Continues on LIC 9099-C*** Unsubstantiated Regarding: Staff does not ensure resident’s special dietary plan is followed. It is alleged that staff does not accommodate resident’s special dietary needs even though the information is noted in their file due to their health condition. It is also alleged that staff will not allow resident to have hot, vegan-based meals even though they cannot eat meals from the regular menu. Interviews with (9) out of (9) staff indicated that the facility ensures that residents’ dietary plans are followed. Seven (7) out of (9) staff indicated that they follow meal service guidelines to meet the dietary needs of residents, including those who have special dietary needs. Staff stated that R1’s dietary plan consists of having plan-based items which the kitchen has available. Staff indicated that the facility has an alternative menu which provides hot and cold vegetarian and vegan and plant-based options; however, R1 has not placed orders for those items, yet. Staff stated that R1 has been informed regarding the plan-based options. Staff also indicated that the kitchen makes meal accommodations for residents, including R1 according to their meal preferences if they provide reasonable advance notice to kitchen staff to ensure timely preparation. Furthermore, (3) staff have stated that R1’s Physician Report information regarding R1’s meal modifications have been discussed during in-service training with staff. Interviews with (12) out of (13) residents indicated that the facility provides meals which meet their dietary needs and have no concerns. LPA reviewed the kitchen’s Special Dietary Needs binder and observed that R1’s Physician Report and meal plan is in place. LPA observed the kitchen’s pantry and refrigerators and observed plant-based items readily available. Interviews, observation and record review cound not corroborate the allegation that the facility is not ensuring that resident’s dietary plan is followed. Regarding: Staff does not ensure resident’s care plan is being followed. It is alleged that day staff are supposed to check on resident every 2 hours, but instead neglect their care and don't follow their care plan. Staff deny the allegation. Interviews with (6) out of (6) staff indicated that staff are conducting wellness checks on residents according to their Care Plan. Staff indicated that R1 is checked (4) times per shift by caregivers and staff from other departments as indicated in R1’s Care Plan. Staff indicated that not only are wellness checks conducted in resident rooms, but also in the common areas and any place residents spend time in within the facility. Staff indicated that R1 steps out of their room during meals and other activities and therefore, staff check on R1’s well-being wherever R1 is at the facility, not just in their room. Staff indicated that R1 is sometimes sleeping and is not disturbed by staff during wellness checks and R1 may not notice staff checking in on them. Staff further indicated that they educate R1 on calling on staff in between checks if needed; however, R1 seldom makes calls to staff requesting a visit in between wellness checks***Continues on LIC 9099-C page 2*** Staff indicated that R1 has not reported being in danger of falling nor having epileptic episodes. Interviews with (11) out of (13) residents indicated that staff follow their Care Plan and conduct wellness checks in a timely manner. Review of R1’s Care Plan revealed that R1 receives (4) checks every shift. Interviews and review of records could not corroborate the allegation that staff do not ensure resident’s care plan is being followed. Regarding: Facility is not posting the resident council meetings notice for residents to view. It is alleged that staff are not posting the resident council meeting notices for residents to view. Staff deny the allegation. Interviews with (4) staff who assist residents with resident council activities indicated that they print and post the monthly meeting notices in the common areas and help distribute them to the residents. Staff indicated that resident council is a resident guided activity; however, facility staff provide help to resident council participants if the help is requested. Staff stated that monthly resident council notices are posted in the main lobby, bistro, activity room, dining rooms, and in the hallways. Staff further stated that as an additional courtesy for residents, staff post the meeting minutes in the bistro and the main lobby bulletin board. Interviews with (4) resident council participants indicated that the facility posts resident council notices about three to four days before the meetings take place, which are conducted on the first Wednesday of every month. Eleven (11) out of (13) residents indicated that staff post the resident council meeting notices around the facility and have observed flyers being passed out in the common areas of the facility. During tours of the facility conducted during the investigation by LPA, the Resident Council Minutes for meetings held on 2/4/2026 at 2:05 p.m. and on 3/4/2026 at 2:02 p.m. were observed on the bulletin board in the lobby by the main entry to the facility. LPA also observed the resident council election result flyers in the lobby’s bulletin board, bistro, hallways by the dining rooms and by the med-tech room. Facility binder with past meeting minutes, meeting notices and other resident council notes was reviewed and observed in the main office. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Alisa Dean, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 19, 2026 · control 28-AS-20260324142913

Allegation investigated: Staff do not follow resident's care plan Resident sustained several injuries due to staff neglect or physical abuse Staff are not following reporting protocols as necessary.

On 6/18/2026 at 09:30 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted two subsequent complaint investigations. The purpose of the visit was explained to Administrator Alisa Dean. During the visit on 6/15/2026, LPA interviewed 10 residents, who will be referred to as resident #1 through #10 (R1-R10). LPA took photos of a document titled " Communication with Administrator” from R1. LPA requested medical reports for R3, R4, and R11. R1 was reinterviewed during the visit. During the visit on 6/02/2026, LPA obtained the resident roster, staff roster, R1's care plan, and R1’s physician's report. LPA toured the facility with the Administrator. LPA interviewed the administrator and four (4) staff members, who shall be referred to as Staff #1 through Staff #4 (S1-S4). R1 was interviewed prior to the visit. Prior to the visit, LPA attempted to contact Staff #5-8 and left a voicemail for a return call. Report Continued on 9099c Unsubstantiated The investigation reveals the following: “Staff does not follow the resident's care plan. “It is alleged that staff have not been following R1’s new care plan since March of this year, which requires the facility to check on R1 4 times a shift. According to the administrator, the staff checks on R1 4 times a shift, but R1 does not like the staff in their rooms, and they are one of their independent residents. Staff check on R1 in the morning while R1 is sleeping, but don’t wake R1 because they don't like it. The administrator further stated that when R1 is out in the facility, staff visually check on them. All interviewed staff denied the allegation, stating that when R1 is around the facility, they visually check on R1. 1 out of 10 residents stated that although they are around the facility, they prefer staff to physically address them for it to count as a check. 9 out of 10 residents denied the allegation, stating that staff provide great care. LPA reviewed R1’s care plan and noted that it stated 4 times per shift, but it did not outline who conducts the checks or how they are to be conducted when the resident is not in their room. LPA also reviewed the document provided by R1, titled "Communication with Administrator." The document contained the dates and initials of night-shift staff who signed off, confirming they conducted checks on R1. When the document was presented to the administrator, they stated that it was not an internal document and that they had not seen it. The administrator stated that the signatures resembled R1’s handwriting and that staff had not informed them of the document. LPA attempted to contact the staff listed on the document and left a message for a return call. The investigation reveals the following: “Resident sustained several injuries due to staff neglect or physical abuse. “It is alleged that R1 received head trauma, fell, broke their nose, and had to be in the hospital. The administrator denied the allegation, stating that in February, the residents had a fall and bruised their faces, but refused to go to the doctor. The administrator stated that R1 eventually went to their own doctors and refused to provide the facility with discharge paperwork. 1 out of 4 staff members stated that when they checked on R1, they saw a bruise, and R1 refused to go to the doctor. They contacted the medtechs to check on R1. 1 of 4 staff members reported that R1 had a fall in February, resulting in a bruise. They further stated that R1 didn’t call anyone because R1 was drinking, and they believed R1 felt embarrassed. All staff denied neglecting or abusing the residents. 10 out of 10 residents denied that the facility neglected or abused them. Report continued on 9099c The investigation reveals the following: “Staff is not following reporting protocols as necessary. “It is alleged that the facility currently has a scabies outbreak and has a quarantine notice on residents' doors, but it was not reported to the health department or licensing office. Prior to the visit, LPA reviewed the facility's incident reports and did not note any incidents related to a scabies outbreak. The Administrator denied that there is currently a scabies outbreak but confirmed that there had been one in the past. During that time, the administrator stated that they had reported to the appropriate agencies. When asked about the isolation rooms, the administrator stated that no one is in isolation. All staff interviewed denied that the facility currently has scabies cases, but confirmed past outbreaks. 1 out of 10 residents stated R3, R4, and R11 have scabies. 3 out of 10 residents stated that they believe R11 may have had scabies for a couple of months due to a rash. 1 out of 10 stated they believed they had scabies. 1 out of 10 stated they are not sure if there are any current cases of scabies. 5 out of 10 stated there are no current cases of scabies. LPA toured the facility with the administrator and observed two resident rooms with bins in front of each room. The administrator stated they are not for isolation. LPA interviewed the residents in those rooms and did a file review to confirm they do not have scabies. LPA also conducted a file review for R3, R4, and R11 and did not observe a scabies confirmation from a physician. Based on LPA's interviews, the investigation revealed that, although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove whether the alleged violation did or did not occur; the allegation is UNSUBSTANTIATED. An exit interview was conducted with Administrator Alisa Dean, and a copy of this record was provided.the state’s words, verbatim · CDSS document, Jun 18, 2026 · control 28-AS-20260601152012

Allegation investigated: Facility staff did not provide adequate supervision resulting in a resident being attacked by another resident.

On 6/18/2026 at 09:30 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted two subsequent complaint investigations. The purpose of the visit was explained to Administrator Alisa Dean. During the visit on 6/15/2026, LPA obtained the resident roster, staff roster, physician's report for R2, notes and incidents for R2, and the admissions agreement for R2, and the house rules. LPA interviewed the administrator and four (4) staff members, who shall be referred to as Staff #1 through Staff #4 (S1-S4). LPA also interviewed 10 residents, who will be referred to as resident #1 through #10 (R1-R10). LPA attempted to interview a former staff member (FM). Prior to the visit, LPA attempted to contact the former staff member (FM) but was unable to interview them. Report Continued on 9099c Unsubstantiated The investigation reveals the following: “Facility staff did not provide adequate supervision, resulting in a resident being attacked by another resident. ”It is alleged that R2 attacked R1 while R1 was exiting the medication room. According to the incident report submitted on 5/16/2026 and the charting notes from FM, the altercation involved R1 asking R2 to move out of the way, and R2 refused to move. R2 pushed and grabbed R1, and R1 almost lost there balance. FM separated both residents. According to the administrator and all staff, R2 usually stays to themselves but is confused and easily irritable. They further stated that this is the first incident in which things have gotten physical involving R2. The police were notified and spoke to both residents. 3 out of 10 residents stated they do not know R2. 3 out of 10 stated they had never witnessed any physical incidents involving R2 but knew R2 to have a temper. They further stated they have heard rumors about R2. 1 out of 10 residents stated they have heard rumors but do not wish to talk about R2 because they are unsure if they are true. 2 out of 10 stated they have witnessed R2 becoming physically aggressive with either themselves or other residents. R2 denied being physically violent with the other residents and stated R1 was trying to control them. After reviewing R2’s file, it was concluded that R2 is not on a 1-1. Based on LPA's interviews, the investigation revealed that, although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove whether the alleged violation did or did not occur; the allegation is UNSUBSTANTIATED. An exit interview was conducted with Administrator Alisa Dean, and a copy of this record was provided.the state’s words, verbatim · CDSS document, Jun 18, 2026 · control 28-AS-20260605093049

Allegation investigated: Facility does not post outcome of complaint after investigation.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation on the allegation listed above. LPA arrived unannounced and met with Administrator, Alisa Dean. The purpose of the visit was explained. LPA obtained copies of the resident and staff rosters, weekly menu, and toured the kitchen. Interviews were held with seven (7) Staff and ten (10) Residents. The investigation revealed the following: Allegation - Facility does not post outcome of complaint after investigation. It is alleged that after a complaint investigation, the report is not posted. LPA did a walkthrough of the facility and did not observe Community Care Licensing reports posted in a conspicuous area, per the Health and Safety Regulations. Substantiated LPA interviewed ten (10) residents, and all stated that they have not seen any postings of the licensing reports. Staff interviewed have not seen or did not know that licensing reports are to be posted for public review. Based on LPA observations 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 and Chapter 03.2), are being cited on the attached LIC9099D. An exit interview was conducted. A copy of this report, plan of correction, and appeal rights were provided. LPA observed a physician’s order to provide Resident #1 (R1) with plant-based foods. Per interviews, the chef holds monthly chats with the residents regarding the food choices and accommodations. Residents were informed and asked to provide the chef with advance notice in order to prepare the plant-based ingredients. However, Resident #1 (R1) has not requested plant-based items after receiving a physician’s order. LPA interviewed ten (10) residents. Eight (8) out of ten (10) residents do not have any special diets. Three (3) stated that the chef would make accommodation upon request. Two (2) indicated that the facility offers vegan products. Based on information gathered, the facility is accommodating the residents’ dietary needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with the Administrator. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 28-AS-20260608121632

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.38(a) · Plan of correction due date: Jun 23, 2026

1569.38 Posting of licensing reports; disclosure to new residents (a) Each residential care facility for the elderly shall place in a conspicuous place copies of all licensing reports issued by the department within the preceding 12 months... This requirement is not met as evidenced by: Based on interviews and observation, the copies of licensing reports are not posted in a conspicuous place which poses a potential personal rights to residents in care.the state’s words, verbatim · CDSS document, Jun 16, 2026

Plan of correction: The licensee shall have copies of licensing reports in a visible area of the facility. A statement acknowledging this regulation and the location of reports is to submitted to LPA by 6/23/26.

Allegation investigated: Staff bribed resident. Staff spoke to resident in an inappropriate manner. Staff does not ensure facility's electricity is in good repair.

Licensing Program Analyst (LPA) Tao conducted an unannounced initial complaint visit to the facility. Upon arriving at the facility, LPA met with Executive Director/Administrator Alisa Dean. LPA explained the purpose of today’s visit and discussed the allegations mentioned above to Administrator. The investigation consisted of residents/staff interviews, physical plant tour and facility records review. LPA obtained residents/staff roster, and residents’ facility files. The investigation revealed the following: In regards of facility staff bribed resident, it was alleged that facility management staff offered the resident six months’ rent if resident wants to relocate. Per resident interviews, one (1) out of twelve (12) residents interviewed was unable to comprehend the interview questions. One (1) out of twelve (12) residents interviewed stated the management offered the resident six months’ rent for relocating to another facility. (-continued on LIC 9099C-) Unsubstantiated The rest of the ten (10) residents could not corroborate with the allegation. It was revealed that they had never been asked to relocate, nor offered any rent to relocate. Per staff interviews, all five (5) out of five (5) staff interviewed could not corroborate with the allegation. It was revealed that management was trying to help the resident by offering financial assistance if the resident wants to relocate to another facility per resident’s preference. Management indicated that any form of bribery was not allowed at the facility. Therefore, there was not preponderance of evidence that management or staff were bribing resident. In regards of facility staff spoke to resident in an inappropriate manner, it was alleged that staff talked to resident inappropriately. Per resident interviews, one (1) out of twelve (12) residents interviewed was unable to comprehend the interview questions. One (1) out of twelve (12) residents interviewed stated the management spoke to the resident inappropriately. The rest of the ten (10) residents could not corroborate with the allegation. It was revealed that staff spoke to them with respect and nicely. Per staff interviews, all five (5) out of five (5) staff interviewed could not corroborate with the allegation. It was revealed that staff cared about residents and spoke to residents with respect. Per observation during the physical plant tour, staff were nice to residents and talked to them politely. The interactions between residents and staff were friendly. Therefore, staff did not speak to residents in an inappropriate manner. In regards of facility staff does not ensure facility's electricity is in good repair, it is alleged that the facility has power outage for days. Per resident interviews, one (1) out of twelve (12) residents interviewed was unable to comprehend the interview questions. One (1) out of twelve (12) residents interviewed stated the facility had power outage for days and no one had come to repair the issue. The rest of the ten (10) residents stated that the facility had power outages for about 12 hours. It was revealed that staff had applied the emergency disaster protocol during the power outage. Per staff interviews, all five (5) out of five (5) staff interviewed stated the facility’s electricity went out was due to the power outage of the entire city. The electricity company did not notify the facility or the city and it was unexpected. Staff had applied emergency and disaster procedures to provide care to residents. Per record review, the administrator had notified Licensing regarding the power outage on 05/22/26, a sign was posted in the common area to inform residents about the electricity company’s scheduled power outage on 05/26/26, and additional back up generator was in place for that power outage. Since the power outage of the city on 05/22/26 was not scheduled, facility had applied their emergency disaster procedures and no incident of injuries or fall occurred during the outage, therefore, the facility was having an electricity outage instead of not in good repair. (-continued on LIC 9099C-) Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Alisa Dean, administrator. The findings were discussed and a copy of this report was provided. Per staff interviews, all five (5) out of five (5) staff interviewed could not corroborate with the allegation. Per observation during the physical plant tour with the Administrator, the facility van's door was jammed, the door handle was missing and required to use a tool to unlatch the door when opening it. Therefore, the facility vehicle is not in good repair. Based on record review, observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Alisa Dean, administrator. The findings were discussed. A copy of this report and appeal right were provided.the state’s words, verbatim · CDSS document, May 28, 2026 · control 28-AS-20260526115258

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 11, 2026

The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: The facility van's sliding door is jammed and not operable. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 28, 2026

Plan of correction: Adminsitrator agreed to repair the facilty van's sliding door or replace the van if needed. Adminsitrator will submit the proof of repair to licensing by the POC due date

Allegation investigated: Resident sustained an injury due to staff neglect. Staff do not answer call buttons. Staff did not report outbreak to required agencies.

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced 10-day complaint visit to investigate the above-mentioned allegations. LPA met with Alisa Dean, Interim Executive Director, and the reason for today’s visit was explained. The investigation consisted of the following: During today’s visit, LPA obtained copies of staff and resident rosters, conducted interviews with Staff 1 – Staff 8 (S1-S8) and Resident 1 – Resident 12 (R1-R12). LPA also obtained copies of R1’s Physician Report (LIC 602A), Care/Service Plan, staff schedules for 2/8 – 2/16/2026, charting notes for R1 for 2/15 – 2/17/2026, caregiver communication notes, and SIR dated 2/15/2026. The investigation revealed the following: ***Continues on LIC 9099-C*** Unsubstantiated Regarding: Resident sustained an injury due to staff neglect. It is alleged that resident’s care plan which indicates that resident has to be checked four times per shift is not being followed which has caused resident to fall causing head trauma and other injuries. Interviews with (5) out of (8) staff indicated that staff are conducting wellness checks on residents according to their Care/Service Plan. Staff indicated that R1 is checked (4) times per shift by caregivers and staff from other departments as indicated by R1’s Care/Service Plan. Staff indicated that not only are wellness checks conducted in resident rooms, but also in the common areas and any place residents spend time in. Staff indicated that on 2/15/2026, R1 sustained injuries to their face after experiencing an unwitnessed fall but was sent to the hospital for evaluation and medical attention, shortly after S2 reported seeing R1 with bruising during response to a call from R1 via call button. Interview with S2 revealed that R1 was assigned to their wellness check rounds on the day R1 experienced the fall and had been checking on R1 approximately every two hours since the start of their shift. S2 indicated that before S2 observed the bruises on R1’s face, S2 had conducted wellness checks at around 10:00 p.m., 12:00 a.m., 2:00 a.m., 4:00 a.m., and then at 5:00 a.m. when R1 called for help. Staff further indicated that staff adhere to wellness check policy by checking on residents according to their Care/Service Plan. S1 and S4 indicated that R1 was released from the hospital on 2/17/2026; however, since R1 is self-responsible, R1 did not share hospital after-visit summary information with staff indicating diagnosis of head trauma. Staff indicated that they continue to monitor R1as stated in their Care Plan. Interviews with (11) out of (12) residents indicated that staff are conducting wellness checks according to their needs and have no concerns. Review of R1’s Care/Service Plan and current Physician’s Report indicated that R1 is self-responsible and manages their medical decisions. Staff and resident interviews and record review do not corroborate the allegation that resident sustained an injury due to staff neglect. Regarding: Staff do not answer call buttons. It is alleged that on 2/16/2026, resident fell out of bed during the night shift (NOC), pressed their call button, but nobody aided resident until 4:00 a.m. It is also alleged that staff did not answer their call due to staff sleeping during their shift. Interview with S1-S4 indicated that staff named on the report (S5) was not scheduled to work in R1’s wing during the NOC shift (10:00 p.m. – 6:30 a.m.) on the day R1 experienced an unwitnessed fall which took place on 2/14/2026 into 2/15/2026 and therefore, could not have been observed sleeping during shift. Interview with S2 revealed that on 2/14-2/15/2026, S2, and not S5, was assigned to conduct rounds in R1’s wing during the NOC shit. S2 stated that S2 checked on R1 at around 4:00 a.m. and observed R1 to be in bed, awake and covering their face with their blanket. ***Continues on LIC 9099-C page 2*** S2 stated that S2 asked R1 if they were okay due to R1 seemingly concealing their face with the blanket. R1 indicated to S2 that they were okay and did not need anything at the moment. At around 5:00 a.m., S2 indicated that R1 called the front office using their call button and S2 proceeded to immediately check on R1. During room visit, S2 noticed redness and bruising on R1’s face and when asked, R1 stated to S2 that they fell as they attempted to walk to the bathroom. S2 indicated that even though R1 did not want S2 to report the incident, S2 proceeded to inform med-tech staff who then proceeded to call 911 to have R1 transported to the hospital for further assessment. S2 further indicated that they were not sleeping during their shift and responded to R1’s call as soon as call came into the office. Interview with S3 indicated that as soon as S2 reported R1’s injuries, S3 checked on resident and called 911. S3 further indicated that before 6:00 a.m., resident was transported to the hospital for further treatment. LPA made several attempts to call S5; however, S5 did not answer. Staff informed LPA that S5 is no longer working at the facility due to retirement. Interviews with (11) out of (12) residents indicated that that staff are answering their calls in a timely manner. Residents also indicated that they have not observed staff sleeping during their shifts. Staff schedules reviewed by LPA indicated that S5 was not scheduled to work in R1’s wing nor was it assigned to S5 to provide care for R1 during the NOC shift on 2/14/2026 into 2/15/2026. SIR received by the department on 2/17/2026 indicated that R1 received care from staff after their fall and was sent to the hospital for further assessment. Staff and resident interviews and record review could not corroborate the allegation that staff did not aid resident after a fall and after calling for help. Regarding: Staff did not report outbreak to required agencies. It is alleged that the facility currently has an outbreak of scabies and has not notified the Health Department or Community Care Licensing. Staff deny the allegation. Interviews with (8) out of (8) staff revealed that the facility does not have an outbreak of scabies. Staff indicated that the facility is not currently experiencing an outbreak of scabies among staff and residents and therefore reports have not been made to the required agencies. Staff indicated that the facility has protocol in place to mitigate outbreaks when they appear among the facility population. Interviews with (11) out of (12) residents indicated that they have not had scabies nor have they heard other residents express concern about an outbreak. Residents indicated that the facility is kept clean and do a good job in preventing scabies and other communicable illnesses. Staff and resident interviews do not corroborate the allegation that the facility did not report an outbreak to the required agencies. ***Continues on LIC 9099-C page 3*** Based on information gathered through staff and resident interviews, LPA did not find 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. Exit interview was conducted with Alisa Dean, Interim Executive Director and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 21, 2026 · control 28-AS-20260511121946

Allegation investigated: Facility staff did not safeguard resident’s belongings.

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced subsequent complaint visit to deliver findings regarding the above-mentioned allegation. LPA met with Alisa Dean, Interim Executive Director, and the reason for the visit was explained. The investigation consisted of the following: During initial 10-day complaint visit on 3/19/2026, LPA obtained copies of staff and resident rosters, toured common areas of the facility including the facility’s laundry room and conducted interviews with Staff 1 – Staff 4 (S1-S4) and Resident 2 – Resident 8 (R2-R8). During subsequent visit on 3/24/2026, LPA obtained copies of staff and resident rosters, toured common areas of the facility and conducted interview with Resident 1 (R1). During today’s visit, LPA toured common areas of the facility, obtained copies of staff and resident rosters, interviewed Resident 9 – Resident 12 (R9-R12) and attempted to interview Resident 13 (R13). During the course of the investigation, LPA also conducted a telephonic interview with Person 1 (P1). ***Continues on LiC 9099-C*** Unsubstantiated The investigation revealed the following: Regarding: Facility staff did not safeguard resident’s belongings. It is alleged that staff washed resident’s clothing but did not return two long sleeve shirts. It is also alleged that several other residents also had multiple items go missing or never returned. Staff deny the allegation. Interviews with (4) out of (4) staff who oversee and conduct laundry services in the facility indicated that residents’ clothes are returned to them after they have been washed by staff. Staff indicated that the facility has a protocol in place to prevent items from being lost or misplaced. Staff stated that clothing is washed and dried separately for each resident to ensure clothing and other articles are not mixed up with other residents’ items. Staff further indicated that residents who use the facility’s laundry services label each article with their name or initials, and some residents even add their room number directly to the label. Staff also stated that after clothes are washed, it is delivered to residents’ rooms by staff within a day or two after initial pick up. S2-S4 informed that residents have not reported lost clothing; however, items have been missorted during the wash and drying cycles but promptly found and returned to the owner. Staff acknowledge that sometimes staff incorrectly sort clothing during the laundry process, but staff work together to locate items as soon as possible. S2-S4 indicated that on 3/17/2026, R1 reported that when their clean laundry was returned, R1 was missing two shirts. S2 and S3 proceeded to look for R1’s shirts in the laundry room and helped R1 look in their room. S2 and S3 indicated that they located R1’s two “missing” shirts in a pile of R1’s own clothes in their closet as R1 observed and R1 apologized and thanked staff for helping locate them. Staff further informed that they ensure that R1’s clothes are properly washed and handled and have not lost any of R1’s clothes. Staff further indicated that they have not received reports regarding missing clothes, towels, toiletries and food from R2 or R2’s representatives. LPA conducted interview with P1, person who visits R2 and revealed that R2 had been misplacing some items due to being visually impaired. P1 indicated that some of R2’s clothes had gone missing; however, the facility has improved in safeguarding R2’s personal belongings and no longer has any concerns with R2’s things going missing. LPA attempted to conduct interviews with Resident 13 (R13) regarding the allegation, but they were not at the facility after several attempts visiting their room. Staff and resident interviews could not corroborate the allegation. Based on information gathered through staff and resident interviews, LPA did not find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. Exit interview was conducted with Alisa Dean, Interim Executive Director and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 21, 2026 · control 28-AS-20260311112646

Allegation investigated: Facility staff did not dispense medications as prescribed.

***This report supersedes the report dated 05/05/26 and was updated to correct the regulation cited on the deficiency page. No other changes were made, and the report findings remain unchanged.*** Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 05/05/2026 to deliver findings related to the above allegation. LPA met with Administrator Jacky Cortez and explained the purpose of the visit. The investigation included a review of the client roster, staff roster, medication technician and caregiver schedules, Medication Administration Record (eMAR) for the specified date, including medication review. LPA conducted interviews with nine (9) staff members and ten (10) residents. A facility walkthrough was conducted, including observation of resident bedrooms, common areas, medication storage areas, and other areas accessible to residents. Substantiated Allegation: Facility staff did not dispense medications as prescribed It is alleged that there were no personnel on-site to administer the daily morning medications to residents. During staff interviews, multiple staff reported that scheduled medication technicians (med techs) were not present at the start of the morning shift due to no-call/no-shows. Staff stated that residents inquired about their medications and that medication administration was delayed until additional staff arrived to provide coverage, resulting in a delay in the morning medication administration window. During resident interviews, residents reported that medication technicians (med techs) were not available and that the Administrator and Assistant Administrator provided coverage and administered medications. Residents stated that medications were administered late. A review of the Medication Administration Records (eMARs) indicated that medications were administered outside of the morning medication window of 7:00 a.m. to 9:00 a.m. Documentation reflected that medications were administered between approximately 9:30 a.m. and 12:30 p.m. A medication review was conducted, and medications were observed to be on hand at the facility. Based on LPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, May 14, 2026 · control 28-AS-20260427120552

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 19, 2026

(a) A plan for incidental medical ... care shall be developed by each facility. The plan shall encourage routine medical care and provide assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation, interviews, and record review, the licensee did not comply with the cited section, as the facility failed to ensure timely administration of morning medications as prescribed on 4/26/26. This deficiency poses an immediate risk to the health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, May 14, 2026

Plan of correction: Administrator shall submit a written plan by the POC due date outlining how medication administration training will be provided to staff to ensure compliance. Administrator shall provide proof of completed training, including sign-in sheets and training curriculum, to the Department by 05/19/2026.

Allegation investigated: Staff did not prevent resident from engaging in inappropriate behavior.

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced initial 10-day complaint visit regarding the above allegations. LPA Gonzalez met with Executive Director Alisa Dean and the purpose of the visit was explained. The investigation consisted of the following: LPA collected rosters for staff and clients. LPA obtained copies of files for Resident #1 (R1) consisting of Face sheet, Resident Agreement, Identification and Emergency Information, medical assessment, Resident Handbook, house rules, History and Physical noted dated 03/05/26. LPA toured the facility and interviewed staff #1-#8 (S1-S8) and residents #2-15? (R2-R15). continued on LIC9099C Unsubstantiated The investigation revealed the following: regarding “Staff did not prevent resident from engaging in inappropriate behavior,” it was reported that there is a resident who engages in indecent exposure by pulling out his private part and urinating all over inside the facility and outside near the facility patio, in front of other residents and residents have to walk around the puddles of urine. 6 out of 8 staff interviewed denied the allegation. S2 stated R1 has had accidents in their room but did not intentionally urinate in the patio or any other facility common areas. S3, S4 and S5 stated they had not received any complaints about any resident urinating in the facility patio or any other common areas, nor had they witnessed any residents urinating in the facility patio or common areas. 9 out of 14 residents interviewed stated they have not witnessed any residents urinating outside in the facility patio or any other common areas. R9 stated yesterday was the first time they had to walk around a puddle, possibly urine, but they thought someone had an accident and it was not done intentionally. R10 and R11 stated residents sometimes have accidents but do not think they are intentionally urinating around the facility. Based on interviews and record review, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Alisa Dean Executive Director.the state’s words, verbatim · CDSS document, May 7, 2026 · control 28-AS-20260428092146

Allegation investigated: Facility staff did not dispense medications as prescribed

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 05/05/2026 to deliver findings related to the above allegation. LPA met with Administrator Jacky Cortez and explained the purpose of the visit. The investigation included a review of the client roster, staff roster, medication technician and caregiver schedules, Medication Administration Record (eMAR) for the specified date, including medication review. LPA conducted interviews with nine (9) staff members and ten (10) residents. A facility walkthrough was conducted, including observation of medication storage areas. Substantiated Allegation: Facility staff did not dispense medications as prescribed It is alleged that on 4/26/26 there were no personnel on-site to administer the daily morning medications to residents. During staff interviews, multiple staff reported that scheduled medication technicians (med techs) were not present at the start of the morning shift due to no-call/no-shows. Staff stated that residents inquired about their medications and that medication administration was delayed until additional staff arrived to provide coverage, resulting in a delay in the morning medication administration window. During resident interviews, residents reported that medication technicians (med techs) were not available and that the Administrator and Assistant Administrator provided coverage and administered medications. Residents stated that medications were administered late. A review of the Medication Administration Records (eMARs) indicated that medications were administered outside of the morning medication window of 7:00 a.m. to 9:00 a.m. Documentation reflected that medications were administered between approximately 9:30 a.m. and 12:30 p.m. A medication review was conducted, and medications were observed to be on hand at the facility. Based on LPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, May 5, 2026 · control 28-AS-20260427120552

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 6, 2026

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation, interviews, and record review, the licensee did not comply with the cited section, as the facility failed to ensure timely administration of morning medications as prescribed on 4/26/26. This deficiency poses an immediate risk to the health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, May 5, 2026

Plan of correction: The Administrator shall submit a written plan by the POC due date outlining how medication administration training will be provided to staff to ensure compliance. Administrator shall provide proof of completed training, including sign-in sheets and training curriculum, to the Department by 05/19/2026.

Allegation investigated: Staff did not seek medical attention for resident in a timely manner.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegations. The purpose of the visit was discussed with Assistant Administrator Alisa Dean. The investigation consisted of the following: On 4/28/26 and today a physical plant inspection of common areas and indoor/outdoor area was completed. Record review and copies of relevant documents were obtained. A total of 14 residents and 9 staff were interviewed. *Pending: Sunday, April 26, 2026, timesheets were not provided due to corrections needed. Substantiated Allegation: Staff did not seek medical attention for resident in a timely manner. The complaint alleges that residents (R1 & R2) engaged in a physical fight that resulted in injuries in both residents that required medical attention i.e. 1st Aid care and the residents did not receive any care because there were no AM med-techs on duty on Sunday April 26, 2026. The alleged incident occurred between 6:30 AM- 7:00 AM. NOC shift med-techs are off at 6:00 AM. A total of 14 residents were interviewed. Residents stated staff typically evaluate and provide care on site if there are minor injuries, and residents are sent out for medical attention if needed. Both residents (R1 & R2) confirmed they sustained injuries that resulted in bleeding. Resident (R1) was injured in the right eyebrow area and R2 had face injuries near the upper lip and right arm area. Staff interviews revealed that there were no med-techs working the morning shift on 4/26/2026. Therefore, residents (R1 & R2) did not receive 1st Aid medical attention at the facility. When residents have minor abrasions or minor open wounds med-techs apply saline solution, A & D ointment, and bandage the affected area(s). However, since all of the med-techs scheduled that day did not show up to work, and the facility currently does not have a Wellness Director that would have evaluated resident (R1 & R2's) injuries, neither resident receive 1st Aid care and/or medical attention in a timely manner. The Administrator and Assistant Administrator arrived at the facility several hours later because there were no med-techs working the morning shift. The residents did not receive timely 1st Aid care for their injuries. Based on record review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, a deficiency was cited. An exit interview conducted with Assistant Administrator Alisa Dean. Due to printing issues the report was emailed. Allegation: Staff do not provide a safe environment for residents in care. It is alleged that on Sunday April 26, 2026, resident (R1) "slugged" resident (R2) causing a laceration in the eyebrow, lip, and arm. The complaint alleges staff are aware of resident behaviors that pose a risk to residents in care but the aggressive incidents are not addressed. According to information obtained, R1 has frequent aggressive behaviors towards other residents that lead to confrontations. It was also reported that there is a male resident that enters without consent the rooms of "vulnerable" females. A total 14 residents were interviewed. 11 out of 14 stated they feel safe, but acknowledged there are some residents that have aggressive behaviors due to mental disabilities. Residents confirmed the altercation/fight. Residents did not report knowledge of an alleged male entering female rooms. The alleged male was interviewed and stated they are invited into the rooms. A total of 9 staff were interviewed. The majority of staff stated the facility is safe. Interviews revealed that the resident altercation occurred between 6:30 AM- 7:00 AM, in the hallway outside the dining room. Resident (R1) hit R2's wheelchair and leg, and punched R2 in the face. Resident (R2) defended themselves and punched R1 back. Both residents sustained minor injuries that resulted in lacerations that bled. Kitchen staff notified staff via walkie-talkie of the incident. Resident (R2) called police later because staff did not notify law enforcement. Staff stated they did not call the police because R2 had already called the police. Due to insufficient information, the allegation cannot be supported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Assistant Administrator Alisa Dean. Due to printing issues the report was emailed.the state’s words, verbatim · CDSS document, Apr 30, 2026 · control 28-AS-20260427112401

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(j) · Plan of correction due date: May 21, 2026

Incidental Medical and Dental Care. In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated as having primary responsibility for assuring that each resident receives needed first aid and needed emergency medical services and for assisting residents as needed with self-administration of medications......This requirement was not met evidenced by: Based on interviews, the findings indicate that on Sunday, April 26, 2026, residents (R1 & R2) had a physical fight that resulted in minor injuries with bleeding that required 1st Aid, but since there were no med-tech working the morning shift they did not receive care. This poses a potential health, safety, and personal rights risk.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: Assistant Administrator agreed to submit: 1. A written plan of correction that addresses personnel shortages, staff schedules, and staff responsibilities. 2. In-service training

Allegation investigated: Staff do not ensure resident's bed is in good repair. Staff do not ensure resident's showering needs are being met. Facility is malodorous. Staff do not ensure facility is clean and sanitary.

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced 10-day complaint visit to investigate the above-mentioned allegations. LPA, met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained. The investigation consisted of the following: During today’s visit, LPA obtained copies of staff and resident rosters, toured the facility, inspected (12) resident rooms, conducted interviews with Staff 1 – Staff 11 (S1-S11), Resident 1 – Resident 12 (R1-R12) and R1’s Power of Attorney (P1). LPA also obtained copies of R1’s Facesheet, Power of Attorney Uniform Statutory Form and Skin Integrity Monitoring Forms for March 2026 – April 2026. The investigation revealed the following: ****Contiues on LIC 9099-C*** Unsubstantiated Regarding: Staff do not ensure resident's bed is in good repair. It is alleged that resident’s mattress was completely soaked and the bed was broken. It is also alleged that it was reported to staff, but staff have not done anything about it. Staff deny the allegation. Interviews with (11) out of (11) staff indicated that residents’ beds are in good repair and mattresses are monitored daily for cleanliness during wellness checks, incontinent care and housekeeping visits. Staff indicated that if beds are worn out, or become damaged, they are replaced immediately. Staff indicated that residents have not complained regarding having a broken bed or a soiled mattress. Seven (7) out of (11) staff indicated that mattresses are protected against spills with mattress covers which are cleaned and sanitized when they become soiled. Staff indicated that bedding is changed (3) to (4) times a week or as needed. Staff indicated that R1 puts extensive wear and tear on their bed and mattress during transfers; however, the facility has changed them out when needed. Staff further indicated that R1 has not complained about their bed being in disrepair or their mattress being soiled. Interview with R1 indicated that they have no concerns with the condition of their bed and mattress. LPA inspected (12) rooms (including R1’s) with (2) beds each and found the beds and mattresses to be in good repair. Beds had mattress pads, fitted sheets and were observed to be dry. Interview with (11) out of (11) residents indicated that their mattress and bed are in good condition and did not have concerns. Interview with R1’s Power of Attorney (P1) indicated that they visit R1 at the facility four times a week and has not observed any issue with R1’s mattress and bed. P1 indicated that R1 has worn out the mattress in the past, but facility staff changed it as soon as P1 requested it. P1 stated that during their visits, the mattress and bedding is clean and dry. P1 stated that R1 is doing well at the facility and staff are doing a good job in caring for R1. Staff and resident interviews, interview with P1 and LPA observations could not corroborate the allegation that resident’s mattress was completely soaked and their bed was broken. Regarding: Staff do not ensure resident's showering needs are being met. It is alleged that resident smelled badly and that resident had been asking staff to bathe them for one week and they would not do it. Staff deny the allegation. Interview with (8) out of (8) staff indicated that residents are bathed (2) times a week or more if needed. Staff indicated that R1 receives bathing assistance from staff; however, R1 sometimes refuses to bathe. Staff indicated that residents cannot be forced to bathe, but R1 is encouraged to do so (3) to (4) times during scheduled bath/shower days. ***Continues on LIC 9099-C page 2*** Staff further indicated that when R1’s declines to bathe, staff conduct a light sponge bath to prevent R1 from having body odor. R1 declined to talk to LPA regarding their bathing needs during interview; however, interview with R1’s POA (P1) indicated that R1 is clean and does not smell bad. P1 further indicated that staff meet R1’s showering needs as best as they can and do not force R1 to bathe. Eleven (11) interviewed residents indicated that they have no issue with their bathing needs. LPA reviewed R1’s Skin Integrity Monitoring Forms and found that R1 is receiving regular bathing assistance and attempts are documented when R1’s refuses their scheduled bath. Staff, resident and POA interviews and record review, do not corroborate the allegation that residents smells bad and that staff are not bathing resident when resident asks. Regarding: Facility is malodorous. It is alleged that resident’s room smells and the floor is sticky. Staff deny the allegation. Interviews with (11) out of (11) staff indicated that the facility is not malodorous. Staff indicated that residents’ rooms nor the common areas of the facility have bad smells or have sticky floors. Staff indicated that residents’ rooms and all common areas are cleaned regularly. Staff indicated that R1’ room is cleaned every day as scheduled by housekeeping staff and extra cleaning is conducted as needed. Staff indicated that R1 is visually impaired and at times may spill juice or milk on the floor, however, staff monitor R1’s room every hour to ensure spills are cleaned up if they happen. Interview with R1 indicated that their room is clean and they do not smell anything bad. Eleven (11) interviewed residents indicated that staff are cleaning their room and mopping their floor regularly. LPA inspected (12) resident rooms and did not observe floors to be unclean or sticky. During resident room checks and tour of the common areas, LPA did not sense foul odors. Interview with R1’s POA (P1) indicated that R1’s room is cleaned daily by facility staff and has no concerns regarding room smelling bad or floor being sticky. Interviews with staff, residents and POA and LPA observations could not corroborate the allegation that the facility is malodorous. ****Continues on LIC 9099-C page 3**** Regarding: Staff do not ensure facility is clean and sanitary. It is alleged that resident’s room is not cleaned on a regular basis. Staff deny the allegation. Interview with (9) out of (9) staff indicated that residents’ rooms and all common areas of the facility are cleaned regularly. Staff indicated that residents’ rooms are cleaned by housekeeping staff daily. Staff indicated that bedding is also changed (2) to (3) times a week but staff will check condition of resident bedding during incontinent care routine and will change it if needed. Staff further indicated that R1’s room is cleaned every day, and staff provide extra monitoring due to R1 being visually impaired and sometimes spilling their drink on the floor. Interview with R1 indicated that their room is cleaned by staff and did not express any issue with their room not being clean and sanitary. Interview with R2, R1’s roommate, indicated that their room is cleaned daily by staff and stated that all is well with their room. Interview with R1’s POA (P1) indicated that they visit R1 (4) times a week at the facility and R1’s room is always observed clean and sanitary. P1 further indicated that during P1’s visits to R1, they observed housekeeping staff clean R1’s room appropriately. During tour of the facility, LPA observed housekeeping staff cleaning resident rooms. LPA inspected 12 rooms, including R1’s, and observed the rooms and bathrooms to be clean. Common areas, hallways and outdoor areas were also observed clean. Ten (10) interviewed residents indicated that staff are cleaning their room and mopping their floor regularly. Residents also indicated that staff do a good job of cleaning their rooms. Staff, resident and POA interviews, and LPA observations do not corroborate the allegation that the facility is not clean and sanitary. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Jaqueline Cortez, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 21, 2026 · control 28-AS-20260413094900

Allegation investigated: Staff does not ensure contact information on filing a complaint is posted in the facility. Staff do not ensure residents care plan is being followed. Staff do not respond to call signal system for resident in care. Staff do not ensure resident is spoken to in an appropriate manner. Staff does not ensure proper food service sanitation practices are followed. Staff served contaminated food to residents in care.

*** This report supersedes the report dated 04/03/26. The superseded report was created to deliver a clarification of the allegations. The findings remain unchanged. *** Licensing Program Analyst (LPA) Tao conducted another unannounced subsequent visit today on 04/20/2026 to re-deliver the findings for clarifying the allegations. The initial visit was conducted by LPA Luis DeLeon on 10/21/25. The subsequent visit was conducted by LPA Tao on 04/03/2026. Today’s visit, LPA Tao met with Jacqueline Cortez, administrator. LPA explained the purpose of today’s visit and discussed the allegations mentioned above to the Administrator. The investigation consisted of residents/staff interviews, physical plant tour and facility records review. LPA obtained residents/staff roster, and residents’ facility files. The investigation revealed the following: (- continues on LIC 9099C -) Unsubstantiated *** This report supersedes the report dated 04/03/26. The superseded report was created to deliver a clarification of the allegations. The findings remain unchanged. *** In regards of facility staff does not ensure contact information on filing a complaint is posted in the facility, it is alleged that the administrator will not provide R1 with the corporate office contact number or fax number to assist R1 in filing a complaint with the corporate office. Per resident interviews, one (1) out of ten (10) residents interviewed stated that the corporate office contact information for filing complaints is not provided. Nine (9) out of ten (10) residents could not corroborate with the allegation. It revealed that residents had resident meetings regarding any issues and those issues could be sent to the facility management and corporate office directly. In addition, Adult Protective Services (APS) poster with its contact information for filing complaints was posted on the wall at the lobby entrance if residents wanted to file complaints. Per staff interviews, seven (7) out of seven (7) staff interviewed could not corroborate with the allegation. Administrator would provide the corporate office’s contact information to residents when residents request it. Besides filing complaints to corporate office, Ombudsman’s and Licensing’s contact information for filing complaints were posted at the entrance and accessible to residents. Per observation, posters with contact information for filing complaints were displayed at the lobby entrance. Each poster was in size of 2.5ft (H) x 1.5ft (W) which residents could easily see them. Therefore, the contact information on filing complaints was accessible to residents. In regards of facility staff do not ensure residents care plan is being followed, it is alleged that R1’s care plan indicates staff are supposed to check on R1 every two (2) hours; however, staff neglect R1’s care and do not check on R1 every two (2) hours to ensure R1 is okay. Per resident interviews, one (1) out of ten (10) residents interviewed stated the staff did not follow resident’s care plan to check on resident every two (2) hours when providing care to the resident. Nine (9) out of ten (10) residents could not corroborate with the allegation. It revealed that residents receive care as stated on their care plan and as needed. Per staff interviews, seven (7) out of seven (7) staff interviewed could not corroborate with the allegation. (- continues on LIC 9099C -) *** This report supersedes the report dated 04/03/26. The superseded report was created to deliver a clarification of the allegations. The findings remain unchanged. *** The Administrator and staff stated they followed residents’ care plans when providing care assistance to residents. Per record review, R1’s care plan did not state R1 needed to be checked on every two (2) hours. R1 was ambulatory, living independently. Thus, staff follow residents’ care plans when providing care to residents.In regards of facility staff do not respond to call signal system for resident in care, it is alleged staff did not respond to residents’ calls while in care. Per resident interviews, four (4) out of ten (10) residents interviewed stated the staff did not respond to their calls on a timely basis. Six (6) out of ten (10) residents interviewed could not corroborate with the allegation. Residents stated staff responded to their call within 10 minutes. Per staff interview, all seven (7) staff interviewed could not corroborate with the allegation. The Administrator stated all call systems are working. As staff indicated, the front office would inform caregivers or housekeepers to go to a resident’s room when a resident presses the call button. Front offices use walkie talkies to communicate with staff. The respond time would not be more than five (5) minutes and staff would always respond to residents’ calls. LPA conducted a random signal system test during today’s visit. LPA tested the signal system in multiple rooms. Staff responded to the calls within a minute and staff arrived at the residents’ rooms in less than ten (10) minutes. Therefore, staff would respond to residents’ calls. In regards of facility staff do not ensure resident is spoken to in an appropriate manner, it is alleged that staff say to R1 inappropriately, such as calling R1 fat regarding R1's weight. Per resident interviews, two (2) out of ten (10) residents interviewed stated staff did not speak to them with a good manner. Eight (8) out of ten (10) residents interviewed could not corroborate with the allegation. It revealed that staff were nice and show respect to the residents when speaking to them. Per staff interview, all seven (7) staff interviewed could not corroborate with the allegation. Staff treat residents with respect and dignity. Per observation, LPA observed residents in the hallway, dining room and activity room. Staff’s interaction with residents is friendly. Staff were nice to residents and residents looked happy when interacting with staff. (- continues on LIC 9099C -) *** This report supersedes the report dated 04/03/26. The superseded report was created to deliver a clarification of the allegations. The findings remain unchanged. *** Some residents would say hi to staff and staff would initiate a short conversation. Per record review, R1 had a history of fabricating stories. Therefore, there is not observed that staff are talking inappropriately to residents. In regards of facility staff does not ensure proper food service sanitation practices are followed, it is alleged that dietary staff did not wear hair nets and gloves while working in the dietary areas. Per resident interviews, two (2) out of ten (10) residents interviewed stated dietary staff did not wear hair nets and gloves. Eight (8) out of ten (10) residents interviewed could not corroborate with the allegation. It revealed dietary staff were wearing hair nets and gloves when serving food. Per staff interviews, all seven (7) staff interviewed could not corroborate with the allegation. Staff stated that wearing hair nets, putting on gloves, washing hands and changing gloves were required all time. Staff were trained in proper food handling. All leftover food and refused food trays were disposed. Disciplinary action would be taken if staff did not follow the protocol. Per observation, kitchen looked clean, food was all covered, and staff wore hair nets/ gloves. Therefore, no sanitation issues in the kitchen were observed. In regards of facility staff served contaminated food to residents in care, it was alleged hair was found in residents’ food plates. Per resident interviews, two (2) out of ten (10) residents interviewed stated they found hair in their food plates. Eight (8) out of ten (10) residents interviewed could not corroborate with the allegation. It revealed residents did not observe their food was contaminated. Per staff interview, all staff have not heard of any residents having hair in their food. Staff are required to wear hair nets. Per observation, dietary staff wear hairnets while working in the kitchen and serving food. Per record review, a communication note reported that the hair that was found in the food plate was placed by residents, not from the kitchen staff. Therefore, residents’ food was not observed to be contaminated. (- continues on LIC 9099C -) *** This report supersedes the report dated 04/03/26. The superseded report was created to deliver a clarification of the allegations. The findings remain unchanged. *** Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Jacqueline Cortez, administrator. The findings were discussed and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 20, 2026 · control 28-AS-20251015145335

Allegation investigated: Staff did not provide adequate supervision, resulting in a resident sustaining multiple falls. Staff did not seek timely medical attention for resident. Staff did not report incident to resident's representative in a timely manner. Staff did not provide emergency medical personnel with resident’s medical information. Staff withheld resident’s personal funds. Staff did not assist resident with incontinence care needs in a timely manner. Staff did not ensure resident was adequately fed.

Licensing Program Analyst (LPA), Mayra Cota, conducted subsequent complaint visit today to deliver findings regarding the above-mentioned allegations. LPA met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained. During initial 10-day visit on 2/3/2026, LPA obtained copies of staff and resident rosters, conducted tour of the facility and conducted interviews with Staff 1 – Staff 3 (S1-S3). LPA also obtained copies of R1's Facesheet, Care Plan, Physician's Report, Identification and Emergency Information (LIC 601) SIR dated 1/18/2026, charting notes screenshots for 1/18/2026 and R1's weight log. During today’s visit, LPA toured common areas of the facility, interviewed Resident 1 – Resident 10 (R1-R10) and through the course of the investigation, interviewed Staff 4 – Staff 9 (S4-S9). The investigation revealed the following: Unsubstantiated Staff did not provide adequate supervision, resulting in a resident sustaining multiple falls. It is alleged that resident has fallen twice at the facility and that staff did not properly supervise resident even though they knew resident was a fall risk. Staff deny the allegation. Interviews with (9) out of (9) staff revealed that staff are conducting safety checks and are providing proper care and supervision for residents to help prevent falls. Staff indicated that residents who are at risk of experiencing falls are provided with extra monitoring. Staff further indicated that the facility follows protocol which consists of residents being evaluated for injuries and if needed, are sent to the hospital, when experiencing a fall. Interviews with (6) out of (9) staff indicated that R1 experienced a fall on 12/27/2025 and on 1/16/2026 in R1’s room. During both incidents, R1 was checked for injuries immediately after staff responded to R1’s calls for help. R1 stated that they were not hurt and staff observed that R1 was able to move their extremities. Staff indicated that during both incidents, R1refused medical care after it was offered by staff and staff continued to monitor R1 for any changes in condition. Staff further indicated that R1 will attempt to get out of bed without requesting assistance; however, staff continue to educate R1 on the importance of calling for help when R1 needs help getting out of bed by using their call button before trying on their own. Staff stated that R1 can make their needs known. However, staff indicated that R1 gets agitated and wants to transfer from their bed to their wheelchair independently, even though R1 needs minimal assistance during transfers. Interview with R1 indicated that staff check on R1 during their rounds every two hours or more and that staff help R1 get in and out of bed when needed. Interviews with (9) out of (10) residents indicated that staff are conducting safety checks and provide them with support to prevent falls. Residents also indicated that staff are proactive if they need medical attention by calling their doctor or emergency services. Review of R1’s Care Plan indicates that R1 transfers independently, but Caregivers and Med-Techs can assist when needed. R1’s Physician’s Report notes that R1 can transfer to and from bed and does not have any motor impairments. Staff and resident interviews, and review of R1’s records, could not corroborate the allegation that staff did not provide adequate supervision resulting in a resident sustaining multiple falls. ***Continues on page LIC 9099-C page 2*** Staff did not seek timely medical attention for resident. It is alleged that resident often complains of pain during transfers and has asked to go to the hospital, but staff did not seek medical care until after two weeks of expressing pain. Staff deny the allegation. Interviews with (9) out (9) staff indicated that the facility calls emergency services for residents when they are experiencing pain and they request to be sent out to receive medical care. Staff indicated that staff will not wait two weeks to call emergency services for residents who are experiencing pain. Staff further indicated that R1 has not reported experiencing pain during transfers and that R1 can express their needs and will tell staff if R1 has pain and needs medical attention. Interview with S1-S4 indicated that on 1/18/2026 at around 6:00 p.m., R1 reported to staff that R1 was experiencing pain on R1’s rear-end. Staff stated that R1 was offered to be sent out to get medical attention; however, R1 declined to be sent out and stated that R1 would “tough it out.” Staff indicated that they provided R1 with pain medication and informed R1’s doctor who directed staff to monitor R1’s pain levels. Interview with R7, who assisted R1during this incident stated that R1 approached R7 in the Med-Tech room on the same day at around 6:30 p.m. and expressed experiencing 10 out of 10 pain on their rear-end. At this time, R1 requested to be sent out to the hospital. Staff then proceeded to prepare R1 to be transported to the hospital for treatment via Emergency Medical Transportation. During interview with R1, they could not remember the events of the day; however, R1 stated that R1 was sent to the hospital for his pain in a timely manner. Review of charting notes indicated that staff documented initial report from R1 for pain on 1/18/2026 and R1’s eventual transfer to hospital between 6:00 – 6:30 p.m. Review of Special Incident Report received by the department indicated that R1 was transferred to hospital for evaluation and treatment on 1/18/2026 30 minutes after initial report of pain by R1 at 6:00 p.m. Interviews with (9) out of (10) residents indicated that staff help them get medical attention in a timely manner and also help them with follow-up appointments with their doctors. Staff and resident interviews and record review could not corroborate the allegation that staff did not seek medical attention until after two weeks of resident expressing pain. ***Continues on page LIC 9099-C page 3*** Staff did not report incident to resident's representative in a timely manner. It is alleged that representative was not notified by staff that resident was taken to the hospital. Staff deny the allegation. Interviews with (5) out of (5) staff indicated that staff provide timely notification to family members, conservators, authorized representatives, Hospice Services or other responsible parties when residents are sent to the hospital for evaluation and treatment, as long as residents give the facility consent to inform. Staff revealed that R1 is self-responsible and has not authorized the facility to notify anyone if R1 is hospitalized or has experienced other unusual incidents. Staff further indicated that R1 can update at any time, their “Point of Care” information to allow facility staff to inform anyone R1 appoints as person who can be notified regarding hospitalization or other incidents experienced at the facility. Interview with R1 revealed that R1 called their family member when admitted to the hospital 1/18/2026 but did not provide further details. R1 indicated that staff did a good job in sending them to the hospital for care and to made their return to the facility from the hospital easy. Review of R1’s Identification and Emergency Information (LIC 601) form, does not list relatives or friends in section: Other Persons to be Notified in Emergency. Interviews conducted with (9) out of (10) residents indicated that the facility does a good job in maintaining communication with their authorized representatives and have no concerns. Staff and resident interviews and record review could not corroborate the allegation that representative was not notified by staff that resident was taken to the hospital. Staff did not provide emergency medical personnel with resident’s medical information. It is alleged that staff did not send medical information with resident when resident was transferred to the hospital. Staff deny the allegation. Interviews with (5) out of (5) staff revealed that they follow policy and procedures when sending out residents to the hospital when emergency services arrive. Staff indicated that residents are sent out to the hospital during emergencies with an “emergency packet” which includes their status of vitals taken by staff during assessment, Facesheet, medication lists and Physician Orders for Life-Sustaining Treatment (POLST) if applicable. ***Continues on LIC 9099-C page 4*** Staff also indicated that emergency medical personnel transporting residents must be informed if residents are on blood-thinners or if they have any specific health code. Staff indicated that on 1/18/2026, R3 and R7 prepared the "emergency packet" and gave it to emergency service personnel. R1 was transported to the hospital due to pain on their rear-end and took with them all the relevant documents needed by medical personnel. During interview, R1, stated that they could not recall if they observed facility staff providing emergency personnel with any documents; however, R1 stated that they had no issues being admitted to the hospital and R1 received medical attention as soon as R1 arrived at the hospital. Interviews with (9) out of (10) residents indicated that staff are competent and are meeting their needs. Staff and resident interviews could not corroborate the allegation that staff did not provide emergency medical personnel with resident’s medical information. Staff withheld resident’s personal funds. It is alleged that staff did not give resident’s funds to a person (P1) since resident was not returning to the facility after hospitalization. Staff deny the allegation. Interview with S1 indicated that P1 is not authorized to receive R1’s funds because they are not the payee or authorized to manage R1’s funds. S1, who oversees managing residents’ funds, revealed that P1is not authorized to receive R1’s funds because the facility is named as the payee on the Social Security Administration check for R1’s funds. S1 stated that they follow protocol that states that unused resident funds must be sent back to the Social Security Administration office. S1 indicated that per communication S1 had with R1 during hospitalization, there was no need to re-route R1’s funds which pay R1’s facility fees to the Social Security Administration because R1 was planning on returning to the facility after R1’s recovery. S1 indicated that R1’s diagnosis was not going to prevent R1 from returning to the facility and therefore, the funds were going to be used to continue payment of R1’s monthly facility fees. S1 indicated that R1 returned to the facility after their recovery on 2/25/2026. S1 further indicated that R1’s monthly fees have been paid and R1’s account is up to date with payments. Interview with R1 revealed that R1 has returned to live at the facility after their hospitalization. R1 stated that the facility is managing their funds appropriately and has no concerns. Interviews with (9) out of (10) staff indicated that facility staff are managing their funds appropriately. Staff and resident interviews could not corroborate the allegation that staff did not give P1 resident’s funds since resident was not returning to the facility after hospitalization. ***Continues on LIC 9099-C page 5*** Staff did not assist resident with incontinent care needs in a timely manner. It is alleged that staff wheeled resident to the dining room to eat but his clothing and wheelchair were soiled with feces because staff did not change him. Staff deny the allegation. Interviews with (6) out of (6) staff deny the allegation. Interviews with staff revealed that residents get help with incontinent needs to ensure residents are dry and comfortable. Staff indicated that R1 requires “full care” for incontinent needs and is assisted during shift rounds made by caregivers, and as needed in between checks. Staff further indicated that residents could request help with diapering and other personal hygiene tasks from caregivers at any time by using their call button. Interviews with S1-S4 indicated that R1 was not wheeled into the dining room with feces soiled wheelchair. S1-S4 indicated that R1 had a bowel movement during R1’s meal in the dining room and feces seeped out of R1’s incontinence briefs. S1-S4 indicated that S4 immediately wheeled R1 back to their room to clean R1. Interview with R1 indicated that their incontinent needs are being met by staff and staff promptly change R1 into dry briefs when needed. R1 further indicated that they do not have any concerns with their incontinent care. Interviews with (6) out of (10) residents with incontinent needs are checked by staff every one to two hours and they are being changed accordingly. Residents also indicated that staff do not leave them in soiled briefs. During tour of the facility, LPA observed sufficient incontinent supplies. LPA, also visited R1’s room and did not observe soiled surfaces or incontinent odors. Interviews with staff and residents and LPA observations, could not corroborate the allegation that staff did not assist resident with incontinent care needs in a timely manner. Staff did not ensure resident was adequately fed. It is alleged that resident weighed 126 pounds because staff would not assist resident with eating. Staff deny the allegation. Interviews with (9) out of (9) staff indicated that residents are being fed full meals and are also provided with snacks throughout the day. Staff indicated that they monitor residents’ appetite patterns for any changes, however, R1 has not experienced any loss of appetite and eats well. Staff further indicated that R1 eats in the dining room every day and does not miss any of their meals. R1 is provided with secondary portions when requested and has no impairments to prevent them from eating independently, although staff can assist if R1 needs assistance. LPA reviewed R1’s file and observed that there were no major fluctuations in weight from admission on 3/2/2023 to the present. R1’s weight has been between 125 – 130 lbs. Weight record does not indicate any significant drops of weight since admission. ***Continues on LIC 9099-C page 6*** Review of R1’s Care Plan and Physician’s Report indicated that R1 does not have any dietary restrictions and can eat normally. Interview with R1 revealed that they get plenty to eat and can eat independently. R1 stated that they eat in the dining room every day, but when they are feeling sick, staff deliver their food at bedside. R1 stated that they like the food and have enough to eat. R1 further indicated that they have no concerns about their weight. Interview with R2-R9 indicated that they like the food and are provided with 3 meals a day. Residents also indicated that snacks are offered throughout the day. Interviews with staff and residents and record review could not corroborate the allegation that staff did not ensure resident was fed adequately. Based on interviews, observation, and record review, although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, with Jacqueline Cortez, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 13, 2026 · control 28-AS-20260129160709

Allegation investigated: Staff does not ensure contact information on filing a complaint is posted in the facility. Staff do not ensure residents care plan is being followed. Staff do not respond to call signal system for resident in care. Staff do not ensure resident is spoken to in an appropriate manner. Staff does not ensure proper food service sanitation practices are followed. Staff served contaminated food to residents in care.

Licensing Program Analyst (LPA) Tao conducted an unannounced subsequent complaint visit to this facility. The initial visit was conducted by Luis DeLeon on 10/21/25. Upon arriving at the facility, LPA met with Jacqueline Cortez, administrator. LPA explained the purpose of today’s visit and discussed the allegations mentioned above to Administrator. The investigation consisted of residents/staff interviews, physical plant tour and facility records review. LPA obtained residents/staff roster, and residents’ facility files. The investigation revealed the following: In regards of facility staff does not ensure contact information on filing a complaint is posted in the facility, it is alleged that facility did not post contact information for filing complaints. Per resident interviews, one (1) out of ten (10) residents interviewed stated the corporate office contact information for filing complaints is not posted. (- continues on LIC 9099C -) Unsubstantiated Nine (9) out of ten (10) residents could not corroborate with the allegation. It revealed that residents have resident meetings regarding any issues and those issues can be sent to the facility management directly. Posters with the contact information for filing complaint are posted on the wall at the lobby entrance. Per staff interviews, seven (7) out of seven (7) staff interviewed could not corroborate with the allegation. Administrator would provide the corporate office’s contact information to residents when residents request it. In addition, posters with the contact information of Ombudsman and Licensing are posted in the entrance where residents can file a complaint. Per observation, posters with contact information for filing complaints are displayed at the lobby entrance where residents can easily see them. Each poster is in a size of 2.5ft (H) x 1.5ft (W). Therefore, the contact information on filing a complaint is available and posted in the facility’s public area. In regards of facility staff do not ensure residents care plan is being followed, it is alleged that staff do not follow resident’s care plan when providing care assistance to residents. Per resident interviews, one (1) out of ten (10) residents interviewed stated the staff did not follow resident’s care plan when providing care to resident. Nine (9) out of ten (10) residents could not corroborate with the allegation. It revealed that residents receive care as stated on their care plan and as needed. Per staff interviews, seven (7) out of seven (7) staff interviewed could not corroborate with the allegation. The Administrator and staff stated they followed residents’ care plans when providing care assistance to residents. Thus, staff follow residents’ care plans when providing care to residents. In regards of facility staff do not respond to call signal system for resident in care, it is alleged staff did not respond to residents’ calls while in care. Per resident interviews, four (4) out of ten (10) residents interviewed stated the staff did not respond to their calls on a timely basis. Six (6) out of ten (10) residents interviewed could not corroborate with the allegation. Residents stated staff responded to their call within 10 minutes. Per staff interview, all seven (7) staff interviewed could not corroborate with the allegation. The Administrator stated all call systems are working. As staff indicated, the front office would inform caregivers or housekeepers to go to a resident’s room when a resident presses the call button. Front offices use walkie talkies to communicate with staff. The respond time would not be more than five (5) minutes and staff would always respond to residents’ calls. LPA conducted a random signal system test during today’s visit. LPA tested the signal system in multiple rooms. Staff responded to the calls within a minutes and staff arrived at the residents’ rooms in less than ten (10) minutes. Therefore, staff would respond to residents’ calls. (- continues on LIC 9099C -) In regards of facility staff do not ensure resident is spoken to in an appropriate manner, it is alleged staff did not show respect to residents when speaking to them. Per resident interviews, two (2) out of ten (10) residents interviewed stated staff did not speak to them with a good manner. Eight (8) out of ten (10) residents interviewed could not corroborate with the allegation. It revealed staff are nice and show respect to the residents when speaking to them. Per staff interview, all seven (7) staff interviewed could not corroborate with the allegation. Staff treat residents with respect and dignity. Per observation, LPA observed residents in the hallway, dining room and activity room. Staff’s interaction with residents is friendly. Staff are nice to residents and residents look happy. Some residents would say hi to staff and staff would initiate a short conversation. Therefore, there is not observed that staff are talking inappropriately to residents. In regards of facility staff does not ensure proper food service sanitation practices are followed, it is alleged that dietary staff did not wear hair nets and gloves while working in the dietary areas. Per resident interviews, two (2) out of ten (10) residents interviewed stated dietary staff did not wear hair nets and gloves. Eight (8) out of ten (10) residents interviewed could not corroborate with the allegation. It revealed dietary staff were wearing hair nets and gloves when serving food. Per staff interviews, all seven (7) staff interviewed could not corroborate with the allegation. Staff stated that wearing hair nets, putting on gloves, washing hands and changing gloves were required all time. Staff were trained in proper food handling. All leftover food and refused food trays are disposed. Disciplinary action would be taken if staff did not follow the protocol. Per observation, kitchen looked clean, food was all covered, and staff wore hair nets/ gloves. Therefore, no sanitation issues in the kitchen were observed. In regards of facility staff served contaminated food to residents in care, it was alleged hair was found in residents’ food plates. Per resident interviews, two (2) out of ten (10) residents interviewed stated they found hair in their food plates. Eight (8) out of ten (10) residents interviewed could not corroborate with the allegation. It revealed residents did not observe their food was contaminated. Per staff interview, all staff have not heard of any residents having hair in their food. Staff are required to wear hair nets. Per observation, dietary staff wear hairnets while working in the kitchen and serving food. Per file review, a communication notes reported the hair found in the food was placed by residents, not from the kitchen staff. Therefore, residents’ food was not observed to be contaminated. (- continues on LIC 9099C -) Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Jacqueline Cortez, administrator. The findings were discussed and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 3, 2026 · control 28-AS-20251015145335

Allegation investigated: Facility is short-staffed.

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced subsequent complaint investigation visit to delivery finding regarding the above-mentioned allegation. LPA met with Jacqueline Cortez, Executive, and the reason for the visit was explained. The investigation consisted of the following: During the initial 10-day investigation visit on 2/14/26, LPA toured common areas of the facility, obtained copies of staff and resident rosters, interviewed Staff 1 – Staff 4 (S1-S4) and Resident 1 – Resident 14 (R1-R14). LPA also obtained a copy of the Electronic Health Record (EHR) Acuity Based Staffing Estimates. During today’s visit, LPA obtained copies of staff and resident rosters and toured the common areas of the facility. LPA also conducted interviews with Staff 5 – Staff 6 (S5-S6) during the span of the investigation. The investigation revealed the following: Substantiated Regarding: Facility is short-staffed. It is alleged that the facility is often understaffed by having only two staff available to care for residents in the PM and NOC shifts on weekends. It is also alleged that diapering, bedside meal trays and wellness checks are delayed due to only two staff being on hand to provide care during a shift. Interviews with (6) out of (6) staff revealed that the facility is short-staffed. S1-S6 indicated that there are days in which only two caregivers are providing care for the residents in the PM shift because the facility is unable to get coverage for staff who call-out staff. S1-S6 further indicated that due to staffing shortages, specifically on weekend PM shifts, services like wellness checks, bathing and incontinent care are delayed. Interview with S1 indicated that the facility follows the Electronic Health Record (EHR) Acuity Based Staffing Estimates to maintain staffing balance when scheduling staff for work; however, it has been difficult to follow the staff balance ratio populated by EHR due to the high number of staff call-outs particularly for the PM shift which is 2:00-10:00 p.m. S1 further indicated that the facility should have (6) caregivers scheduled to work in the AM, (6) caregivers in the PM and (4) caregivers in the NOC shift, scheduled to work every day for the number of residents who live in the facility and the level of care the residents need from caregivers. Interviews with S1-S2 indicated that during short-staffed days, the two to three staff who report to work will have to “run it,” which means that caregivers must divide up the assignments for care of residents between the staff on shift and additionally, provide care for residents on their workloads. S1 and S2 indicated that call-outs are immediately addressed by calling other staff who are off shift to come in to cover; however, staff cannot come in to cover. Interviews with (10) out of (14) residents revealed that caregivers are late doing their wellness checks in the P.M. shift, two to three times a week, especially on the weekends. Residents indicated that they noticed that only two caregivers are on shift to provide care for the whole facility population and indicated that having only two staff is not enough to provide proper care for the residents who live in the facility. Eight (8) out of (14) residents indicated that caregivers are late in responding to calls from residents and have had to wait more than 20-30 minutes past the scheduled time for assistance with baths and incontinent care. Review of the current Electronic Health Record (EHR) Acuity Based Staffing Estimates indicated that the facility should have (6) caregivers scheduled to work in the AM, (6) caregivers in the PM and (4) caregivers in the NOC shift, scheduled to work every day for the number of residents who live in the facility the average census of the facility is 140-150 for the past two months. However, the facility did not follow the EHR plan and per interviews, the facility is not using a staffing agency. ***Continues on LIC 9099-C page 2*** Based on information obtained from staff and residents during interviews, and review of facility’s staffing model, the allegation that the facility is short-staffed is corroborated. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations (Title 22), is cited on the attached LIC 9099-D. An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Mar 30, 2026 · control 28-AS-20260220104301

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a)(5) · Plan of correction due date: Apr 6, 2026

Plan of Operation 87208 (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49…(5) Staffing plan, qualifications and duties. This requirement was not met as evidenced by: based on interviews and record review, the facility has staffing shortages which have delayed wellness checks, bathing and incontinent care for residents which poses a potential risk for persons in care.the state’s words, verbatim · CDSS document, Mar 30, 2026

Plan of correction: Licensee/Administrator will send LPA a plan regarding how to keep staffing consistent. Administrator will also send LPA, an updated copy of the updated staff roster.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced Case Management – Other visit today to address second level appeals received by the department. LPA met with Jacquline Cortez, Executive Director, and the reason for the visit was explained. The appeals stem from a Required-1 year visit conducted by LPA Cota on 7/17/2025 in which deficiencies were issued for Section 87555(b)(27) General Food Service Requirements and Section 87303(e)(3) Maintenance and Operation. Review and response to the second level appeals have determined that the citation for Section 87555(b)(27) General Food Service Requirements has been changed from Type A to Type B deficiency. Civil Penalty is re-issued for the amount of $900 for not correcting POC by due date. Citation for Section 87303(e)(3) Maintenance and Operation has been dismissed. Exit interviews was conducted with Jacquline Cortez, Executive Director, and a copy of the report, 809-D, Civil Penalty (LiC 421FC) form and Appeal Rights was provided. .the state’s words, verbatim · CDSS document, Mar 24, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(27) · Plan of correction due date: Jul 25, 2025

General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on observation on 7/17/25, the licensee did not comply with the section cited above in that several live cockroaches were observed in the dishwashing area of the kitchen during visit, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 24, 2026

Plan of correction: Licensee will contract services for pest control to alleviate the presence of cockroaches. Licensee shall closely monitor the cockroach issue and have the pest control company treat the facility. Licensee will send LPA, invoice of pest control services by POC due date. POC is cleared.

Allegation investigated: Staff are interfering with the resident council

Licensing Program Analyst (LPA) Vaid conducted initial complaint investigation and was met by Administrator Jackie Cotez and reason for the visit was discussed. LPA Vaid requested, obtained and reviewed the following documents: staff roster, residents’ roster, Resident #1 and Resident #2 face sheet and physicians report. Resident Council Meeting Minutes. LPA Vaid interviewed staff and residents. Regarding the allegation: Staff is interfering with resident council. It is alleged that facility staff are interfering with residents’ council meetings by attending the residents’ council meetings. Three (3) of three (3) staff interviewed deny interfering with residents’ council meetings, according to staff they only are allowed to attend the meeting at the request of the council President and with majority approval from the residents at the meeting. Staff attended the last meeting on request of the residents. CONTINUED ON 9099C.............. Unsubstantiated During the last resident council meeting on 03/04/26, the staff attending were only assisting the Council President take the notes for the meeting minutes, during the exchange of ideas and concerns in the first half of the meeting the staff did not take part in the meeting and the meeting was conducted without the presence of any facility personnel according to residents interviewed. Eight (8) of ten (10) residents interviewed could not corroborate this allegation. According to the residents, the staff do not sit in during the entire meeting. Six (6) of ten (10) residents stated requesting staff person during last resident council meeting on 03/04/26 to assist resident council President with taking of the meeting minute notes. Three positions on the resident council are vacant and need to be filled, the residents intewrviewed stated the council President cannot multitask the vacant positions and take notes at the same time, therefore staff was requested by resident President and approved by majority of residents at the meeting to attend the resident council meeting and assist residents with taking minute notes for the council meeting. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted and copy of licensing complaint report was provided to Administrator Jackie Cortez.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 28-AS-20260305110842

Allegation investigated: Payment was not authorized by resident.

Licensing Program Analyst (LPA), Mayra Cota, conducted a subsequent complaint visit today to deliver findings regarding the above-mentioned allegation. LPA, met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained. The investigation consisted of the following: During initial visit conducted on 1/26/2026, LPA toured common areas of the facility, obtained copies of staff and resident rosters, interviewed Staff 1 – Staff 7 (S1-S7) and Resident 1 – Resident 9 (R1-R9). LPA, also reviewed and collected copies of R1’s Face Sheet, Residence and Care Agreement and Payer Adendum, Rent Payment receipts for April – December 2025, payment transaction history for September – December 2025 and Request for Refund report for January 9, 2026. Copies of facility’s Plan of Operation, Rent Payment Schedule, and Business Manager's itinerary for October 2025 were also obtained. During today's visit, LPA obtained copies of staff and resident rosters and toured the common areas of the facility. LPA also interviewed Staff 8 (S8) during the span of the investigation. ***Continues on LIC 9099-C*** Substantiated The investigation revealed the following: Regarding: Resident was not notified of payment made to the facility. It is alleged that the facility withdrew funds without notifying the resident. S1 and S8 deny the allegation. Staff indicated that R1 was notified verbally that R1 had an unpaid rent balance for the month of September 2025. S8, who is in charge of handling resident rent payments, indicated that S8 provided R1 with a verbal reminder that R1 still had a balance for unpaid rent for September 2025. S8 indicated that R1 was notified that a withdrawal for partial payment in the amount of $420.07 was made on 10/8/2025 after R1 verbally provided consent for S8 to move forward with the withdrawal. S8 further indicated that the withdrawal took place during a meeting with R1 in S8’s office on 10/8/2025. Interview with R1 indicated that a meeting with S8 on 10/8/25 did not happen. R1further indicated that they did not receive verbal or written notice reminding them about unpaid rent from September 2025, nor notification about the facility making the withdrawal on 10/8/25. During the investigation, it has been determined that there is not enough information to corroborate the allegation that resident was not notified of payment made to the facility. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Jacqueline Cortez, Executive Director, and a copy of this report was provided. The investigation revealed the following: Regarding: Payment was not authorized by resident. It is alleged that staff withdrew an additional $400 in October 2025 without authorization from R1 even though rent is automatically withdrawn each month. Interviews with S1 and S8 revealed that staff withdrew an additional $420.07 on 10/8/2025 for partial payment for September 2025 rent from R1’s account. Interview with S8, who is in charge of handling resident rent payments indicated that S8 provided R1 with a verbal reminder that R1 had a balance for the amount of $1,420.07 for September 2025 rent and therefore, R1 gave S8 verbal authorization to withdraw the money from R1’s account. S8 indicated that R1 authorized the withdrawal for the amount of $420.07 on 10/8/2025 as a partial payment for September 2025 rent and R1 agreed to pay the remaining $1,000.00 at a later time. S8 stated that S8 and R1 conducted a verbal payment plan so that R1 could pay off the remaining $1,000.00, but S8 did not document the terms of the payment plan at the time. S8 further indicated the authorization to withdraw the $420.07 from R1’s account was provided by R1 verbally, and nothing in writing was obtained from R1 to confirm the authorization from R1 to withdraw the additional $420.07 for September 2025 rent. Interview with R1 indicated that R1 did not authorize S8 to withdraw $420.07 on 10/8/2025 from R1’s account to pay off a portion of a balance for September 2025 rent. R1 indicated that R1 did not provide staff with verbal or written consent to withdraw the additional $420.07 on 10/8/2025. Interviews with R2-R9 indicated that they have no concerns with how the facility manages their rent payments. However, LPA review of payment history records indicated that on 10/6/2025, the facility processed a payment for October 2025 rent in the amount of $1,420.00 but also processed an additional payment in the amount of $420.07 on 10/8/2025. During record review, facility was unable to furnish email communications, correspondence or consent/authorization forms which would indicate that R1 authorized the additional withdrawal made on 10/8/2025 from R1’s account. Interviews and record review corroborate the allegation that staff withdrew an additional $420.07 from R1’s account without authorization. The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulation (Title 22), is being cited on the attached LIC 9099-D. An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report, 9099-D, and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 28-AS-20260114170504

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(3)(G) · Plan of correction due date: Mar 13, 2026

Admission Agreements (g) Admission agreements shall specify the following: (3) Payment provisions, including the following: (G) A comprehensive description of billing and payment procedures. This requirement is not met as evidenced by: Based on record review, Resident 1's admission agreement does not indicate rent payment provisions for payment procedures and proper notification to resident for outstanding balances if it applies, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: The licensee shall ensure the admission agreement specifies rent payment provisions, including description of billing and payment procedures. Licensee will also ensure that procedures for notification to residents for payments made or balances due (continues below) are also included in residents' admission agreement. The licensee shall review all the residents' admission agreements to ensure that regulation policies are included accurately. Licensee will submit a statement indicating the resident records have been reviewed and a statement acknowledging the regulation have been read by POC due date.

Allegation investigated: Staff yell at residents

Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced complaint investigation visit regarding above allegations. LPA met with Administrator Jackie Cortez and explained the reason for the visit. The investigation consisted of the following: LPA requested a copy of resident roster and staff roster. LPA obtained staff #4 (S4) file and completed a record review. LPA Gutierrez interviewed Administrator, staff 1-9 (S1-S9), residents 1-11 (R1-R11), and delivered findings. SEE LIC 9099C Unsubstantiated In regard to the allegation “Staff yell at residents “, It is alleged that S4 yelled at R1 for telling him/her how to do their job about taking care of their roommate R5 and R1 felt threatened when being told that. During interviews with Administrator and staff ten (10) out of ten (10) staff stated that they have never yelled at residents. Administrator stated R1 did voice their concerns to the front desk about that particular staff and that S4 was spoken to about the alleged incident and denied allegation. S4 stated that he/she never yells at the residents and on that particular day S4 was explaining to R1 that he/she knows how to take care of R5 and that R1 did not like that. S4 believes that R1 wants the room to his/herself therefore complains when staff doesn’t take R5 out of the room right away. During interviews with residents one (1) resident was confused and could not answer any questions, and six (6) out of (11) residents stated that staff has not yelled at them and they have never witnessed staff yelling at other residents. R7 stated that they do hear residents yelling and being aggressive toward staff and that if a resident is cussing at S4 he/she will throw up their hands and say, “I’m done and walk away”. R4 stated that staff is good and has no problems with them. Review of S4’s staff records indicated that S4 does not have any write-ups or disciplinary actions on file for not speaking to residents in a respectful manner or any other misconduct. 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 provided.the state’s words, verbatim · CDSS document, Feb 5, 2026 · control 28-AS-20260203102212

Allegation investigated: Staff changed residents care plan without residents consent.

Licensing Program Analyst (LPA) Mayra Cota conducted an unannounced subsequent complaint visit to investigate the above-mentioned allegation. LPA met with Jaqueline Cortez, Executive Director, and the reason for the visit was explained. The investigation consisted of the following: During initial visit on 1/30/2026, LPA obtained copies of staff and resident rosters, toured the common areas of the facility, conducted interviews with Staff 1 - Staff 3 and Resident 1 - Resident 12. LPA also obtained copies of R1's Care Plan. During today’s visit, LPA obtained staff and resident rosters and toured the common areas of the facility. LPA also conducted interviews during the span of the investigation with Staff 4 – Staff 9 (S4-S9). The investigation revealed the following: *****Continues on LIC 9099-C***** Unsubstantiated Regarding: Staff changed resident’s care plan without resident’s consent. It is alleged that staff changed resident’s care plan without resident’s consent. Staff deny the allegation. Interviews with Staff 1 – Staff 4 (S1-S4) revealed that staff have not changed resident’s (R1) Care Plan without their consent. Staff indicated that staff have not made changes to R1’s Care Plan. Staff indicated that in order to make changes to a resident’s Care Plan, a re-evaluation from the wellness staff must be conducted before determining if changes to residents’ Care Plan need to be made to best meet their needs. Interview with S1-S3 indicated that R1 has not been re-evaluated to determine if a change to their Care Plan is warranted. S1-S3 further indicated that R1’s Care Plan continues to stand since R1 was last assessed by staff on 10/21/2025. Interview with S5-S9 indicated that they are not part of the team who determines if changes need to be made to residents’ Care Plans and were unable to provide information regarding the allegation. Interview with R1 indicated that staff are trying to make changes to R1’s Care Plan without R1’s consent. However, file review conducted by LPA revealed that R1’s Care Plan is still current and there have been no changes since 10/21/2025. Interviews with R2 – R12 indicated that their needs are being met by facility staff and have no concerns regarding their Care Plan being changed without their consent. Based on interviews and record review, the allegation that staff changed resident’s Care Plan without resident’s consent could not be corroborated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 3, 2026 · control 28-AS-20260126094305

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Mayra Cota, completed this Case Management-Deficiencies during a complaint investigation visit. During tour of the common areas of the facility, LPA observed the (2) resident dining rooms, which are missing floor tiles/panels in the main dining room by kitchen door under a table and between the doorway which leads into the secondary resident dining room. Both affected areas have lifted edges and grime accumulated on the surface creating a trip hazard. Deficiency cited under California Code of Regulations Title 22. Refer to LIC 809D. Exit interview conducted with Jacqueline Cortez, Executive Director and a copy of this report and Appeals Rights were provided.the state’s words, verbatim · CDSS document, Feb 3, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Mar 3, 2026

87303(a)(1) Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met as evidenced by: during inspection of (2) resident dining rooms, missing floor tiles/panels were observed in the main dining room by kitchen door under table and between doorway to secondary resident dining room. Both affected areas have lifted edges and grime accumulated on the surface creating a trip hazard, which poses a potential health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Licensee will replace missing floor tiles/panels in both areas of the dining rooms and will send LPA photos of the repairs/corrections by POC due date.

Allegation investigated: Staff are not ensuring that facility is clean and sanitary after meal services. Staff do not follow resident’s care plan.

Licensing Program Analyst (LPA), Mayra Cota, conducted a subsequent complaint visit to continue with the investigation regarding the above-mentioned allegations. LPA met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained. The investigation consisted of the following: During initial 10-day complaint visit, LPA obtained copies of staff and resident rosters, conducted tour of the facility with a focus on inspecting the resident dining rooms and conducted interviews with Staff 1 – Staff 4 (S1-S4) and (7) residents. LPA also obtained copies of Care Plan for R1 and Plan of Operation. During today’s visit, LPA obtained copies of staff and resident rosters, inspected the two facility dining rooms for residents, conducted interviews with Staff 5 – Staff 11 (S5-S11) and Resident 8 – Resident 12 (R8-R12). LPA also reviewed and obtained copies of Mealtime Schedules, Server Duty Logs for the month of January 2025. ****Continues on LIC 9099-C Substantiated The investigation revealed the following: Regarding: Staff are not ensuring that facility is clean and sanitary after meal services. Regarding: Staff are not ensuring that facility is clean and sanitary after meal services. It is alleged that staff are leaving food out on the tables when returning for lunch and dinner, not cleaning tables and chairs, sweeping floors and leaving food on walls when residents spill something. Interviews with (6) out of (11) staff who work directly in the kitchen and dining rooms indicated that the two resident dining rooms are cleaned before and after every meal service. Staff indicated that tables and chairs are cleaned and sanitized, floors are swept and mopped 2-3 times a day and spills are wiped down immediately. However, staff indicated that sometimes time is limited during cleaning and staff are unable to do more frequent cleaning of the walls and baseboards which have stains from drinks and food. Interview with S1 and S7 further indicated that walls, baseboards and some areas of the floors are hard to clean due dated surfaces. Interviews with (11) out of (12) residents indicated that they have no concerns regarding the dining rooms not being kept clean by staff. However, LPA inspection and observation of the two dining rooms during and after meal services revealed that several walls and baseboards have splattered stains from drinks and other food particles. LPA also observed dirt and grime stains around the corners of the floor by the grand piano and doorways in both dining rooms. Interviews with staff and LPA observation corroborate the allegation that staff are not ensuring that the facility is clean and sanitary after meal services. Regarding: Staff do not follow resident’s care plan. It is alleged that staff are not checking on resident every two hours as stated on their care plan. Interviews with (6) out of (11) staff revealed that residents who are “independent” and do not require incontinence care are checked on “frequently” during a work shift which is 7.5 hours a day. Staff indicated that residents get visits from staff three times per shift if they are considered independent and do not require incontinence care which would be noted on their Care Plan. Interview with S1-S3 indicated that R1 is now receiving “frequent” checks due to being “independent” and not needing incontinence care. Staff further indicated that “frequent” checks for R1 are a minimum of 2 checks, maximum 3 checks per shift. However, review of R1’s Care Plan in R1’s resident file indicated that R1 has “safety checks – 4 times per shift.” Further interviews with S1 and S2 indicated that no changes to R1’s current Care Plan have taken place and therefore, the Care Plan stands. *****Continues on LIC 9099-C page 2***** Interviews with (11) out of (12) residents indicated that their needs are being met by facility staff; however, staff interviews and record review corroborate the allegation that staff do not follow resident’s care plan. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations (Title 22), are being cited on the attached LIC 9099 D. An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 28-AS-20260122151256

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

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: inspection and observation of the two dining rooms during and after meal services revealed that several walls and baseboards have splattered stains from drinks and other food particles. Also observed dirt and grime stains around the corners of the floor by the grand piano and doorways in both dining rooms.the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: Licensee will be paiting walls and baseboards and will do a deep clean on the floors to remove the grime througt the floors of both dining rooms. Licensee will send photos of the corrections by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Feb 6, 2026

87208(a) Plan of Operation (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so... This requirement was not met as evidenced by: R1's Care Plan indicates safety checks to be conducted 4 times per shift; however, staff indicated that staff conduct safety checks 2 to 3 times per 7.5 hour shiftthe state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: Licensee will conduct an in-service training regarding following resident care plans to meet their needs and provide LPA proof of training via sign-in log and training topics and agenda.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced Case Management – Other visit today to address appeals received by the department on 8/7/2025. LPA met with Jacquline Cortez, Executive Director, and the reason for the visit was explained. The appeals stem from a Required-1 year visit conducted by LPA Cota on 7/17/2025 in which deficiencies were issued for Section 87555(b)(29) General Food Service Requirements and Section 87303(e)(3) Maintenance and Operation. Review and response to the appeals have determined that the citations mentioned above have been changed from Type A to Type B deficiencies. During today’s visit, LPA will re-issue both citations as Type B on LIC 809-D. Exit interviews was conducted with Jacquline Cortez, Executive Director, and a copy of the report, 809-D and Appeal Rights was issued.the state’s words, verbatim · CDSS document, Jan 30, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(3) · Plan of correction due date: Feb 2, 2026

Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by not having the warning sign posted by the kitchen dishwashing sink for water delivered at 125 degrees F. during inspection which poses a potential safety risk for kitchen staff/empoyees.the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: Licensee will post the warning sign above or by the kitchen dishwashing sink by POC due date and send LPA a photo as proof.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(29) · Plan of correction due date: Feb 2, 2026

General Food Service Requirements b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above in that two dry food containers for rice and oatmeal had broken lids and content was exposed during time of visit, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: Licensee will replace broken dry food containers to ensure lids are tight-fitting by the POC due date. Licensee will send a copy of purchased containers and photo of the replaced containers along with their lids.

Allegation investigated: Resident died due to staff neglect. Staff handles resident in a rough manner. Facility restroom is not accessible to wheelchairs. Staff are not responding to resident’s call button in a timely manner. Staff does not provide a comfortable room temperature for resident.

Licensing Program Analyst (LPA), Mayra Cota, conducted a subsequent complaint visit today to deliver findings on the above-mentioned allegations. LPA met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained. LPA was provided with copies of staff and resident rosters and a tour of the common areas of the facility was also conducted. The investigation conisted of the following: On 12/4/2025, LPA conducted initial investigation visit and did the following: LPA obtained copies of Resident 1 (R1)'s: Facesheet and Emergency Information, Physician's Report, Care Plan, Appraisal, Needs and Service Plan, Death Report, Death Report Worksheet, Physician Orders for Life-Sustaining Treatment (POLST) form and Medication Administration Record (MAR) for August - November 2025. During today’s visit, LPA will render findings after having interviewed Staff 1 – Staff 11 (S1-S11), Resident 2 – Resident 11 (R2-R11) and Resident 1’s (R1) family member (P1) and reviewed relevant document pertaining to R1 in the span of the investigation. ***Continues on LIC 9099-C page 1*** Unsubstantiated The investigation revealed the following: Regarding: Resident died due to staff neglect. It is alleged that a resident passed away from choking on their food. It is also alleged that resident’s food may have required cutting. Staff deny the allegation. Interviews with (10) out of (11) staff revealed that R1 did not die from choking on their food and staff also indicated that R1 did not require their food to be cut. Staff stated that R1 did not need any dietary accommodation like cutting, chopping, pureeing, mincing or liquifying their food. Staff indicated that R1 passed away on 11/25/2025 at 9:45 p.m. in R1’s room as R1 rested in bed. Interview with S1, S2, S3 and S10 revealed that S3 called a STAT upon entering R1’s room for a routine wellness check. S3 indicated that R1 was observed gasping for air and immediately radioed base for help with R1. S10 indicated that they immediately answered the STAT call from S3 and observed R1 in bed gasping for air. S10 indicated that they proceeded to elevate R1 to an upright position and started a check for vitals as other staff called 911. S10 could not get a reading from R1’s oxygen and blood pressure due to both being low. S10 indicated that medics arrived shortly after and did not procced to attempt resuscitation due to R1 having a Do Not Resuscitate (DNR) document in place. S1, S2, S3 and S10 indicated that R1 was pronounced deceased at 9:45 p.m. by medics due to “Respiratory Failure.” S2, S3 and S10 indicated that they did not observe any signs of choking or food or other objects in R1’s mouth. Interview with (1) staff indicated that although they were informed by staff that R1 had passed away, (1) staff indicated that they do not know the cause of death of R1. Review of R1’s Care Plan indicated that R1 was on a no sodium diet; however, R1’s food did not require special dietary modifications like chopping, pureeing, mincing or liquifying. Care Plan indicated that R1 is independent and needed no assistance with food intake. R1’s Appraisal Need and Service Plan indicated that R1 “feeds self independently” and dietary needs or dietary accommodations were not observed listed on “Services Needed” section. Interview with R1’s family member (P1) indicated that R1 passed away from ailments R1 had been dealing with for an extended period. P1 indicated that R1 did not die from choking on R1’s food. P1 further indicated that R1 did not need any dietary accommodation like chopping, mincing, dicing or liquifying R1’s food and was on a regular diet which R1 was able to eat comfortably. P1 stated that they have no suspicion regarding R1’s death and that the facility provided appropriate care for R1 till the end of R1’s life. Interviews with R3-R11 indicated that they don’t have concerns with staff neglecting residents. Staff, resident and P1’s interviews, and record review do not corroborate the allegation that resident passed away from choking due to staff not cutting his food. ***Continues on LIC 9099-C page 2*** Regarding: Staff handles resident in a rough manner. It is alleged that all facility caregivers are rough when assisting a resident. It is alleged that staff pull and push resident and are rough even though resident is paralyzed on their left side. Staff deny the allegation. Interviews with (9) out of (11) staff revealed that caregivers are not rough with residents. Staff stated that they do not pull or push residents under any circumstance. Staff indicated that residents are treated with dignity and respect and that they are trained to follow policy and procedures regarding the proper care of residents. Staff further indicated that they are mandated reporters and any suspicion of abuse is reported immediately to the proper authorities. Interview with S3 indicated that they have never been rough, nor pushed or pulled R2. S3 indicated that R2 is treated with respect and dignity. S3 indicated that due to R2s medical needs, S3 takes their time to assist R2 during transfers and helping R2 change their clothes. S3 stated that at times, R2 complains about experiencing pain when S3 assists R2 during transfer from R2’s bed to their wheelchair; however, S3 indicated that S3 is careful when helping R2 by making their move as comfortable as possible. Further information obtained from interviews with S1 and S2 indicated that they have not observed S3 treat R2 or any resident inappropriately. S1 and S2 further indicated that they have not received any reports of S3 treating R2 inappropriately, nor placed disciplinary actions on S3 for misconduct toward residents. Interviews with (10) out of (11) residents indicated that residents are never pushed, pulled or treated roughly by caregivers. Residents also indicated that they are treated with respect and dignity and would report any inappropriate conduct from staff to the authorities. Review of S3’s staff record indicated that S3 does not have any write-ups or disciplinary actions on file for not providing appropriate care to residents or other midconduct. Staff and resident interviews and record review do not corroborate the allegation that staff treat resident roughly by pushing and pulling resident while providing care. Regarding: Facility restroom is not accessible to wheelchairs. Is alleged that when resident tries to use the bathroom, their wheelchair does not fit because the door is narrow. Staff deny the allegation. Interviews with (9) out of (11) staff revealed that R2’s wheelchair enters their bathroom with no difficulty. Staff indicated that R2’s wheelchair can be pushed in the bathroom and can be positioned next to the toilet for a comfortable transfer. ****Continues on LIC 9099-C page 3*** Staff further indicated that when a caregiver assists R2 during toileting and bathing needs, the wheelchair is only partially entered into the bathroom so that both caregivers and R2 can have enough space to assist with personal hygiene care for R2. Interview with (7) out of (11) residents who use wheelchairs indicated that their wheelchairs fit through the doorways of their bathrooms with no difficulty and have no concerns. Inspection conducted by LPA of R2's wheelchair and bathroom doorway indicated that R2’s wheelchair enters and fits in R2’s bathroom. During visit, LPA pushed R2’s wheelchair into the bathroom via the doorway and positioned it next to the toilet. LPA was able to rotate the wheelchair parallel to the toilet in R2’s bathroom and apply the break. LPA measured the doorway and observed that the width of the doorway measures 32 inches. LPA also measured R2’s wheelchair and measured 30 inches in width, leaving one inch clearance on each side of the wheelchair to enter the bathroom with no difficulty. Interviews with staff and residents and LPA observations do not corroborate the allegation that resident's wheelchair does not fit in their bathroom because the door is narrow. Staff are not responding to resident’s call button in a timely manner. It is alleged that staff are not responding to resident’s call button in a timely manner. It is also alleged that resident waits one (1) to two (2) hours to be assisted with getting covered with a blanket, getting water, helping resident in the bathroom, and being taken outdoors. Staff deny the allegation. Interviews with (10) out of (11) staff revealed that staff respond to call button notifications in a timely manner. Staff indicated that staff assigned to conduct rounds in their assigned wings of the facility, respond within five to ten minutes of receiving calls on their radios from dispatch in the font desk. Staff indicated that if the assigned caregiver is not available to answer a call made via call button, front desk staff will dispatch another caregiver to cover for the one who is busy helping other residents. Staff also indicated that R2 and all residents are provided with blankets, water, assistance in the bathroom and help with being taken outdoors when needed. Staff indicated that R2 can move around independently with the use of their wheelchair around the facility and is observed leaving the facility for appointments and errands without help. Interviews with (10) out of (11) residents indicated that staff respond to call button pushes within five to ten minutes. Residents indicated that they have no concerns with caregivers not responding in a timely manner to their calls. Staff and resident interviews do not corroborate the allegation that staff are not responding to call button in a timely manner. ***Continues on LIC 9099-C page 4 Staff does not provide a comfortable room temperature for resident. It is alleged that resident’s room is cold and resident is not being provided with a comfortable room temperature. Staff deny the allegation. Interviews with (9) out of (11) staff revealed that the facility is kept at a comfortable temperature for all residents. Staff indicated that each resident room has its own AC/heater unit in which temperature of the room can be regulated by the residents. Staff indicated that residents are free to set the temperature of their room to make it warm or cool. Staff stated that they have not received any complaints regarding resident rooms not sustaining comfortable temperature. Staff further indicated that the facility provides residents with extra blankets if needed. Staff further indicated that R2’s room is equipped with its own heater and R2 can set it at any temperature, and R2 has been provided with extra blankets and sheets. Interviews with (10) out of (11) residents revealed that the temperature in their room is appropriate and have no concerns regarding their room not being at a comfortable temperature. Residents also indicated that they can ask caregivers for extra blankets and will be provided to them if needed. Interview with R2 indicated that R2’s room is cold and staff do not keep it at a comfortable temperature. LPA inspected R2’s room during visit on 12/4/25 and measured the temperature with a probe thermometer. Temperature of the room measured at 78.9 degrees F. LPA also inspected (10) resident rooms at random during today’s visit and temperature was found to be between 78.9-83.4 degrees F. which is within compliance range. During inspection of the rooms, LPA observed the temperature control units to be working properly. Staff and resident interviews and observations do not corroborate the allegation that resident’s room is cold and not at a comfortable temperature. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 28-AS-20251203151808

Allegation investigated: Staff do not ensure that residents’ incontinence needs are met

Licensing Program Analyst (LPA) Daniel Konishi conducted a subsequent unannounced complaint visit in regard to the allegation listed above. LPA met the Receptionist, Sherry Juarez, who assisted with today’s visit. On 12/18/2025, the initial investigation visit was conducted. The investigation consisted of the following: LPA obtained a copy of the staff and resident rosters. LPA interviewed the Licensee, Staff #1 (S1) to Staff #7 (S7), and Resident #1 (R1) to Resident #14 (R14). LPA obtained pertinent documents from R1’s file such as: Identification and Emergency Information, Pre-Placement Appraisal, Physician’s Report, Shower Logs, and Resident Notes. LPA also obtained weekly work schedule and monthly meal. LPA observed the kitchen and have sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. LPA also observed residents during the mealtime at lunch. Substantiated During today's visit, LPA obtained the following documents: staff and resident rosters. LPA interviewed the Care Coordinator and Resident #15 (R15). The investigation revealed the following: in regard to the allegation, “Staff do not ensure that resident's incontinence needs are met.” It is alleged that on 12/12/2025, R1 is supposed to have her incontinence supplies changed every two hours but R1 waited four hours to be changed. LPA interviewed one (1) out of 15 residents that corroborated with the allegation stating waiting for four hours for incontinence supplies to be changed when staff are supposed to change incontinence supplies for the resident every two hours. One (1) out of 15 residents corroborated with the allegation stated wait one hour and a half from the scheduled time to be changed. LPA also observed Resident #14 R14’s) room had a strong urine odor. Two (2) out of 15 residents interviewed could not confirm nor deny the allegation since they stated they do not require any incontinence supplies change from the staff. 11 out of 15 residents denied the allegation by stating that the staff meets their incontinence needs and they don’t have any problems. LPA interviewed the Executive Director, Care Coordinator and one (1) out of seven (7) staff corroborated with the allegation stated that there was a delay in providing incontinence change for residents on 12/12/2025 and the incontinence change service for R1 was provided at 9:15am which is two hours when it should have been done at the scheduled time of 7am. LPA interviewed Care Coordinator which stated that 40 to 48 residents out of the facility census of 147 residents required incontinence change service in the AM shift on 12/12/2025. Per Care Coordinator interview, there are normally five (5) caregivers on duty in the Friday AM shifts on which each caregivers are assigned 10 to 12 residents that need incontinence change service. LPA observed the staff schedule for 12/12/2025 and confirmed with the Executive Director and the Care Coordinator that there were two (2) caregivers calling off and one (1) caregiver off on vacation. Per Executive Director and Care Coordinator interview, there were only two (2) caregivers in the AM shift to provide incontinence change service for 40 to 48 residents which caused a delay in providing incontinence change service for residents on 12/12/2025. LPA interviewed the three (3) out of seven (7) staff that denied the allegation by stating that the care staff change the residents in a timely manner. LPA interviewed three (3) out of seven (7) staff that could not confirm nor deny the allegation since they are not involved in providing this service. Therefore, there was sufficient evidence to corroborate with the allegation. Based on LPA interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. An exit interview and a copy of the report and appeal rights were provided to Med Tech, Michael Yepez. During today's visit, LPA obtained the following documents: staff and resident rosters. LPA interviewed the Care Coordinator and Resident #15 (R15). The investigation revealed the following: in regard to the allegation, “Staff did not serve residents' meals in a timely manner.” It is alleged that on 12/12/2025, the facility served the residents breakfast from 7:00am to 8:30am. LPA interviewed one (1) out of 15 residents corroborated with the allegation stating that meals were served late from 7:00am to 8:30am on 12/12/2025. LPA interviewed 13 out of 15 residents denied the allegation stating that meals were served in a timely manner at 12/12/2025. However, one (1) out of 15 residents stated that meals are brought late and cold to the resident’s room. LPA interviewed the Executive Director, Dietary Director, and seven (7) out of seven (7) staff denied the allegation stating that meals were served on a timely manner on 12/12/2025. Dietary Director and two (2) out of seven (7) staff also stated that breakfast was served from 7am to 8am on 12/12/2025. LPA observed residents eating their meal at the dining hall during lunch time from 10:45pm to 11:30am during the initial visit on 12/18/2025. LPA also observed residents eating the following items: spaghetti with meatballs, cauliflower, lemon pudding, and beverage on 12/18/2025. LPA observed the dietary staff prepare the to-go meals at 10:40am and the care staff take the to-go meals to deliver to residents in their rooms at 11am on 12/18/2025. LPA observed that the meals were served in a timely manner on 12/18/2025. Therefore, there are not enough sufficient evidence to corroborate the allegation. Allegation: “Staff did not assist residents with showering.” It is alleged that on 12/12/2025, R1 did not receive shower assistance due to lack of staff. LPA interviewed 12 out of 15 residents denied the allegation stating on receiving shower assistance on 12/12/2025. However, one (1) out of 15 residents stated that shower assistance was received two hours after the scheduled time on 12/12/2025. One (1) out of 15 residents denied the allegation stating on receiving shower assistance from staff every Monday. Two (2) out of 15 residents could not confirm nor deny the allegation since they stated not receiving shower assistance LPA interviewed the Executive Director, the Care Coordinator, and three (3) out of seven (7) staff that denied the allegation stating that bathing assistance was provided to residents on 12/12/2025. One (1) out of seven (7) residents denied the allegation but stated that shower assistance was provided two hours after the scheduled time for one resident on 12/12/2025. Three (3) out of seven (7) staff could not confirm nor deny the allegation since they are not involved in providing this service. LPA reviewed resident shower logs that indicated that R1 and other residents have been receiving shower assistance as scheduled. Therefore, there are not enough sufficient evidence to corroborate the allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was held and a copy of this report was provided to the Med Tech, Michael Yepez.the state’s words, verbatim · CDSS document, Jan 2, 2026 · control 28-AS-20251212083834

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Jan 16, 2026

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above as on 12/12/2025, there was two (2) caregivers on duty in the AM shift to provide incontinence care for 40 to 48 residents out of the facility census of 147 residents. Resident #1 (R1’s) incontinence needs was not met as incontinence service was provided by staff at 9:15am which was two hours and fifteen minutes passed the scheduled time of 7am. LPA also observed a strong urine odor in Resident #14 (R14’s) room. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 2, 2026

Plan of correction: Facility will submit a written plan on what to do when multiple caregiver staff call out and to ensure that residents’ incontinence needs are met and provided in a timely manner.

Allegation investigated: Staff were not responsive to resident's communication.

Licensing Program Analyst (LPA), Mayra Cota, conducted a subsequent visit today to investigate the above-mentioned allegation. Today’s visit stems from a 10-day complaint investigation visit conducted on 10/30/25. LPA met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained. The investigation consited of the following: During today’s visit, LPA, obtained copies of staff and resident rosters, toured the common areas of the facility and conducted interviews with Staff 1 – Staff 8 (S1-S8) and Resident 1 – Resident 10 (R1-R10). The investigation revealed the following: Regarding: Staff were not responsive to resident's communication. ****Contiues on LIC 9099-C**** Unsubstantiated It is alleged that resident (R1) had been trying to inquire about a letter they received in their mail slot from management stating that R1 owes money to the facility; however, staff will not answer R1’s phone calls in the office. Staff deny the allegation. Interviews with (8) out of (8) staff revealed that they are responsive to residents’ communication. Staff indicated that residents’ phone calls and/or requests to talk to staff are not ignored. Staff indicated that phone calls received are answered by front office staff and messages are taken if persons requested to talk to are not available. Staff further indicated that residents have many means to communicate with management staff like call button pushes, messages sent by caregivers and med-techs to management and residents can visit management in their office at any time when they need to talk. Staff stated that they answer the phone in the offices they are stationed in and return calls when voicemail messages are left, promptly. S1 indicated that they have been responsive to R1’s questions by conducting visits to R1’s room and talking to R1, per R1’s request. R1 further indicated that they have an open-door policy, and residents can visit S1’s office at any time if they want to discuss any concern they may have. Interviews with (9) out of (10) residents indicated that they have no concerns regarding staff not answering the phone in the font office when they want to talk to staff. Residents also indicated that staff are responsive when they need to talk to staff. Interview with R1 indicated that they visited S1 in their office to discuss the letter they received regarding a balance they had on their account and discussed the issue. R1 stated that they have no concerns about staff not being responsive to their communication because they have now resolved the issue. R1 indicated that his phone calls are answered, and staff are conducting visits to their room. Staff and resident interviews do not corroborate the allegation that phone calls are not answered in the office to talk to management. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Jacqueline Cortez, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 28-AS-20251023134654

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Mayra Cota, conducted a Case Management – Incident visit today to follow-up on two (2) Special Incident Reports (SIR) received by the department. LPA, met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained. According to the first SIR, date of occurrence 10/19/2025, a staff member (Staff 3/S3) raised their voice and made an inappropriate comment to a resident (Resident 1/S1) during an encounter in which R1 requested help. R1, reported the incident to the Executive Director (Staff 1/S1) and Care Coordinator (Staff 2/S2). According to interview with S1, S1 spoke to S3 to remind them that residents need to be always spoken to calmly and with respect. S1 stated that, S3 admitted to raising their voice and making inappropriate comment toward R1. S1 indicated that S1 and S2 assessed R1 after the incident and did not observe any injuries and R1 continued their normal routine the rest of the day. S1 indicated that S1 talked to S3 on 10/31/25 regarding the incident, and a formal meeting and write-up regarding professional conduct and resident standards took place on 11/12/25. During this meeting, the written notice was discussed and provided by S2 to S3. Interview with S2 indicated that S3 has been taken off assignment of R1’s room and is not allowed to enter R1’s room at any time. S2 stated that they monitor the assignments and ensure that S3 does not interact with R1. Interview with R1 indicated that S3 is not coming into their room anymore and is glad that staff were proactive after R1 reported the incident. ****Continues to LIC 809-C**** According to second SIR, date of occurrence 10/25/25, staff member (Staff 4/S4), was observed by a resident (Resident 3/R3) raising their voice toward another resident (Resident 2/R2) as R3 walked down the hallways by R2’s room. SIR also reports that S4 was heard yelling at R2, “Leave me alone you lunatic or I will call the cops.” Interview with S1 indicated that upon receiving the report from R3, S1 scheduled a meeting with S4 on 10/31/25, due to S4 working primarily during the night shift and S1 working during the day shift. S1 stated that during the meeting, S4 was suspended for further investigation. S1 took S4s statements and presented them to Human Resources. S1 indicated that they conducted the investigation and could not obtain any information from the alleged victim (R2) or other possible witnesses. S1 stated that they attempted to obtain more information from R2; however, R1 could not recall the incident. S1 indicated that due to insufficient evidence, S4 was reinstated to their job duties on 11/7/25; however, S4 still received counseling from S1 regarding expectations and protocols and working effectively with residents who may present behavioral challenges. S1 further indicated that S4 denied raising their voice at R2 and saying inappropriate statements. Interview conducted with R3 and R3 indicated that they heard S4 yelling loudly at R1 but could not remember what S4 said to R2 during the incident. LPA, attempted to interview R2, however, R2 was not responsive to LPA’s questions and stated, “I don’t remember that.” During today’s visit, LPA did not observe any potential or immediate health and safety risks to residents in care. A citation is issued today per California Code of Regulations (Title 22). Exit interview was conducted with Jacqueline Cortez, Executive Director, and a copy of this report, 809-D and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Dec 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Dec 18, 2025

Personal Rights of Residents in All Facilities (a) Residents...shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This requirement was not met as evidenced by: Interviews conducted with staff and resident indicate that staff member acknowledged raising their voice at resident and making inappropriate statement to resident in care.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: Administrator provided proof of disciplinary written notice for violations of professional conduct and resident care standards. POC cleared at the time of visit.

Allegation investigated: Staff did not dispense medications in a timely manner

Licensing Program Analysts (LPA) Luis De Leon conducted an initial unannounced complaint investigation visit for the allegation listed above. LPA met with the Administrator Jacqueline Cortez and explained the reason for the visit. The investigation consisted of the following: On today’s visit, LPA De Leon toured the physical plant and obtained the current client and staff roster. LPA obtained relevant copies of resident file records such as admission agreement, physician's report, needs and service plan, physician's orders, and Medication Administration Record (MAR) logs. Report continues on page LIC-9099C... Unsubstantiated Regarding allegation: Staff did not dispense medications in a timely manner. It is alleged that staff did not give residents the morning medication in a timely manner even though that R1 was in the room. R1 confronted staff and staff denied seeing R1 in the room. The investigation reveals the following: interview with staff revealed that seven (7) out of seven (7) staff denied the allegation above. Staff described the process that staff follow to give out residents medication. Staff described that there is a set period on each morning, noon, evening, and bedtime where staff will go to residents’ rooms to give residents the medication. Med Tech will go to dining room to find residents to give them their medication. If not found, Med Tech staff will go to resident’s rooms. If resident is not found, Med Tech staff will inquire from caregiver if caregiver has seen residents. Staff indicated that staff makes an effort to locate residents in the facility and sometimes even outside the facility across the street in the park. If resident is still not found, the proper documentation is done and administrator is informed so that the follow up calls can be made. Interview with residents revealed that eight (8) out of ten (10) residents denied the above allegation. The residents indicated that staff always find them in the facility to get their medication. R10 indicated that in some instances staff has gone across the street, in the park, to give R1 medication. LPA reviewed five (5) out of five (5) resident MARs records with their respective medication and observed that all missing dosage was properly documented for medication refusal, out of facility for appointments or other activities. LPA did not observed any health and safety risk from medication dispensing. Based upon the investigation, resident and staff interviews, document review, and LPA observations, the facility is dispensing medication in at timely manner within each medication period throughout the day for residents in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held with Jacqueline Cortez. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 28-AS-20251204134917

Allegation investigated: Staff are not safeguarding resident's personal property.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 12/05/2025, regarding the above allegation to deliver a superseded licensing report. LPA Ramirez identified herself to front desk staff and was greeted by Administrator Jacqueline Cortez. LPA Ramirez explained the purpose of today’s visit to Cortez. The findings remain the same, however, LPA Ramirez reissued deficiency 87468.2(a)(25) from a Type A to Type B deficiency. LPA Ramirez conducted an unannounced initial complaint investigation visit on 10/22/2025 regarding the above allegation. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster, Staff#1 - 7 interviews (S1 – S7), Resident#1 – 8 (R1 – R8), Copy of Admission Agreement, Review of Client/Resident Personal Property and Valuables (LIC 621) for R1 – R6, and physical plant tour. SEE 9099-C for continued report Substantiated The investigation revealed the following: regarding the allegation “Staff are not safeguarding resident's personal property.” It is alleged staff are not safeguarding residents’ personal belongings such as clothing and delivery packages. Six (6) out of the ten (10) residents interviewed corroborated this allegation. R3 revealed that in July of 2025, R3 purchased items from Amazon and received confirmation from Amazon that the package was delivered to the facility’s front desk. According to R3, Amazon provided a photo as proof of package delivery, however, when R3 went to retrieve their package from the front desk, they were advised that their package was not there. R3 revealed after a week of searching for their package, R3 was notified by facility staff that their package was not located. R3’s family emailed S7 proof of delivery confirmation and proof of the items purchased. Interview with S2 and S7 corroborated R3’s statements. S2 revealed that because R3’s did not receive their package due to loss or theft after it was delivered to facility staff, R3 was reimbursed for the loss of their package. S2 revealed all resident packages are delivered to the front desk and front desk staff will safeguard these packages until the packages are picked up by residents. Interview with R2 revealed several articles of clothing were reported missing after staff picked up R2’s dirty laundry for washing. According to R2, some of their clothing were found and some were not located. Per Health and Safety Code 1569.153(c)(d)-"Documentation of lost and stolen resident property with a value of twenty-five dollars ($25) or more within 72 hours of the discovery of the loss or theft and, upon request, the documented theft and loss record for the past 12 months shall be made available to the State Department of Social Services, law enforcement agencies and to the office of the State Long-Term Care Ombudsman in response to a specific complaint. (d) A written resident personal property inventory is established upon admission and retained during the resident’s stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident’s representative, and dated. A copy of the written inventory shall be provided to the resident or the person acting on the resident’s behalf. All additions to an inventory shall be made in ink, and shall be witnessed by the facility and the resident or resident’s representative, and dated. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the written request of the resident, the resident’s family, a responsible party, or a person acting on behalf of a resident. The facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory. A copy of a current inventory shall be made available upon request to the resident, responsible party, or other authorized representative. The resident, resident’s family, or a responsible party may list those items which are not subject to addition or deletion from the inventory, such as personal clothing or laundry, which are subject to frequent removal from the facility. SEE 9099-C for continued report LPA Ramirez requested the facility theft and loss log for the last 12 months. Per S2, the facility does not maintain a theft and loss log. LPA Ramirez reviewed Client/Resident Personal Property and Valuables (LIC 621) for R1 through R6 and found these forms did not contain any entries of personal property and valuables. LPA Ramirez observed various personal belongings such as clothing, tv's, microwaves, lamps, radios and other valuables in ten (10) out of the ten (10) resident rooms toured. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. One (1) Type B deficiency has been issued. Exit interview was conducted. A copy of this report, 9099-D and appeals rights was provided. The investigation revealed the following: regarding the allegation “Staff are threatening a resident with an unlawful eviction.” It is alleged that R3 is being unlawfully evicted. One (1) out of ten (10) residents interviewed corroborated this allegation. Interviews with seven (7) out of seven (7) staff interviewed denied this allegation. Review of R3’s resident record did not corroborate this allegation. Interview with R3 revealed they have never been served with an eviction notice nor have they been threatened with an eviction. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited for this complaint allegation. A copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 5, 2025 · control 28-AS-20251014144300

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(25) · Plan of correction due date: Dec 5, 2025

(a) In addition to the rights listed in Section 87468.1, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (25) To protection of their property from theft or loss according to Health and Safety Code sections 1569.152, 1569.153, and 1569.154. This requirement was not met as evidenced by: 6 out of 10 residents did not have property protected from theft or loss. This poses a potential risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Dec 5, 2025

Plan of correction: *POC CLEARED ON 10/21/25 & 11/03/25. NO FUTHER ACTION REQUIRED* Administrator will submit plan as to when all staff retraining will be conducted. Plan must be received by 10/22/25 via email. All staff will receive retraining on Health and Safety Code sections 1569.152, 1569.153, and 1569.154. Proof of staff retraining is required by 11/4/2025.

Allegation investigated: Residents are being denied access to dining room. Staff are isolating residents.

Licensing Program Analyst (LPA), Mayra Cota, conducted an unnanounced 10-day complaint visit to investigate the above-mentioned allegations. LPA, met with Jacqueline Cortez, Executive Director and the reason for the visit was explained. The investigation consisted of the following: During today's visit, LPA, obtained copies of staff and resident rosters, toured common areas of the facility, conducted interviews with Staff 1 - Staff 8 (S1-S8) and Resident 1 - Resident 13 (R1-R13). The investigation revealed the following: ****Continues on LIC-9099C Unsubstantiated Regarding: Residents are being denied access to dining room. It is alleged that on Thursday evening, the dining room is closed and that this would be happening on Thanksgiving. Staff deny the allegation. Interviews with (8) out of (8) staff revealed that both dining rooms in the facility are open to residents 24 hours a day, seven days a week. Staff indicated that on Thursday, November 27, 2025, Thanksgiving Day, both facility dining rooms remained open after full-service breakfast, lunch and dinner delivery to residents’ rooms were conducted. Staff further indicated that although the facility kitchen closed after 3:00 p.m. on Thursday, November 27, 2025, Thanksgiving Day, residents were not denied access to the two dining rooms in the facility. Staff stated that they did not receive complaints regarding the dining room not being open on Thursday evening or at Thanksgiving. Interviews with (13) out of (13) residents revealed that both dining rooms in the facility never close. Interviews with (11) residents indicated that they have never been denied access to the two dining rooms in the facility. Two (2) residents indicated that they do not eat in the facility dining rooms; however, they have not observed the dining rooms closed. Residents further indicated that both dining rooms are always open, even on holidays like Thanksgiving. Information obtained during interviews with staff and residents does not corroborate the allegation. Regarding: Staff are isolating residents. It is alleged that residents are being isolated on Thursday evenings and staff are partying at that time and should be allowed to be with friends and family on Thanksgiving.Staff deny the allegation. Interviews with (8) out of (8) staff revealed that staff are not isolating residents on Thursday evenings or any other day of the week. Staff indicated that staff do not hold parties at the facility. Staff further indicated that they do not prevent residents from being with friends and family on Thanksgiving or any other day of the year. Staff stated that isolating residents and preventing them from being with friends and family goes against residents’ rights and as mandated reporters would report any indications of resident isolation to the proper authorities. Staff indicated that they have not received any complaints from residents regarding being isolated or being prevented by staff from being with friends and family. Staff also stated that they have not received complaints from residents regarding staff having parties at the facility. Interviews with (13) out of (13) residents revealed that they are not isolated by staff on Thursdays or any other day of the week. Residents indicated that they have not observed staff having parties at the facility. Residents also indicated that they are not prevented from being with friends and family at any time. Information obtained during staff and resident interviews does not corroborate the allegation. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Jacqueline Cortez, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 28-AS-20251201123912

Allegation investigated: Staff do not ensure emergency drills are conducted. Staff do not ensure facility is clean and sanitary. Staff do not follow food service sanitation practices

Licensing Program Analyst (LPA), Mayra Cota, conducted an unnanounced 10-day complaint visit to investigate the above-mentioned allegations. LPA, met with Jacqueline Cortez, Executive Director and the reason for the visit was explained. The investigation consisted of the following: During today's visit, LPA, obtained copies of staff and resident rosters, toured the facility with a focus on inspecting the kitchen and (2) dining rooms, conducted interviews with Staff 1 - Staff 13 (S1-S13) and Resident 1 - Resident 13 (R1-R13), counducted record review and obtained copies of Fire Drill Reports for June - November 2025 Fire Drill Reports and Personal Hygiene: Head Covering policy and procedures. LPA also conducted observation of meal services during today's visit. ****Continues on LIC-9099C Unsubstantiated The investigation revealed the following: Regarding: Staff do not ensure emergency drills are conducted. It is alleged that staff never conduct any fire drills and that although the alarm is tested, staff do not evacuate the residents or conduct any drills. Staff deny the allegation. Interviews with (13) out of (13) staff revealed that fire drills are conducted every month and are trained in safety procedures. Staff indicated that earthquake, active shooter and evacuation drills are conducted interchangeably during the monthly fire drills. Eight (8) staff indicated that the drills also include training on keeping safe during gas leaks and grease fires, and how to safely evacuate staff and residents if ever needed. Staff further indicated that staff conduct inspections of fire extinguishers, smoke and carbon monoxide detectors, and test the fire alarms monthly. S1 stated that resident participation is welcomed and encouraged, and a few residents participate in the drills and evacuation procedures even though their participation is not mandatory. S1 further stated that all facility staff must take safety in-service trainings and if on shift, must participate in the monthly drills. Interviews with (10) out of (13) residents revealed that they observe the facility staff conducting fire drills every month. Two (2) out of (13) residents indicated that they have not seen fire drills taking place because they don’t leave their room most of the day. Interview with (1) out of (13) residents indicated that facility staff do not conduct fire drills nor evacuate residents; however, a review of records by LPA indicated that the facility conducts fire drills every month by a contracted vendor with staff participation who is on shift. Record review further indicated that fire alarms, doors, extinguishers, shut off valves, and exit routes are checked and tested during the monthly drills. Staff and resident interviews and record review do not corroborate the allegation that staff never conduct fire drills and do not evacuate the residents. Regarding: Staff do not ensure facility is clean and sanitary. It is alleged that on 11/25/25, resident saw egg particles from breakfast on the dining room table while resident was having lunch and that this happens a lot. Staff deny the allegation. Interviews with (8) out of (13) staff revealed that tables and chairs are cleaned before, after and as needed between every meal service. Staff stated that tables are cleaned after being used by residents but will wait for residents who take longer to eat than others before initiating cleaning the tables. ***Continues on LIC 9099-C page 2 Staff indicated that they have not observed any tables left with egg or other food particles nor have they received any complaints from residents regarding tables being left dirty with food particles. Staff further indicated that staff follow policy and procedures regarding proper cleaning and disinfecting of tables and chairs and that kitchen grade sanitation liquid and hot water is used to clean tables and chair surfaces. Interviews with (5) out of (13) staff indicated that they are not familiar with the table cleaning procedures the kitchen has in place; however, they have not observed the tables with food particles before or after meals are provided nor have, they received any complaints from residents regarding the dining room tables being dirty. Interview with (2) out of (13) residents indicated that they have observed tables being left dirty with egg and cherry pie stains in between the breakfast and lunch meal service. However, interviews with (11) out of (13) residents indicated that they have not observed food particles on left on the tables before they sit down to eat and do not have any concerns regarding tables not being cleaned by staff. After breakfast and lunch ended, LPA inspected all tables in the facility’s two dining rooms and did not observe any food particles on the tables. LPA, also observed staff cleaning the two dining rooms including the tops of the tables after breakfast and lunch. After cleaning was conducted by staff, LPA conducted another inspection of all the tables in the two dining rooms before the dinner services began and did not observe any food particles on the tables. Staff and resident interviews and LPA observations could not corroborate the allegation that tables are left with food particles. Regarding: Staff do not follow food service sanitation practices. It is alleged that one kitchen staff does not wear a hair net and that staff serves food and people are getting hair in their food. Staff deny the allegation. Interviews with (8) staff indicated that kitchen staff who work in the preparation and cooking of food always wear hair nets. Staff indicated that they follow policy regarding safe and sanitary food handling and are trained in maintaining proper hygiene. Staff further indicated that although policy indicates that servers are not mandated to wear hair nets, staff use them to prevent hair from falling into residents’ food. Staff also indicated that caps can be used to protect food from hair or other things from falling in. Interview with one server staff indicated that they wear a hair net even though policy states they do not have to wear one. Staff interviews further indicated that residents have not expressed concerns regarding staff not wearing caps or hair nets during meal services or finding hair in their food. Interview with R1 indicated that R1 has observed one server staff not wearing a hair net and that other people have had hair in their food. However, during interview, ***Continues on LIC 9099-C page 3 R1 did not provide names of other people who R1 states have had concerns about one server staff not wearing a hair net during meal services. Interviews with (12) out of (13) residents revealed that they have no concerns regarding staff following food services and sanitation practices like wearing hair nets during meal service and have not found hair in their food. LPA observation of today’s breakfast and lunch meal service indicated that staff handling food were wearing caps and hair nests. LPA further observed that all the servers in the dining rooms were all wearing hair nets. Record review of the facility’s hygiene policy indicated that only cooks are required to wear hair nets or caps; however, servers do not have to wear them but are encouraged to do so. Interviews with staff, residents, observations and record review do not corroborate the allegation that one server staff does not wear a hair net and people are getting hair in their food. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Jacqueline Cortez, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 28-AS-20251126131229

Allegation investigated: Staff is not maintaining complete and accurate records regarding resident in care. Staff is not adhering to resident's Admissions Agreement. Staff is not meeting redident's needs.

Licensing Program Analyst (LPA), Mayra Cota, conducted a subsequent complaint visit to conduct additional interviews and to deliver findings for the above-mentioned allegations. LPA Cota, met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained. During initial visit on 10/9/2025, LPA Cota, obtained copies of staff and resident rosters, toured common areas of the facility, conducted interviews with Staff 1 – Staff 6 (S1-S6) and Resident 1 – Resident 13 (R1-R13), reviewed R1’s file and obtained copies of relevant documents, toured the facility and tested call buttons in rooms 165, 162, 161, 157, 181, 167, 105, 114, 184, 154, 186, 173 and 107. A total of 13 rooms were visited, and 26 call buttons were checked. During today’s visit, LPA conducted interviews with Staff 7 – Staff 10 (S7-S10) and Resident 14 – Resident 15 (R14-R15), reviewed R1’s medical records, Admissions Agreement, Release of Medical Information forms, and delivered findings. ***Continues on LIC 9099-C Unsubstantiated The investigation revealed the following: Regarding: Staff are not maintaining complete and accurate records regarding resident in care. It is alleged that R1 has been asking staff for a copy of resident’s medical records, but staff are only providing records that are incomplete or inaccurate. It is also alleged that medical records are missing due to being misplaced on purpose or because of staff being incompetent. Staff deny the allegation. Interviews with (5) staff indicated that R1 has received copies of medical records the facility has on file, at R1’s request. S1-S3 indicated that copies of R1’s medical records were provided to R1 on 9/23/25 and R1 signed a Release of Medical Information on 9/23/25 and 10/3/25. S1-S3 indicated that the medical records given to R1 were not incomplete or inaccurate and R1’s documents have not been lost or misplaced. S1-S3 further indicated that the medical records the facility has on file are the medical records R1 volunteered to the facility to have on file and other records obtained from the medical services provided at the facility, before R1 changed their doctors. S1-S5 further indicated that due to R1 managing her medical appointments independently, orders and testing results have not been received by the facility from R1’s doctors. Staff stated that they have advised R1 to follow up with their doctors to obtain their medical information and if needed, facility staff can help. Staff stated that R1 has refused to provide them with their doctors’ contact information and therefore, have not been able to provide R1 with assistance in obtaining the medical records R1 is requesting. Interview with R1 indicated that staff did not give them all their medical records and that staff lose them on purpose. However, interviews with (13) out of (15) residents indicated that they have no concerns with how the facility handles their medical records and that medical records released to them are accurate and complete. Record reviews indicated that S1 provided R1 with the requested medical records on 9/24/25 per the Release of Medical Information forms kept on file, signed by S1 and R1. Record reviews also indicated that the facility does not have orders from R1’s doctors requesting labs or other testing. Tour of the med-tech room revealed that resident medical records are centrally stored, kept locked and inaccessible to unauthorized individuals. Based on interviews, record review and observations, the allegation that staff are not maintaining complete and accurate resident records could not be corroborated. ***Report continues on LIC 9099-C page 2 Regarding: Staff are not adhering to resident's Admissions Agreement. It is alleged that staff are supposed to check resident’s blood pressure daily after dizzy spells per resident’s Admissions Agreement, but staff are not doing so. Staff deny the allegation. Interviews with (5) staff revealed that R1 does not have a physician’s order in place to have their blood pressure checked daily. Staff indicated that blood pressure checks are conducted on residents who have physician’s orders in place or when emergencies services are called for residents who may be experiencing medical emergencies to have the vials information on hand to be provided to medics. S1 further indicated that the facility’s parameters for medical aid do not include taking vital signs from residents without a physician’s order in place. S3-S6 also indicated that they have advised R1 to provide the facility with any orders from their doctor if there has been changes to their health; however, R1 has not done so. Interviews with (14) out of (15) residents indicated that staff meet their medical needs according to their doctor’s orders and have no concerns at this time. Interview with R1 indicated that staff are not checking their blood pressure after their dizzy spells as indicated by their Admissions Agreement; however, review of R1’s Admissions Agreement does not indicate that the facility must conduct blood pressure checks on R1. Further record review indicated that R1 does not have an order from their physician on file for blood pressure checks. Based on interviews and record reviews, the allegation that staff are not adhering to resident’s Admissions Agreement could not be corroborated. Regarding: Staff are not meeting resident's needs. It is alleged that per resident’s Admissions Agreement, staff are supposed to check on resident every 4-6 hours because they are a fall risk, but they are not. Staff deny the allegation. Interviews with (10) out of (10) staff revealed that staff would not wait 4-6 hours to check on residents because checks are conducted every (2) hours or sooner. Staff indicated that all residents who live at the facility, whether they are independent or require a higher level of care, are checked on by staff every (2) hours or as needed in between scheduled checks. Staff further indicated that residents who are at risk of falling get checked on every (1) to (2) hours during scheduled rounds. Interviews with (14) out of (15) residents revealed that staff are conducting visits every (1) to (2) hours by caregivers and additional visits are conducted during medication passes by med-tech staff. Residents further indicated that they have no concerns about how staff are conducting their checks during their rounds. ***Report continues on LIC 9099-C page 3 R1 stated during interview that staff do not follow their Admissions Agreement, which R1 says that the agreement indicates that staff must check on them every 4-6 hours. However, review of R1’s Admissions Agreement does not indicate that the facility should be checking on resident every 4-6 hours. Based on interviews and record review, the allegation that staff are not meeting resident’s needs could not be corroborated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 28-AS-20251003104730

Allegation investigated: Staff spoke to resident in an inappropriate manner.

Licensing Program Analyst (LPA) Daniel Konishi conducted a subsequent unannounced complaint visit in regard to the allegation listed above. LPA met the Executive Director, Jacqueline Briceno, who assisted with today’s visit. On 11/06/2025, the initial investigation visit was conducted. The investigation consisted of the following: LPA interviewed Executive Director, Staff #1(S1) to Staff #5 (S5), and Resident#1 (R1) to Resident #14 (R14). LPA obtained copies of the following documents: staff roster, resident roster, R1’s face sheet and physician’s reports. LPA obtained copies of S1’s file such as Personnel Record LIC501 and Staff Training documents. During today's visit, LPA obtained the following documents: staff and resident rosters. LPA interviewed the Executive Director, Resident #15 (R15) and Resident #16 (R16). LPA obtained Staff In-Service document. Unsubstantiated The investigation revealed the following: in regard to the allegation, " Staff spoke to resident in an inappropriate manner." It is alleged that on 11/04/2025, at approximately 12:10pm, S1 got upset when R1 requested R1’s meat to be cooked medium rare at the time of an upcoming dinner. S1 allegedly repeatedly yelled at R1 very loudly, telling R1 that R1 needed to leave. LPA interviewed R1 that corroborated with the allegation stating that S1 yelled at R1 and S1 got closer to R1. Additionally, there was one resident interviewed that observed staff in the past yelled at residents but could not provide specific details on the incident that occurred and did not corroborate this particular incident. LPA interviewed 14 out of 16 residents that could not corroborate the allegation stating that they have not witnessed S1 yell at R1 or any other resident. Most of the residents indicated that S1 treats residents with kindness and respect. One (1) out of 16 residents stated witnessing the incident on 11/04/2025 involving R1 and S1 and stated that S1 did not yell at R1. LPA interviewed the Executive Director and four (4) out of five (5) staff that denied the allegation stating that S1 did not speak inappropriately or yell at any residents. Two (2) of the five (5) staff interviewed stated witnessing the incident on 11/04/2025 involving S1 and R1 and stated that S1 did not yell or speak inappropriately to R1. LPA attempted to obtain video footage of the incident. However, the facility does not have any footage of the incident that occurred on 11/04/2025. LPA interviewed S1 that denied the allegation stating that on 11/04/2025, S1 and R1 were having a conversation trying to address R1’s concerns regarding the staff and S1 also indicated that S1 did not yell at R1. S1 has been employed since 06/24/2024 up until the present time and LPA did not observe any written warnings of S1 having inappropriate interactions with residents. Based on the facility’s internal investigation, they did not reveal any concerns regarding S1’s interactions with residents. Therefore, S1 was not suspended or terminated. LPA observed facility conducted a staff in-service training document as refresher dated 11/06/2025 which covered the topic on how to deal with residents in difficult situations. There is not enough supportive evidence to concur with the reported allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was held and a copy of this report was provided to the Executive Director, Jacqueline Briceno.the state’s words, verbatim · CDSS document, Nov 13, 2025 · control 28-AS-20251104130842

Allegation investigated: Staff is retaliating against a resident in care for filing a complaint with licensing. Staff did not transport resident to a medical appointment.

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Med-Tech Kaitlyn Gomez who assisted with today’s visit. The investigation consisted of the following: During the initial visit conducted on 10/21/2025, LPA interviewed Administrator, and residents 9 (R1-R9). LPA obtained copies of the following documents: staff roster, resident roster, R1’s physicians reports, admission agreement, identification information (LIC 601), face sheet, and transportation log. On 10/30/2025 visit LPA Gutierrez interviewed staff #2- staff #7 (S2-S7). During today’s visit LPA Gutierrez delivered findings. SEE LIC 9099C Unsubstantiated In regard to the allegation “Staff is retaliating against a resident in care for filing a complaint with licensing”, it is alleged that staff are retaliating against R1 for filing a complaint and are now refusing transportation to the market. During interviews with Administrator and staff seven (7) out of seven (7) stated that they do not retaliate against residents for filing complaints. Administrator stated there is a schedule for transportation and that only on Tuesdays are they able to take residents to the stores all other days are used to take residents to doctor appointments. Administrator also stated on that particular day R1 wanted to go to the market it was a Thursday and even though R1 knows the transportation schedule Administrator ordered R1 an Uber as a one-time courtesy. LPA obtained copies of the transportation schedule along with Uber receipt. During interviews with residents seven (7) out of nine (9) residents stated that staff has never retaliated against them for filing a complaint. Six (6) residents stated that they have never witnessed another resident being retaliated against either. In regard to the allegation “Staff did not transport resident to a medical appointment”, it is alleged that in the past facility refused to transport R1 to medical appointments. During interviews with Administrator and staff seven (7) out of seven (7) stated that they have never denied transportation to a resident for medical appointments if van is full there are different ways to get a resident to appointments. Administrator stated that R1 will usually use their ride services to get to their doctors’ appointments and in the past has used facility van. S6 stated that R1 is in charge of making their own appointments and staff is told that it is none of their business who their doctor is and where their doctor is located. During interviews with residents six (6) out of nine (9) residents stated that they have never missed a ride to doctors or had any problems with the transportation the facility provides. LPA asked R1 for documents of missed doctor’s appointment and was not provided with any. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Kaitlyn Gomez.the state’s words, verbatim · CDSS document, Nov 8, 2025 · control 28-AS-20251016123915

Allegation investigated: Staff overcharged resident. Staff do not provide residents with a notificatoin letter for the increase of rent.

Licensing Program Analyst (LPA), Mayra Cota, conducted initial 10-day investigation visit regarding the above-mentioned allegations. LPA met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained. During today’s visit: LPA obtained copies of staff and resident rosters, toured the facility, conducted interviews with Staff 1 – Staff 8 (S1-S8), interviewed Resident 1 – Resident 15 (R1-R15) and conducted record review for resident’s rent ledger for October 1, 2024 – November 1, 2025 and Past Due notice from 10/10/25. ***Continues on LIC 9099-C Unsubstantiated Regarding: Staff overcharged resident. It is alleged that resident owes the amount of $73.25 for rent that had been late and that resident has been trying to inquire about it but staff will not answer the phone in the office. Interview with S1 denies the allegation. Interview with S1 indicated that the amount of $73.25 owed by the resident is not a late charge for resident’s rent. S1 indicated that the amount of $73.25 is a balance the resident had for the yearly rent increase that took effect on 1/1/2024. S1 indicated that the facility collected rent on 1/1/24 from the resident without the yearly increase and as a result, the resident had a balance of $75.25. S1 stated that resident’s admission date is 12/20/23 and a rent increase took effect the following month on 1/1/24. S1 indicated that the balance was paid by resident’s authorized representative and resident’s account is up to date and no other balances are owed because resident pays their rent on time every month. S1 indicated that they are the staff who handles the collection of rent and oversees notifying residents about the yearly increases. Per interviews with S2-S8, it was indicated that S1 handles the collection of rent and informes residents about the rent increase. Interviews conducted with (14) out of (15) residents indicated that facility does not overcharge them for rent and that increases happen once a year. Record review of resident’s ledger indicated, rent for 1/1/24 was paid on time however, the amount was short $73.25, which was the increase amount for the new year of 2024. Record review also indicated that resident’s rent has been paid in full and on time since resident’s initial admission till the present. Interview with (1) resident indicated that resident did receive a letter from the facility dated 10/10/25 informing of the $73.25 balance resident; however, they were confused and not sure why they owed the amount since resident’s rent for 10/1/25 was paid in full and on time. Interviews with staff, residents and record review, do not corroborate the allegation. Regarding: Staff do not provide residents with a notification letter for the increase of rent. It is alleged that every December, the facility raises the rent and that each time they raise the rent, they do not give any notice to the residents. Staff deny the allegation. Interview with S1 revealed that residents receive notification in writing from the facility regarding upcoming increase in their rent. S1 indicated that all resident whether they pay from private funds or through the Assisted Living Waiver (ALW) program, receive notice of the yearly rent increase by letter ahead of time. ***Continues on LIC 9099-C page 2*** The yearly increase takes effect on January of each year and therefore, residents receive notification starting September for residents paying through private funds and November for residents paying rent through the ALW program. S1 indicated that they are the staff who handles the collection of rent and notifying residents about the yearly increases. Per interviews with S2-S8, it was indicated that S1 handles the collection of rent and informs residents about the rent increases. Interviews with R2-R15 indicated that the facility informs them about the yearly rent increase via letter provided to them by S1 and have no concerns about not receiving prior notice about the yearly rent increase. Interview with (1) resident indicated that resident is aware that the facility increases rent every year around December or January; however, resident has not been provided with a letter to indicate the increase. Review of records by LPA indicated that residents who pay rent through private funds received a letter on 9/25/25. Rent increase notification letters have not been generated for residents who pay rent through the ALW program because those notifications are generated until November, according to S1. Interviews with staff, residents and record review do not corroborate the allegation. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Jacqueline Cortez, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 30, 2025 · control 28-AS-20251023134654

Allegation investigated: Staff did not respond to resident's call button in a timely manner. Staff did not follow resident's care plan.

Licensing Program Analyst (LPA), Mayra Cota, conducted a 10-day investigation visit today regarding the above mentioned allegations. LPA, met with Jacqueline Cortez, Executive Director and the reason for the visit was explained: During today's visit: LPA, obtained copies of staff and resident rosters, toured the facility, conducted interviews with Staff 1 - Staff 8 (S1-S8) and Resident 1 - Resident 15 (R1-R15) and obtained copies of caregiver floor assignments for resident care and care plan for (1) resident. ***Continues on LIC 9099-C Unsubstantiated Regarding: Staff did not respond to resident's call button in a timely manner. It is alleged that resident pulled their call button but no one went to their room, even after pressing the button three more times. It is also alleged that staff finally went to resident’s room after three hours of the button being pulled. Staff deny the allegation. Interviews with (8) out of (8) staff revealed that staff respond to residents who push their call button in a timely manner. Interviews with staff indicated that staff do not wait three hours to check in on a resident if their call button was pushed. Staff indicated that if a call button is pushed and the staff assigned to check in on a resident is attending to another resident’s needs, front desk staff will call on other staff who are available to check in on resident who called for help. Staff further indicated that although their resident assignments call for them to check on residents every two hours, checks on residents are ongoing during staff rounds. Interview with (14) out of (15) residents indicated that staff respond in a timely manner to their calls if they activate their call button. Residents further indicated that they have no concerns regarding staff not responding in a timely manner to calls made using their call button. Staff did not follow resident's care plan. It is alleged that resident’s care plan states that staff need to check on resident every two hours because they are a fall risk and they have a medical condition. Staff deny the allegation. Interviews with (8) out of (8) staff revealed that staff check on all residents who live in the facility every two hours and during ongoing walks through the facility. Staff indicated that all residents get visits from staff whether they are independent, on hospice or require full care. Staff further indicated that residents’ care plans are followed to ensure residents’ needs are met appropriately. Interviews with (14) our of (15) residents indicated that staff check in on them every two hours or sooner. Residents further indicated that staff conduct visit to their rooms and also look for them in the common areas of the facility to check in on them. Residents stated that they have no concerns with staff not checking in on them every two hours or not following their care plan. Based on interviews, the allegations could not be corroborated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 30, 2025 · control 28-AS-20251021162441

Allegation investigated: Staff does not maintain adequate food supply at facility. Staff denied resident food.

Licensing Program Analyst (LPA) Elizabeth Irra conducted a visit to investigate the above allegations. LPA met with Vera Sebastian (Wellness Director). Jackie Cortez (Administrator) arrived at approximately 8:40 A.M.. LPA discussed the purpose of this visit. During this visit, LPA obtained a copy of the resident and staff rosters, interviewed Staff #1 (S-1) through Staff #9 (S-9), interviewed Resident #1 (R-1) through Resident #15 (R-15), obtained a copy of the October 2025 food menu, a copy of the lunch and dinner list of food alternatives, a copy of the food chat meeting conducted on 10/21/25 (including sign-in sheet) and conducted a tour of the kitchen (including the food supply). Refer to LIC 9099C for the continuation of this report. Unsubstantiated Allegation: Staff does not maintain adequate food supply at facility. It has been alleged that on 10/26/25, staff served a resident (resident arrived late to dinner) spaghetti without sauce and that the facility is running out of food. Staff interviews revealed that this facility maintains adequate food supply at all times. Interviewed staff indicated that this facility is not running out of food. (5) out of (9) interviewed staff indicated that this facility receives food supply (perishable and non-perishable) twice per week (Monday’s and Thursdays). (5) out of (9) interviewed staff indicated that on 10/26/25, the spaghetti served had meat sauce mixed in with the spaghetti noodles (sauce was not served on the side). Interviewed staff indicated that this facility also offers food alternatives to residents as well. Resident interviews revealed that this facility has adequate food supply. Interviewed residents indicated that the spaghetti served had the spaghetti sauce mixed in with the spaghetti noodles. Interviewed residents indicated that this facility also offers alternative food options. Interviewed residents did not have any concerns pertaining to this matter. LPA conducted a tour of the kitchen and observed ample food supply (perishable and non-perishable) to meet the meals noted on the menu. Interviews and tour do not corroborate this allegation. Allegation: Staff denied resident food. It has been alleged that on 10/26/25, staff denied making more “meat sauce” for resident and that staff denied to provide dinner to the resident. Staff interviews indicated that staff do not deny food to clients (including meals). Interviewed staff indicated that the spaghetti had the meat sauce mixed in with the spaghetti noodles (sauce was not served on the side). Interviewed residents indicated that staff have not denied any food nor meals to residents. Interviewed residents indicated they do not have any concerns. Interviews do not corroborate this allegation. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this report and appeal rights were provided to Jackie Cortez.the state’s words, verbatim · CDSS document, Oct 30, 2025 · control 28-AS-20251027134925

Allegation investigated: Staff do not safeguard residents' personal belongings

Licensing Program Analysts (LPA) Elena Mallett and Luis De Leon conducted an initial unannounced complaint investigation visit for the allegation listed above. LPA met with the Administrator Jacqueline Cortez and explained the reason for the visit. The investigation consisted of the following: On today’s visit, LPA De Leon toured the physical plant and obtained the current resident and staff roster, Incontinence supply orders, physician’s reports, appraisals, and physician orders. Regarding allegations: Staff do not safeguard residents' personal belongings. It is alleged that staff are using incontinence supplies on residents from the personal supply of a second resident. It is also alleged that staff is using higher quality supply on residents who have orders of lower quality incontinence supplies. It is alleged that residents are not aware of staff placing orders for incontinence supplies using resident’s names. Report continues on page LIC-9099C... Unsubstantiated The investigation reveals the following: Staff interviews revealed that seven (7) out of seven (7) staff denied the above allegation. Two (2) out of two (2) staff responsible for coordinating residents’ supplies denied placing orders for residents personal incontinence supplies. S1 denied having access to supplier order system. Care Coordinator (S2) will send resident’s name list to supplier for those resident’s who need incontinence supplies. The supplier will get approval from doctors and insurance and will send incontinence supplies to facility based on quantity approved by insurance. Six (6) out of seven (7) staff stated that personal continence supplies for a resident are only used for that resident and no other resident. Resident interviews revealed that ten (10) out of ten (10) residents denied the above allegation. All residents stated that residents received their incontinence order and have access from their supply. All residents stated that they are not aware of staff using their personal incontinence supply to assist other residents. Through interviews and record reviews of residents who use incontinence supplies, ten (10) out of ten (10) residents received the supplies that were designated to residents. Based upon the investigation, resident and staff interviews, document review, and LPA observations, the licensee ensures that residents in care had their incontinence supply safeguarded and available to residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview was held with Administrator Jacqueline Cortez. A copy of the report was providedthe state’s words, verbatim · CDSS document, Oct 28, 2025 · control 28-AS-20251024114624

Allegation investigated: Staff did not seek timely medical attention for a resident. Staff did not timely provide a resident's medical results.

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit to deliver findings for the allegations listed above. LPA met with Jacqueline Cortez, Executive Director and explained the purpose of the visit. The investigation consisted of the following: LPA conducted visits on 05/29/2025, 08/26/2025 and 10/20/2025 and obtained copies of the staff/resident roster, Staff in service training about incontinence and hygiene care and Care staff assignment schedule, Resident #1 (R1) files such as: Face sheet (ID and Emergency Info.), Physician’s report, Admission Agreement, Functional Capability Information/Service Plan, Medication Administration Records (MARs)/list for April-May 2025, Care notes/charting, Xray result, Hospital discharge summary and Incident reports (SIRs) related to the allegations. LPA interviewed Staff #1 (S1) - Staff #5 (S5), Resident #1 (R1) - Resident #15 (R15) and had delivered findings for the other allegations. *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: Allegation: “Staff did not seek timely medical attention for a resident.” It is alleged that R1 fell, hurt their ankle and had a mobile x-ray but the results were not provided on time which showed R1 had a fracture. Allegedly, this delay might have led to receive care late and further injury to R1’s fracture. Interviewed staff denied the allegation and stated that staff respond quickly to residents needing medical help. Some staff interviewed explained their procedure that, when they first become aware of the resident's change in condition or if they suffer an injury, caregivers report it to med tech, who assess, document, and notify the physician and family. And for serious injuries, they call 911. Staff indicated they have sufficient staff and training to recognize changes in residents' conditions. S1 stated that when R1 fell, a staff member assisted R1 immediately, who refused to be taken to the hospital and did not report pain or symptoms later. R1 confirmed that when they fell, staff assisted them immediately and that they declined to be taken to the emergency room because they thought it was not a big deal. (13) out of (15) residents interviewed indicated that staff assist them when they need medical attention or have been injured. Some residents indicated that staff would order medical tests for them if needed or requested. Interviews and reviewed documentation do not corroborate this allegation. Allegation: “Staff did not timely provide a resident's medical results” It is alleged that R1 had a mobile x-ray for an ankle injury three weeks ago (end of Apr 2025), but R1 only got the results two days (3rd week of May 2025). (5) of (5) staff interviewed stated that they do not read or interpret xray findings because they are not radiologists. S1 indicated that licensed medical professionals like doctors and radiologists are qualified to interpret x-rays. Interviewed staff also stated that R1's doctor is responsible to go over the x-ray results with them. Staff stated that they helped R1 by scheduling and coordinating with a mobile x-ray service that comes to the facility. Reviewed files showed that R1's family member is the responsible party who is involved in care decisions, communicating with R1's doctors and authorized to receive R1's medical results. Interviewed residents indicated they had medical tests done at the facility and their doctors explained the findings to them and some ask the staff to check if results are ready before contacting their doctors. Documentation reviewed and interviews conducted do not corroborate this allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Jacqueline Cortez, Executive Director.the state’s words, verbatim · CDSS document, Oct 24, 2025 · control 28-AS-20250522124740

Allegation investigated: Staff are not safeguarding resident's personal property.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 10/22/2025 regarding the above allegations. LPA Ramirez identified herself to front desk staff and was greeted by Activities Director- Brenda Martinez. LPA Ramirez explained the purpose of today’s visit to Martinez. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster, Staff#1 - 7 interviews (S1 – S7), Resident#1 – 8 (R1 – R8), Copy of Admission Agreement, Review of Client/Resident Personal Property and Valuables (LIC 621) for R1 – R6, and physical plant tour. SEE 9099-C for continued report Substantiated The investigation revealed the following: regarding the allegation “Staff are not safeguarding resident's personal property.” It is alleged staff are not safeguarding residents’ personal belongings such as clothing and delivery packages. Six (6) out of the ten (10) residents interviewed corroborated this allegation. R3 revealed that in July of 2025, R3 purchased items from Amazon and received confirmation from Amazon that the package was delivered to the facility’s front desk. According to R3, Amazon provided a photo as proof of package delivery, however, when R3 went to retrieve their package from the front desk, they were advised that their package was not there. R3 revealed after a week of searching for their package, R3 was notified by facility staff that their package was not located. R3’s family emailed S7 proof of delivery confirmation and proof of the items purchased. Interview with S2 and S7 corroborated R3’s statements. S2 revealed that because R3’s did not receive their package due to loss or theft after it was delivered to facility staff, R3 was reimbursed for the loss of their package. S2 revealed all resident packages are delivered to the front desk and front desk staff will safeguard these packages until the packages are picked up by residents. Interview with R2 revealed several articles of clothing were reported missing after staff picked up R2’s dirty laundry for washing. According to R2, some of their clothing was found and some were not located. Per Health and Safety Code 1569.153(c)(d)-"Documentation of lost and stolen resident property with a value of twenty-five dollars ($25) or more within 72 hours of the discovery of the loss or theft and, upon request, the documented theft and loss record for the past 12 months shall be made available to the State Department of Social Services, law enforcement agencies and to the office of the State Long-Term Care Ombudsman in response to a specific complaint. (d) A written resident personal property inventory is established upon admission and retained during the resident’s stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident’s representative, and dated. A copy of the written inventory shall be provided to the resident or the person acting on the resident’s behalf. All additions to an inventory shall be made in ink, and shall be witnessed by the facility and the resident or resident’s representative, and dated. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the written request of the resident, the resident’s family, a responsible party, or a person acting on behalf of a resident. The facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory. A copy of a current inventory shall be made available upon request to the resident, responsible party, or other authorized representative. The resident, resident’s family, or a responsible party may list those items which are not subject to addition or deletion from the inventory, such as personal clothing or laundry, which are subject to frequent removal from the facility. SEE 9099-C for continued report LPA Ramirez requested the facility theft and loss log for the last 12 months. Per S2, the facility does not maintain a theft and loss log. LPA Ramirez reviewed Client/Resident Personal Property and Valuables (LIC 621) for R1 through R6 and found these forms did not contain any entries of personal property and valuables. LPA Ramirez observed various personal belogings such as clothing, tv's, microwaves, lamps, radios and other valuables in ten (10) out of the ten (10) resident rooms toured. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. One (1) Type A deficiency has been issued. Exit interview was conducted. A copy of this report, 9099-D and appeals rights was provided. The investigation revealed the following: regarding the allegation “Staff are threatening a resident with an unlawful eviction.” It is alleged that R3 is being unlawfully evicted. One (1) out of ten (10) residents interviewed corroborated this allegation. Interviews with seven (7) out of seven (7) staff interviewed denied this allegation. Review of R3’s resident record did not corroborate this allegation. Interview with R3 revealed they have never been served with an eviction notice nor have they been threatened with an eviction. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited for this complaint allegation. A copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 21, 2025 · control 28-AS-20251014144300

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(25) · Plan of correction due date: Oct 22, 2025

(a) In addition to the rights listed in Section 87468.1, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (25) To protection of their property from theft or loss according to Health and Safety Code sections 1569.152, 1569.153, and 1569.154. This requirement was not met as evidenced by: 6 out of 10 residents did not have property protected from theft or loss. This poses an immediate risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Administrator will submit plan as to when all staff retraining will be conducted. Plan must be received by 10/22/25 via email. All staff will receive retraining on Health and Safety Code sections 1569.152, 1569.153, and 1569.154. Proof of staff retraining is required by 11/4/2025.

Allegation investigated: Staff do not properly dress a resident while in care. Staff do not meet a resident's diapering needs.

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit to continue investigating the allegations listed above. LPA met with Jacqueline Cortez, Administrator and explained the purpose of the visit. The investigation consisted of the following: On 05/29/2025 and 08/26/2025, LPA obtained copies of the staff/resident roster, Staff in service training about incontinence and hygiene care and Care staff assignment schedule, Resident #1 (R1) files such as: Face sheet (ID and Emergency Info.), Physician’s report, Admission Agreement, Functional Capability Information/Service Plan, Medication Administration Records (MARs)/list for April-May 2025, Care notes/charting, Xray result, Hospital discharge summary and Incident reports (SIRs) related to the allegations. LPA also interviewed Staff #1 (S1) - Staff #5 (S5). During today's visit, LPA obtained copies of the staff/resident roster, reviewed pertinent documents related to the allegations and interviewed Resident #1 (R1) - Resident #15 (R15). ***CONTINUED ON LIC9099-C*** Unsubstantiated The investigation revealed the following: In regards to the allegation: “Staff do not properly dress a resident while in care”. It is alleged that the facility is not dressing R1 in clothes. No further information given. (5)of (5 ) staff interviewed denied the allegation. Staff interviewed stated that caregivers help all residents, including R1, with daily activities (ADLs) such as changing clothes. Staff stated that R1 is incontinent and has limited mobility, but staff assist R1 with dressing daily. Staff also stated they respect R1's personal choice to not wear pants at times, but ensure R1 never leaves the room without pants. Some staff indicated that R1 mentioned feeling comfortable using the urinal without pants as it is easier for R1. (15) out of (15) residents interviewed stated that staff assist them with activities of daily living (ADLs), like showering and changing clothes, and denied seeing anyone without clothing. R1 stated they feel comfortable and satisfied with their clothing and prefers not wearing pants at times because it is less troublesome when using the urinal. Other residents stated that they are comfortable with how the staff helps and treats them. During all the visits, LPA did not observe residents without clothing and residents appeared comfortable in their clothing. Therefore there was insufficient evidence to corroborate with the allegation. In regards to the allegation: “Staff do not meet a resident's diapering needs”. It is alleged that the facility is neglecting R1 by leaving him in his adult diaper and not taking care of his personal care needs. (5) of (5) staff interviewed denied the allegation, stating that caregivers are properly trained in changing diapers. Staff stated that caregivers conduct regular rounds and change residents' diapers every two hours or as needed. Staff indicated that they manage their time to ensure all residents are changed on schedule and that there are enough incontinent supplies available. Out of (15) interviewed residents, (11) are incontinent and stated that they either change pull-ups themselves, only use them at night, or ask for staff assistance when needed. R1 stated a preference for staff assistance in the morning only, which the staff respect. Interviewed residents indicated that staff usually change their diapers on time, even though it may sometimes take a while for them to receive help. LPA observed staff doing rounds and taking care of the residents' needs during the visits. Therefore there was insufficient evidence to corroborate with the allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Jacqueline Cortez, Administrator.the state’s words, verbatim · CDSS document, Oct 20, 2025 · control 28-AS-20250522124740

Allegation investigated: Staff falsified residents' signature. Staff does not ensure facility is in good repair.

Licensing Program Analyst (LPA) Galarza conducted an initial visit to investigate the above allegation. LPA met with Executive Director Jacqueline Cortez. The investigation consisted of: A physical plant tour of the interior and exterior was conducted, with special focus on video surveillance, office and break room areas. Records were reviewed. Relevant copies of resident (R1's) file documents were reviewed and obtained, along with facility rosters, job descriptions, and policies. Refer to LIC 9099C for the continuation of this report. Substantiated Allegation: Staff falsified residents' signature. It is alleged that resident (R1's) signature was falsified on "Release of Resident Medical Information" and "Consent for Emergency Medical Treatment.." The complaint alleges that staff falsified their signature so that the resident was able to be seen by the in-house physician, as well as that a med-tech staff falsified R1's signature stating the resident was given their medications on 12/24/24. According to the complaint, R1 was not at the facility on (12/24/25), the date medications were allegedly given to the resident. Staff interviewed denied the allegation. Record review of forms: "Release of Resident Medical Information" and "Consent for Emergency Medical Treatment" did not indicate there was signature falsification because they were electronically signed by R1 on 11/7/24 via Dropbox Sign. However, on 12/24/25, the facility filled out a Medication Release form. Resident (R1's) signature on that date was compared to other document signatures. The signature appears different and inconsistent with the majority of signatures on record. Copies of the Medication Release forms were obtained. There is sufficient evidence to support the allegation. Allegation: Staff does not ensure facility is in good repair. The complaint alleges the facility surveillance cameras are inoperable. According to information obtained, residents had an understanding the facility has surveillance cameras for their safety. However, in recent months many of the cameras have not been working. A total of 14 residents were interviewed, all the residents interviewed had knowledge of video surveillance in the building. However, the majority of the residents stated they do not know whether all the cameras are operable. Staff interviews confirmed that there are exterior cameras throughout the property, and that the majority of the interior cameras were removed. LPA observed one (1) surveillance camera in the hallway by the lobby area. Executive Director stated the camera video does not show on the main office monitor, and at this time only 3 cameras are displayed in the office surveillance monitor. Based on observation, the facility has multiple cameras, of which only 3 are showing as operable as of today. Based on observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. An exit interview was conducted with Executive Director Jacqueline Cortez. A copy of the report and appeal rights were issued. Allegation: Staff are not adhering to job duty. The complaint alleges that night shift staff have been observed sitting in the main office asleep resting their heads down on the desk after they conduct their rounds. According to information obtained, the staff set alarms to wake up and continue with their rounds, and once they finish doing their rounds they go back to sleep. It is alleged that staff tend to sleep between 12 AM - 4 AM. Based on eight staff interviews, the findings indicate that there is a total of 3 night shift caregiver staff, 2 night shift med-techs, and a receptionist that works from 3:30 PM - 12:00 AM. Caregiver staff are in the main office or break room and med-tech staff are located in the medication room. According to staff interviews, caregivers are required to attend to residents in care and do 2 hourly checks at night. Med-techs pass out medications, respond to incidents and/or emergencies, and organize medications. Two (2) out of the eight (8) staff stated sometimes night shift caregivers do put their head down on the desk, but they are not asleep. A total 14 residents were interviewed. Two (2) out of 14 residents stated they have observed staff sleeping during the night shift hours. It is unknown if night shift staff are on break when they have been seen with their head down on the office counter. Based on interviews conducted, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Executive Director Jacqueline Cortez. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 14, 2025 · control 28-AS-20251010093333

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Oct 28, 2025

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 was not met evidenced by: Based on record review of Medication Release form dated 12/24/24 and multiple other forms on different dates it was observed that form dated 12/24/24's signature is different and inconsistent with the majority of signatures on record. Therefore, there is a signature mismatch. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: Executive Director agreed to: 1. Provide proof of med-tech in-service training on Medication Release form, and protocols regarding obtaining resident signatures of residents that are unable to sign on their own. 2. Submit a written plan with facility procedures and training materials.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 11, 2025

Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met evidenced by: Based on observation, there is one (1) indoor surveillance camera located in the hallway by the lobby, and multiple cameras in the exterior of the building. The main office camera monitors only show 3 operable cameras. The indoor camera is not operable. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: Executive Director agreed to submit a written plan that addresses surveillance use, policy, and repairs. If cameras are to be used indoors, the facility plan of operation, sketch, and admission agreement must be updated and submitted to Community Care Licensing.

Allegation investigated: Staff does not provide adequate food service. Staff does not ensure to follow food handling practices. Staff do not provide residents with a sufficient amount of food.

Licensing Program Analyst (LPA), Mayra Cota, conducted a 10-day complaint investigation visit regarding the above-mentioned allegations. LPA met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained. During today’s visit: LPA conducted tour of the common areas of the facility, with a focus on inspecting the kitchen and dining rooms, obtained copies of staff and resident rosters, interviewed Staff 1 – Staff 9 (S1-S9) and Resident 1 – Resident 15 (R1-R15). LPA, also reviewed and obtained copies of facility's Plan of Operation and Resident and Employee Lunch forms. The investigation revealed the following: ***Continues on LIC 9099-C Unsubstantiated Regarding: Staff does not provide adequate food service. It is alleged that a resident had placed an order for a meal prior to going to the dining room and had to wait 45 minutes before getting their food. It is also alleged that staff are not assisting with delivery of meal services for (2) residents and that resident is the one to take their food to their room. Staff deny the allegation. Interviews with (9) out of (9) staff revealed that meal service schedules are followed every day and that meals are served within (5) to (10) minutes of an order being taken by staff for residents waiting in the dining room. Staff indicated that many residents have their meals in the dining area and therefore, sufficient servers are available to conduct meal service in a timely manner. Staff further indicated that they have not received complaints from residents regarding waiting for prolonged periods of time for their food. Furthermore, staff indicated that bedside meal trays are delivered to all residents who have the service as part of their care plan and for residents who have minor/temporary illness or are recovering from surgery with a physician’s order. Caregiving staff indicated that they deliver all scheduled meals to residents and return to check on residents in case residents want a second helping of food or need their trays to be taken away after finishing their meals. Interviews with (12) out of (15) residents revealed that meal services are conducted in a timely manner in the dining area and residents usually get their food within (10) minutes from the time their order was taken by staff. A resident who stated that they deliver meals to R2 and R3 indicated that staff are not delivering meals and therefore, resident picks up meals for R2 and R3 to ensure they have something to eat. Interviews with R2 and R3 indicated that they go to the dining area to have their meals, unless they are sick in which their meals are then delivered to their room by staff. R2 and R3 indicated that their care plan does not include their meals being delivered to their rooms; however, the facility has made accommodations to have meals delivered to their rooms when they are sick and recovering from illness. R2 indicated, a resident does not deliver their food to their room. R3 indicated that a resident has delivered food to their room; however, R3 had already eaten in the dining room and had an extra meal in her room which they did not need. R2 and R3 indicated, when their meals had to be delivered to their room by staff when they were sick, all their trays arrived in a timely manner, and no meals were skipped due to staff not conducting the delivery. LPA review of Plan of Operation indicates, bedside meal trays are available to residents with minor/temporary illness or recovering from surgery with a physician order. Staff and resident interviews do not corroborate the allegation. ***Continues on LIC 9099-C page 2 Regarding: Staff does not ensure to follow food handling practices. It is alleged that staff are not wearing a hair net and hair is getting into resident’s food. Staff deny the allegation. Interviews with (9) out of (9) staff revealed that staff who work in the kitchen preparing the food must always wear a hair net. Staff indicated that cooks cannot be in the kitchen without a hair net which has to cover their hair when they are handling food. Staff stated they always adhere to safe food handling practices at all times. Staff further indicated that staff nor residents have expressed concerns regarding hair being in the food served at the facility. Interviews with (14) out of (15) residents also deny the allegation. Residents indicated that they have not observed cooks or other staff handling food without a hair net. Residents stated that they have not observed any hair in their food and have not heard other residents express concerns about finding hair in their food. A resident indicated that they observed a staff from the kitchen without a hair net during food preparation and service; however, resident did not indicate finding hair in their food. During today’s visit, LPA observed staff handling food were wearing a hair net. Staff and resident interviews, and LPA observation do not corroborate the allegation. Regarding: Staff do not provide residents with a sufficient amount of food. Staff do not provide residents with sufficient amount of food. It is alleged that a staff’s meal had more food than the rest of the residents. Staff deny the allegation. Interviews with (9) out of (9) staff revealed that staff meals are not portioned differently from residents’ meals. Staff indicated that when staff request the (1) meal a day the facility provides, it is prepared equitably for residents and staff. Staff indicated that staff have to place their order by using the Employee Lunch Form in advance to be able to get their meal for the day, however, resident meals are priority and kitchen staff serve residents first and would not give staff more food than residents. Interviews with (14) out of (15) staff indicated that they have no concerns with portions not being appropriate. Residents indicated their food is plentiful and if needed they can request seconds from the kitchen staff. Interview with a resident indicated that they observed a staff member receiving more food than what residents were being served. Interviews with staff and residents do not corroborate the allegation. ***Continues on LIC 9099-C page 3 Based on interviews and observation the above mentioned allegations could not be corroborated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Jacqueline Cortez and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 14, 2025 · control 28-AS-20251006131012

Allegation investigated: Staff did ensure resident was provided a safe environment while in care. Licensee is financially abusing resident in care.

***This report supersedes the report delivered on 10/28/25. The reason for the amendment is to remove confidential information listed on the initial report. The findings will remain unsubstantiated. *** On 10/28/25, Licensing Program Analyst (LPA) S Vaid conducted a subsequential complaint investigation visit for the above allegations. LPA met with Jacqueline Cortez-Administrator, and the purpose of the visit was discussed. On 4/22/25, LPA Vaid conducted an initial 10-day complaint investigation visit for the above allegations. LPA met with Ruth Villa, Wellness Director and Joel Niblett, Administrator. The investigation consisted of the following: LPA toured the physical plant. LPA Interviewed staff #1-#6 (S1-S6) and residents #1-#15 (R1-R15). LPA requested, collected, and reviewed documents from R1's face sheet, physicians reports, residential admissions agreement, medication, physicians’ orders, residents' facility financial history for R1. Staff and client rosters were obtained. LPA collected six (6) random residents files. The investigation revealed the following: CONTINUED ON 9099C....................... Unsubstantiated ***This report supersedes the report delivered on 10/28/25. The reason for the amendment is to remove confidential information listed on the initial report. The findings will remain unsubstantiated. *** Regarding the allegation: Staff did ensure resident was provided a safe environment while in care. It is alleged that the facility staff are not providing a safe environment for the residents that reside at the facility. R1 was placed with an aggressive resident/roommate who was verbally abusive and R1 felt uncomfortable and unsafe. Six (6) out of six (6) staff deny this. The staff stated they provide all residents with comfortable living accommodations and safety throughout the facility. Staff determine compatibility when placing residents together. The staff stated they ensure that all residents are provided with a safe environment by settling disputes between residents and keeping residents comfortable and treating the residents with respect and dignity. Fourteen (14) out of fifteen (15) residents interviewed could not corroborate this allegation. Nine (9) out of fifteen (15) residents interviewed stated they feel safe and comfortable living here and the staff assist with residents’ well-being. According to interviews with residents, R3, R14 and R15 have not resided in room #131 with R1 as a roommate. Based upon observations and interviews conducted the findings indicate that, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Licensee is financially abusing resident in care. It is alleged that the licensee is financially abusing resident #1(R1) in care by charging R1 with services not provided while resident was at Westwood Acute Care in another facility. Per co-complaint, the business office is not providing residents with copies of residents facility financial records. It is further alleged that staff are stealing monies from residents banking accounts by making residents sign blank pieces of paper. Six (6) out of six (6) staff interviewed deny this allegation. According to R1’s admissions agreement, ‘Residents are obligated to pay rent when on vacation or transferred temporarily to an outside health care facility’. Admissions agreement, pages 8-9, section VI-Fees, subsection D-Adjustments to fees and services, item 4- Absence from the Community. Signed by R1 on 05/03/2024 acknowledging the rules and responsibilities for residing in the facility. Staff interviewed stated that financial transactions related to the monthly rent and financial records are handled by the corporate accounting office to ensure proper billing and payments are received and correctly posted to residents’ accounts. The accounting office sends financial receipts to all residents for monthly rent and residents can receive a copy of their financial records upon written request. Staff stated they are not making any residents sign blank sheets of paper to gain access to the residents’ bank accounts. Thirteen (13) out of fifteen (15) residents could not corroborate licensee financially abusing residents. Seven (7) out of fifteen (15) residents stated they are not having monies stolen by staff. Most residents have their family handling money matters. Based upon records reviewed and interviews conducted the findings indicate that, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Copy od this report was provided to Jacqueline Cortez -Administrator.the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 28-AS-20250418090103

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Mayra Cota, conducted a Case Management – Incident visit today to follow up on incident report received by the department. LPA met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained. According to Special Incident Report (SIR), a medication error was noted on 9/25/25 in which Resident #1 (R1) was administered Oxycodone three times within a six-hour period. The order for Oxycodone is for every six hours for R1. According to Staff #1 (S1), a staff who was monitoring documentation informed S1 that a medication error was noted on the narcotic count sheet from 9/25/25 for R1. S1 checked R1’s QuickMar entries and found that Oxycodone was administered at 4:00 p.m., 7:00 p.m. and 10:00 p.m. S1 indicated that review of R1s QuickMar confirmed that R1 received excessive dosage of Oxycodone medication on 9/25/25 between the noted time period. S1 stated, R1 had to be closely monitored by staff to ensure R1 did not experience adverse effects from the medication. R1’s vitals were closely monitored and R1’s physician was notified immediately about the incident. The incident was also reported to the ombudsman and licensing. S1 further indicated, R1’s physician ordered a temporary suspension of R1’s Oxycodone and doses were resumed once R1’s vitals stabilized. Interview with Staff #2 (S2) indicated, S2 became aware of the medication error through staff communication and was assigned to conduct check of vitals on R1. S2 further indicated that during wellness checks, R1 slept soundly, and later was observed walking around the facility. S2 also stated that R1was observed returning their food tray which showed indications that food was eaten by R1. ***Continues on LIC 809-C S1-S2 stated, once R1 was observed to continue with normal activity, med-tech staff resumed administration of R1’s Oxycodone on 9/26/25 at 10:00 p.m. According to S1, R1 was informed about the medication error and R1 agreed to have the medication paused while staff observed R1. Review of R1’s Controlled Medication Count Sheet, indicates Oxycodone was administered on 9/25/25 at 4:00 p.m., 7:00 p.m. and 10:00 p.m. S1 stated, they conducted meetings with the staff who administered the medication incorrectly to R1 and corrective actions were discussed and set in place. LPA conducted interview with R1 during today’s visit. R1 indicated, staff have been managing their medication correctly after the incident on 9/25/25 and has no concerns at this time. Further action may be required, and LPA Cota may return to gather additional documents and conduct additional interviews. Deficiency noted and citation issued during today’s visit. Exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Oct 9, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 10, 2025

87468.2 (a)(4) Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on interviews conducted and documents reviewed, licensee did not ensure that R1 received their medication at the correct times and thus, received excessive medication within a six-hour period. Medication was administered too soon between doses which poses an immediate risk to the health, safety, or personal rights to residents in care.the state’s words, verbatim · CDSS document, Oct 9, 2025

Plan of correction: Administrator will provide medication training to med-tech staff which will include shadowing and will submit a copy of training log, topic, description of training, and duration of training by POC due date.

Allegation investigated: Staff did not ensure resident received medical care in a timely manner Staff does not ensure residents are spoken to in an appropriate manner

The purpose of this Amended Report 12/01/25 is to remove confidential information from the subsequent complaint visit conducted on 10/07/25. Licensing Program Analyst (LPA) Glenn Trueman, made an unannounced subsequent complaint visit in response to the above mentioned allegations. LPA met with Jacqueline Cortez, Administrator, and explained the purpose of the visit. The initial visit was conducted on 8/25/25 and included the following: LPA obtained a copy of the staff and resident roster, Special Incident Report's (SIR's), and Staff Communication Notes. LPA Interviewed the Administrator and Staff S1. File was reviewed for Resident R1 and Resident R2 and various documents were submitted. Resident and Staff Roster was submitted., At today's visit Resident's R1- R16 were interviewed . Administrator and Staff S1-S3 were interviewed. Unsubstantiated In regards to the allegation Staff did not ensure resident received medical care in a timely manner, based on interviews conducted and information gathered 14 of 16 residents stated that staff have been quick to help them. Also stated that staff does a good job with any type of medical attention including visits with the primary care doctor, medication administration and 911 calls and visits to Urgent Care. Resident R2 stated he was found unconscious in his room and the staff responded right away. Resident R13 stated that he broke his ankle at night falling on the sprinkler. Said staff responded right away. Resident R9 stated that he knows of Resident R1. Stated R1 harasses residents and staff. Said R1 jumps into argue for someone else and causes problems. Administrator stated that Resident R17 was at the front desk waiting for Hospice to arrive. Said R1 was diagnosing R17 and that staff doesn't have to explain what they are doing. Said there are HIPPA laws. Staff S1-S3 all stated that R1 was diagnosing R17 and telling R17 that he was having a heart attack. Said that R17 was on Hospice and the protocol is to wait for the Hospice Nurse to tend to R17. Hospice Notes dated 08/15/25 at 9 PM and Hospice checked vitals for R17. States R17 had been given medication for chest pain during the day. Hospice had facility call 911 and R17 was sent to San Gabriel Hospital and admitted on 08/16/25. Discharge instructions to follow-up with your Prmary Care Provider in 1 to 2 weeks. Although the allegation 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. In regards to the allegation Staff does not ensure residents are spoken to in an appropriate manner, based on interviews conducted and information gathered 14 out of 16 residents stated that staff have not yelled or screamed at residents. Also stated that residents are the ones who scream at staff. Said staff have to use a loud and stern voice. Stated the staff act respectfully and check on them often. Administrator stated that staff didn't tell R1 to stay in her room. Said staff did tell R1 to stay out of other resident's business. Staff S1-S3 all stated they are mandatory reporters and they know that you are not allowed to hold resident's in their room. Said they did ask R1 to stop diagnosing resident's. Special Incident Report dated 08/19/25 and states R17 had chest pain and was taken immediately to USC Arcadia hospital and returned the same day with no new orders. On 08/21/25 SIR indicates that medication prescribed in a Physican's order was administered. R17 still had chest pain and 911 was called immediately. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted and report issued to Administrator Jacqueline Cortez.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 28-AS-20250820143204

Allegation investigated: Staff did not prevent resident from being harmed by another resident.

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced subsequent complaint investigation visit to deliver findings on the above-mentioned allegation. Today’s visit stems from an initial visit conducted on 9/25/25. LPA met with Jacqueline Cortez, Administrator, and explained the reason for today’s visit. The investigation consisted of the following: During visit on 9/25/25, LPA obtained a copy of the staff and resident roster, reviewed Resident 1 and Resident 2's (R1-R2) file, obtained copies of relevant documents and conducted interviews with Staff 1-6 (S1-S6) and R2. During today’s visit, LPA toured common areas of the facility, obtained a copy of staff and resident rosters and conducted interviews with Resident 3 – Resident 8 (R3-R8) and telephonic interviews were conducted with R1 and (2) of R1’s family members. The investigation revealed the following: ***Continues on LIC 9099-C Unsubstantiated Regarding: Staff did not prevent resident from being harmed by another resident. It is alleged that resident has been punched by roommate multiple times in which one incident resulted in a bruise on resident’s torso. It is also alleged that resident reported the incident to staff and asked to be moved to another room, but nothing was done. Interviews with (6) out of (6) staff deny the allegation. Staff interviews indicated that R1 did not report an altercation with R2 which resulted in an injury to R1’s torso to staff. Staff stated that no other incidents between R1 and R2 have been reported by them to staff. Staff stated that R1 and R2 have disagreements from time to time about the volume on the television set being too loud or about the AC settings being too cold; however, disagreements do not escalade to physical aggression. S1- S4 indicated, R1 had been moved to another room after R1 made a request to administrative staff; however, R1 requested to be moved back to the room with R2. S1 and S2 indicated that when the change of room was granted for R1 to return to the room with R2, R1 was informing that requesting another room change may be difficult to undergo due to rooms not being available. Staff further indicated, when residents have altercations with their roommates, staff intervene by deescalating tension between them and providing the option to spend the night in an empty room to put space between residents. Furthermore, staff are mandated reporters, and any form of abuse is reported to ombudsman, licensing and or/law enforcement. Interview with R2 indicated that R2 did not hit R1 on the torso and has never hit R1. R2 stated, R1 and R2 sometime argue about the temperature in the room being too cold, but they have not hit R1 during their disagreements. R2 further indicated, their health is not good and cannot make jolting movements to hit another person. R2 stated, they suffer from joint pain and have had heart surgery in the past and cannot risk getting hit back by a person. Telephonic interview conducted with R1 indicated, R1 and R2 have argued about the temperature of the room which R2 likes to maintain in the coldest setting. R1 indicated, R2 punched R1 on the left side of their torso due to complaining to staff about the disagreements they have had about R2 setting the AC too cold and about R2 engaging in frequent sexual acts in R1’s presence. Two (2) of R1’s family members were also interviewed telephonically, and they indicated that R1 expressed concerns about R2 punching R1 in the torso as retaliation for R1 reporting R2 to staff. Family members also indicated that they saw the bruise on R1’s left side below the arm pit which looked like a fist mark. Record review indicated that R1 was moved to a secondary room after initial admission to the facility. Record indicates, R1 remained in the secondary room for a short period; but requested to return to the room R1 was initially installed in with R2. Based on interviews and record review, the allegation could not be corroborated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Jacqueline Cortez, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 28-AS-20250923115304

Allegation investigated: Staff spoke to resident in an inappropriate manner. Staff threatened to withhold resident’s medication.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit for the allegations listed above. LPA met with Administrator Jacqueline Cortez to explain the purpose of the visit. On 9/30/25, LPA Chan obtained copies of the staff and resident rosters and interviewed the administrator and a staff. During the visit today, LPA interviewed an additional four (4) staff and ten (10) residents. The investigation revealed the following: Allegations - Staff spoke to the resident in an inappropriate manner. It is alleged that a staff “screamed her bloody head off, ahh” after observing an extra plate of food on the resident’s walker and “acted like a B.” LPA interviewed staff and residents regarding this allegation. Administrator and Staff stated they are provided training on ways to communicate with residents, and they do not speak to residents inappropriately. Unsubstantiated Staff do not yell at residents or make inappropriate comments. Staff treat residents with dignity and respect. LPA interviewed the administrator, who stated that it was brought to her attention and written statements from staff were provided for this incident. Per the statements, S1 knocked on the door and went inside the room to take out the trash. The resident started to yell, so the staff took out the trash and closed the door. LPA interviewed S1, who denied making any statements/comments to the resident while in the room. The other staff who was present confirmed that S1 did not talk back to the resident. Nine (9) out of ten (10) residents have not been spoken to inappropriately by the staff. Residents stated that staff are respectful and do not put them down. Allegation - Staff threatened to withhold the resident’s medication. It is alleged that the staff threatened to withhold the resident’s medication if the resident did not treat the new girl nicely. LPA interviewed the administrator and staff who had not heard any staff threatening the residents. Staff stated they are not allowed to and do not threaten residents to get them to comply or to treat others kindly. Nine (9) out of ten (10) residents stated they have never been threatened by the staff or seen staff threatening others. 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 with the administrator. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Oct 6, 2025 · control 28-AS-20250922121137

Allegation investigated: Staff did not prevent resident from smoking in the room resulting in a fire. Staff are not responding to residents call button. Staff do not provide adequate food service to residents in care.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to review records and deliver findings on the above allegations. The purpose of the visit was explained to Executive Director Jacqueline Cortez. The investigation consisted of: On 6/17/2025, a physical plant tour of the interior and exterior was conducted, with special focus on medication room, residents' room signal system, kitchen food preparation/servings, and outdoor smoking areas. A total of nine (9) staff and 15 residents were interviewed. LPA reviewed and collected resident (R1 & R2's) file documents; which include Identification and Emergency Information, Physician's Report, Medication Administration Records, Care Plan, June 2025 food menus, alternative food menu, and kitchen resident diet list. LPA interviewed R1's pharmacist and Primary Care Physician's office representative. *Narrative continues next page. Unsubstantiated Allegation: Staff did not prevent resident from smoking in the room resulting in a fire. It is alleged that there was a fire in a resident rooms #143 or #144 and smoke was going into the hallway. Date of incident and resident room number is unknown. A total of 15 residents were interviewed. One (1) out of 15 residents confirmed the allegation. The majority of the residents said that they had no knowledge of any fire in the facility grounds. Residents stated they are allowed to smoke outside in the patio. A total of nine (9) staff were interviewed. All staff denied the allegation. Staff interviewed stated that most of the residents are compliant with smoking rules. The residents are not allowed to smoke in the front of the facility. There are 2 patios in the center area of the facility. During the physical plant inspection, there was no indication of a previous fire in the identified rooms and in other rooms toured. The facility has operable sprinklers. There is insufficient evidence to support the allegation. Allegation: Staff are not responding to residents call button. It is alleged that on 6/15/2025 at approximately 10:30 PM, a resident pressed the call button for incontinence care assistance and staff did not respond to the call, as a result another resident walked to the med-tech room and found the receptionist staff talking instead of responding to the call button request. A total of 15 residents were interviewed. Six (6) out of 15 residents stated they press the call button and often times staff take a long time to respond and/or they do not respond at all. Residents stated they call signal is operable, but the issue is staff response time. According to staff interviews, when residents press the call signal buttons in their room the receptionist communicates through walkie talkies and/or overhead speakers. If caregiver staff are busy, another caregiver is asked to assist with the call signal request. Staff stated staff in all shifts conduct 2-hour checks. Based on interviews conducted, the findings indicate there is a staff person at the front desk 24 hours a day/7 days a week, that monitors call from the signal system. Caregivers are to respond to call requests within a 7 minute time frame, and if they are busy then med-tech staff are to assist with call follow up. The signal system was tested and found to be operational. Staff responded promptly. There is insufficient evidence to support the allegation. Allegation: Staff do not provide adequate food service to residents in care. It is alleged that the facility serves burnt and hard to chew food, over season the food, put onions and peanuts on food of allergic residents, and they run out of bread, coffee, and milk. LPA toured the kitchen and dining room during lunch and dinner meal service. The food supply and cooked was inspected. A resident diet board was posted in the kitchen, meal ticket orders were observed, and the special diet list was reviewed to determine if resident (R1) requires a special diet. Resident (R1) requires a special diet. A total of 15 residents were interviewed, of which 3 residents stated the food is not good and does not meet their dietary requirements. However, most of the residents stated the food is good and a variety of foods are served. Staff interviews revealed that residents may select alternative food if they do not like the food items served during mealtimes. Staff stated they never run out of food and food delivery orders are Mondays and Thursdays. Staff said that some residents are picky eaters, but kitchen staff accommodate their requests. There is insufficient proof to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted with Jacqueline Cortez. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 23, 2025 · control 28-AS-20250616120107

Allegation investigated: Staff had inappropriate interactions with resident Staff does not treat resident with respect

Licensing Program Analyst’s (LPA’s) Christian Gutierrez, and Gabby Castro conducted a subsequent complain visit in regard to the allegations listed above. LPA’s met with Administrator Jackie Cortez and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 09/16/2025, LPA toured the facility and obtained copies of the following documents: staff roster, resident roster. During visit on 09/19/2025 LPA’s Gutierrez, and Castro interviewed: Administrator, staff #1-staff 6, residents #1-residents #10, obtained copies of R1 physician report, identification sheet, resident assessment, service plan, and R1’s intake notes. LPA’s also delivered findings. See 9099C Unsubstantiated In regard to the allegation “Staff had inappropriate interactions with resident”, and ‘Staff does not treat resident with respect”, it is alleged that staff inappropriately touched resident in care and are aggressive. During interviews with Administrator and staff seven (7) out of seven (7) stated that to their knowledge no staff has had any inappropriate interactions with residents. Administrator stated no corrective actions or write ups have been given addressing these concerns. Seven (7) out of seven (7) staff all stated that they treat all residents with dignity and respect and have not been aggressive with residents. During interviews with residents seven (7) out of ten (10) residents stated that staff has not been inappropriate with them and that they are treated with respect. R4 stated that staff should knock on their doors and that it’s disrespectful for them just to come in. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Jackie Cortezthe state’s words, verbatim · CDSS document, Sep 19, 2025 · control 28-AS-20250912150740

Allegation investigated: Staff did not seek medical assistance for resident in a timely manner

Licensing Program Analyst (LPA) Glenn Trueman, made an unannounced complaint visit in response to the above mentioned allegation. LPA met with Jacqueline Cortez, Administrator, and explained the purpose of the visit. At today's visit LPA obtained a copy of the staff and resident roster, and Staff Communication Notes. Interviewed Residents 2-8 ( R2-R8) and Staff 1-2 (Staff S1- S2). Administrator also interviewed. File was reviewed for Resident R1 and various documents to be submitted which included Physician's Report, Admissions Agreement and Emergency ID page. In regards to the allegation Staff did not seek medical assistance for resident in a timely manner, based on interviews conducted and information gathered Resident's R2-R5 all stated that they have had to go to the hospital and staff acted appropriately by calling 911 immediately. Stated the whole process of going to the hospital and back to the facility went smoothly. Resident's R6-R8 stated that staff assist with any medical needs. Stated that they have observed residents in need of medical assistance and the staff act quickly and if needed call 911 right away. Unsubstantiated R7 and R8 said they have gone to the hospital and 911 was called immediately and that staff communicates well and the process has gone smoothly. Spoke with Administrator who stated Resident R1 had an unwitnessed fall and was assessed. Stated R1 didn't have a head injury and everything was normal. Said R1 normally has slurred speech. Interview with Staff S1 who stated that R1 fell and was assessed right away and had no head injury, and no wounds. Vitals were normal. Said all was normal with R1. Stated slurred speech is normal. It is baseline. Interview with Staff S2 who stated that if resident had fallen they don't just send them to the hospital. They assess and with R1 didn't have a head injury or wound. Stated R1 was oriented x4 and R1 is self responsible and was fine and didn't want to go to the hospital. Admissions Record dated 2/19/24 lists R1 as responsible party. Staff communication notes state that on 09/09/25 at 12:10 AM that R1 was on the floor. Also said that there were no bumps or bruises and R1 didn't hit head or have any pain. It should be noted that R1 is currently in the hospital. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated.the state’s words, verbatim · CDSS document, Sep 18, 2025 · control 28-AS-20250912092956

Allegation investigated: Staff pushed a resident in care. Staff spoke to residents in an inappropriate manner. Staff threatened a resident in care. Staff did not serve a meal to resident in a timely manner. Staff did not ensure that resident's medical needs are being met.

Licensing Program Analyst (LPA) Glenn Trueman, made an unannounced subsequent complaint visit in response to the above mentioned allegations. LPA met with Jacqueline Cortez, Administrator, and explained the purpose of the visit. The initial visit was conducted on 06/19/2025 and the following was done: LPA obtained a copy of the staff and resident roster, Special Incident Report's (SIR's), and Staff Communication Notes. Interviewed Residents 1-4 ( R1-R4) and Staff 1-2 (Staff S1- S2) File was reviewed for Resident R1 and various documents were submitted. At today's visit interviews were conducted with Resident's R5- R10, the Administrator and Staff S3. In regards to the allegations Staff pushed a resident in care, Staff spoke to residents in an inappropriate manner, Staff threatened a resident in care based in interviews conducted and information gathered 9 of 10 residents interviewed stated that staff have not been inappropriate with the residents.All stated that if anything the residents are the aggressors. Unsubstantiated They also stated they have not seen or heard of physical, or verbal abuse and no one has been threatened by the staff. Interview with Resident R10 who stated that R1 has been the aggressor toward Staff S3. Will also call Staff S3 and other staff racist words and seems like R1 has a vendetta toward S3. Said S3 is kind to all the residents. Interview with Staff S2 who said R1 is extremely mean and calls her the B word and she doesn't respond. No one pushed, yelled or threatened R1. If anyone does that it is her. R1 harasses staff and residents. Staff S3 stated R1 is the aggressor and said there has never been pushing, threatening or speaking inappropriately to R1 or any resident. The Administrator stated that Staff S3 didn't push R1. R1 harasses and calls S3 the B word. Said S3 is kind to all the residents. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. In regards to the allegation Staff did not serve a meal to resident in a timely manner, based on interviews conducted and information gathered 9 out of 10 residents stated the food service is good and that they are all served pretty quickly for all 3 meals. Said the staff organize alot of residents very efficiently. The Administrator stated that there are multiple servers and the system is very good. Staff S1-S3 said the servers are very efficient and the process moves very fast for all 3 meals. Staff S3 stated that there is a red line in front of the kitchen and it says not to cross it because it's only for employees. Said R1 attempted to get in the kitchen 3x and service had just started when R1 said out loud I'm waiting 45 minutes. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. In regards to the allegation Staff did not ensure that resident's medical needs are being met, based on interviews conducted and information gathered 9 out of 10 residents stated that staff will give immediate attention if it may be urgent and will call 911 right away. Said if they call for help staff come quickly. Said staff will arrange doctor appointments. R1 confirmed that facility arranged for her to go to the hospital after an unwitnessed fall. LPA during initial visit conducted on 06/19/2025 observed R1's call button to be operable. Resident R11 had been treated by Home Health and had gone to the hospital 06/18/2025 and moved out of the facility on 07/03/2025. Resident R6 stated that she had fallen and injured her foot and the staff came immediately after pressing the call button. Staff S1- S3 all stated that residents are helped right away and they call for assistance from the call button in their room. Said they also help immediately if they see the resident in need of medical attention. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.the state’s words, verbatim · CDSS document, Sep 11, 2025 · control 28-AS-20250612164021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(i)(1)(A)(B)(C) · Plan of correction due date: Sep 12, 2025

Maintenance and Operation Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit. This requirement is not met as evidenced by: Facility failed to have a signal system operable in R7 and R9's room which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 11, 2025

Plan of correction: Facility to submit by POC due date verification of a scheduled appointment with a company to repair call buttons. Also to submit receipts when the work is completed.

Allegation investigated: Resident was not accorded privacy while in care. Staff yelled at resident. Staff did not administer resident's medication in a timely manner. Facility is not meeting resident's dietary needs.

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced 10-day investigation visit regarding the above-mentioned allegations. LPA met with Jacqueline Cortez, Executive Director and the reason for the visit was explained. The investigation consisted of the following: LPA obtained copies of staff and resident rosters, toured the facility, conducted interviews with Staff 1 – Staff 9 (S1-S9) and Resident 1 – Resident (10), conducted record review for R1 and obtained copies of relevant documentation. Investigation revealed the following: ***Continues on LIC 9099-C Unsubstantiated Regarding: Resident was not accorded privacy while in care. It is alleged that staff enter a resident’s room during the night without consent, making it difficult to sleep. Interviews with (6) out of (6) staff deny the allegation. Interviews with staff indicated that staff have to enter rooms to conduct health checks on all residents, particularly those who need assistance with (ADLs) which include doing checks on residents during the night shift. Staff stated that before entering residents’ rooms, they must knock, announce themselves and wait for permission from residents to enter their rooms. Interviews with staff further indicated, staff are respectful of residents’ privacy and will only visit rooms if residents allow staff to enter or if there is a medical emergency and staff need to have access to residents in distress. Interviews with (9) out of (10) residents indicated they are accorded with privacy, and they do not have any concerns. Residents further indicated that staff are respectful when visiting their rooms and understand that staff have to enter their rooms to help meet their needs. Interview with R1 indicated that staff were entering their room during the night shift without R1 requesting staff to come to their side; however, staff are now visiting their room, once before bedtime to get help with personal hygiene and then in the morning to help R1 prepare for their day. Staff and resident interviews do not corroborate the allegation. Regarding: Staff yelled at resident. It is alleged that staff are verbally aggressive and that staff yell at a resident. Interviews with (9) out of (9) deny the allegation. Staff interviews revealed that staff are not verbally aggressive toward residents nor yell at them. Staff also indicated that they have not heard other staff yell at residents. Staff stated they are respectful and use a soft tone of voice when speaking to residents. Interviews with (9) out of (10) residents indicated, staff do not use verbal aggression nor yell at them. Residents indicated, staff are friendly and respectful when talking to residents. Residents further stated staff interactions are appropriate, and they have no concerns. Interview with R1 indicated, staff sometimes do not talk to them calmly and use loud tones of voice when speaking to them; however, the situation has become better, and staff are using more appropriate tones to talk to R1. Staff and resident interviews do not corroborate the allegation. Regarding: Staff did not administer resident's medication in a timely manner. It is alleged that staff are not checking a resident’s vitals nor providing resident with their medication in a timely manner. Staff deny the allegation. Interviews with (6) out of (6) staff indicated, R1has been provided with their medication in a timely manner. Staff indicated that R1 receives all their medication as prescribed by their doctor, and medication is administered on time and documented accordingly. However, R1 has been requesting Acetaminophen 500 mg. tablets (PRN) in between the doctor prescribed doses which are to be given to R1 for pain every six hours. Staff have informed R1, they cannot receive “extra” doses of the Acetaminophen tablets outside of the doctor ordered doses which are given to R1 every six hours for recurring pain. Staff have explained to R1 that over-medication can be harmful to their health and therefore, physician’s orders have to be followed. Staff also indicated, vitals are taken of residents if there is a physician’s order in place or if resident is experiencing a medical emergency. Staff further stated, R1 does not have an order by their physician to have their vitals checked; however, if R1 complains about having a medical emergency, staff will proceed with taking vitals and getting the appropriate medical attention for R1. Record review/eMAR for R1 indicated, R1 is receiving their daily doses of Acetaminophen 500 mg. tablets (PRN) as prescribed by their doctor. Record review for R1 also indicated, R1 does not have an order from their physician for staff to check their vital signs in R1’s facility record. Interview with R1 indicated, they request “extra” Acetaminophen tablets from staff because they want to take it before the recurring pain in her knee and sometimes headaches set in. Interviews with (9) out of (10) residents indicated they have no concerns with receiving their medication in a timely manner. Staff and resident interviews and record review do not corroborate the allegation. Regarding: Facility is not meeting resident's dietary needs. It is alleged that resident is having difficulty eating the food served in the facility. Interviews with (6) out of (6) staff deny the allegation. Interviews with staff indicated, when providing meals to R1, they have to follow the mechanical diet specifications so that R1 can eat their meals conformably. Specifications indicate, R1’s food has to be soft and chopped which is ordered by R1’s doctor. Staff indicated, all kitchen staff follow the dietary needs of all residents who need modifications when preparing their food. ***Continues on LIC 9099-C page 2 When residents want something other than what is on the menu, they can choose something from the alternative menu which will also be modified to meet their dietary needs. Staff further stated, resident allergies, intolerances and type of modifications needed are posted in the kitchen and updated accordingly. Interviews with (9) out of (10) residents stated, facility provides them with adequately prepared food for their dietary needs and have no concerns. Interview with R1 indicated, facility’s kitchen does not prepare their food to their liking and stated that they give R1 the same food every day. LPA observation of R1’s meal services (breakfast and lunch) indicated, items on R1’s plates were observed chopped and served according to physician orders. Review of the facility’s menu indicated there is proper variation of food items throughout the month. Review of R1’s records indicate, resident is to be provided with a mechanical soft diet which should consist of soft, chopped food items. Further record review indicated, kitchen has updated list of resident dietary needs which is referred to when preparing resident meals. Staff and resident interviews, LPA observations and record review do not corroborate the allegation. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Jacqueline Cortez, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 8, 2025 · control 28-AS-20250902101443

Allegation investigated: Staff are mismanaging resident's medications.

***This is a corrected version of the original report dated 8/11/25. The purpose of the report is to correct a deficiency issued in error on the LIC 9099-D (section 87465 (b)(3)) which will be dismissed. On today's visit, LPA is issuing a citation under section 87465(c)(3)*** Licensing Program Analyst, Mayra Cota, conducted a subsequent visit to investigate the allegation above. LPA met with Jacqueline Cortez, Exective Director and the reason for the visit was explained. Itnitial 10-day visit was conducted on 6/5/25 by LPA Cota. During initial visit, LPA, obtained a copy of the staff and resident rosters, conducted medication review and obtained medication records for Residents 1-8 (R1-R8). Interviews were also conducted with Staff 1-8 (S1-S8). During today's visit, LPA obtained copies of staff and resident rosters, toured common areas of the facility, interviewed Resident 1 - Resident 8 (R1-R8) and delivered findings. ***Continues on LIC 9099-C Substantiated The investigation revealed the following: Regarding: Staff are mismanaging resident's medications. It is alleged that Medication Administration Record (MAR) had multiple medication errors regarding a medication dose for pain relief. The medication in reference to is Oxycodone. It was reported that medication error is on file at RCFE. QuckMAR reviewed for R1 indicated, medication administration was not recorded on May 2, 2025, for the 2:00 p.m. dose, May 4, 2025, for the 2:00 p.m. dose and May 5, 2025, for the 8:00 p.m. dose of the PRN Oxycodone-Acetaminophen 325 mg tablets. The three days are missing initials from administering staff. Interview with S2 indicated, staff did not "click" on the days which are missing initials, which would indicate that medication was administered correctly to resident. S2 further indicated, most likely, R1 did receive the medication on the days the initials are missing; however, the missing initials on R1's QuickMar are errors made by med-techs for not "clicking" on those specific days after "popping" the medication and giving it to R1. S2 further indicated, R1 would not miss doses of this particular medication because R1 has chronic pain and the medication helps alleviate it. S2-S8 acknowledged during interviews that sometimes, med-techs forget to "click" on the QuickMar after administering medication to residents to indicate that it was provided. Staff also indicated, QuickMar, at times, has connectivity issues and therefore, a "back-up" paper MAR is kept to document the administration of medication like Oxycodone for those residents who are prescribed to take it. At the time of visit, R1's paper MAR for May 2025, was not available for review for the fore mentioned dates. Interview with R1 indicated, staff are administering all their medication correctly and in a timely manner. R1 further stated, med-techs have not missed any dosages of their medication, especially their PRN Oxycodone because they suffer from chronic back pain and therefore, they need it to ease their pain. Interviews with R2-R8 indicated, they have no concerns regarding how the facility manages their medication. It has been found that there is sufficient evidence to corroborate the allegation. Based on record review and staff and resident interviews, the facility was unable to provide a record of each dose including date and time the PRN medication was taken, the dosage taken, and the resident's response for May 2, 4 and 5, 2025 for R1. The preponderance of evidence standard has been met, therefore the above allegation is substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099- D. An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 28-AS-20250530112753

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(3) · Plan of correction due date: Aug 18, 2025

Incidental Medical and Dental Care 87465(c)(3): (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement was not met as evidenced by: at the time of visit on 8/11/25, the facility was unable to provide a record of each dose including date and time the PRN medication was taken, the dosage taken, and teh resident's response for May 2, 4 and 5, 2025 for R1.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Licensee will ensure med-techs receive additional training regarding proper documentation of medication administration, documenting and reporting documentation errors and notifying physicians of errors by POC due date. Licensee will send training sign-in log and an agenda stating the topics discussed with staff.

Allegation investigated: Facility staff do not provide resident with their medications as prescribed. Facility staff do not provide adequate food service to resident in care. Facility staff do not assist residents with clothing.

Licensing Program Analyst (LPA), Mayra Cota, conducted a subsequent investigation visit to deliver findings for the above mentioned allegations. LPA met with Jacqueline Cortez, Executive Director and the reason for the visit was explained. The investigation consisted of the following: LPA obtained copies of the staff and resident rosters, toured the physical plant, inspected 12 resident rooms, interviewed Residents #1-12 (R1-R12) and Staff #1-11 (S1-S11). Medication review was conducted for R1, and copies of medication records for R1 were obtained. The investigation revealed the following: ***Continues on LIC 9099-C Unsubstantiated Regarding: Staff do not provide resident with their medication as prescribed. It is alleged that staff failed to provide resident with medications as scheduled and ordered by physician. The investigation revealed the following: Facility staff deny the allegation. Interviews with S1-S2 indicated, resident arrived to the facility from skilled nursing hospital with a five-day supply of medication due to R1's new order not being filled till 5/20/25 per pending order status on R1’s physician order documents. Staff stated R1’s family member, delivered medication from pharmacy not contracted with the facility due to R1’s medical insurance being outside of facility’s network before the five-day supply finished. Staff interviews further indicated, family member delivered the medication and staff have been providing the medication to resident as prescribed and without interruption. Interview with R1’s family member (authorized representative) indicated, they brought R1 from the skilled nursing hospital to the facility with a five-day supply of medication. Family member stated, once R1’s pharmacy called family member to pick up the new medication order, it was picked up and promptly delivered to the facility and given to the med-tech staff to store and administer to R1. Family member stated, per their observations during their visits to R1, staff are providing R1 with all their medication as prescribed. LPA's review of resident’s LIC 622/Centrally Stored Medication and Destruction Record indicates, medication was started as of 5/15/25. Review of Medication Administration Record (MAR) for resident also indicates medications were administered as of 5/15/25. Review of resident’s file indicated resident was admitted to the facility on 5/14/25 from skilled nursing hospital. LPA reviewed R1's medication and found all medication prescribed to be present at the facility. Interviews with (10) out of (12) residents indicated, staff provide them with their medication as prescribed. Two (2) residents manage their own medication and therefore, do not get medication from facility staff. Medication and record review, interviews with staff, family member and residents do not corroborate the allegation. Regarding: Facility staff do not provide adequate food service to resident in care. It is alleged that staff have frequently failed to provide resident with meals and water and is often left hungry. Interviews with (7) staff indicated, the kitchen provides food to all residents, daily, whether meals are served in the dining room or delivered to their room. Sufficient food is prepared for residents, and extra food is available for residents who wish to have additional portions. ****Continues on LIC 9099-C page 2 Staff stated, if physician’s orders call for a texture-modified diet, it is prepared accordingly and provided to the resident to ensure they can eat it. Staff follow the resident diet list to ensure residents receive proper meals to meet their needs. Staff also stated, water and other drinks like a variety of juices, milk and coffee are always available for residents throughout the day. Interviews with (10) out of (12) residents indicated, the kitchen provides them with scheduled meals every day and have not missed a meal, whether delivered to their room or served to them in the dining room. Residents stated, kitchen staff make changes to their meal when requested and sufficient food is available. Residents stated, the kitchen has an alternative menu which they can order from if they prefer something different from the regular menu. Residents stated, water and other drinks are available for residents throughout the day. One (1) resident interviewed did not provide information about the facility's food service because they purchase their own food. Interview with R1’s family member indicated, they have observed R1 receiving their meals from staff which they deliver to R1’s room as scheduled. Family member stated, R1 gets food which they can chew, and portions are plentiful. Family member stated, they have observed staff encourage R1 to eat and even help with setting R1 to eat when food is delivered to R1’s room. Family member also stated, staff assist R1 by taking R1 to meal service in the dining area via wheelchair to eat and socialize with other residents. Family member stated, they feel the staff are providing nutritious meals on time and for the ability to be eaten by R1. LPA observation of food preparation and service in the kitchen indicates meals are being provided to meet resident’s dietary needs. Observation also indicated, meals are delivered accordingly to resident’s rooms during scheduled time, along with drinks. Water and other drinks like apple juice and milk were observed during service and are available for residents to take at any time. Staff, resident and family member interviews, and LPA observation do not corroborate the allegation. Regarding: Facility staff do not assist residents with clothing. It is alleged that resident is unable to call for staff for assistance with diapering or getting dressed because her call button is not working, which leaves resident having to complete those tasks by themselves. Interviews with (5) staff indicated, caregiving staff help residents when help is requested, with dressing, personal hygiene and other activities of daily living (ADLs). When assistance is warranted due to health impairments which limit resident’s ability to do things on their own, staff are available to provide care to residents. Staff stated, not only do they follow physician’s orders when providing care to residents per their abilities and limitations but also help in any way even when residents don’t have limitations. Staff are courteous and responsive to all residents. ***Continues on LIC 9099-C page 3 Staff stated, R1 is helped requested and during scheduled rounds to their room. Staff stated, there are times, R1 is offered help with dressing, but has refused to let caregivers assist because R1 states, they can do it themselves. Staff further stated, R1’s requests for assistance from staff are answered and not ignored. Interviews with (10) out of (12) residents indicated, caregivers help with things like dressing, personal hygiene, and other activities of daily living (ADLs) when requested and during caregiver’s rounds when visiting residents who need the assistance. Interview with R1 family member indicated, R1 is alert and can independently take care of their ADLs. R1 stated, they have observed caregivers coming to R1’s room to conduct care; however, R1 refuses to let staff help. R1 family member stated, they observed caregivers be courteous and responsive to R1’s requests. Interviews with residents, staff and R1 family member do not corroborate the allegation. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report was provided. Regarding: Resident call bell is inoperable. It is alleged that resident is unable to call staff for assistance due to call bell now working. LPA inspected (24) call buttons in (12) resident rooms. During inspection, (4) out of (24) call buttons were inoperable. When buttons were pressed on the call speakers, staff did not respond to the call made by LPA during testing for (4) call attempts. LPA conducted observation of the switchboard located in the main office which alerts staff of the calls made by residents and found that the (4) buttons located in the (2) resident rooms, did not trigger an alert. Front desk staff further indicated, they did not get an alert when the call button was pushed for those particular rooms. Interview with S1 indicated, when those call buttons were checked by maintenance staff, they observed that the internal wiring was malfunctioning. LPA tested R1's call button and observed it to be operable during visit. Interview with staff and LPA observations corroborate the allegation. Based on LPA’s observations 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), is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 28-AS-20250527152658

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(A) · Plan of correction due date: Aug 29, 2025

87303 (i)(A) Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (A) Operate from each resident’s living unit. This requirement is not met as evidence by: During inspection, (4) out of (24) call buttons were inoperable. Four (4) buttons located in (2) resident rooms, did not trigger an alert to front desk staff.the state’s words, verbatim · CDSS document, Aug 18, 2025

Plan of correction: Licensee will conduct checks to ensure call buttons are working properly in resident rooms. Licensee will log call button inspections for the next five days and provide LPA a copy of the log by POC due date.

Allegation investigated: Staff do not ensure medications are inaccessible to others in care. Staff do not follow proper food handling practices.

Licensing Program Analyst, Mayra Cota, conducted subsequent complaint investigation visit to deliver findings for the above mentioned allegations. LPA met with Jacqueline Corez, Executive Director and the reason of the visit was explained. The investigation consisted of the following: LPA, toured common areas of the facility, including the kitchen and dining room, conducted interviews with Staff 1 - Staff 13 (S1-S13) and Resident 1 - Resident 14 (R1-R14). Unsubstantiated Regarding: Staff do not ensure medications are inaccessible to others in care. It is alleged that staff often leave medications unattended in the dining room. It is alleged that a resident was given medication by Med-Tech staff; however, the resident did not take the medication and the medication remained on the table in the cup for over an hour. It is also alleged that this was not the first instance of medications being left accessible and unattended in the dining area. The investigation revealed the following: Thirteen (13) out (13) staff deny the allegation. Interviews with staff indicated, they have not observed medication left accessible and unattended in the dining room nor have they observed medication left accessible and unattended in any other location in the facility. Eight (8) staff stated that medication administration procedures require medication technicians to provide scheduled medications to residents in a small cup and provide them with drinking water and supervise the residents as they take it. Staff stated technicians cannot walk away from residents until they ensure residents consume their medications whether taken in the dining room, their rooms or anywhere else in the facility. Staff visually check to see if residents swallow medication before moving on to assist the next resident with their medication. If residents want to wait on taking their medication, staff cannot leave scheduled medication with residents. Staff take back medications, lock them in the medication cart and inform residents they will come back to give them their medication when they are ready to take it. Interviews with (12) out of (14) residents indicated they have not observed medication left unattended and accessible to residents in the dining room by staff nor have they observed medication left accessible to residents and unattended in any other location in the facility. Ten (10) residents who need assistance with medication administration stated, staff wait for residents to take their medication before they walk away and take back any medication not taken at the time. One (1) of (14) residents did not provide information regarding this allegation. ****Continues on LIC 9099-C page 2 Regarding: Staff do not follow proper food handling procedures. It is alleged that resident noticed a long black hair in resident’s baked potato and stated that roommate does not have black hair. Staff deny the allegation. Interviews with (13) out of (13) staff indicated that residents have not complained about observing hair in the food prepared and provided by the facility’s kitchen. Interviews with eight (8) staff indicated that it is mandatory for staff handling food during preparation and service to use gloves and hairnets to prevent foreign objects from falling into the food. Staff further stated hand washing practices are always enforced. Food handling gloves are changed between handling different food items to ensure safe food handling practices. Food is covered with plastic film or refrigerated to avoid anything falling into it before it is served. Staff stated cutting boards are specifically assigned for the preparation of all proteins and all surfaces are cleaned and disinfected before and after use. All staff monitor food as it is going out for consumption to ensure freshness. Twelve (12) out of (14) residents indicated, they have never observed hair in their food when taken in the dining room or when it’s delivered to their room by staff. Residents stated the food is well prepared and during visits to the dining room, kitchen staff are observed wearing hair nets and food gloves. One (1) out of (14) residents did not provide information regarding this allegation. During tour of the kitchen and dining area, LPA observed staff wearing hair nets and food handling gloves during food preparation and service to residents. Food which was ready to be served was observed covered before servers brought it out to the residents in the dining area. LPA observation also indicated, meal trays on the kitchen carts which were ready to be delivered to resident's rooms, were also individually covered. Interviews with staff and residents and LPA observations do not corroborate the allegation. Although the allegations may have happened or are valid, there is no 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 provided.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 28-AS-20250606124958

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced Case Management Visit to follow up on a Special Incident Report (SIR) received on 7/30/25. LPA met with Jacqueline Cortez, Executive Director and explained the reason for the visit. Per SIR, Resident 1 (R1) was found in their room on the floor and was observed to be disoriented on 7/28/25. Staff made a 911 call and R1 was transported to the hospital for further treatment and evaluation. SIR also indicated, R1 was displaying signs of possible accidental overdose when found in their room. During today's visit LPA interviewed Executive Director (Staff 1/S1) who stated, R1 was transported to the hospital due to displaying signs of possible accidental overdose from mismanaging their medication. At the hospital, R1 was treated for possible overdose and was released to a skilled nursing facility due to the incident. S1 further stated, R1 will no longer be coming back to the facility due to R1 requiring a higher level of care. Interviews with Wellness Director and med-tech staff 1 (S1) indicated, R1 was managing their own medication and R1 had never experienced a medical emergency like the one experienced on 7/28/25. Review of R1's Clinical Requisition/Physician's Orders documentation indicated, R1 was able to self-administer medication. LPA toured common areas of the facility and no immediate health and safety concerns were observed during time of visit. No deficiencies noted during today's visit. Exit interview held with Jacqueline Cortez and a copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 18, 2025

Allegation investigated: Staff mismanaged resident's medications.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit for the allegation listed above. LPA arrived unannounced and met with the Business Office Manager, Alisa Dean, to explain the reason for the visit. On 7/25/25, LPA Chan conducted the initial visit and interviewed Staff #1 - #5 and Residents #1 - #10. LPA obtained copies of the staff and resident rosters and reviewed medications for ten residents. Staff #6 - #8 were interviewed via telephone on another date. The investigation revealed the following: Allegation – Staff mismanaged resident’s medications. It is alleged that Resident #1 (R1) needed the Nitroglycerin pill but was told by staff that they had lost it. Substantiated During the visit on 7/25/25, LPA reviewed medications for ten residents. LPA observed all of R1’s medications in the med room, including the Nitroglycerin tablet, and they are managed by the staff. The Nitroglycerin medication is a PRN and is given to the resident upon request. LPA interviewed the medication staff regarding this allegation. One of the staff confirmed that the Nitroglycerin medication could not be found on 7/17/25 when R1 requested it. Staff stated another staff helped search for the medication but could not find it either, so R1 was sent out to the hospital. The staff on the next shift was able to locate the medication. Eight (8) out of ten (10) residents stated that the staff do not give them their medications on time and/or that they were missing. Based on 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 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Correction was reviewed and developed with the administrator via telephone. A copy of this report and appeal rights were provided. The meal plan is created with residents’ suggestions and their dietary needs. The cooks stated they include servings from the different food groups and ensure there are alternatives each day. Staff stated they follow any special diets that each resident may have. If a resident’s dietary needs change, the kitchen staff are informed right away. Staff interviewed also stated there are sugar-free drinks and desserts available for residents. Staff provide sugar-free drinks and desserts to those who are diabetic; however, if they choose to get the regular ones, staff will give to them even though they remind them they should not consume sugary items. During the kitchen tour on 7/25/25, LPA observed sufficient food supplies with fresh vegetables and sugar-free drinks and desserts. The kitchen has a list of residents who have dietary needs/restrictions and are diabetic. Two (2) out of (10) residents interviewed feel that the facility does not have sugar-free drinks and desserts, and the food is cooked with lots of sugar. Eight of the residents stated the facility serves sugar-free items and offers a variety of food. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with the administrator via telephone. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 28-AS-20250722152959

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Aug 16, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interview, Staff could not find R1's PRN medication which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 15, 2025

Plan of correction: The licensee shall submit a written plan explaining how PRN medications are stored and documented when given. The plan is due to LPA by 8/16/25.

Allegation investigated: Staff does not ensure residents are provided clean towels. Facility has unqualified staff dispensing medications to residents in care. Staff does not ensure medications are dispensed as prescribed. Staff does not ensure residents incontinence care needs are being met in a timely manner. Staff was observed using smoking products while in the facility.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit to investigate the allegations above. LPA discussed the purpose of the visit with Executive Director Jacqueline Cortez/ The investigation consisted of: A physical plant inspection of laundry room, common areas, outdoor designated smoking area, and resident rooms was conducted. Residents (R1- R13) and staff (S1- S12) were interviewed. Resident (R14) is currently at a higher level of care facility and was not interviewed. Copies of relevant documents were obtained. *Narrative continues next page. Unsubstantiated Allegation: Staff does not ensure residents are provided clean towels. It is alleged that over the weekend of Aug. 9, 2025 - Aug. 10, 2025, there were no clean towels for resident use. A total of 13 residents were interviewed, of which all denied the allegation. A total of 12 staff were interviewed. Staff interviews revealed that the facility has a contract with a linen service company that drops off clean linens twice a week. On August 1, 2025, the facility changed linen companies from Mission Linen to Braun Linen. Braun Linen drops off items [sheets/pillow cases, hand/bath towels, blankets, and kitchen linen supplies every Tuesday and Friday. Per staff interviews, there was never a linen/towel shortage during the transition of linen service. Staff denied the allegation and stated all residents were provided clean towels the weekend of 8/9/25- 8/10/25. Residents are provided towels that are to be kept in their bathroom for regular use. Staff interviews revealed that the facility has a large inventory of linens and towels, but has a housekeeping staff shortage, which sometimes causes resident requests i.e. additional towel delivery to rooms to be delayed. LPA inspected the laundry area and observed sufficient towels and linens in the laundry room and 5 large bins outside the laundry area that contained clean linens/towels. Allegation: Facility has unqualified staff dispensing medications to residents in care. It is alleged that due to staff shortages the facility has staff working double shifts, and kitchen staff are also working as med-techs. All the residents interviewed stated they do not know whether med-techs are qualified for the job. Staff interviews revealed that staff (S7) began working at the facility as a server and was promoted to medication technician in March 2025. Based on record review, the findings indicate that staff (S7) completed 8 hours of medication administration training on March 16, 2025. There are 15 med-tech employed at the facility. Record review confirmed all have completed medication administration training. Therefore, the allegation cannot be supported. Allegation: Staff does not ensure medications are dispensed as prescribed. It is alleged that approximately 2 weeks ago a staff tried giving resident (R1) a pink medication pill that is not prescribed to the resident. According to information obtained, the alleged staff was suspended. Staff interviews revealed that on 7/21/25, caregiver staff (S8) entered R1 and R14's room and placed a medication cup near R1, that contained a Tylenol pill that was given to S8 by S11 for personal use. Resident (R1) picked up the medication cup and told staff it is not their medication. Caregiver (S8) stated that they were wearing gloves when they entered R1's room, and placed the medication cup on R1's walker while they removed their gloves and did not administer the medication to R1. Med-tech staff (S11) said they administered to R14 their Rosuvastatin Calcium 20 mg tab. According to S8, they only placed the Tylenol medication there while the gloves were removed. However, staff (S8) is not a med-tech, therefore should not have handled any medications in a resident's room. Neither staff were suspended. This allegation was investigated on a previous complaint control # 28-AS-20250722151911, in which the allegation was substantiated. LPA was provided copies of proof of correction addressing the aforementioned allegation. Therefore, the allegation is not supported because it has been addressed. Allegation: Staff does not ensure residents incontinence care needs are being met in a timely manner. it is alleged that staff leave residents in wet diapers for extended periods of time. The complaint alleges staff do not change incontinent residents as required. A total of 13 residents were interviewed. One (1) out of 13 residents confirmed the allegation. Residents said they are checked and changed often by staff, but on occasion the residents are left wet due to staff shortages and later response times. Staff interviews revealed that residents are checked every 2 hours and are assisted with incontinence care if needed. All staff denied the allegation, and said they have no knowledge of resident concerns pertaining to incontinence care. There is not sufficient proof to support the allegation. Allegation: Staff was observed using smoking products while in the facility. The complaint alleges that facility employees have been seen smoking in the building. Based on staff and resident interviews, the facility has an outdoor patio area designated as the smoking area for residents. All residents and staff denied seeing any staff smoke in the premises. Staff interviews revealed that the facility is a smoke-free workplace for all employees, and prohibits smoking e-cigarettes and vapor cigarettes. Based on interviews, in the past there was a staff person that smoked, but they have not worked at the facility since early 2025. There is insufficient proof to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted with Executive Director Jacqueline Cortez. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 12, 2025 · control 28-AS-20250811083659

Allegation investigated: Staff are mismanaging resident's medications.

Licensing Program Analyst, Mayra Cota, conducted a subsequent visit to investigate the allegation above. LPA met with Jacqueline Cortez, Exective Director and the reason for the visit was explained. Itnitial 10-day visit was conducted on 6/5/25 by LPA Cota. During initial visit, LPA, obtained a copy of the staff and resident rosters, conducted medication review and obtained medication records for Residents 1-8 (R1-R8). Interviews were also conducted with Staff 1-8 (S1-S8). During today's visit, LPA obtained copies of staff and resident rosters, toured common areas of the facility, interviewed Resident 1 - Resident 8 (R1-R8) and delivered findings. The investigation revealed the following: ***Continues on LIC 9099-C Substantiated Regarding: Staff are mismanaging resident's medications. It is alleged that Medication Administration Record (MAR) had multiple medication errors regarding a medication dose for pain relief. The medication in reference to is Oxycodone. It was reported that medication error is on file at RCFE. QuckMAR reviewed for R1 indicated, medication administration was not recorded on May 2, 2025, for the 2:00 p.m. dose, May 4, 2025, for the 2:00 p.m. dose and May 5, 2025, for the 8:00 p.m. dose of the Oxycodone-Acetaminophen 325 mg tablets. The three days are missing initials from administering staff. Interview with S2 indicated, staff did not "click" on the days which are missing initials, which would indicate that medication was administered correctly to resident. S2 further indicated, most likely, R1 did receive the medication on the days the initials are missing; however, the missing initials on R1's QuickMar are errors made by med-techs for not "clicking" on those specific days after "popping" the medication and giving it to R1. S2 further indicated, R1 would not miss doses of this particular medication because R1 has chronic pain and the medication helps alleviate it. S2-S8 acknowledged during interviews that sometimes, med-techs forget to "click" on the QuickMar after administering medication to residents to indicate that it was provided. Staff also indicated, QuickMar, at times, has connectivity issues and therefore, a "back-up" paper MAR is kept to document the administration of medication like Oxycodone for those residents who are prescribed to take it. At the time of visit, R1's paper MAR for May 2025, was not available for review for the fore mentioned dates. Interview with R1 indicated, staff are administering all their medication correctly and in a timely manner. R1 further stated, med-techs have not missed any dosages of their medication, especially their Oxycodone because they suffer from chronic back pain and therefore, they need it to ease their pain. Interviews with R2-R8 indicated, they have no concerns regarding how the facility manages their medication. It has been found that there is sufficient evidence to corroborate the allegation. Based on record review and staff and resident interviews, staff did not ensure that QuickMar for R1 for was adequately completed and thus the preponderance of evidence standard has been met, therefore the above allegation is substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099- D. An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 11, 2025 · control 28-AS-20250530112753

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(b)(3) · Plan of correction due date: Aug 18, 2025

Incidental Medical and Dental Care (b) If resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement was not met as evidenced by: QuickMAR has multiple medication errors regarding a medication dose for pain relief for May 2, 4 and 5, 2025 for R1.the state’s words, verbatim · CDSS document, Aug 11, 2025

Plan of correction: Licensee will ensure med-techs receive additional training regarding proper documentation of medication administration, documenting and reporting documentation errors and notifying physicians of errors by POC due date. Licensee will send training sign-in log and an agenda stating the topics discussed with staff.

Allegation investigated: Staff does not ensure resident's door lock is in good repair.

Licensing Program Analyst, Mayra Cota, conducted a 10-day complaint visit today and met with Jacqueline Cortez, Executive Director. The reason for the visit was explained. The investigation consisted of the following: During today’s visit, LPA, obtained copies of staff and resident rosters, toured the facility, conducted interviews with Staff 1 – Staff 4 (S1-S4) and Resident 1 – Resident 9 (R1-R9), inspected (9) resident rooms with a focus on inspecting the locks on the doors, leading into their rooms. The investigation revealed the following: ***Continues on LIC 9099-C Unsubstantiated Regarding: Staff does not ensure resident's door lock is in good repair. It is alleged that the lock in resident's room is broken and door had to be forced open by maintenance. It is also alleged, maintenance tried to fix it but were unable to. Interviews with S1-S4 revealed that R1's door lock malfunction was reported to maintenance staff on 8/2/25. S2 indicated, they contacted the locksmith the facility regularly hires, on the same day the issue was reported by R1. Locksmith was scheduled to come out on 8/4/25; however; S1-S3 stated, locksmith did not come out as they had scheduled to do so, because the door lock ordered to replace R1's had not yet arrived to the locksmith’s shop. S1 indicated, they talked to S2 and S3 to see if something else could be done to repair the lock for R1's room while they waited for the locksmith to come out. S1-S3 stated that the facility had an extra door lock from a vacant room which was installed on R1's door on 8/7/25 while staff wait for the locksmith to deliver and install the new door lock and to ensure R1 could lock their door, accordingly. S1-S4 revealed, after the malfunctioning door lock was checked and removed for replacement, staff found that the doorknob had glue inside the keyhole. Staff stated, in the past, they had an issue with a resident putting "Gorilla" glue in the key holes of some residents doors as a type of "prank" which they believe caused R1's door lock to malfunction. Staff further indicated that they did not forcefully open R1’s door; however, they had to wiggle the key to soften the glue which was still not completely dry. S1-S3 also stated, they did not ignore R1’s concern for their malfunctioning doorknob. They kept R1 in communication and resolved the issue as best as they could. Interview with R1 indicated, they are glad the doorknob was replaced by a new one. R1 stated, "It was fixed and now my door works. I was given a new shiny key and they tested it and I also tested it myself." R1 indicated, staff installed the new lock and made sure the door locked and unlocked appropriately. R1 further indicated, they have no more concerns regarding their door lock because staff were able to fix it as fast as they could. Inspection of (9) out of (9) resident rooms, including R1's indicated, doors can lock and unlock properly. LPA inspected the (9) locks on each door and found them to be in good repair. Interviews with (8) out (9) staff indicated, their door locks work properly and have not had any issues. Nine (9) out of (9) residents stated, they know they can report to administrative and maintenance staff if they need repairs of any kind done in their room. LPA also, received confirmation of delivered door locks which will be kept on hand if replacement is needed, via photo from S2. Staff and resident interviews and LPA observations do not corroborate the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted,with Jacqueline Cortez, Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 11, 2025 · control 28-AS-20250806113019

Allegation investigated: Staff administered the incorrect medication to resident.

***This is an amendment of the original report. The purpose of the amendment is to correct an error on the LIC 9099-D (citation). There is no change in the findings. The findings remain the same.*** Licensing Program Analyst (LPA), Mayra Cota, conducted unannounced 10-day investigation visit regarding the above mentioned allegation. LPA Cota, met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained. The investigation consisted of the following: LPA Cota, obtained copies of staff and resident rosters, toured the common areas of the facility, with a focus on inspecting the medication room and medication for Resident 1 (R1), interviewed Staff 1 - Staff (S1-S5) and Resident 1- Resident 5 (R1-R5) and obtained copies of relevant documentation. ***Report continues on LIC-9099 Substantiated Regarding allegation: Staff administered the incorrect medication to resident. It is alleged that caregiving staff gave R1 medicine on 7/21/25 at around 8:00 p.m., which is not prescribed to R1 and was told to take it. It is alleged that when R1 told staff the medication wasn’t theirs, caregiving staff told R1 “You gotta take it.” The investigation revealed the following: Interviews with Staff 1 – Staff 6 (S1-S6) revealed, caregiving staff are not allowed to administer medication to residents at any time. S1-S6 stated, the only staff who are allowed and qualified to administer medication are medical technicians per education training, facility policy and procedures. However, interview with S3 (caregiver) indicated, they were asked by S5 to please give R2 (R1’s roommate) a medication as S5 waited outside R2’s room with medication cart during medication pass, due to R1 not allowing S5 to enter R1’s room. S3 stated, they took the cup with a “pink” pill from S5 because S5 asked S3 to please give R2 the medication, even though S3 is aware that only medical technician staff are allowed to do so, which S3 is not. S3 stated, they proceeded to enter R1/R2’s room, and once in the room, S3 placed the cup with the medication on R1’s walker table. S3 stated, the medication was meant for R2 and not for R1 which at that time, S3 was able to retrieve the cup with the medication from R1 and proceeded to give it to R2. S5, denies the allegation; however, record review of R2’s medication administration record (QuickMar) for July 2025 indicates, S5 signed off on administrating R2’s bedtime routine medication at 8:00 p.m. on 7/21/25, which S5 does admit to being the staff who passed R2’s medication on that day. Interview with R1 indicated, S3 gave them the cup of medication with a “pink” pill which they did not take due to medication not being part of their regular routine medication prescribed by their doctor. R1 further indicated, they do not take any “pink” pills with their routine medication and can identify exactly which medication R1 takes, daily. Review of R1’s medication indicated, R1 does not take any medication fitting the description of the pill given to them by S3 on 7/21/25. Further review of R2’s medication revealed, R2 takes medication which includes a pink pill of Rosuvastatin Calcium 20mg tab which was administered on 7/21/25 at 8:00 p.m. by S5. R2 was unable to be interviewed due to being hospitalized at the time of visit. LPA observation, record review, and staff and resident interviews, corroborate the allegation. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 28, 2025 · control 28-AS-20250722151911

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(4) · Plan of correction due date: Jul 29, 2025

87411(d)(4) Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement was not met as evidenced by: based on observation, staff and resident interviews and record review, licensee did not ensure that caregiving staff who are not qualified to administer medication to residents refrain from administering medication to a resident.the state’s words, verbatim · CDSS document, Jul 28, 2025

Plan of correction: Licensee will conduct training with caregiving and medical technician staff regarding medication administration policies and precedures. Licensee will submit proof of training by POC due date in a form of sign-in log of staff in attendance and topics discussed via an agenda of training.

Type of visit: POC

Licensing Program Analyst, (LPA), Mayra Cota, conducted a Plan of Correction (POC) visit today. LPA met with Jacqueline Cortez, Executive Director, and explained the reason for the visit. During today’s visit, Civil Penalties were assessed for Sections CCR 87555(b)(27), 87555(b)(29), 87303(e)(3), 87303(e)(4) and 87465(a)(4) for deficiencies issued on 7/17/25 for Failure to Correct by Plan Of Correction (POC) due date of 7/18/25. Civil Penalties which were assessed today for $1000 each deficiency not corrected, total to $5000. LPA Cota, received POCs during today’s visit of 7/28/25 by means of obtaining photo of repair of the grab bar in resident's bathroom, purchase receipt for container lids replaced in the food pantry, photo of water temperature warining sign above the kitchen dishwashing sink, service receipt for pest control conducted on 7/25/25 and in-service training sign-in log which took place on 7/21/25 for medication administration policy and procedures. POCs have now been corrected, per documentation received during today’s visit of 7/28/25. Exit interview conducted with Jacqueline Cortez, Executive Director and copies of this report, Civil Penalty Assessments - Failure to Correct, and Appeal Rights provided at the time of visit.the state’s words, verbatim · CDSS document, Jul 28, 2025

Allegation investigated: Resident missed medication.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation regarding the allegations listed above. LPA met with Alisa Dean, the Business Office Manager, and explained the purpose of the visit. The investigation consisted of the following: On 6/19/25, LPA Chan conducted the initial visit and obtained copies of the resident and staff rosters. LPA toured the kitchen, dining room, and medication room. Interviews were held with the administrator, Staff #1 - #5, and Residents #1 - #5. During the visit today, LPA interviewed an additional four Staff and five Residents and reviewed medications for residents. (continue on LIC9099C) Substantiated The investigation revealed the following: Allegation - Resident missed medication. It is alleged that residents have missed medications due to medications not being refilled on time. LPA interviewed Staff and Residents for this allegation. Three of the med techs stated that residents may have missed their medications due to pending physician’s approval for the refills. Staff stated they would order refills about 7-10 days prior to medications running out. Staff noted that self-managed medications are refilled by the residents themselves. Residents interviewed stated that the facility manages their medications and do not believe they have missed any. LPA reviewed medications for ten residents. Two out of the ten residents have at least one of their medications for which they have a physician’s order to self-manage. Staff stated they would assist with ordering refills if residents asked. LPA reviewed Resident #3’s medications with the medication administration record (MAR). It appeared that the medication Alendronate Sodium 70 MG tablet was prescribed once a week in June 2025 and was indicated on the MAR log with the staff’s initials. However, the medication could not be located in the med room/cart. LPA confirmed with the staff that the medication was not available in June because the refill has not been obtained by the family member. There were no staff notes available for this medication to follow up on a refill. Based on LPA observation and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. A copy of this report, a plan of correction, and appeal rights were provided. The administrator and staff stated they do not retaliate and have not observed any staff mistreat residents for filing complaints. The alleged staff denied showing any form of retaliation against the resident who contacted the police and alleged that the staff pushed the resident. LPA interviewed ten residents and nine out of ten do not feel that staff retaliate against anybody filing complaints. The majority of the residents feel that the staff are respectful and assist them when needed. Allegation - Staff spits in the resident's food. LPA interviewed the administrator and staff. All the staff denied spitting in the resident’s food, and they have not seen any staff do so. Kitchen staff interviewed stated they treat residents with respect and would not do such a thing. LPA interviewed ten residents, and nine out of ten have not seen any staff spit in their food. Allegation - Staff is unsanitary when handling food. It is alleged that a staff does not change their gloves after wiping their nose or face and will continue serving the food with the contaminated gloves. It is also alleged that residents have been getting sick due to salads containing mayonnaise being left out of the refrigerator for 4-5 hours until they are served to residents. LPA conducted interviews with the administrator, kitchen staff, and residents. The kitchen staff stated they have received training on the appropriate handling of food and etiquette toward residents. Staff stated they are required to wear hair nets and gloves while preparing and serving food. When they need to sneeze, wipe their noses or faces, they will use a tissue or another part of their arm. Afterwards, they will discard the gloves, wash their hands, and put on a new pair. Staff have not witnessed other staff using a contaminated glove and serving food to residents. Staff also do not prepare food many hours ahead of mealtime and leave them unrefrigerated. Nine out of the ten residents interviewed stated that they have not seen staff being unsanitary or have not gotten ill from food served at the facility. 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 with A. Dean. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Jul 18, 2025 · control 28-AS-20250613170613

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 19, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review, Resident #3 did not take the medication Alendronate Sodium 70 MG once a week in June which poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 18, 2025

Plan of correction: The licensee shall ensure medications are refilled timely and that residents do not miss any dosage. An in-service training for medication staff shall be conducted and the log to be submitted to LPA by 7/19/25.

Type of visit: Required - 1 Year

***This is an amendment of the original report. The purpose of the amendment is to add identifiers in the Deficient Practice Statement on the LIC 9099-D (citation). There citations stands and remains the same.*** Licensing Program Analyst (LPA), Mayra Cota, conducted the required annual inspection visit. LPA arrived unannounced and met with Jacqueline Cortez, Executive Director. The purpose of the visit was explained. The facility is licensed for 150 non-ambulatory residents, ages 60 and over, of which (20) may be bedridden. There is a hospice waiver approved for (20) residents. Facility is operating within the scope of its license. The facility is located in a residential area of Temple City and the building consists of: (89) resident rooms with bathroom included in each room, main entry lobby/lounge, (5) administrative office, medication room, kitchen, (2) dining rooms, (2) patios/courtyards, movie theater room, activities room, (6) staff/visitor restrooms, garden room, staff break room, (2) maintenance/housekeeping storage rooms, chemical room, record room and parking lot. LPA toured the facility inside and out. LPA, randomly selected (10) resident rooms to inspect as well as the common areas. Hot water temperature in resident bathrooms were tested and measured within the range of 105-120 degree F. Each resident room has the required furniture, closet space, and lighting. However, LPA observed a safety grab bar in (1) resident shower breaking off the wall. The rooms have call buttons located by the resident's beds which were tested and operating during visit. A fireplace was observed and was adequately covered. There are no items nor debris obstructing the walkways. There are no swimming pools or other bodies of water on the premises. The facility has smoke and carbon monoxide combo detectors that are hardwired and connected to the fire department. Several fire extinguishers were also observed throughout the facility and were observed charged. The kitchen was inspected however, several live cockroaches were observed in the dishwashing area, the kitchen sink did not have the hot water warning sign posted by the sink, two dry food containers for rice and oatmeal's lid observed broken and content was exposed and two kitchen staff observed without a hair net during food preparation were observed during visit. ***Continues on LIC 809-C Adequate food supplies of 2 day perishable and a week of nonperishable were observed. Ten (10) staff and (10) resident records were randomly chosen and reviewed. Records reviewed had the required documents in place. Staff are fingerprint cleared and associated to the facility. Resident files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, pre-appraisal form, and care plan. Medication review was conducted. Resident medication is centrally stored in the medication room. The facility uses an electronic Medication Administration Record (MAR) log to document medications given. LPA reviewed (10) resident medications; however, medication errors were observed. LPA observed a medication present in the bubble pack and not given to a resident which should have been administered on 7/8/25 (Famotidine 20 mg) Staff interview indicated, they forgot to give the resident the medication at the time it was due for administration. Also, an evening medication was administered too early on 7/17/25. LPA observed missing medication in the evening slot for 7/17/25 (Quetiapine Fumarate 25 mg). Deficiencies are noted on LIC 809-D. Exit interview was conducted with Alisa Dean, Business Office Manager due to administrator leaving for a prior engagement, and a copy of this report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jul 17, 2025

Allegation investigated: Staff are mismanaging resident's medications.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the allegation listed above. The purpose of the visit was explained to Executive Director Jacqueline Cortez. The investigation consisted of: A physical plant tour of the interior and exterior was conducted, with special focus on medication room, residents' room signal system, kitchen food preparation/servings, and outdoor smoking areas. A total of nine (9) staff and 15 residents were interviewed. LPA reviewed and collected resident (R1 & R2's) file documents; which include Identification and Emergency Information, Physician's Report, Medication Administration Records, Care Plan, June 2025 food menus, alternative food menu, and kitchen resident diet list. LPA interviewed R1's pharmacist and Primary Care Physician's office representative. *Narrative continues next page. Substantiated Allegation: Staff are mismanaging resident's medication. The complaint alleges that resident (R1) did not receive blood pressure medications Furosemide 20 mg or Hydrochlorothiazide 25 mg for three days, and when med-techs were asked about the non-filled medications they had no idea why the medications were not filled. Resident (R1) stated in the past staff have given the resident another resident's medications, but the error was caught by the resident. A total of 15 residents were interviewed, of which 2 residents stated they have not been administered medications as directed by their physician. A total of nine staff were interviewed. Med-tech and Administration staff acknowledged that on June 14, 2025, resident (R1) ran out of the two aforementioned medications but did not contact R1's doctor or pharmacy until Saturday June 15, 2025. LPA called the facility pharmacy and R1's Primary Care Physician's office. The findings indicate that med-tech staff contacted the pharmacy and doctor until after the resident ran out of the medications. Based on record review of Medication Administration Records, med-tech staff did not communicate to Wellness Director or Executive Director that the pharmacy did not have a physician order for medications Furosemide 20 mg or Hydrochlorothiazide 25 mg. The pharmacist stated that on Sat. June 14, 2025 they delivered an emergency 3-day supply of medications. However, the QuickMar MAR states the medications were not dispensed, and notes indicate the medications are still pending. In addition, the pharmacy sent all the routine medications to the facility on June 11, 2025, with the exception of the two medications. Staff did not observe the two medications were not delivered. Therefore, there is sufficient evidence to corroborate the allegation. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Executive Director Jacqueline Cortez. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 17, 2025 · control 28-AS-20250616120107

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Jun 18, 2025

Incidental Medical and Dental Care. For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement was not met evidenced by: Based on record review and interviews conducted, on June 14m, 2025 R1 ran out of 2 medications [ Furosemide 20 mg or Hydrochlorothiazide 25 mg]. Facility does not have a current physician order for the medications and they have not been filled as of today. This poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: Executive Director agreed to submit 1. A written statement on medication administration protocols, and a plan that addresses the medications errors. 2. All med-tech staff shall obtain medication training from a medical professional 3. Physician orders for medications Furosemide 20 mg or Hydrochlorothiazide 25 mg.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff hit resident.

Licensing Program Analyst (LPA), Mayra Cota, conducted a subsequent complaint visit to conduct additional interviews regarding the above mentioned allegation. LPA met with Jacqueline Cortez, Administrator and explained the reason for the visit. The investigation consisted of the following: LPA, Cota, obtained copies of resident and staff rosters and conducted interviews with Resident 15 (R15) and Staff 11 (S11). Regarding: Staff hit resident. It is alleged, that two months ago, staff walked past a resident and hit resident on the shoulder in the dining area. ***Continues on LIC 9099-C*** Unsubstantiated Interviews with (11) out of (11) staff indicated, they have not received information regarding incident in which staff hit a resident on the shoulder in the dining room two months ago nor have they been involved in incidents in which staff hit residents. Staff stated, staff have not observed other staff hit nor treat residents with any form of aggression. Staff stated, they are respectful towards residents and they are trained in mandated reporting. Interviews with (13) out of (15) residents indicated, they have not been hit by staff nor have they witnessed any staff hit residents. Residents stated, staff are courteous, helpful and caring. Residents stated, staff treat them with dignity and have not heard other residents state that staff are hitting them. Interviews with staff and residents do not corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jun 13, 2025 · control 28-AS-20250605125710

Allegation investigated: Staff do not ensure that residents' dietary needs are met. Staff hit resident.

Licensing Program Analyst (LPA), Mayra Cota, conducted an initial unannounced complaint visit to investigate the above allegations. LPA met with Jacqueline Cortez, Administrator and explained the reason for the visit. The investigation consisted of the following: LPA, Cota, obtained copies of client and staff rosters, toured common areas of the facility including the dining room and kitchen, conducted record review for R1 and facility menus and special dietary needs postings, and interviewed Staff 1-Staff 10 (S1-S10) and Resident 1 – Resident 14 (R1-R14). Regarding: Staff do not ensure that residents' dietary needs are met. It is alleged, that resident is being served fish products even though they are allergic to fish. It is also alleged that facility staff, fries all foods in the same oil that they fry fish or foods containing fish residue, staff are not preparing enough food for residents to eat, and staff are eating the meals prepared for residents. ***Continues on LIC 9099C Unsubstantiated The investigation revealed the following: Interviews with eight (8) staff revealed, it is mandatory for staff handling food to use gloves and hairnets to serve the food provided to the residents. Staff further stated hand washing practices are always enforced. Food handling gloves are changed between handling different food items to prevent cross-contamination. Food is covered with plastic film or refrigerated to avoid anything falling into it before it is served. Staff stated, food like fish is prepared separately from food prepared for individuals who are allergic to fish. Cutting boards are specifically assigned for the preparation of all proteins. There is also enough food for residents and food is never short. Staff stated that although kitchen staff follow healthful portion guidelines, extra food is prepared for residents who may ask for a second helping. Furthermore, snacks and other alternative food items are available to accommodate for food allergies, intolerance, religious customs, and preferences. Staff stated fish is hardly ever fried. Fish is baked in the oven and the oil in the fryer is changed constantly. Staff stated, they do not eat the food prepared for residents. Record review revealed, kitchen staff are informed by administrative staff of resident’s food allergies, intolerances, religious food customs and preferences. Staff have meetings to incorporate meal plans for residents with special dietary needs. Interviews with (13) out of (14) residents indicated, they don’t have concerns with meals not meeting their dietary needs. Residents stated, they observe kitchen staff use gloves and hairnets when serving their food. Residents stated, they have enough food to eat, and a variety of snacks are available in the front office like fruit and sandwiches after kitchen is closed. Residents stated, they like the food, and they know there is an alternate menu they can resort to when they don’t like the meal on the menu for the day. Residents stated, fried food is not served often, and fish is backed or grilled. Residents stated, if there is a change in their dietary needs, the kitchen staff will make the accommodations they need to get the appropriate food in their diet. LPA conducted tour of the dining room and kitchen and observed all staff wearing gloves and hairnets during food preparation. LPA also observed, staff practicing hand washing and glove replacement after contact with different food items. Food preparation and cooking areas were observed, and stove tops, grills, griddles and fryers were also observed clean. Food was observed covered appropriately before being served and portions met the nutritional guidelines. At the time of visit, LPA did not observed staff eating resident’s food, nor any other food items during their work shift. Staff and resident interviews, record review and LPA observation, do not corroborate the allegation. Record review indicated, there is a standard menu in place in addition to a menu with alternative food choices which are available daily. Record review and interview with R1 do not indicate a reactions has occurred. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. ****Contines on LIC 9099-C Exit interview conducted with Alisa Dean, Business Office Manager due to Administrator leaving the facility for a prior engagement, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 11, 2025 · control 28-AS-20250605125710

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Deficiencies in conjunction with a complaint visit (Complaint Control #28-AS-20250522124740). During the visit, LPA reviewed files for Resident #1 (R1) and observed that the facility did not submit an incident report for R1 who fell on 04/25/2025 and sustained an injury. The Administrator, Jacqueline Cortez searched through the files and confirmed that the facility failed to submit the incident report (SIR) and will be faxing the incident report to CCL today. Deficiency is noted on LIC 809D. Exit interview, a copy of this report and Appeals Rights were provided to Jacqueline Cortez, Administrator.the state’s words, verbatim · CDSS document, May 29, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: May 30, 2025

87211(a)(1) 87211 Reporting Requirements: (a) Each licensee shall furnish..: (1)A written report shall be submitted to the licensing agency... within seven days of the occurrence...(D)Any incident which threatens the welfare, safety or health of any resident.... This requirement is not met as evidence by: LPA observed that the facility did not submit an incident report for Resident #1 (R1) who fell on 04/25/2025 and sustained an injury which poses a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: Administrator agreed to conduct in-service training for staff and create the incident report for R1 and submit it to CCL/LPA by POC due date.

Allegation investigated: Staff are mismanaging resident's medication

Licensing Program Analyst (LPA) Sanjay Vaid conducted an initial 10-day complaint visit to investigate the listed allegation. The purpose of the visit was explained to Administrator- Jacqueline Cortez and Wellness Director- Ruth Villa. LPA Vaid conducted a tour of the facility and did not observe any health and safety concerns. The investigation consisted of the following: Requested, obtained and reviewed ten (10) residents face sheets and identification, physicians’ reports, physician orders and MARs January 2025 to present (5/21/25), staff and resident roster, staff rosters by department. List of residents with medication insurance issues, list of self-medicating residents. Regarding the allegation: Facility is not properly managing resident's medication. It is alleged that the staff are not administering prescribed medications to the resident, staff have failed to give the residents their medications as ordered. Continued on 9099C.................. Unsubstantiated Five (5) out of five (5) staff interviewed deny this allegation. According to the staff, the medications are administered to residents as ordered from their physicians. The staff stated they keep watchful eye over the medications management to the residents, staff are following and managing protocols for administering medications. Staff contacts the physicians and pharmacy when the physician orders are not clear or missing vital information. Medications to the residents are administered by medication management and protocols; staff locates the resident, opens resident profiles in the MARs (medication administered record), matches names to the bubble packed meds, checks the time and dosage, matches the pills to picture shown on screen, some residents will inquire of new medications. Discontinued medications will appear in the MARs, and the medications is disposed. Medication refusal is entered into MARs to communicate to next shift of the residents’ medications issues. Ten (10) out of fourteen (14) residents interviewed could not corroborate this allegation, residents interviewed stated that their medications are available after prescribed by the doctor and processed through the pharmacy. A few residents stated they like to see the medication before they take it. A few residents interviewed stated they self-administer their own medication. Eight (8) out of fourteen (14) residents stated that the facility is correctly managing their medications and have not had issues with receiving their medications. Based on records reviewed, interviews conducted, and observations made, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. A copy of this report was given to Wellness Director Ruth Villa.the state’s words, verbatim · CDSS document, May 22, 2025 · control 28-AS-20250516122852

Allegation investigated: Licensee did not provide notice of rate increase to residents in care. Staff did not dispense medications as prescribed. Staff do not ensure residents medications are properly managed. Staff do not ensure residents are treated with dignity and respect by others residents in the facility. Staff did not ensure residents personal belongings were kept safely secured. Staff did not provide resident with copy of requested records.

***This report supersedes the report delivered on 04/07/2025. The reason for the supersede is to add information not listed on the initial report. The findings will remain unsubstantiated. *** Licensing Program Analyst (LPA) S Vaid conducted a subsequent complaint visit today regarding the listed allegations and to deliver complaint investigation findings. Met with Ruth Villa, Wellness Director and explained purpose of the visit. LPA Vaid and Wellnesses Director toured the facility and did not observe any health and safety concerns. The investigation conducted on 01/06/25, consisted of the following: LPA toured the physical plant. LPA Interviewed staff 1-7 (S1-S7) and clients 1-14 (C1-C14). LPA requested, collected, and reviewed documents from C1's face sheet, physicians reports, service plan, needs and services, medication file, and copies of six (6) random clients: face sheet, medication list, written physicians’ orders, physician reports. Facility Plan of Operations regarding controlled substance management, copy of posted flyer for pharmacy change, letter sent to SSI recipients regarding rate increase. Continued on 9099C..... Unsubstantiated ***This report supersedes the report delivered on 04/07/2025. The reason for the supersede is to add information not listed on the initial report. The findings will remain unsubstantiated. *** Regarding the allegation: Licensee did not provide notice of rate increase to clients in care. It is alleged that facility owners increased the monthly rent on all the clients without proper notification. Seven (7) out of seven (7) staff deny this allegation. According to business office staff, increase in the rental room rate is increased per year, as per Admissions Agreement. Notice of increase is communicated by letter to the residents’ and their POA. Higher needs and services require skilled nursing. Notice of new room rate increase and personal needs allowance was communicated to all the residents. According to the business office staff and records residents who were assessed by August Health(third party health point system) and determined an increased/decreased in level of care, was communicated to the residents and their POAs, by the business office staff. Resident was at Level 2 from January 2024 thru October 2024. Resident was reassessed by August Health in October 2024 to level 1, decreasing the monthly care rate. Statement of notice was delivered to Resident, by business office staff. Records for October 2024 thru January 2025 shows rent increase and level of care rate decreased. Resident has been paying 2024 rent rates for the year 2025 and thus is behind in rental payments. The business office is attempting to work with resident to collect the balance. Thirteen (13) out of fourteen (14) residents interviewed could not corroborate the allegation. Interviews with residents reveals that rate increase occurs when care and need levels increase, when a resident is determined unable to perform self-ADL’s like continence care an increase occurs, and are informed by staff before charge is made to the clients account. Several residents stated, they have been notified by staff when an increase is made in their level of care and yearly rental increases. Several other residents stated they receive SSI (Social Security Income), and they were given statement of notice for the rate increase for new rooms and increase in monthly personal needs expenses, by the business office staff. Based on interviews conducted and records reviewed, there is insufficient evidence to support this allegation. 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. Continued on 9099C...... ***This report supersedes the report delivered on 04/07/2025. The reason for the supersede is to add information not listed on the initial report. The findings will remain unsubstantiated. *** Regarding the allegation: Staff did not dispense medications as prescribed. It is alleged that the medication technicians (Med-Techs) are not dispensing the correct medication to residents. Thirteen (13) out of fourteen (14) residents interviewed could not corroborate the allegation. Residents stated they are receiving their medications daily. Seven (7) out of seven (7) staff interviewed deny this allegation and stated that they have not observed the med-tech staff mismanaging the resident’s medication. The Med-techs interviewed, stated that medication is administered as prescribed by physician orders and logged into the Medication Administration Record. LPA's review of five (5) random residents medications, and medication administration records, observed that medication are administered by staff as prescribed. During the afternoon, LPA observed AM-shift med-techs performing medication count before the PM shift was assigned the mobile medication carts. The PM shift med-tech then also make a pill count before next round of late afternoon/evening medications administration. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation. 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. Regarding the allegation: Staff do not ensure residents medications are properly managed. It is alleged that Medications is not being ordered in timely manner causing medication shortages for the residents. Thirteen (13) out of fourteen (14) residents interviewed stated they have not had interruptions in medications they receive. New prescriptions are filled and started within a few days of the doctors’ visit. Seven (7) out of seven (7) staff interviewed deny this allegation. Med-techs interviewed stated, through the electronic medication management system, notification of low medication supply is electronically sent to the pharmacy who can restock the medications without interruptions for the residents. The med-techs works closely with the pharmacy to ensure medications re-ordered by the facility and new medication prescribed by the physicians are readily available to the residents. 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. Continued on 9099C..... ***This report supersedes the report delivered on 04/07/2025. The reason for the supersede is to add information not listed on the initial report. The findings will remain unsubstantiated. *** Regarding the allegation: Staff do not ensure residents are treated with dignity and respect by other residents in the facility. It is alleged that facility staff is not ensuring that all residents get along with one another and that residents treat each other with dignity and respect. Seven (7) out of seven (7) staff interviewed deny this allegation. Staff stated they treat all the residents in their care with respect and dignity. Staff request all residents to treat each other with kindness and mutual respect. However, the staff cannot control the attitudes and views of all residents. Thirteen (13) out of fourteen (14) residents interviewed stated they get along with each other, sometimes there are disagreements between residents. One resident stated, sometimes residents have a heated exchange of words and sometimes gets loud, and fights break out, however, staff quickly intervene and redirect the residents. Another resident stated, people here don’t always get along, I don’t need to be nice and friendly to everyone, only civil. Based on interviews conducted 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. There was a concern regarding a resident being harassed by another resident. It appears they had a personal relationship based on resident interviews. However, it could not be determined this was due to facility’s lack of supervision, based on interview with Administrator Joel Niblett. Resident was advised that the other resident has right to reside at the facility. Administrator advised both residents to respect each other’s right to privacy and keep distant from one another. Continued on 9099C..... ***This report supersedes the report delivered on 04/07/2025. The reason for the supersede is to add information not listed on the initial report. The findings will remain unsubstantiated. *** Regarding the allegation: Staff did not ensure residents personal belongings were kept safely secured. It is alleged Staff are taking items from residents’ room while resident are not in resident’s room. Seven (7) out of seven (7) staff deny this allegation. The residents’ rooms are lockable and the keys for each room are assigned to resident(s) of the room. Staff keeps spare room key for housekeeping and emergencies to ensure residents safety when needed. Housekeeping cleans and sanitizes the rooms and have set time parameters for each room. Staff always ensures to remind residents to lock their rooms when leaving, even for a few minutes. Staff reported that R1 has a room and shares the room with another resident who also has a room key. Thirteen (13) out of fourteen (14) residents interviewed stated, the staff is respectful of their belongings, housekeeping helps to keep rooms clean. Resident reported, they have not had items missing from their rooms. One resident stated people are respectful of other resident’s personal property. Another resident stated, they keep their room keys with themselves whenever leaving the room and hope their roommates do the same. Another resident stated, keeps their belongings locked, because some people have greedy eyes. Interview with R1 revealed that R1 was unable to report what items were removed from R1 room and the investigation did reveal that items were removed from R1’s room or that staff do not safeguard resident belongings. Based on interviews conducted and observations made, 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. Regarding the allegation: Staff did not provide resident with copy of requested records. It is alleged that the business office staff did not provide a resident with monthly rent records in a timely manner, however staff asked resident to pay rent based on the amount previously charged and staff would reconcile the payment at a later date. Seven (7) out of seven (7) staff interviewed deny this allegation. Business office staff stated computers were not operating the entire day for one day only due to telecommunications interruption and were up the next day. Requests for records are completed via written request from the residents stating: type of record(s), the date range of the request. Staff stated all requests are completed within 1-2 days. Continued on 9099 C....... ***This report supersedes the report delivered on 04/07/2025. The reason for the supersede is to add information not listed on the initial report. The findings will remain unsubstantiated. *** A verbal request to staff requesting lengthy records is not permitted to ensure correct information is provided to the requestor. A written request such as a copy of vaccine record or copy of a medication list can be facilitated immediately. Thirteen (13) out of fourteen (14) residents interviewed were not able to corroborate this allegation. Residents interviewed stated their request for records is completed by staff in a reasonable amount of time. Other residents interviewed stated they have not had issues with requesting and receiving records and/or receive information within 2-3 days, depending upon the size of the request. Interview with R1 confirmed that staff provided R1 with the requested record in a timely manner. Based on interviews conducted and observations made, 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. Exit interview was conducted and copy of this report was provided to Ruth Villa -Welness Director.the state’s words, verbatim · CDSS document, May 7, 2025 · control 28-AS-20241230090004

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sanjay Vaid conducted an unannounced Case Management Visit at 1210PM to follow up on a clients’ drug overdose. LPA met Administrator Joel Niblett and explained the reason for the visit. Per Unusual Incident Report received on 03/31/2025, on 03/29/25 at 12pm resident was found by staff conducting usual check on the residents. Staff found R1 in their room with a syringe in their neck unresponsive and called 911 and was taken to USC Arcadia. R1 was treated and release on 03/30/25 with diagnosis of substance abuse disorder. R1 was prescribed OTC and prescription medicines only as ordered by the hospital physician. On 03/30/25 after R1 had returned to the facility, at approximately 0940AM staff heard thumping noise coming from R1’s room, staff found R1 confused with swelling and discoloration over their eyes and head. 911 was called. EMS and staff noticed a white substance sprawled over R1’s clothing and found syringe and spoon along with white powdery substance. Temple City Sherriff deputies confiscated the syringe, spoon and white substance. R1 was transported to USC Arcadia for further evaluation and treatment. Upon release from the hospital, R1 was placed into a skilled nursing facility for higher level of care. R1 will remain at the skilled nursing until R1’s POA can locate a facility that R1 can be placed. Staff spoke with R1’s POA and R1 was discharged from Santa Anita Assisted Living and transferred to the skilled nursing facility on 04/01/25. No deficiencies observed during today's visit. Exit interview held and a copy of the report was provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 14, 2025

Allegation investigated: Licensee did not provide notice of rate increase to residents in care. Staff did not dispense medications as prescribed. Staff do not ensure residents medications are properly managed. Staff do not ensure residents are treated with dignity and respect by others residents in the facility. Staff did not ensure residents personal belongings were kept safely secured. Staff did not provide resident with copy of requested records.

Licensing Program Analyst (LPA) S Vaid conducted a subsequent complaint visit today regarding the listed allegations and to deliver complaint investigation findings. Met with Ruth Villa, Wellness Director and explained purpose of the visit. LPA Vaid and Wellnesses Director toured the facility and di not observe any health and safety concerns. The investigation conducted on 01/06/25, consisted of the following: LPA toured the physical plant. LPA Interviewed staff 1-7 (S1-S7) and clients 1-14 (C1-C14). LPA requested, collected, and reviewed documents from C1's face sheet, physicians reports, service plan, needs and services, medication file, and copies of six (6) random clients: face sheet, medication list, written physicians’ orders, physician reports. Facility Plan of Operations regarding controlled substance management, copy of posted flyer for pharmacy change, letter sent to SSI recipients regarding rate increase. Continued on 9099C..... Unsubstantiated Regarding the allegation: Licensee did not provide notice of rate increase to clients in care. It is alleged that facility owners increased the monthly rent on all the clients without proper notification. Seven (7) out of seven (7) staff deny this allegation. According to business office staff, increase in the rental room rate is increased per year, as per Admissions Agreement. Notice of increase is communicated by letter to the residents’ and their POA. Higher needs and services require skilled nursing. Notice of new room rate increase and personal needs allowance was communicated to all the residents. According to the business office staff and records residents who were assessed by August Health(third party health point system) and determined an increased/decreased in level of care, was communicated to the residents and their POAs, by the business office staff. Resident was at Level 2 from January 2024 thru October 2024. Resident was reassessed by August Health in October 2024 to level 1, decreasing the monthly care rate. Statement of notice was delivered to Resident, by business office staff. Records for October 2024 thru January 2025 shows rent increase and level of care rate decreased. Resident has been paying 2024 rent rates for the year 2025 and thus is behind in rental payments. The business office is attempting to work with resident to collect the balance. Thirteen (13) out of fourteen (14) residents interviewed could not corroborate the allegation. Interviews with residents reveals that rate increase occurs when care and need levels increase, when a resident is determined unable to perform self-ADL’s like continence care an increase occurs, and are informed by staff before charge is made to the clients account. Several residents stated, they have been notified by staff when an increase is made in their level of care and yearly rental increases. Several other residents stated they receive SSI (Social Security Income), and they were given statement of notice for the rate increase for new rooms and increase in monthly personal needs expenses, by the business office staff. Based on interviews conducted and records reviewed, there is insufficient evidence to support this allegation. 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. Continued on 9099C...... Regarding the allegation: Staff did not dispense medications as prescribed. It is alleged that the medication technicians (Med-Techs) are not dispensing the correct medication to residents. Thirteen (13) out of fourteen (14) residents interviewed could not corroborate the allegation. Residents stated they are receiving their medications daily. Seven (7) out of seven (7) staff interviewed deny this allegation and stated that they have not observed the med-tech staff mismanaging the resident’s medication. The Med-techs interviewed, stated that medication is administered as prescribed by physician orders and logged into the Medication Administration Record. LPA's review of five (5) random residents medications, and medication administration records, observed that medication are administered by staff as prescribed. During the afternoon, LPA observed AM-shift med-techs performing medication count before the PM shift was assigned the mobile medication carts. The PM shift med-tech then also make a pill count before next round of late afternoon/evening medications administration. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation. 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. Regarding the allegation: Staff do not ensure residents medications are properly managed. It is alleged that Medications is not being ordered in timely manner causing medication shortages for the residents. Thirteen (13) out of fourteen (14) residents interviewed stated they have not had interruptions in medications they receive. New prescriptions are filled and started within a few days of the doctors’ visit. Seven (7) out of seven (7) staff interviewed deny this allegation. Med-techs interviewed stated, through the electronic medication management system, notification of low medication supply is electronically sent to the pharmacy who can restock the medications without interruptions for the residents. The med-techs works closely with the pharmacy to ensure medications re-ordered by the facility and new medication prescribed by the physicians are readily available to the residents. 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. Continued on 9099C..... Regarding the allegation: Staff do not ensure residents are treated with dignity and respect by other residents in the facility. It is alleged that facility staff is not ensuring that all residents get along with one another and that residents treat each other with dignity and respect. Seven (7) out of seven (7) staff interviewed deny this allegation. Staff stated they treat all the residents in their care with respect and dignity. Staff request all residents to treat each other with kindness and mutual respect. However, the staff cannot control the attitudes and views of all residents. Thirteen (13) out of fourteen (14) residents interviewed stated they get along with each other, sometimes there are disagreements between residents. One resident stated, sometimes residents have a heated exchange of words and sometimes gets loud, and fights break out, however, staff quickly intervene and redirect the residents. Another resident stated, people here don’t always get along, I don’t need to be nice and friendly to everyone, only civil. Based on interviews conducted 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. There was a concern regarding a resident being harassed by another resident. It appears they had a personal relationship based on resident interviews. However, it could not be determined this was due to facility’s lack of supervision, based on interview with Administrator Joel Niblett. Resident was advised that the other resident has right to reside at the facility. Administrator advised both residents to respect each other’s right to privacy and keep distant from one another. Continued on 9099C..... Regarding the allegation: Staff did not ensure residents personal belongings were kept safely secured. It is alleged Staff are taking items from residents’ room while resident are not in resident’s room. Seven (7) out of seven (7) staff deny this allegation. The residents’ rooms are lockable and the keys for each room are assigned to resident(s) of the room. Staff keeps spare room key for housekeeping and emergencies to ensure residents safety when needed. Housekeeping cleans and sanitizes the rooms and have set time parameters for each room. Staff always ensures to remind residents to lock their rooms when leaving, even for a few minutes. Staff reported that R1 has a room and shares the room with another resident who also has a room key. Thirteen (13) out of fourteen (14) residents interviewed stated, the staff is respectful of their belongings, housekeeping helps to keep rooms clean. Resident reported, they have not had items missing from their rooms. One resident stated people are respectful of other resident’s personal property. Another resident stated, they keep their room keys with themselves whenever leaving the room and hope their roommates do the same. Another resident stated, keeps their belongings locked, because some people have greedy eyes. Interview with R1 revealed that R1 was unable to report what items were removed from R1 room and the investigation did reveal that items were removed from R1’s room or that staff do not safeguard resident belongings. Based on interviews conducted and observations made, 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. Regarding the allegation: Staff did not provide resident with copy of requested records. It is alleged that the business office staff did not provide a resident with monthly rent records in a timely manner, however staff asked resident to pay rent based on the amount previously charged and staff would reconcile the payment at a later date. Seven (7) out of seven (7) staff interviewed deny this allegation. Business office staff stated computers were not operating the entire day for one day only due to telecommunications interruption and were up the next day. Requests for records are completed via written request from the residents stating: type of record(s), the date range of the request. Staff stated all requests are completed within 1-2 days. Continued on 9099 C....... A verbal request to staff requesting lengthy records is not permitted to ensure correct information is provided to the requestor. A written request such as a copy of vaccine record or copy of a medication list can be facilitated immediately. Thirteen (13) out of fourteen (14) residents interviewed were not able to corroborate this allegation. Residents interviewed stated their request for records is completed by staff in a reasonable amount of time. Other residents interviewed stated they have not had issues with requesting and receiving records and/or receive information within 2-3 days, depending upon the size of the request. Interview with R1 confirmed that staff provided R1 with the requested record in a timely manner. Based on interviews conducted and observations made, 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. Exit interview was conducted and copy of this report was provided to Administrator Joel Niblett.the state’s words, verbatim · CDSS document, Apr 7, 2025 · control 28-AS-20241230090004

Allegation investigated: Staff physically abused resident, resulting in resident sustaining a bruise

*** This licensing report issued on 4/17/25 supersedes that licensing report dated 4/4/25, LPA Vaid obtained additional information, however, the investigation findings will remain the same*** Licensing Program Analyst (LPA) S Vaid conducted a subsequent complaint visit today regarding the listed allegation and to re-deliver complaint investigation finding. Met with Joel Niblett-Administrator and explained purpose of the visit. Requested and obtained staff and client rosters. Conducted a tour of the facility and did not observe any health and safety concerns. On 02/03/25, Licensing Program Analyst (LPA) S Vaid conducted an initial 24-hour complaint investigation visit for the above allegation. LPA met with Ruth Villa, Wellness Director and the purpose of the visit was discussed. The investigation consisted of the following: LPA toured the physical plant. LPA Interviewed staff #1-#8 (S1-S8) and residents #1-#10 (R1-R10). LPA requested, collected, and reviewed documents from R1's face sheet, physicians reports, residential appraisal-individual service plan. CONTINUED 0N 9099C............... Unsubstantiated Caregiver sign-in for month of January. Residents census and resident roster, caregiver staff roster (01/20/25-01/31/25), S4 employee file-caregiver duties and disciplines. Regarding the allegation: Staff physically abused resident, resulting in resident sustaining a bruise. It is alleged that resident #1 (R1) was punched in the arm by a caregiver who changes residents’ diapers during NOC shift. Eight (8) out of eight (8) staff interviewed deny the allegation. All staff interviewed deny physically abusing the R1 or any residents. Nine (9) out of ten (10) residents interviewed were not able to corroborate the allegation. Residents interviewed stated; they have not encountered issues with staff during continence care. Interview with R1 revealed that R1 is does not recall how R1 sustained the bruising. The investigation revealed that S4 recalled an incident that occurred between R1 and S4 on 01/23/25, S4 reported that S4 explained to R1 that the color of the adult brief was the correct size, however R1 did not want S4 to use that color and preferred a different color, which per S4 was the incorrect size for R1. S4 proceeded to change R1 into the correct size adult brief. Per S4, R1 became upset regarding the color of the adult brief that S4 was using to change R1, resulting in R1 hitting S4 with R1’s arms. S4 reported holding up S4’s arms and hands in a cross formation to block R1 from hitting S4 during the altercation. S4 does not recall R1 sustaining any injury during the incident. It was also reported that on 01/26/25, S7 recalls observing R1 with a bruise on R1’s upper inside left arm while bathing R1. S7 recalls R1 reporting that R1 was unsure of how the injury/bruise occurred. Additionally, according to R1’s Physicians Report dated 2/28/23 and R1s Individualized Service Plan dated 09/07/2022, R1 is prone to bruising due to prescribed medications. On 02/03/25 while LPA Vaid interviewed R1, LPA did not observe any visible bruising on R1s arm. The investigation did not reveal any evidence to support that staff physically abused R1 and/or that staff caused R1 injury which resulted in R1 sustaining a bruise. Based on interviews conducted, observations made, and documents reviewed. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted with Administrator Joel Niblett.the state’s words, verbatim · CDSS document, Apr 4, 2025 · control 28-AS-20250131145836

Allegation investigated: Staff physically abused resident, resulting in resident sustaining a bruise

Licensing Program Analyst (LPA) S Vaid conducted a subsequent complaint visit today regarding the listed allegation and to re-deliver complaint investigation finding. Met with Joel Niblett-Administrator and explained purpose of the visit. Requested and obtained staff and client rosters. Conducted a tour of the facility and did not observe any health and safety concerns. On 02/03/25, Licensing Program Analyst (LPA) S Vaid conducted an initial 24-hour complaint investigation visit for the above allegation. LPA met with Ruth Villa, Wellness Director and the purpose of the visit was discussed. The investigation consisted of the following: LPA toured the physical plant. LPA Interviewed staff #1-#8 (S1-S8) and residents #1-#10 (R1-R10). LPA requested, collected, and reviewed documents from R1's face sheet, physicians reports, residential appraisal-individual service plan. CONTINUED 0N 9099C............... Unsubstantiated Caregiver sign-in for month of January. Residents census and resident roster, caregiver staff roster (01/20/25-01/31/25), S4 employee file-caregiver duties and disciplines. Regarding the allegation: Staff physically abused resident, resulting in resident sustaining a bruise. It is alleged that resident #1 (R1) was punched in the arm by a caregiver who changes residents’ diapers during NOC shift. Eight (8) out of eight (8) staff interviewed deny the allegation. All staff interviewed deny physically abusing the R1 or any residents. Nine (9) out of ten (10) residents interviewed were not able to corroborate the allegation. Residents interviewed stated; they have not encountered issues with staff during continence care. Interview with R1 revealed that R1 is does not recall how R1 sustained the bruising. The investigation revealed that S4 recalled an incident that occurred between R1 and S4 on 01/23/25, S4 reported that S4 explained to R1 that the color of the adult brief was the correct size, however R1 did not want S4 to use that color and preferred a different color, which per S4 was the incorrect size for R1. S4 proceeded to change R1 into the correct size adult brief. Per S4, R1 became upset regarding the color of the adult brief that S4 was using to change R1, resulting in R1 hitting S4 with R1’s arms. S4 reported holding up S4’s arms and hands in a cross formation to block R1 from hitting S4 during the altercation. S4 does not recall R1 sustaining any injury during the incident. It was also reported that on 01/26/25, S7 recalls observing R1 with a bruise on R1’s upper inside left arm while bathing R1. S7 recalls R1 reporting that R1 was unsure of how the injury/bruise occurred. Additionally, according to R1’s Physicians Report dated 2/28/23 and R1s Individualized Service Plan dated 09/07/2022, R1 is prone to bruising due to prescribed medications. On 02/03/25 while LPA Vaid interviewed R1, LPA did not observe any visible bruising on R1s arm. The investigation did not reveal any evidence to support that staff physically abused R1 and/or that staff caused R1 injury which resulted in R1 sustaining a bruise. Based on interviews conducted, observations made, and documents reviewed. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted with Administrator Joel Niblett.the state’s words, verbatim · CDSS document, Apr 4, 2025 · control 28-AS-20250131145836

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) S. Vaid conducted a subsequent complaint visit regarding the amended report and substantiated findings for the investigated complaint. Explained the purpose of the amended report is to clear state the findings regarding the substantiated allegation.the state’s words, verbatim · CDSS document, Dec 20, 2024

Allegation investigated: Staff are mismanaging resident's medications.

*** This licensing report issued on today’s visit, 12/06/2024 supersedes that licensing report dated 10/11/2024, LPA Vaid is reissuing the report and citations, however, the investigation findings will remain the same*** Licensing Program Analyst (LPA) S. Vaid conducted a subsequent complaint visit regarding the allegation listed above to reissue the report and to reissue citation for the investigated complaint findings. Regarding the allegation: Staff are mismanaging residents’ medication. It is alleged that staff give residents day and evening medication together. The investigation consisted of interviews with staff and residents, including resident #20 (R#20) and review of R#20 Medication Administration Record. The investigation revealed, on 08/08/24, staff #21 gave R#20 the afternoon blood pressure (name medication) a dosage of 10 mg in the morning. This medication error was observed by Staff 10 (S10) during the medication audit conducted during the Med Tech staff shift change. The protocol for shift change is for each med-tech to audit the medications in the medication carts before starting their shift. S10 reported the medication error former administrator Maya Mnoyan, who contacted R#20 physician and placed S#21 on suspension during the facility’s internal investigation. Based upon the facility’s investigation S#21 was terminated from employment. Therefore, S#21 did not properly administer R#20 blood pressure medications. Substantiated Based on interviews conducted, and records collected and reviewed the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. Deficiencies are being cited according to California Cade of Regulations, Title 22. Citation is on 9099-D page. Exit interview was conducted and copy of report and appeals were given to the Administrator Aaron Khodorkovsky. Regarding allegation: Staff are overdosing residents. It was alleged that staff are overmedicating residents with a Narcotic called Avitan used to treat adults with insomnia caused by anxiety and can cause drowsiness. Staff S1-S14 interviewed denied the allegation. Fourteen (14) out of fourteen (14) staff interviewed stated that they have not observed med-tech staff overmedicating any of the residents. The Med-techs have stated that the medication is administered as prescribed as needed. Each residents’ medication that is administered is logged into the MARs. The medication cart and the medication room is audited each month, by management. LPA's review of five (5) random residents’ medication, and medication administration records, observed medication to be administered as prescribed by physician’s orders. All medications are accounted, as shown in the MARs log, LPA performed pill count of medications in the bubble packs. LPA reviewed residents that are prescribed Avitan, the MARs indicate that the Avitan has been administered sparingly, administered when needed to specific residents with attributing health conditions. Resident R1-R20 interviewed were unable to corroborate the allegation. Based upon records review and interviews conducted, the findings indicate that, 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. Regarding the allegation: Staff are administering unprescribed medications to residents. It is alleged that the staff had administered unprescribed medications to the residents who misbehave during the night, by logging incorrect information of medication administered. Covering up the pill count. Fourteen (14) out of fourteen (14) staff interviewed stated that they have not observed the medication technician staff administer unprescribed medication to residents. The Med-techs stated that medication is administered as prescribed. The narcotics log used to record time, date and dosage administered to the resident(s). The narcotics medication(s) are audited randomly each month for each resident using medications containing heavy narcotics. Medication audits are performed monthly by the Wellness Director to ensure medications are being administered as prescribed by the physician orders, constant communications with the pharmacy via eMARs (electronic medication administered records) ensure consistent supply of all medications continues. LPA's review of five (5) random resident medication, and medication administration records, shows that medication appears to be administered as prescribed by physician orders and pharmacy orders. Resident R1-R20 interviewed were unable to corroborate the allegation. Based upon records review and interviews conducted, the findings indicate that, 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. con't 9099C... Regarding the allegation: Staff do not answer the resident’s call button in a timely manner. It is alleged that staff are not answering the call button in a timely manner when residents call for assistance. Fourteen (14) out of fourteen (14) staff interviewed stated that they have not observed the staff not answering the call button switchboard in a timely manner. LPA observed a call come into the office by a resident asking for assistance, within 1-2 minutes a caregiver answered the office to acknowledge the call being handled, the call was answered by a staff person from the resident’s room. Residents R1-R15 interviewed stated that the caregivers come within 2-3 minutes after call is made on the residents’ call box, someone always answers. Based upon observations made and interviews conducted, the findings indicate that, 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. Regarding the allegation: Staff do not ensure residents’ showering needs are being met. It is alleged that staff are not ensuring residents showering needs are being met. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. Caregiver staff and direct person staff(DSP) interviewed state, the caregivers staff assist the Home Health Aides with bathing the residents 2-3 times per week as noted in the resident’s needs/services plan. When residents refuse bathing, a note is made for bath refusal in the ADL (assisted daily living) clinical notes. Basic ADLs like brushing teeth, washing face, and combing hair, dressing is applied daily. Fifteen (15) out of fifteen (15) residents interviewed stated the staff gives baths twice a week, some residents stated they were given bathes three times a week by the home health agencies, the caregiver staff provides the rest. Based upon records review and interviews conducted, the findings indicate that, 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. Con't 9099C... Regarding the allegation: Staff do not ensure facility has adequate food supply. It is alleged that the staff is not ensuring adequate food supply for residents. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. Kitchen staff interviewed state, grocery list is planned and ordered on Sunday and Wednesday for delivery of food on Monday and on Thursday. The kitchen was observed to have enough foods to feed all the residents, during tour of the kitchen LPA observed delivery being made, many boxes and bags of fruit and vegetable along with canned and dry food items being delivered. Fifteen (15) out of fifteen (15) residents interviewed state they like the food served and have never experienced food shortage at the facility. Based upon records review and interviews conducted, the findings indicate that, 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. Regarding the allegation: Staff do not ensure residents attend scheduled medical appointments. It is alleged that a staff person is cancelling residents’ medical and other important appointments. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. The residents with medical appointments, relay information to the caregivers and the care coordinator, who then logs in the appointments in the transportation log to ensure the drivers are aware of resident’s appointments. The protocol for the appointment scheduling is verified by the care coordinator to ensure all necessary paperwork and insurance paperwork is ready for the residents. Fifteen (15) out of fifteen (15) residents interviewed stated they are happy with the transportation protocols and have not had any problems with keeping their appointments. Based upon records review and interviews conducted, the findings indicate that, 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. con't 9099C.... Regarding the allegation: Staff do not ensure residents’ air conditioner is in good repair. It is alleged that the staff is not ensuring that the air conditioner system is not in good repair. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. The air conditioner units are maintained by the maintenance staff, all air-conditioner systems are operational. When a unit breaks down or needs service, a work order is issued for maintenance to repair, repairs are handled within 24 hours unless parts are needed ordering. Accommodations for the residents are made if repair takes longer than anticipated. Regarding maintenance all work orders are logged to ensure completion of the projects in timely manner. Fifteen (15) out of fifteen (15) residents interviewed stated they have no concerns of the A/C units, staff is always fixing and are repairing things around the facility. Based upon records review and interviews conducted, the findings indicate that, 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. LPA did not observe any Health and Safety concerns during the visit, an exit interview was held and copy of this report was given to the Administrator Aaron Khodorksky.the state’s words, verbatim · CDSS document, Dec 6, 2024 · control 28-AS-20240815132940

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Dec 13, 2024

87465 Incidental Medical and Dental Care.(c)If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. Title 22, Division 6 Chapter 8 This requirement was not met as evidenced by: On 08/08/24, staff #21 gave R#20 the afternoon blood pressure medication, a dosage of 10 mg in the morning.the state’s words, verbatim · CDSS document, Dec 6, 2024

Plan of correction: Administrator will provide staff with medication administering training by 12/13/24.

The state marks this report as 16 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Allegation investigated: Staff hit resident resulting in a bruise Staff do not ensure that resident's personal items are safeguarded Staff did not prevent resident from inappropriately touching other residents Staff do not speak to residents in a respectful manner Staff did not ensure resident medications are properly managed Staff do not provide residents with a sufficient amount of food.

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complaint visit in regard to the allegations listed above. LPA met with Wellness Director Ruth Villa and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 11/12/2024, LPA interviewed Staff #1- Staff #7, Resident #1 -Resident #10, and toured the facility’s kitchen. LPA obtained copies of the following documents: staff roster, resident roster, identification and emergency information, Individual service plans, physician report for R1, food invoices, food menu, physicians order for R9 and staff records. SEE 9099C Unsubstantiated In regard to the allegation that “Staff hit resident resulting in a bruise” the department previously investigated this allegation on 09/23/2024 and it was found to be unsubstantiated. LPA reviewed records, interviewed residents, and staff and no additional information was given. In regard to the allegation that “Staff do not ensure that resident's personal items are safeguarded” it is alleged that R3 goes into residents’ room and steals money. During interviews with residents seven (7) out of ten (10) residents state they have not had any items missing from their rooms. One (1) resident R7 was in hospital and one (1) resident R1 was confused at time of interview. R5 stated that his/her roommate steals their clothes to sell. During interviews with staff four (4) out of seven (7) staff have not heard about items missing from resident’s room. S6 and S7 state that one resident was missing wallet but was unsure of where wallet was left. S6 states that R3 doesn’t steal and is very helpful to residents. In regard to the allegation that” Staff did not prevent resident from inappropriately touching other residents ‘it is alleged that a resident goes into females’ rooms and touches them and has forced residents to kiss them. During interviews with residents eight (8) out of ten (10) residents state they have never witnessed any inappropriate touching between residents or been touched. One (1) resident R7 was in hospital and one (1) resident R1 was confused at time of interview. During interviews with staff six (6) out of seven (7) staff indicate they have never witnessed any inappropriate touching between residents. S6 stated that there are couples in the facility and that they do hang out like boyfriend and girlfriend. S7 stated there is holding hands between couples but it is consensual. In regard to the allegation that “Staff do not speak to residents in a respectful manner” it is alleged that staff does not treat residents with respect and are mean to them. During interviews seven (7) out of ten (10) residents stated that staff talks to them with respect. One (1) resident R7 was in hospital and one (1) resident R1 was confused at time of interview. R9 stated “some do some don’t”. During interviews with staff six (6) out of seven (7) staff stated that staff speak to residents with respect. S5 stated that one staff was let go for not speaking to residents with respect. SEE 9099C In regard to allegation that “Staff did not ensure resident medications are properly managed” it is alleged that medications are not being ordered and that medicated shampoo for R9 is not available. During interviews with residents seven (7) out of ten (10) residents stated they get their medication when needed. One (1) resident R7 was in hospital at time of interview and one (1) resident R1 was confused at time of interview. R9 stated sometimes medication are late but that he/she has medicated shampoo in his/her room. Interviews with Four (4) staff reveled that only MedTech’s handle medication so they would not have any knowledge of medication. Interviews with two (2) staff stated that all medication is given and ordered on time and that the only delay would be if Drs. Approval is needed for refills. LPA conducted random check on five residents’ medication and no errors were observed at time of visit. In regard to the allegation that “Staff do not provide residents with a sufficient amount of food” it is alleged that residents are given small portions of food and that residents are always hungry. During interviews with residents seven (7) out of ten (10) residents state there is enough food. One (1) resident R7 was in hospital and one (1) resident R1 was confused at time of interview. R9 stated” there is enough food, but I really don’t like it” R10 stated “There is enough for me. I can ask for more”. During interviews with staff five (5) out of seven (7) stated there was enough food. S2 had no knowledge of food supply. S3 stated that “we have never not had enough food”. S5 stated that they even get food to take to their rooms. LPA toured kitchen and food supply during time of visit and sufficient food supply was observed. 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 copy of this report was left with the Wellness Director Ruth Villa.the state’s words, verbatim · CDSS document, Dec 5, 2024 · control 28-AS-20241104144910

Allegation investigated: Staff did not take appropriate steps to prevent the spread of communicable disease.

Licensing Program Analyst (LPA) S. Vaid conducted a subsequent complaint visit regarding the allegation listed above to deliver findings for the investigated complaint. Met with Wellness Director Ruth Villa. LPA didnot observe any health and safety concerns. On 10/31/2024, LPA Vaid conducted a 10-day complaint visit to the facility. The investigation consisted of the following: LPA obtained and reviewed staff schedule and client roster, client list of names that are being tracked and isolated, copy of In-Service staff training for Scabies, PPE-gown, and handwashing. LPA interviewed fourteen (14) clients and seven (7) staff. Five (5) Four Tech Laboratory reports for the affect clients. The investigation revealed the following. Regarding Allegation: Staff did not take appropriate steps to prevent the spread of communicable disease. Seven (7) out of seven (7) staff interviewed stated that one resident had been diagnosed with scabies and three other clients are being tracked for the illness, all the clients have been isolated to their rooms. Continued on 9099C....... Unsubstantiated The affected clients were educated about the scabies rash and physician and family were informed of the resident’s communicable disease and of the precautions taken, isolation until scabies rash is gone. Four (4) residents were tracked for scabies starting on 10/16/24, 10/17/24 and 10/23/24 for rash and were given Permethrin cream to apply to rash. Staff explains the details of the isolation procedures that are followed to ensure that the Scabies is not spread to other residents. Gowns, gloves, and masks are worn when servicing the isolated clients, PPE are constantly changed after each resident is visited. Fourteen (14) out of fourteen (14) residents interviewed have said that they have observed the staff use gowns, gloves and masks when making their rounds and visiting the isolated residents. Residents interviewed also state that they were told to stay in their rooms if they developed a rash, but some do not listen and wander all around the facility. Clients interviewed state that the staff is doing their very best to keep the facility clean and free from illnesses in the facility. LPA Vaid observed caregivers and Med-tech staff taking extra precautions when delivering services to infected residents. Scabies skin scraping and testing was conducted on 11/04/24. Out of one hundred forty-seven (147) residents, one hundred six (106) residents were tested, fifteen (15) residents refused testing, twenty six (26) residents were out of the facility. From all the residents that were tested only one resident was diagnosed by the physician to have scabies. Based upon the investigation, interviews conducted with residents and staff, documents collected and reviewed, and observations made by LPA the investigation did not reveal any evidence to support that staff did not take appropriate steps to prevent the spread of communicable disease. 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 allegation is unsubstantiated. An exit interview was conducted and copy of this report was left with the Wellness Director Ruth Villa.the state’s words, verbatim · CDSS document, Dec 3, 2024 · control 28-AS-20241023134312

Allegation investigated: Staff mishandled a resident's medication

Licensing Program Analyst (LPA) S Vaid conducted a subsequent complaint visit on 11/14/24 regarding the listed allegation and to deliver complaint investigation findings. Met with Ruth Villa, Wellness Director and explained purpose of the visit. Toured the physical plant and did not observe any Health and Safety concerns. On 11/12/24, Licensing Program Analyst (LPA) S Vaid conducted an initial 10-day complaint investigation visit for the above allegation. LPA met with Ruth Villa, Wellness Director and the purpose of the visit was discussed. The investigation consisted of the following: LPA toured the physical plant. LPA Interviewed staff 1-7 (S1-S7) and residents 1-14 (C1-C14). LPA collected and reviewed documents from C1's medication file, and copies of four (4) random residents: medication list, written physicians’ orders. Facility Plan of Operations regarding medication administration. Continued on 9099C....... Unsubstantiated Regarding the allegation: Staff mishandled a resident's medication. It is alleged that the medication technician staff do not distribute the residents’ medications in a timely fashion. It is also alleged that six (6) medications pills were disposed by a new nurse (name not given), one hour later. Seven (7) out of seven (7) staff interviewed deny this allegation. The medication is administered to the residents at the correct times, AM, Noon, evening, PM, and bedtime. The medication is given to the residents within one hour before or one hour after the initial times. It is also confirmed by the physicians whom subscribe the medications and dosages, the morning medications are given between the hours of 6am to 8am for residents requiring morning medication. Noon medication is given between 11am to 1pm, evening medication is given between 5pm to 7pm and this occurs throughout the day. Med-techs also monitor residents who require medication administration every four (4) to six (6) hours. The medication that is refused by the residents is logged in the electronic medications administration record (EMAR) the refused medication is then properly disposed. Refused medications cannot be administered at any other times. Protocols for administering medications are being followed as per Plan of Operation regarding medications: delivery procedures for medications, section B thru section H: facility policies and procedures regarding, new medication order for current residents, medication direction changes, PRN medications, residents refusing medications, charting of medications. Thirteen (13) out of Fourteen (14) residents interviewed stated they have gotten their medication daily and could not corroborate the allegations. Thirteen (13) residents stated, the med-techs speak to them while administering their medications and answer questions regarding their medication. Seven (7) out of fourteen (14) residents know the shape and size of their medications and are aware of the medications they are given. Based on interviews conducted, observations made, and documents reviewed, residents’ medication list, written physicians’ orders, facility Plan of Operations regarding medication administration. 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 allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was given to Ruth Villa, Wellness Director.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 28-AS-20241106101156

Allegation investigated: Personal Rights/Resident sustained an unexplained injury while in care.

Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced visit to interview Resident #3 (R-3) through Resident #7 (R-7) and deliver findings. LPA met with Jacqueline Cortez and explained the purpose of this visit. On 09/23/24, LPA Irra conducted the initial investigation visit. During this visit, LPA conducted a tour of the building and grounds and did not observe any signs of neglect, abuse or other immediate health and safety threats. LPA reviewed Resident #1 (R-1's) and Resident #2 (R-2) files and obtained relevant documentation. Additionally, LPA obtained a copy of the staff roster and a copy of the Resident roster. During the course of this investigation, Investigator Christine Ferris (Department of Social Services- Investigative Bureau/IB) interviewed R-1, R-2, Staff #1 (S-1), Staff #2 (S-2), Staff #3 (S-3), Staff #4 (S-4) and Staff #5 (S-5). Investigator Ferris also obtained documentation from Los Angeles County Sheriff-Temple City Station pertaining to this allegation. On 10/21/24, LPA interviewed R-3 through R-7. ***Refer to LIC 9099C for the continuation of this report** Unsubstantiated Allegation: Personal Rights/Resident sustained an unexplained injury while in care. It has been alleged that a bruise was observed on R-1’s right rib area. Per Investigator Ferris’ investigation, R-1 did not disclose how R-1 sustained the bruise nor did R-1 disclose abuse or concern for neglect. Per Investigator Ferris’ investigation, staff interviewed denied knowledge of how R-1 sustained the bruise. Additionally, the Los Angeles County Sheriff’s Department determined no crime was committed. The investigation revealed no evidence to support abuse or neglect. R-3 through R-7 interviews revealed that they do not have any concerns, they have not heard of anyone complaining about this matter and that they feel safe residing at this facility. Interviews and police documentation do not corroborate this allegation. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview, appeal rights and a copy of this report was provided to Jacqueline Cortez.the state’s words, verbatim · CDSS document, Oct 21, 2024 · control 28-AS-20240920160331

Allegation investigated: Staff are overdosing residents. Staff are mismanaging resident's medications. Staff are administering unprescribed medications to residents. Staff do not answer residents’ call button in a timely manner. Staff do not ensure residents’ showering needs are being met. Staff do not ensure the facility has an adequate food supply. Staff do not ensure residents attend scheduled medical appointments. Staff do not ensure residents’ air conditioner is in good repair.

Licensing Program Analyst (LPA) S Vaid conducted a subsequent complaint visit regarding the above allegations. LPA conducted the initial complaint visit on 08/19/2024, this is a residential care facility for the elderly, a housing arrangement for persons, 60 years old and over. 24-hour non-medical care and supervision is provided. During today’s visit LPA met with Administrator Maya Mnoyan and explained the purpose of today’s visit. On today’s visit LPA Vaid conducted a physical plant tour with Admin Mnoyan and did not observe any health and safety concerns. Staff and home health agencies were observed assisting residents. The investigation consisted of the following: LPA Vaid interviewed Administrator, staff, and residents and toured the physical plant with Administrator and observed staff assisting residents with ADL (assisted daily living). LPA Vaid interviewed Administrator, staff #S2-S14 and residents #R1-R15. Continued on 9099C..... Unsubstantiated LPA Vaid requested and obtained the following documents: Staff and resident rosters, maintenance log for A/C repairs and call box signal repairs and installation for 2024, five random residents EMARS and other pertinent documents regarding this investigation. Regarding allegation: Staff are overdosing residents. It was alleged that staff are overmedicating residents with a Narcotic called Avitan used to treat adults with insomnia caused by anxiety and can cause drowsiness. Staff S1-S14 interviewed denied the allegation. Fourteen (14) out of fourteen (14) staff interviewed stated that they have not observed med-tech staff overmedicating any of the residents. The Med-techs have stated that the medication is administered as prescribed as needed. Each residents’ medication that is administered is logged into the MARs. The medication cart and the medication room is audited each month, by management. LPA's review of five (5) random residents’ medication, and medication administration records, observed medication to be administered as prescribed by physician’s orders. All medications are accounted, as shown in the MARs log, LPA performed pill count of medications in the bubble packs. LPA reviewed residents that are prescribed Avitan, the MARs indicate that the Avitan has been administered sparingly, administered when needed to specific residents with attributing health conditions. LPA did not perform pill count as the medication is bottled. Resident R1-R15 interviewed were unable to corroborate the allegation. Based upon records review and interviews conducted, the findings indicate that, 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. Regarding the allegation: Staff are mismanaging residents’ medications. It is alleged that staff are mismanaging residents’ medication by giving out one residents’ medication to another when first residents’ medication runs out. Fourteen (14) out of fourteen (14) staff interviewed stated that they have not observed the med-tech staff mismanaging the resident’s medication. The Med-techs and staff interviewed, stated that medication is administered as prescribed and logged into the Medication Administration Record. LPA's review of five (5) random resident medication, and medication administration records, shows that medication appears to be administered as prescribed. During the afternoon, LPA observed AM-shift med-techs performing medication count before the PM shift was assigned the mobile medication carts. The PM shift med-tech then also make a pill count before next round of late afternoon/evening medications administration. Resident R1-R15 interviewed were unable to corroborate the allegation. Residents have no knowledge of this incident. Based upon records review and interviews conducted, the findings indicate that, 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. Con't 9099C.... Regarding the allegation: Staff are administering unprescribed medications to residents. It is alleged that the staff had administered unprescribed medications to the residents who misbehave during the night, by logging incorrect information of medication administered. Covering up the pill count. Fourteen (14) out of fourteen (14) staff interviewed stated that they have not observed the medication technician staff administer unprescribed medication to residents. The Med-techs stated that medication is administered as prescribed. The narcotics log used to record time, date and dosage administered to the resident(s). The narcotics medication(s) are audited randomly each month for each resident using medications containing heavy narcotics. Medication audits are performed monthly by the Wellness Director to ensure medications are being administered as prescribed by the physician orders, constant communications with the pharmacy via eMARs (electronic medication administered records) ensure consistent supply of all medications continues. LPA's review of five (5) random resident medication, and medication administration records, shows that medication appears to be administered as prescribed by physician orders and pharmacy orders. Resident R1-R15 interviewed were unable to corroborate the allegation. Based upon records review and interviews conducted, the findings indicate that, 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. Regarding the allegation: Staff do not answer the resident’s call button in a timely manner. It is alleged that staff are not answering the call button in a timely manner when residents call for assistance. Fourteen (14) out of fourteen (14) staff interviewed stated that they have not observed the staff not answering the call button switchboard in a timely manner. LPA observed a call come into the office by a resident asking for assistance, within 1-2 minutes a caregiver answered the office to acknowledge the call being handled, the call was answered by a staff person from the resident’s room. Residents R1-R15 interviewed stated that the caregivers come within 2-3 minutes after call is made on the residents’ call box, someone always answers. Based upon observations made and interviews conducted, the findings indicate that, 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. Continued on 9099C...... Regarding the allegation: Staff do not ensure residents’ showering needs are being met. It is alleged that staff are not ensuring residents showering needs are being met. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. Caregiver staff and direct person staff(DSP) interviewed state, the caregivers staff assist the Home Health Aides with bathing the residents 2-3 times per week as noted in the resident’s needs/services plan. When residents refuse bathing, a note is made for bath refusal in the ADL (assisted daily living) clinical notes. Basic ADLs like brushing teeth, washing face, and combing hair, dressing is applied daily. Fifteen (15) out of fifteen (15) residents interviewed stated the staff gives baths twice a week, some residents stated they were given bathes three times a week by the home health agencies, the caregiver staff provides the rest. Based upon records review and interviews conducted, the findings indicate that, 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. Regarding the allegation: Staff do not ensure facility has adequate food supply. It is alleged that the staff is not ensuring adequate food supply for residents. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. Kitchen staff interviewed state, grocery list is planned and ordered on Sunday and Wednesday for delivery of food on Monday and on Thursday. The kitchen was observed to have enough foods to feed all the residents, during tour of the kitchen LPA observed delivery being made, many boxes and bags of fruit and vegetable along with canned and dry food items being delivered. Fifteen (15) out of fifteen (15) residents interviewed state they like the food served and have never experienced food shortage at the facility. Based upon records review and interviews conducted, the findings indicate that, 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. Regarding the allegation: Staff do not ensure residents attend scheduled medical appointments. It is alleged that a staff person is cancelling residents’ medical and other important appointments. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. The residents with medical appointments, relay information to the caregivers and the care coordinator, who then logs in the appointments in the transportation log to ensure the drivers are aware of resident’s appointments. The protocol for the appointment scheduling is verified by the care coordinator to ensure all necessary paperwork and insurance paperwork is ready for the residents. Fifteen (15) out of fifteen (15) residents interviewed stated they are happy with the transportation protocols and have not had any problems with keeping their appointments. Continued on 9099C.... Based upon records review and interviews conducted, the findings indicate that, 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. Regarding the allegation: Staff do not ensure residents’ air conditioner is in good repair. It is alleged that the staff is not ensuring that the air conditioner system is not in good repair. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. The air conditioner units are maintained by the maintenance staff, all air-conditioner systems are operational. When a unit breaks down or needs service, a work order is issued for maintenance to repair, repairs are handled within 24 hours unless parts are needed ordering. Accommodations for the residents are made if repair takes longer than anticipated. Regarding maintenance all work orders are logged to ensure completion of the projects in timely manner. Fifteen (15) out of fifteen (15) residents interviewed stated they have no concerns of the A/C units, staff is always fixing and are repairing things around the facility. Based upon records review and interviews conducted, the findings indicate that, 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. LPA did not observe any Health and Safety concerns during the visit, an exit interview was held and copy of this report was given to the Administrator Maya Mnoyan.the state’s words, verbatim · CDSS document, Oct 11, 2024 · control 28-AS-20240815132940

Allegation investigated: Staff do not ensure infection control guidelines are being followed Staff do not ensure changes in residents health conditions are being monitored

Licensing Program Analyst (LPA) Vaid conducted an unannounced initial 10 day complaint visit regarding the above allegations. LPA met Maya Mnoyan (Administrator) and explained the reason for the visit. During today's visit, LPA reviewed and obtained client and staff roster, client admissions agreement, face sheet, physician order. LPA toured the physical plant with Administrator Mnoyan and did not observe any deficiencies or health and safety concerns. LPA Vaid interviewed Staff 1-6 (S1-S6). LPA interviewed residents 1-14(R1-R14). Regarding the allegation: Staff do not ensure infection control guidelines are being followed. It is alleged the facility staff are not following the infection control guidelines. Six (6) out of (6) staff deny the allegation. Fourteen (14) out of (14) residents interviewed could not corroborate this allegation. LPA reviewed the facilities Infection Control plan. ...... CONTINUED ON 809 C......... Unsubstantiated Last reviewed and updated by Administrator on 03/28/24. LPA observed the staff using PPE’s through out the facility, no reported cases of COVID-19 at the facility. Based on documents reviewed, observations made, and interviews conducted. 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 allegation is UNSUBSTANTIATED. Regarding the allegation: Staff do not ensure changes in residents health conditions are being monitored. It is alleged that the facility is not monitoring the residents’ health conditions. Six (6) out of (6) staff interviewed deny this allegation. Fourteen (14) out of (14) residents could not corroborate the allegation. The residents who are with serious medical issues are monitored every two hours, some residents are monitored every hour depending upon their medical conditions. Caregivers and med-techs communicated with one another via communication logs, to alert the next shift caregivers and med-techs of any medical issues, residents are experiencing and level of monitoring that needs to be administered. There have not been any reported, no serious incident reports(SIR) of residents hospitalized for excessive cough have been filed. Based on documents reviewed, observations made, and interviews conducted. 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 allegation is UNSUBSTANTIATED. An exit interview was conducted and copy of this report was left with the Administrator, Maya Mnoyan.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 28-AS-20240827135724

Allegation investigated: Licensee did not provide responsible party with a refund.

***This licensing report supersedes licensing report (LIC 9099) dated 07/30/24.*** Licensing Program Analyst (LPA) Vaid conducted a follow complaint visit to the facility. Upon arriving at the facility, LPA met with Wellness Director Yumi Ludwig, Administrator Maya Mnoyan arrived shortly after to assisted with the visit. LPA discussed and explained the purpose of today’s visit, which was to reissue the findings issued on/07/30/24. On todays, visit LPA spoke and toured the physical plant along with Maya Mnoyan and did not observe any Health and Safety concerns. During today’s visit LPA obtained resident/ staff roster, complete admissions agreement. CONTINUED ON 9099 A...... Substantiated ***This licensing report supersedes licensing report (LIC 9099) dated 07/30/24.*** On 07/30/24 LPA Vaid conducted an initial complaint visit, during visit, LPA Vaid obtained resident/ staff roster, admissions agreement, and email correspondence showing responsible party’s email with facility officers. LPA also interviewed administrator Maya Mnoyan. 7 out 0f 7 residents could not corroborate the allegation and 5 out of 5 staff deny the allegation. Based on interviews conducted and documents review the findings indicate the facility was notified on 04/13/24 by the responsible party that the belongings of R1 were being moved to the rehab center where R1 would be residing for the remainder of their rehabilitation after being discharged from the hospital. On 04/16/24 R1 passed away, and on 04/17/24 responsible party notified the administrator via email correspondence, to start the prorated refund. The business office notified the responsible party the refund needed to go thru the corporate office, the corporate office would close out all outstanding accounts and the refund would be sent directly to the responsible party. R1’s responsible party (RP) contacted facility staff S1 and S2 via email correspondence to inquire of the refund on 05/17/24, 06/09/24, 06/17/24, 07/14/24, and 07/23/24. R1’s RP was assured the by facility staff S1 and S2 the refund was being handled. The facility failed to refund the prorated funds to R1’s responsible party within 15 days after property was removed on 04/13/24. Notification by the responsible party on 04/17/24 of R1’s death on 04/16/24 via email correspondence, as agreed to in the admissions agreement section VIII -termination and section C-death, dated 02/03/24. Therefore, based on LPA’s observations, interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D. Exit interview was conducted and copy of this report and appeals rights were discussed and given to the Administrator.the state’s words, verbatim · CDSS document, Aug 1, 2024 · control 28-AS-20240725105346

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(5)(c) · Plan of correction due date: Aug 1, 2024

Admission Agreements 87507(5) Refund conditions.(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility... the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. This requirement not met as evidence by: Based on interviews and record review, licensee failed to refund monies with 15 days after R1's belonging were removed and after R1's death. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited.the state’s words, verbatim · CDSS document, Aug 1, 2024

Plan of correction: Administrator produced the proof of refunded monies to R1's responsible party on 07/29/24. Proof of correction has been satisfied.

Allegation investigated: Licensee did not provide responsible party with a refund

On 07/30/24 at 08:45 a.m., Licensing Program Analyst (LPA) S Vaid conducted an ten day unannounced complaint visit to the facility. Upon arrival LPA met with Alyssa Morales (Business Officer) and explained the purpose of the visit. Maya Mnoyan(Administrator) arrived shortly after. During today’s visit LPA obtained resident/ staff roster, admissions agreement, physicians report, facesheet and email correspondence showing responsible party’s email with facility officers. LPA also interviewed administrator Maya Mnoyan. Toured the physical plant with the Administrator and did not observe any health and safety concerns. Based on interviews conducted and documents reviewed the findings indicate the facility was notified on 04/13/24 by the responsible party the belongings of R1 were being moved to the rehab center where R1 would be residing for the remainder of their rehabilitation after being discharged from the hospital. Continued on 9099C... Unsubstantiated On 04/16/24 R1 passed away at the hospital, on 04/17/24 responsible party notified the administrator via email correspondence to start the prorated refund. 7 out of 7 residents were not aware of the refund process. 5 out of 5 staff interviewed denied the allegation. The administrator notified the responsible party the refund needed to go thru the corporate office, the corporate office would close out all outstanding accounts and the refund would be sent directly to the responsible party. On 07/14/24 the Business Office Manager informed the responsible party that the corporate office had completed the refund request and will be mailing the prorated refund. On 07/26/24, check in the amount of $699.07 was sent to the responsible party via USPS mail. The process for refunds depends upon corporates Accounts Payable department and their due diligence by Social Security and insurance payments according to the business officer. Based on interviews conducted and documents obtained, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Administrator Maya Mnoyan and copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 30, 2024 · control 28-AS-20240725105346

Allegation investigated: Illegal eviction

Licensing Program Analyst(LPA) S Vaid conducted an unannounced 10 day complaint investigation visit for the allegation listed above. LPA met with Executive Director Maya Mnoyan to discuss the purpose for today’s visit. LPA toured the facility, interviewed the Administrator, staff #2-#5, interview residents #1-#5, and requested a copy of the staff roster, resident roster, face sheet, admission agreement, physicians report, needs and services. Regarding allegation: illegal eviction. On 07/04/24 R1 was taken by paramedics to Arcadia USC due to shortness of breath, R1 was under the impression they would return to the facility upon being discharged from the hospital. On 07/05/24, facility administrator spoke to the Social Worker regarding R1 state of health and suggested that higher level of care was needed, both the social worker and facility administrator agreed. On 07/09/24, R1 family collected R1 personal belongings and medication for safe keeping, not knowing the protocols of the facility. CONTINUE ON 9099C... Substantiated There was no exchange in communications by the family nor the facility on whether R1 would be returning. No notice was given by resident(R1) to the facility of their plans to leave the facility, as indicated in the admissions agreement a 30-day notice is expected by the facility for anyone moving out of the facility. The administrator is refusing to allow the resident back into the facility citing no beds available. The capacity of the facility is 150 beds and todays census is 146, therefore the facility has room for four more residents until full to capacity. Administrator stated that four beds were reserved for new residents, however the facility is taking new residents when exsisting residents are still admitted to facility. The facility is in direct violation of the admissions agreement. R1 is ready to be discharged from the hospital however facility does not have room available, R1 room was given to another resident. Based on interviews, records reviewed and obtained, 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, is being cited on the attached LIC 9099D. En exit interview was conducted and a copy of this report was provided to the along with the appeals rights.the state’s words, verbatim · CDSS document, Jul 25, 2024 · control 28-AS-20240722134903

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(a) · Plan of correction due date: Jul 25, 2024

87224 Eviction Procedures...(a) The licensee may evict a resident.. Thirty (30) days written notice to the resident is required.... This requirement is not met as evidenced by: The facility did not comply with regulation of evictions procedures. R1 is ready to be discharged from the hospital however facility does not have room available for R1, facility gave away room to other resident. R1 did not given 30 day notice to facility about leaving.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Within 24-48 hours facility will send nurse to hospital and perform an assesment and then R1 will continue residing at the facility until more skilled nursing home is found for the resident.

Allegation investigated: Facility staff does not meet residents grooming needs. Staff don't answer facility phone.

*This is a corrected version of previous report dated 6/14/24. LPA Ramirez corrected number of residents interviewed. LPA Ramirez met with Barbara Lopez and explained the purpose of the visit. LPA Ramirez redelivered this report on 7/6/24 with no changes to the findings.* Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 06/14/2024 regarding the above allegations. LPA Ramirez was met by Receptionist Tyryse Robinson. Administrator Maya Mnoyan, arrived shortly after to assist with tour. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 6 interviews (S1 – S6), Resident#1 – 10 (R1 – R10), copies of Resident#1 (R1)- Physician’s Report (LIC 602), Identification and Emergency Information form, Admission Agreement, Medication Administration Record (MAR), Facility resident progress notes, Caregiver assignment log for R1, and physical plant tour. See 9099-C for continuation. Unsubstantiated The investigation revealed the following. Regarding Allegations: Facility staff does not meet residents grooming needs- It is alleged staff do not assist R1 with grooming. R1 arrived at the facility on 02/03/2023. Per R1’s Physician Report dated 3/4/24, R1 needs assistance with grooming. Six (6) out of the six (6) staff interviewed deny this allegation. Eight (8) out of the ten (10) residents interviewed deny this allegation. LPA Ramirez reviewed the facility Caregiver Assignment Logs for R1 which indicated R1 was assisted with grooming on different days R1 was present at the facility for the months of May and June 0f 2024. Staff interviews revealed R1 would leave the facility for days at a time. Staff revealed they would assist R1 with grooming when he returned. During facility tour and interviews with residents, LPA Ramirez observed residents to tidy in appearance. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff don’t answer facility phone- It is alleged staff do not answer the facility phone when family members call the facility. On 6/12/ 2024, at 11:15 am, LPA Ramirez dialed facility phone number and was greeted by facility staff. On 6/13/2024, at 4:45 pm, LPA Ramirez dialed facility phone number and was greeted by facility staff. During facility tour, LPA Ramirez observed facility phone ringing and staff answering calls. Six (6) out of the six (6) staff interviewed deny this allegation. Nine (9) out of the ten (10) residents interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited for this investigation complaint. Exit interview conducted with Administrator Mnoyan. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 6, 2024 · control 28-AS-20240610162952

Allegation investigated: Staff did not provide adequate supervision to resident resulting in fall. Staff physically abused resident in care.

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint investigation regarding the above allegations. LPA met with Administrator, Maya Mnyoyan who assisted with the visit. Regarding the allegation that : Staff did not provide adequate supervision to resident #1 resulting in fall. The investigation consisted of interviews with Administrator, staff #1 - staff #3, and resident #2 - resident #11. LPA also reviewed resident #1's file, and obtained copies of specific documents, including incident report dated 6/9/24. The investigation revealed the following : Administrator and staff interviewed stated that on 6/9/24, resident #1 experienced a fall at 10:42am while a caregiver was assisting resident #1 from a chair to her bed. Resident #1 was assessed and not found to have any injuries. Resident #1 experienced a second fall at 1:40pm, which was unwitnessed. Staff #2 assessed resident #1 and observed that resident #1 stated they were not in pain, and there were no visible injuries. Administrator stated that the doctor advised the facility to send resident #1 to the hospital for a more thorough assessment. Resident #1 is currently hospitalized. Unsubstantiated Administrator and staff interviewed denied the allegation. Four out of four staff interviewed stated that staff do provide adequate supervision to residents in care. Staff interviewed stated that if a resident experiences a fall, they are immediately assessed for injuries. Residents interviewed were unable to corroborate the allegation. Nine out of ten residents interviewed stated that staff provide adequate supervision to residents in care. Resident #1 is currently hospitalized and was unable to be interviewed. Although resident #1 did sustain a fall, the preponderance of evidence does not show that any Title 22 regulations were violated. Regarding the allegation that : Staff physically abused resident #1 in care. The investigation consisted of interviews with Administrator, staff #1 - staff #3, and resident #2 - resident #11. Administrator and staff interviewed denied the allegation. Four out of four staff interviewed stated that they have not observed any staff physically abuse any of the residents in care. Staff interviewed stated that they have not had any resident(s) report any physical abuse. Resident(s) interviewed were unable to corroborate the allegation. Ten out of ten residents interviewed stated that they have not observed any staff physically abuse any resident(s) in care. Resident #1 is currently hospitalized and was unable to be interviewed. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, and a copy of the report was provided to Administrator.the state’s words, verbatim · CDSS document, Jun 14, 2024 · control 28-AS-20240611084216

Allegation investigated: Facility staff does not meet residents grooming needs. Staff don't answer facility phone.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 06/14/2024 regarding the above allegations. LPA Ramirez was met by Receptionist Tyryse Robinson. Administrator Maya Mnoyan, arrived shortly after to assist with tour. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 6 interviews (S1 – S6), Resident#1 – 10 (R1 – R10), copies of Resident#1 (R1)- Physician’s Report (LIC 602), Identification and Emergency Information form, Admission Agreement, Medication Administration Record (MAR), Facility resident progress notes, Caregiver assignment log for R1, and physical plant tour. See 9099-C for continuation. Unsubstantiated The investigation revealed the following. Regarding Allegations: Facility staff does not meet residents grooming needs- It is alleged staff do not assist R1 with grooming. R1 arrived at the facility on 02/03/2023. Per R1’s Physician Report dated 3/4/24, R1 needs assistance with grooming. Six (6) out of the six (6) staff interviewed deny this allegation. Two (2) out of the ten (10) residents interviewed deny this allegation. LPA Ramirez reviewed the facility Caregiver Assignment Logs for R1 which indicated R1 was assisted with grooming on different days R1 was present at the facility for the months of May and June 0f 2024. Staff interviews revealed R1 would leave the facility for days at a time. Staff revealed they would assist R1 with grooming when he returned. During facility tour and interviews with residents, LPA Ramirez observed residents to tidy in appearance. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff don’t answer facility phone- It is alleged staff do not answer the facility phone when family members call the facility. On 6/12/ 2024, at 11:15 am, LPA Ramirez dialed facility phone number and was greeted by facility staff. On 6/13/2024, at 4:45 pm, LPA Ramirez dialed facility phone number and was greeted by facility staff. During facility tour, LPA Ramirez observed facility phone ringing and staff answering calls. Six (6) out of the six (6) staff interviewed deny this allegation. One (1) out of the ten (10) residents interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited for this investigation complaint. Exit interview conducted with Administrator Mnoyan. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 14, 2024 · control 28-AS-20240610162952

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Deficiencies on 06/14/2024, stemming from initial complaint investigation conducted on 06/14/2024. LPA Ramirez was greeted by Administrator Maya Mnoyan. Case Management-Deficiencies findings: Resident#1 (R1) was admitted into the facility on 2/3/2023 and has an admission agreement dated 2/3/2023. LPA Ramirez discovered R1 and facility representative signed a document indicating the following “R1 has agreed to stay in this community here at Santa Anita Assisted Living under the following conditions: Stays in the building every day without leaving overnight. (Building closes at 10pm). Pay rent every single month on the 5th, starting June 5th, 2024, with no missed payment. If these conditions are not followed and being done, resident has agrees to leave facility and discharge themselves.” This document is dated 5/31/2024. Review of R1’s Physician Report (LIC 602) dated 3/4/2024, indicates R1 may leave the facility unassisted. R1 is self-responsible and is not conserved. Per Title 22, Division 6, Chapter 8- 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities- (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (3) To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights. Interview with R1 revealed R1 left the facility on 6/7/24. On 6/10/24, Administartor Mnoyan phoned R1 to advise R1. they broke their agreement signed on 5/31/24 and could not return to the facility. As of 6/14/2024, R1 has not returned to the facility. LPA Ramirez and Administrator Mnoyan phoned R1 and R1 was told they may return to the facility. R1 agreed to phone the facility to get transportation arrangements. Facility staff violated R1’s personal rights by asking R1 to sign above referenced document; which violates R1's right to leave the facility freely, interfere and retaliate against R1 for exercising their rights. One deficiency was cited during this visit. A copy of this report, 809-D and appeals rights was provided.the state’s words, verbatim · CDSS document, Jun 14, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a)(3) · Plan of correction due date: Jun 28, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities- (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (3) To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights.the state’s words, verbatim · CDSS document, Jun 14, 2024

Plan of correction: This requirement was not met as evidence by: R1 was asked to sign a document violating thier right to leave the facility freely, interfere and retaliate against R1 for exercising their rights. Licensee will retrain staff on this regulation and send proof of re-training by 6/28/24. Licensee will recind this notice by 6/17/24 and send proof to LPA Ramirez via email.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection on 5/21/24. LPA arrived unannounced and met with Administrator, Maya Mnoyan. The purpose of the visit was explained. The facility is licensed for 150 non-ambulatory residents, ages 60 and over, of which (20) may be bedridden. There is a hospice waiver approved for (20) residents. LPA inspected the facility using the Compliance and Regulatory Enforcement (CARE) tool. The following were observed: Infection Control: The facility is continuing to follow their Infection Control Plan. Staff are using gloves to assist residents and performing adequate hand hygiene. Staff are receiving annual in-service training on Infection Control. Operational Requirements: The facility is operating within the approved fire clearance. Facility accepts and retains residents with dementia. The liability insurance is current and has the sufficient amount covering the injury of residents and guests. Physical Plant & Environment Safety: The single story facility is located in the residential area. LPA randomly selected 12 rooms to inspect as well as the common areas. The hot water temperature in the rooms was measured within the range of 105-120 degree F. The common areas are clean and furnished. Each resident room has the required furniture, closet space, and lighting. The rooms have a call cord located by the residents bed and in the bathrooms. The fireplace is not in use and adequately screened. There are no items obstructing the walkways. There is no swimming pool on the premises. The facility has smoke and carbon monoxide combo detectors that are hardwired and connected to the fire department. Food Service: Adequate food supplies of 2 day perishable and a week of nonperishable were observed. The kitchen area is clean and free of rodents and insects. Food is properly covered to avoid contamination. Planned Activities: Facility has a full-time Activity Director providing activities to residents. There are planned daily activities and are posted on the bulletin board. Staffing: Per the administrator, there is sufficient staffing on each shift. The overnight shift staff are all awake and providing supervision to residents. There is at least one staff who is CPR & First Aid certified on each shift at all times. Personnel Records-Training: LPA reviewed 6 personnel records. The administrator's (Maya Mnoyan) certificate expires on 10/9/25. Staff are fingerprint cleared and associated to the facility. Staff have appropriate dementia care training and ongoing training. Resident Rights/Information: Information for appropriate reporting agencies are posted at the facility. Residents' rights are respected and implemented by staff. Resident Records/Incident Reports: LPA reviewed 14 resident files. Resident files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, pre-appraisal form, and care plan. Incidental Medical and Dental: Medications are centrally stored in the medication room. The facility uses an electronic Medication Administration Record (MAR) log to document medications given. LPA reviewed 14 residents' medications and did not find any discrepancies. Disaster Preparedness: The facility has the updated LIC610E Emergency Disaster Plan posted. Annual training is provided to staff. The facility conducts monthly disaster drills for different shifts and are documented. Residents with Special Health Needs: Residents utilizing oxygen tanks have the proper sign posted outside their doors. Staff are ensuring that incontinence residents are changed often and the facility remains free of odor from incontinence. There are no deficiencies observed during the visit today. An exit interview was held and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, May 21, 2024

Allegation investigated: Staff allow residents to use illegal drugs in the facility. Staff sell illegal drugs to residents in care. Staff do not ensure that the facility is clean. Staff do not ensure that resident is provided transportation to medical appointments.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit to the facility for the purpose of contiunuing the investigation of the above-allegations. LPA met with Business Office Manager, Alyssa Morales, and explained the purpose for the visit. Administrator Maya Mnoyan arrived shortly after to assist with the visit On 09/25/23, LPA Maldonado conducted an initial visit to the facility. The visit consisted of the following: LPA obtained a copy of resident/staff rosters, conducted a tour of physical plant and common areas with Administrator, Maya, and obtained the following documents for Residents# 1-4 (R1-R4): Facesheet, Physician's Report, Pre-Placement Appraisal, and Needs and Services Plan. LPA observed food supplies and random resident rooms. The residents were also observed to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns during today's visit. (Report continued on LIC9099-C...) Unsubstantiated The following allegation: Staff sell illegal drugs to residents in care, was investigated by the Department. The departments investigation consisted of the following: Interviews conducted with Staff#1-9 (S1-S9), Resident#1 (R1), Residents#5-10 (R5-R10), and Former Resident#1 (FR1). IB also obtained records from R5-R11's files, facility incident reports, Charting notes, SOC341 records completed by the facility, and documented staff encounters to incidents of possible drug use by residents. The investigation revealed the following: Regarding allegation: Staff sell illegal drugs to residents in care. It is alleged that residents are buying illegal drugs, such as methamphetamines, from S1. Per IB's interviews conducted with staff, (9) of (9) staff denied selling illegal drugs, including methamphetamines, to residents. Staff stated to have witnessed some residents showing signs of being under the influence of methamphetamines (staring off, talking to themselves, and dilated pupils). Staff also stated that S2 met with the suspected dealer, R1, to stop selling at the facility. Facility was unable to evict R1 due to lack of evidence to formally evict R1. Per S2, facility staff were instructed to notify S2 and document any suspicious activity on facility grounds. Incident Reports obtained by IB reflected the facility has reported these incidents to the licensing agency. The incident reports documented residents reporting to staff that R1 was selling drugs to other residents. SOC341's were also completed and incidents were reported directly to law enforcement, by the facility. Per the interview conducted with S1, S1 denied ever being in possession of any drugs or selling them to residents at the facility. Per interview with R1, R1 denied S1 to have sold methamphetamine's to R1 or other residents. R1 also denied selling drugs to residents. Therefore, this allegation is Unsubstantiated. During today's visit, LPA Maldonado, continued the investigation regarding the following allegations: Staff allow residents to use illegal drugs in the facility. Staff do not ensure that the facility is clean. Staff do not ensure that resident is provided transportation to medical appointments. LPA obtained a copy of the resident and staff rosters and a copy of Admission's Agreement for R1. LPA also conducted interviews with Staff#2-5 (S2-S5), Staff#10-11 (S10-11), Residents#1-2 (R1-R2), and Residents #11-14 (R11-R14). The laundry room/services were also inspected and observed. The investigation revealed the following: (Report Continued on LIC9099-C...) Regarding allegation: Staff allow residents to use illegal drugs in the facility. It is alleged that several residents at the facility were using methamphetamine with staff and Administrator knowledge, and allowed it. Per staff interviews, (6) of (6) staff denied allowing residents to use illegal substances on facility premises. Staff stated that any suspicious activity observed that may depict residents using illegal substances or being under the influence are to be reported to the Administrator immediately and to document the observation. Per resident interviews, (5) of (6) residents denied the allegation. Residents stated using illegal drugs/substances is prohibited as part of the house rules and staff do not allow it. If staff believed someone was under the influence, law enforcement is called. Per SOC341's obtained by IB, it was documented that the facility reported the incidents directly to law enforcement. Incident reports also obtained by IB indicate that the facility documented and reported known incidents of residents observed under the influence of illegal substances. Therefore this allegation is Unsubstantiated. Regarding allegation: Staff do not ensure that the facility is clean. It is alleged that facility staff do not wash resident's bedding and do not vacuum. Upon entry to the facility, LPA Maldonado observed (3) different housekeeping staff pushing carts with clean and folded linens, taking out trash from resident rooms, and sweeping and mopping resident rooms and hallways. During resident interviews, LPA observed housekeepers exiting rooms 119 with trash, observed the laundry room to be operating and fully stocked with clean folded clothes. LPA observed laundry staff delivering clean clothes on a hangar to room#145. The facility was free from odors and appeared to be clean and sanitary. Per staff interviews, (6) of (6) staff denied the allegation. Staff stated that housekeeping staff is on facility grounds (7) days a week and regularly clean resident rooms. Per S10, housekeeping change linens (2) to (3) times a week and as needed, laundry for all residents is done daily, and resident rooms are vacuumed once a week, unless a resident refuses housekeeping services on a certain day. Per resident interviews, (5) of (6) residents denied the allegation. Residents stated their rooms are cleaned daily, laundry is done daily and as needed, sheets are changed often and as needed, and rooms are vacuumed. Regarding allegation: Staff do not ensure that resident is provided transportation to medical appointments. It is alleged that facility staff are not assisting with taking R1 to R1's medical appointments due to being too far, although they are taking other residents to appointments that are further. Per staff interviews, (6) of (6) staff denied the allegation. Staff stated that S4 and S5 assist residents with making medical appointments when needed, and the receptionist will schedule the transportation for the medical appointments via the facility vehicle or a company contracted service. (Report continued on LIC9099-C...) Residents also have the option of requesting transportation services provided through their insurance. Staff also stated that if a resident's appointment is far, they will assist with finding a physician closer to the area, if the resident chooses. Per R1, R1 has been taken to medical appointments before by the facility van. However, they facility did not want to give R1 a ride to the liquor store and R1 had to pay for a taxi to take R1. (6) of (6) residents interviewed denied the allegation. Per interview with R13, R13's medical appointments are far and facility staff accommodate R13 to get R13 to their medical appointments. 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. Per California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. An exit interview was conducted with Administrator, Maya Mnoyan, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 14, 2024 · control 28-AS-20230922131350

Allegation investigated: Staff did not provide adequate food service for resident.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced complaint visit to the facility for the purpose of investigating the above-mentioned allegation. LPA Maldonado met with Administrative Assistant, William Woods, and explained the purpose for the visit. During today's visit, LPA Maldonado obtained a copy of the resident and staff rosters, a copy of the food menu, conducted a tour of the physical plant with special focus on the kitchen and food services, and obtained the Facesheets and Physician's Reports for Residents# 1-8 (R1-R8). LPA also conducted interviews with Staff# 1-5 (S1-S5) and R1-R8. The investigation revealed the following: (Report continued on LIC9099-C...) Unsubstantiated Regarding allegation: Staff did not provide adequate food service for resident. It is alleged that on 1/23/24, a resident was denied breakfast upon their return from a medical appointment, due to them being out of the facility during the meal time, although they were promised breakfast upon their return. Per interviews conducted, (5) of (8) residents denied the allegation. Residents stated that snacks are provided to take with them to their appointments, and a meal is provided upon their return. Residents also stated that they have not had any issues with receiving a meal upon their return from their appointments. (2) of (8) residents interviewed could not corroborate the allegation as they stated they do not leave for regular medical appointments. (5) of (5) staff interviewed denied the allegation. They stated that it is the facility's policy to hold a meal for the residents any time they are out for a medical appointment. And if the meal is not held, the kitchen staff will personally prepare a fresh meal for the resident upon their return the facility. Staff state to be unaware of any resident being denied a meal upon their return from their medical appointment in the last 2 weeks. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 29, 2024 · control 28-AS-20240123134117

Allegation investigated: Staff did not prevent resident from attacking another resident resulting in injuries Staff did not notify resident's authorized representative of incident Staff did not notify residents authorized representatives of COVID outbreak

Licensing Program Analyst (LPA) Angelica Rea conducted another visit to deliver the final results of the investigation. LPA met with Assistant Administrator, William Woods who assisted with today's visit. Regarding the allegation that : Staff did not prevent resident from attacking another resident resulting in injuries. The investigation consisted of interviews with Resident #1 - Resident #12, Assistant Administrator, and staff #1 - staff #4. The investigation revealed the following : Assistant administrator stated that on 10/28/23, resident #1 and resident #13 had a disagreement, and resident #1 pushed resident #13. Assistant administrator stated that the incident happened in the lobby area of the facility, and a special incident report was submitted to Community Care Licensing. Staff interviewed stated that resident #13 was assisted and assessed for injuries. Assistant administrator and staff interviewed stated that staff do try to intervene and prevent altercations between residents from occurring. Residents interviewed were unable to corroborate the allegation. 12 out of 12 residents interviewed stated that staff do try to intervene and prevent alteracations from occurring. Unsubstantiated Regarding the allegation that : Staff did not notify resident's authorized representative of incident. The investigation consisted of interviews with Resident #1 - Resident #12, Assistant Administrator, and staff #1 - staff #4. Assistant administrator and staff interviewed stated that the facility does notify residents' authorized representative(s) of incident(s). Staff #1 stated that he contacted the authorized representative(s) listed on resident #13's contact list, and was able to contact resident #13's son. Residents interviewed were unable to corroborate the allegation. 12 out of 12 residents stated that they were not sure if the facility contacts residents authorized representative(s) of incident(s). Regarding the allegation that : Staff did not notify residents authorized representatives of COVID outbreak. The investigation consisted of interviews with Resident #1 - Resident #12, Assistant Administrator, and staff #1 - staff #4. Assistant administrator and staff interviewed stated that the facility did notify the resident(s) who have authorized representatives of the Covid outbreak at the facility. Residents interviewed were unable to corroborate the allegation. 12 out of 12 residents interviewed stated that they are self responsible. They stated that they don't know if the facility notified residents authorized representatives of COVID outbreak. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 28-AS-20231030142152

Allegation investigated: Staff did not prevent the spread of scabies

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint visit in response to the above allegation. LPA met with Assistant Administrator, William Woods who assisted with today's visit. On today's visit, LPA interviewed Assistant Administrator and Staff #1- Staff #3, reviewed Resident #1's file and interviewed Resident #2 - Resident #12. LPA also requested and obtained copies of specific documents from resident #1's file. The investigation revealed the following : Regarding the allegation that staff did not prevent the spread of scabies. Assistant administrator and staff interviewed denied the allegation. They stated that resident #1 lived at the facility from 1/23/23 - 7/1/23. Staff interviewed stated that resident #1 did not have scabies. Staff interviewed stated that resident #1 did have a rash and did complain of being itchy. Review of resident #1's file indicated that resident #1 was diagnosed with shingles on 6/17/23. LPA did not observe a scabies diagnosis during review of resident #1's file. Unsubstantiated Residents interviewed were unable to corroborate the allegation. 11 out of 11 residents interviewed stated that there has not been a scabies outbreak in the facility to their knowledge. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 28-AS-20231206084832

Allegation investigated: Staff mismanaged residents medications. Staff did not ensure faciltiy was free from bed bugs.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced initial complaint investigation regarding the above allegations. LPA met with Maya Mnoyan - Executive Director and explained the purpose of the visit. The investigation consisted of the following: LPA obtained copies of Staff and Resident Roster’s, copies of Resident #1 (R1): Face Sheet, Current Physician Report, Discharge Paperwork from Hospital (of most recent visit), and Medical Documents. LPA conducted facility tour and inspected 6 client bedrooms. LPA conducted Staff #1 - 5 interviews (S1 – S5) and Resident #1-10 interviews (R1 – R10). Continued on 809-C Unsubstantiated The investigation revealed the following: Allegation: Staff mismanaged residents’ medications. It is alleged that R1 was given medication that was not needed. Medication in question was a 1% topical lotion, R1 states that S2 was giving them the wrong medication as it should have been 5%. LPA reviewed discharge paperwork from R1’s file and medication that was prescribed by doctor was a 1% topical lotion, this error was not done due to staff changing a medication. R1 cancelled the medication, and a new order was given by doctor for the correct 5% topical lotion. Interviews with S1 and S2 revealed that staff are not able to make any adjustments to resident medications and all medications are prescribed by doctor and administered per doctor’s orders. Interview with S2 revealed that S2 followed up with a phone call to doctor as medication prescribed is usually used to treat scabies and as precaution wanted confirmation as isolation protocols would follow if this was the case, doctor stated that the medication is provided to help cure mild skin allergies/irritations and did not confirm nor deny this was caused by bed bugs. LPA interviewed 10 Residents and 8 out of 10 Residents denied the above allegation and state they are confident that the facility manages their medication correctly and they are administered their medication per doctor’s orders. Allegation: Staff did not ensure facility was free from bed bugs. It is alleged that R1 has bed bugs in their room. LPA toured facility, inspected R1’s bedroom along with 5 other resident bedrooms, Rooms inspected were #’s 126, 145, 171, 177, 178, 186. LPA inspected the mattresses linens and carpets in each room and did not observe bed bugs or insects in any of the bedrooms. LPA reviewed R1 medical records and observed that R1 was provided with medications to cure a skin disorder, R1 was provided with Bed Bug Information Sheets at discharge, however, the diagnosis of skin condition did not identify that it was due to bed bug bites. LPA reviewed R1’s medical records and there are records showing R1 has had minor cuts/abrasions and skin tear treatment since 2/29/2023. LPA interviewed 5 staff and 5 out of 5 staff stated that no other resident besides R1 has brought the concern of bed bugs to their attention. 5 out of 5 staff stated that although they have not seen the bed bugs R1 claims to have in their room, there have been precautionary measures taken to ensure resident does not have bed bugs. Mattress has been switched out on three different occasions in R1’s room, housekeeping cleans regularly using a steamer on resident rooms twice weekly and weekly laundry is done where sheets are washed and replaced. LPA interviewed 10 Residents and 9 out of 10 Residents stated that their rooms are cleaned daily, sheets are washed weekly and they have never had any issues with bed bugs in their rooms. Continued on LIC 9099-C Based on statements and interviews conducted with staff and Residents and review of Resident #1 files, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Executive Director Maya Mnoyan.the state’s words, verbatim · CDSS document, Nov 20, 2023 · control 28-AS-20231117101225

Allegation investigated: Facility grounds are littered with trash and cigarette buds. Resident was given incorrect medication by staff. Facility emergency call button in resident room is in disrepair all.

**This is corrected version of previous report dated 10/17/23. Verbiage on 9099-C was corrected from " Three (3) out of the four (4) staff interviewed deny this allegation" to " Three (3) out of the four (4) residents interviewed deny this allegation." No changes to findings.** Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 10/17/23 regarding the above allegations. LPA Ramirez was met by Assistant Administrator William Woods and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 4 interviews(S1 – S4), Resident #1-4 interviews (R1 – R4 ), copies of Resident #1 (R1): Face Sheet, Physician Report Dated 08/25/21, Medication Administration Record (MAR) for the months of September and October, Physicians Orders dated May 2023, current medications as of 10/17/23, review of medical file, and physical plant tour. See 809-C for continuation. Unsubstantiated The investigation revealed the following. Regarding Allegation(s): Facility grounds are littered with trash and cigarette buds.- At 11:17 am, LPA Ramirez toured indoor and outdoor of the facility grounds. LPA Ramirez did observe several discarded cigarette buds in planter located on the outside main entry walkway of the facility. LPA Ramrez observed staff inspecting front grounds with a broom and scoop pan, and removing discarded cigarette buds from front grounds. LPA Ramirez did not observe trash scattered around facility grounds. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Resident was given incorrect medication by staff.- It is alleged facility staff gave R1 incorrect medication. Four (4) out of four (4) staff interviewed deny this allegation. Three (3) out of the four (4) residents interviewed deny this allegation. LPA Ramirez reviewed R1’s Medication Administration Record for the months of September and October. LPA Ramirez did not observe and discrepancies. LPA Ramirez reviewed R1’s medical file and could not locate any medical records indicating R1 was sent to the hospital or treated for being over medicated or under medicated. LPA Ramirez did not observe and Special Incident Reports (SIRs) for R1 indicating medication was given incorrectly or missed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Facility emergency call button in resident room is in disrepair.- It is alleged the facility emergency call button in R1’s bathroom is in disrepair. LPA Ramirez toured R1’s room (159) and tested emergency call button located in bathroom. Initially call button was not working properly however, this was due to call button not being reset. After second attempt and reset, emergency call button functioned accordingly. LPA Ramirez tested emergency call buttons in bathrooms: 120 and 132. LPA Ramirez observed these to be in working order. Four (4) out of four (4) staff deny this allegation. Three (3) out of the four (4) residents interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted. No deficiencies were cited during this visit. A copy of this report and appeals rights was provided.the state’s words, verbatim · CDSS document, Nov 14, 2023 · control 28-AS-20231011133210

Allegation investigated: Illegal eviction Facility is retaliating against resident

Licensing Program Analyst(LPA) Nicol Wesley conducted an unannounced 10 day complaint investigation visit for the allegation(s) listed above. LPA met with Executive Director Maya Mnoyan and Administrative assistant William Woods to discuss the purpose for todays visit. LPA toured the front of the facility, interviewed the Executive Assistant, staff #1-#2, interview residents, and requested a copy of the staff roster, resident roster, face sheets and eviction notices issued within the last 30 days. Regarding allegation: illegal eviction. There were roomers that resident #1 and resident #2 were selling drugs, but the administrator has no evidence. She said she called the Temple City Police Special assignment deputy's but they wouldn't go inside resident #1 and resident #2's room without them being present. Residents who were interviewed 1 out of 3 said they had knowledge resident #1 selling drugs in the facilty, Unsubstantiated but no proof was provided. On September 19, 2023, Executive Director Maya Mnoyan issued a 30 day eviction to the resident based on hearsay of other residents. On October 17, 2023, LPA Kimberly Ramirez requested that the Executive Director Maya Mnoyan rescind the 30 day notice for resident #1 and the Executive Director rescinded the 30 day notice on October 25, 2023. LPA Wesley was unable to interview resident 1 because they are not in the facility and based on the text conversation from the resident, they will not be returning. Regarding allegation: Facility is retaliating against resident. Based on the pictures provided the condition that resident #1 room was altered, the sprinklers, the call box was not working, the closet doors contained graffiti on them, and the room was thrashed. When the resident came back to the facility after being gone for a number of days, the administrator place her in room 122 which was a better kept room and the resident had a roommate that she got along with. There was no reason for resident to feel that she wasn't issued the same room because she contacted Community Care Licensing Division, as she was given the room assignment prior to her contacting Community Care Licensing Division as the room she was in was altered and there was no way of the resident using the call button and the sprinklers in her room were not operable. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Oct 26, 2023 · control 28-AS-20231020154831

Allegation investigated: Facility staff hit resident in care. Facility staff did not safeguard resident's personal belongings. Facility staff did not ensure resident's record was completed accurately.

**This is a corrected version of previous report dated 8/25/23. No changes in findings. Verbiage on 9099 was corrected to reflect correct staff identifier (S1). ** Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/25/23 regarding the above allegations. LPA Ramirez was met by Staff #1(S1) and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 4 interviews (S1 – S4), Resident #1-4 interviews (R1 – R3, R5),attempted interview of Resident#4 (R4), copies of Resident #4 (R4): Admission agreement, Emergency and identification, Preplacement Appraisal Information dated 1/19/23, Physician’s Report 1/24/23, other pertinent documents and physical plant tour. Unsubstantiated Regarding allegation(s): Facility staff hit resident in care. It is alleged an unknown staff member hit Resident #4 (R4). Four (4) out of the four (4) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. LPA Ramirez attempted to interview R4 in R4’s accommodation. R4 denied entry to LPA Ramirez and refused to be interviewed. LPA Ramirez reviewed R4’s medical file and did not observe and Special Incident Reports (SIR) indicating R4 sustained any injures within the last 2 weeks. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Facility staff did not safeguard resident's personal belongings. It is alleged facility staff stole R4’s wallet and jewelry. Four (4) out of the four (4) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. During the interview of R5, it was revealed that R5 found R4’s wallet in the dining room couch on 8/24/23. According to Administrator Mnoyan, R5 stated they found the wallet and the facility returned it back to R4. R4 refused to be interviewed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Facility staff did not ensure resident's record was completed accurately. It is alleged that facility staff are not ensuring R4’s medical records are current. Four (4) out of the four (4) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. R4 was admitted into the facility on 1/19/23. Physician’s Report dated 1/24/23 and Preplacement Appraisal Information dated 1/19/23 both indicate R4 is ambulatory and does not require assisted devices to get around the facility. Four (4) out of the four (4) staff interviewed confirm R4 is ambulatory without assisted devices. R5 revealed that R4” accidentally left their wallet on dinning room couch and walked away.” LPA Ramirez could not find any discrepancies while reviewing R4’s file. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Administrator Mnoyan.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 28-AS-20230823112141

Allegation investigated: Facility grounds are littered with trash and cigarette buds. Resident was given incorrect medication by staff. Facility emergency call button in resident room is in disrepair.all

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 10/17/23 regarding the above allegations. LPA Ramirez was met by Assistant Administrator William Woods and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 4 interviews(S1 – S4), Resident #1-4 interviews (R1 – R4 ), copies of Resident #1 (R1): Face Sheet, Physician Report Dated 08/25/21, Medication Administration Record (MAR) for the months of September and October, Physicians Orders dated May 2023, current medications as of 10/17/23, review of medical file, and physical plant tour. See 809-C for continuation. Unsubstantiated The investigation revealed the following. Regarding Allegation(s): Facility grounds are littered with trash and cigarette buds.- At 11:17 am, LPA Ramirez toured indoor and outdoor of the facility grounds. LPA Ramirez did observe several discarded cigarette buds in planter located on the outside main entry walkway of the facility. LPA Ramrez observed staff inspecting front grounds with a broom and scoop pan, and removing discarded cigarette buds from front grounds. LPA Ramirez did not observe trash scattered around facility grounds. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Resident was given incorrect medication by staff.- It is alleged facility staff gave R1 incorrect medication. Four (4) out of four (4) staff interviewed deny this allegation. Three (3) out of the four (4) staff interviewed deny this allegation. LPA Ramirez reviewed R1’s Medication Administration Record for the months of September and October. LPA Ramirez did not observe and discrepancies. LPA Ramirez reviewed R1’s medical file and could not locate any medical records indicating R1 was sent to the hospital or treated for being over medicated or under medicated. LPA Ramirez did not observe and Special Incident Reports (SIRs) for R1 indicating medication was given incorrectly or missed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Facility emergency call button in resident room is in disrepair.- It is alleged the facility emergency call button in R1’s bathroom is in disrepair. LPA Ramirez toured R1’s room (159) and tested emergency call button located in bathroom. Initially call button was not working properly however, this was due to call button not being reset. After second attempt and reset, emergency call button functioned accordingly. LPA Ramirez tested emergency call buttons in bathrooms: 120 and 132. LPA Ramirez observed these to be in working order. Four (4) out of four (4) staff deny this allegation. Three (3) out of the four (4) residents interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted. No deficiencies were cited during this visit. A copy of this report and appeals rights was provided.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 28-AS-20231011133210

Allegation investigated: Resident is being illegally evicted.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 10/17/23 regarding the above allegation. LPA Ramirez was met by Assistant Administrator William Woods and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 4 interviews(S1 – S4), Resident #1-4 interviews (R1 – R4 ), copies of Resident #1 (R1): Face Sheet, proof of service dated 09/19/23, signed Admission Agreement, signed Facility House Rules, 30-Day to Terminate dated 09/19/23, and physical plant tour. See 809-C for continuation. Substantiated The investigation revealed the following. Regarding Allegation: Resident is being illegally evicted.- It is alleged R1 is being illegally evicted. On 9/19/23, LPA Ramirez received notification of R1’s 30-Day to Terminate. The eviction alleged R1 failed to comply with the general policies of the community, R1’s conduct poses a danger to themselves or others at the community, R1 was disruptive and created unsafe conditions, and R1 engaged in conduct that violated federal, State or local laws, or ordinances. Facility staff could not provide LPA Ramirez with a police report or arrest report from local law enforcement that indicates R1 violated federal, State, local laws or ordinances. LPA Ramirez could not locate any Special Incident Report (SIRs) indicating R1 was found with illegal drugs in their persons or in their accommodation. On 09/22/23, LPA Ramirez reviewed R1 30-Day to Terminate and contacted Administrator Mnoyan. LPA Ramiez advised Administrator Mnoyan against eviction for R1 based on lack of criminal evidence of R1 allegedly selling illegal drugs in the facility. Administrator Mnoyan advised LPA Ramirez that local law enforcement refused to search R1’s room and advised the facility to seek a warrant so that local law enforcement may search R1’s room. Interviews with staff revealed R1 has never been found with illegal drugs in R1’s possession or found in R1’s room. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Exit interview conducted. One (1) deficiency is being cited. A copy of this report, 809-D, and appeals rights was provided. Resident is being harassed by staff- It is alleged R1 is being harassed by staff. Four (4) out of four (4) staff deny this allegation. Three (3) out of the four (4) residents interviewed deny this allegation. LPA Ramirez viewed signs posted in facility main reminding all residents, staff and visitors of Residents’ Rights and how to report any types of abuse or harassment. LPA Ramirez toured R1’s room and did not observe any hazards. LPA Ramirez toured facility grounds and observed several staff providing care and supervision. LPA Ramirez did not observe any staff harassing residents during visit. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Facility has bed bugs and insects- It is alleged the facility has bed bugs and insects in R1’s room. Four (4) out of four (4) staff deny this allegation. Three (3) out of the four (4) residents deny this allegation. LPA Ramirez toured rooms: 120, 123, 132, 145,153 and 159. LPA Ramirez inspected mattresses, linens and carpets in each room. LPA Ramirez did not observe bed bugs or insects in any of the rooms. LPA Ramirez did not locate any medical records treatment for R1 receiving treatment for bed bug bites. LPA Ramiez did not locate any work orders to treat any resident rooms for bed bugs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 28-AS-20231011091749

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: Oct 25, 2023

(d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement was not met as evidence by: Licensee did not provide R1 in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.the state’s words, verbatim · CDSS document, Oct 17, 2023

Plan of correction: Licensee will rescind eviction. Licensee could not provide factual evidence that resident failed to comply with state or local law and received written notice of the alleged violation.

Allegation investigated: Facility staff hit resident in care. Facility staff did not safeguard resident's personal belongings. Facility staff did not ensure resident's record was completed accurately.

**This is a corrected version of previous report dated 8/25/23. No changes in findings. Verbiage was corrected.** Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/25/23 regarding the above allegations. LPA Ramirez was met by Staff #1 (S1) and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 4 interviews (S1 – S4), Resident #1-4 interviews (R1 – R3, R5),attempted interview of Resident#4 (R4), copies of Resident #4 (R4): Admission agreement, Emergency and identification, Preplacement Appraisal Information dated 1/19/23, Physician’s Report 1/24/23, other pertinent documents and physical plant tour. See 9099-C for continuation. Unsubstantiated Regarding allegation(s): Facility staff hit resident in care. It is alleged an unknown staff member hit Resident #4 (R4). Four (4) out of the four (4) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. LPA Ramirez attempted to interview R4 in R4’s accommodation. R4 denied entry to LPA Ramirez and refused to be interviewed. LPA Ramirez reviewed R4’s medical file and did not observe and Special Incident Reports (SIR) indicating R4 sustained any injures within the last 2 weeks. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Facility staff did not safeguard resident's personal belongings. It is alleged facility staff stole R4’s wallet and jewelry. Four (4) out of the four (4) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. During the interview of R5, it was revealed that R5 found R4’s wallet in the dining room couch on 8/24/23. According to Administrator Mnoyan, R5 stated they found the wallet and the facility returned it back to R4. R4 refused to be interviewed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Facility staff did not ensure resident's record was completed accurately. It is alleged that facility staff are not ensuring R4’s medical records are current. Four (4) out of the four (4) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. R4 was admitted into the facility on 1/19/23. Physician’s Report dated 1/24/23 and Preplacement Appraisal Information dated 1/19/23 both indicate R4 is ambulatory and does not require assisted devices to get around the facility. Four (4) out of the four (4) staff interviewed confirm R4 is ambulatory without assisted devices. R5 revealed that R4” accidentally left their wallet on dinning room couch and walked away.” LPA Ramirez could not find any discrepancies while reviewing R4’s file. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Administrator Mnoyan.the state’s words, verbatim · CDSS document, Sep 28, 2023 · control 28-AS-20230823112141

Type of visit: Case Management - Deficiencies

**Please note this is corrected version from previous report dated 7/17/23. Deficiency issued on 7/17/23 has been changed from Type A to Type B. Please see new LIC 809-D page.** Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management VISIT DEFICIENCIES on 7/17/23 at 10am, stemming from initial complaint investigation on 7/17/23. LPA Ramirez gained entry into the facility at 9:25 am. LPA Ramirez requested and obtained copies of Resident #1 (R1): Face sheet, Physician Visit dated 06/15/23, Identification and Emergency Information form, Physician’s Report dated 3/23/23, Order Summary Report dated 4/5/2023, Individual Service Plan (ISP) dated 3/20/2023, Medication Administration Record (MAR) for May, June and partial month July of 2023, Resident #2 (R2) Face sheet, Physician’s Report dated 5/23/23, Resident #3 (R3) Face sheet, Physician’s Report, Resident #8(R8) Face sheet, Physician Visit dated 06/15/23, Identification and Emergency Information form, Physician’s Report dated 6/01/23, Order Summary Report dated 6/12/2023, and facility Blood Sugar Log for June 26, 2023. Case Management-Deficiencies findings: · LPA Ramirez conducted four (4) record reviews of Resident #1, 2,3, and 8 (R1, R2, R3, R8) medical file. · LPA Ramirez discovered that R1 seen their physician on 6/15/23 and R1’s physician ordered R1 blood sugar to be checked before breakfast, lunch and bedtime. Individual Service Plan (ISP) dated 3/20/2023 states Assisted Living Facility (ALF) will monitor blood sugar 3x/day and will report high or low glucose to MD. LPA Ramirez could only locate documentation for 6/26/23 that indicates facility staff checked R1’s blood sugar. LPA Ramirez could not locate documentation that facility staff checked R1 blood sugar from 6/16/23 to 6/25/23 3x per day as ordered by R1’s physician. · LPA Ramirez discovered that R8 seen their physician on 6/15/23. R8’s physician ordered R8’s blood pressure to be monitored and logged for seven (7) days. R8’s Physician Report dated 6/1/23 indicates R8 should “hold” on taking a certain prescribed medication if R8’s blood pressure is under 100. Facility staff could not provide proof of log to LPA Ramirez. Deficiencies are being cited. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided.the state’s words, verbatim · CDSS document, Sep 28, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(13) · Plan of correction due date: Sep 28, 2023

87506 Resident Records (b) Each resident’s record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services. This requirement is not met as evidence by: R1 physican ordered R1 have blood sugar monitored and recorded 3x a day, R8 physican ordered R8 have blood pressure monitored and recorded. Staff only recorded 1 day of R1's blood sugar and no proof of monitoring or logging of R8 blood pressure.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: Licensee will certify plan to re-train staff on providing assistance in meeting medical needs of residents and following the physicans orders in regards to medical needs. Licensee will provide proof of staff training attendance sheet by 7/25/23. *No further action required*