Savant of Jurupa Valley

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a case management visit relating to the staff #1 (S1). LPA Prieto met with Resident Service Director Banuela and explained the elements of the visit. Banuela confirmed that S1 is not employed at the facility. Banuela provided LPA with a current staff roster during this visit.the state’s words, verbatim · CDSS document, Jul 17, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a case management visit regarding an inquiry of resident #1 (R1). LPA Prieto met with Resident Service Director Banuelos and explained the elements of the visit. LPA interviewed R1 regarding the safeguard monies and financial matters. R1 states that he is aware, and in control, of all his financial matters. R1 reassures that follow up will be conducted by himself at a later time, relating to these financial matters. LPA asked if staff at the facility will be assisting him on this matter. R1 stated that they will not and his financial matter are handle by himself. LPA asked R1 if staff were with him when financial transactions were conducted. R1 stated the staff was not. Resident Service Director Banuelos provided LPA with documentation confirming that R1 was not at the facility at time financial transaction.the state’s words, verbatim · CDSS document, Jul 17, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Executive Director Pacia and was granted entry to the facility. Licensed capacity is (197) current census (140). LPA was accompanied by Executive Director Marc Pacia and Office Manager Danielle Garcia to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, and the CCL complaint poster, were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated office for client/staff files. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. Dishes, cups, and utensils were also stored properly. Culinary Director list residents with special dietary needs and serving the residents according to their dietary needs. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed (10) resident files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed (10) resident medications and (1) hospice files. LPA also reviewed (10) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Executive Director Pacia.the state’s words, verbatim · CDSS document, Jul 16, 2026

Allegation investigated: Staff communicate inappropriately to resident Staff did not ensure residents have access to drinking water

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to initiate a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director Pacia and explained the elements of the complaint. Allegation #1 - LPA Prieto interviewed resident #1 (R1), R2, R3, R4, R5, R6, R7 and R8. All residents interviewed state that staff communicate with them with respect and treat them well during their stay at the facility. R9, in question, was not available for interview. Allegation #2 - LPA Prieto interviewed resident #1 (R1), R2, R3, R4, R5, R6, R7 and R8. All residents interviewed state that staff does provide them with sufficient food and access to water during their stay at the facility. R9, in question, was not available for interview. LPA tour of the facility, with Executive Director, observed iced water drinking stations in the lobby area and on each wing of the 1st floor. Unsubstantiated Based on the information obtained there is not enough evidence that staff communicate inappropriately to resident and staff did not ensure residents have access to drinking water. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and copy was left with the facility.the state’s words, verbatim · CDSS document, May 5, 2026 · control 56-AS-20260424093006

Allegation investigated: Staff did not order resident's medications in a timely manner Staff did not respond to the resident's signal system in a timely manner Staff did not prevent residents from smoking inside the facility Staff did not order a new wheelchair for resident in care Staff did not dispense medications as prescribed

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA met with Executive Pacia and explained the elements of the complaint. LPA interviewed resident and staff during this investigation. Allegation #1 - LPA Prieto interviewed resident #1 (R1), in question, who states that medications are ordered through his insurance company and understands that there may be a delay when there is a a change with his pharmacy. Staff #1 (S1) documents contact with R1's pharmacy and the delay that occurred due to a change in pharmacy. Allgation #2 - LPA Prieto intervied R1 in his room at time of investigation. During this time, med tech entered the room, cleared R1's pendant and prepared to dispense medication. LPA asked how long it took staff to respond to the call. R1 stated 10 minutes. LPA toured the room with Businees Office Manger (S2) who state that pendant was pressed and staff responsed, as another staff was in the room when LPA entered. Unsubstantiated S2 states that R1 does communicate with her and he calls her cell phone directly for any needs. Allegation #3 - S1 produced a recent reminder to resident's at the facility, that resident's who smoke must do so in designated areas. S1 also provided LPA with a copy of the facility house rules that smoking is not permitted at the community unless in a designated area. Copies of this documentation was obtained during this investigation. Allegation #4 - LPA interviewed R1 who stated that his wheelchair is working condition and has requested a new chair from his Durable Medial Equipment (DME) company. S1 confirmed with LPA that medical equipment is order from the company, through the resident's themselves. Allegation #5 - LPA interview with R1 states that his medications are being dispensed ad prescribed, as they were being dispensed to R1 at time of visit. S1 provided LPA with R1's progress notes indicating the dispensing of R1's medications. Based on the information obtained there is not enough evidence to substantiate the allegations made in this complaint. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left with the facility.the state’s words, verbatim · CDSS document, Mar 13, 2026 · control 56-AS-20260312084407

Allegation investigated: Staff handled resident in a rough manner Staff do not answer residents' call buttons in a timely manner Staff do not ensure that a resident's incontinence needs are met

Licensing Program Analyst (LPA) Javier Prieto arrive to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director Pacia and explained the elements of the complaint. Allegation #1 - Investigation revealed that resident #1 (R1), in question, received a bed bath and alleged that R1 was treated in a rough manner. Interview with R1 reveal that staff does not treat her in a rough manner and staff continue to provide "outstanding" care. Documentation obtained from Residence Service Director (S1), reveal the bathing incident agreeing to bed bath. Allegation #2 - LPA observed R1 wearing her call button. LPA asked R1 if she utilizes her call button often to have staff address her needs. R1 replied that she does and does not have to use it much because staff are attentive to her needs. Unsubstantiated Allegation #3 - LPA interviewed R1, who states her incontinence care needs are being met. Interview with S1 states R1's incontinence care are being met and provided LPA with R1's needs and care plan indicating that R1 has daily incontinence care relating to bladder, bowels and skins check, daily. Based on the information obtained there is not enough evidence to support the allegations made in this complaint. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was singed by LPA Prieto and Executive Director Pacia this report was left with the facility.the state’s words, verbatim · CDSS document, Feb 17, 2026 · control 56-AS-20260209090340

Allegation investigated: Staff abandoned resident at hospital.

Licensing Program Analyst (LPA) Javier Prieto arrive to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director Pacia and explained the elements of the complaint. Allegation #1 - LPA interview resident #1 (R1), in question, at the facility, who states that there was no delay in returning to the from a visit to a medical facility. R1 states that she was not denied a return to the facility and returned to the facility the same day. Interview with Executive Director (S1) states that R1 arrived to a medical facility relating to a medical condition, and returned to the facility the same day. Based on the information obtained there is not enough evidence that to support the allegation made in this complaint. Therefore, the allegations is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director and a copy was left that the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 17, 2026 · control 56-AS-20260213142215

Allegation investigated: Staff ransacked the residents' rooms Staff did not safeguard resident's personal belongings Staff do not ensure resident was taken to appointments Staff are neglecting resident's health

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility conduct a complaint investigation regarding the above allegations. LPA met with Wellness Director Banuelos and explained the elements of the complaints. Allegation #1 - LPA Prieto and Wellness Director Banuelos (S1) tour the room of resident #1 (R1) and observed that the was neat and in order. R1 was not available for interview during this investigation. Allegation #2 - Observation of R1's room could not conclude that any belongings were not safeguarded. Staff does not have any records of R1 stating that their room was ransacked or that any personal belongings were taken. Allegation #3 - Staff produced R1 progress records showing that appointments are being made and staff provided transportation to these appointments. Unsubstantiated Allegation #4 - LPA obtained needs and care plan for R1. A review of the plan and interview with staff indication that staff are meeting R1's health care needs. Based on the information obtained there is not enough evidence to substantiate the allegations made in this complaint. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left with the facility.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 56-AS-20260205113818

Allegation investigated: Staff does not ensure resident's bed is assembled in a timely manner.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA met with Resident Service Director Banuelos and explained the elements of the complaint. Allegation #1 - LPA arrived to the facility to inspect the room of resident #1 (R1) in question. LPA observed the bed in question, that was stored in a separate room. R1 was not available for interview at time of inspection. Resident Service Director Banuelas (S1), produced documentation revealing that the bed in question is doctor prescribed and ordered from a medical supply company. The assembling of this bed must be done by R1's Home Health Agency and/or the medical supply company. LPA also collected documentation for R1's specific medical condition that constitutes this specialized bed. Facility staff does not have jurisdiction to assemble or modify R1's bed. ***contununued on LIC 9099*** Unsubstantiated Based on the information obtained there is not enough evidence that staff does not ensure resident's bed is assembled in a timely manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Resident Service Director Liz Banuelos and a copy was left with the facility.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 56-AS-20260123083123

Allegation investigated: Staff are not meeting resident's medical needs.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Executive Director Pacia and explained the elements of the complaint. Allegation #1 - LPA interviewed resident #1 (R1), in question, who states that the facility provides for her medical needs that facility staff are required to do for her care. R1 adds that she is also provided services from an outside agency (Home Health) that treats her for wound care that the facility staff are not allowed to provide. R1 adds that the care that is being provided to her by Home Health is satisfactory and her needs are being met in that aspect. Facility staff #1 (S1) provided LPA with R1's service plan indicating that the coordination with outside agency, one if which is Home Health and the other a Skilled Home Health. Also included, are the recent services provided by Home Health and R1's wound care. ***continued on LIC 9099C*** Unsubstantiated In addition, a schedule of R1's recent visit to by Home Health and Skilled Nursing was provided to LPA during this visit. Based on the information obtained there is not enough evidence to support the allegation that staff are not meeting resident's medical needs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 13, 2026 · control 56-AS-20260105172214

Allegation investigated: Staff do not ensure resident's room is clean and sanitary Staff do not ensure resident has clean bedding Staff do not ensure resident's showering needs are being met Staff do not ensure resident's is being assisted with dressing

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Executive Director Pacia and explained the elements of the complaint. Allegation #1 - LPA Prieto toured the room of resident #1 (R1), in question, and the room was observed to be clean and sanitary. The carpet was freshly cleaned and room was neat and in order. Executive Director (S1) provided LPA with orders for the carpet cleaning which was 4 times for the current year. These orders were obtained for this complaint investigation. R1 states that staff does a good job of ensuring room is clean. Allegation #2 - LPA Prieto toured the room of R1 was observed to have clean linings. R1 states that his bedding is changed accordingly. R1 service plan was provide to LPA by S1 indicating that R1 has additional services with laundry, housekeeping, daily tidy and trash pick up. These services are routine and as scheduled by housekeeping staff. Unsubstantiated Allegation #3 - R1 states that his showering needs are being met. R1 service plan was provide to LPA by S1 indicating that R1 has full assistance with showering. S1 states that R1's needs are being met of being assisting R1 with bathing, 1 person assist, 2X per week. Allegation #4 - R1 states that his dressing needs are being met. R1 service plan was provide to LPA by S1 indicating that R1 has full assistance with dressing. S1 states that R1's needs are being met of being assisting R1 with dressing in the morning and at bedtime. Based on the information obtained there is not enough evidence to support the allegations made in this complaint. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left with the facility.the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 56-AS-20251201104421

Allegation investigated: Staff mismanaged resident's medication

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Executive Director Pacia and explained the elements of the complaint. Allegation #1 - LPA Prieto interviewed resident #1 (R1) who stated she manages her own medication and medication in question was found on the same day that R1 inquired with staff. R1 states medication is usually retrieved by R1 herself, but a mix up with the pharmacy, and not the facility, occurred during delivery. LPA Prieto interviewed Resident Service Director (S1) who states R1 handles their own medication and the medication in question was located within 5 minutes of inquiry. Interview with Executive Director (S2) states that R1 revealed to him a surplus of the medication in question when inquiry was made. ***continued on LIC 9099C*** Unsubstantiated Based on the information obtained there is not enough evidence that to support the allegation made in this complaint . Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left with the facility.the state’s words, verbatim · CDSS document, Dec 1, 2025 · control 56-AS-20251126093709

Allegation investigated: Facility staff do not assist resident with attending dialysis appointments

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Executive Director Pacia and explained the elements of the complaint. Allegation #1 - LPA interviewed Pacia related to resident #1 (R1), in question, and appointments made to the dialysis center. Pacia produced R1's schedule for this service and found that appointments are being met. Also obtained during this visit are incident reports when R1 was sent to a medical facility for unrelated medical conditions, some of which were on dates for a dialysis procedure. Dialysis were performed on those dates at the medical facility during those visits. Documentation of these visits and R1's medical assessment were obtained during this investigation. Based on the information obtained there is not enough evidence to support the allegation made in this complaint. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left with the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 21, 2025 · control 56-AS-20251120152723

Allegation investigated: Questionable death. Staff are not sanitizing common area bathrooms.

Licensing Program Analyst (LPA) Javier Prieto conducted a visit to the facility to deliver the findings of a complaint investigation into the allegation mentioned. Upon arrival, LPA Prieto identified himself and explained the purpose of the visit to Executive Director Pacia . Allegation: Questionable Death. The Department’s investigation included interviews with facility staff and residents, LPA collected and reviewed relevant facility records, and review of residents #1 (R1’s) medical and death records. According to documentation obtained R1 passed away on December 21, 2022. The death certificate and supporting medical records indicate that R1’s cause of death was due to natural causes, complications from underlying medical conditions. Based on the interviews conducted and documents reviewed, including medical documentation, the Department did not find sufficient or corroborating evidence to support the claim that R1’s death was questionable or that the facility failed to provide appropriate care and supervision. Unsubstantiated Allegation: Staff are not sanitizing common area bathroom. LPA Prieto toured facility with Executive Director Pacia and observed that common bathrooms and were found to be clean and sanitized. LPA interviewed resident #1 (R1), R2, R3, R4, R5, R6 and R7, all stating that the bathrooms in the common area are clean and sanitized. The allegation of a questionable death is unsubstantiated. This means that although the allegation may have occurred or is valid, there is not enough evidence to prove that the facility was negligent in the care or supervision of R1. An exit interview was conducted, and a copy of this report (LIC9099) was provided to Administrator Pacia.the state’s words, verbatim · CDSS document, Oct 29, 2025 · control 56-AS-20221223094924

Allegation investigated: Staff are not properly addressing scabies in the facility Staff do not ensure resident's showering needs are being met Staff do not ensure that resident has clean bedding

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Executive Director Pacia and explained the elements of the complaint. Allegation #1 - Resident Services Director (S1), produced records revealing that resident #1 (R1) does not have scabies. R1 was seen by a Physician that treats R1 for a rash woth medication, which staff has applied to R1. R1 has been on checks from facility staff every 8 hours. Records of this treatment was obtained during this investigation. Allegations #2 - S1 produced R1's service plan that reveals that R1 has moderate assistance with bathing. S1 states that R1 was bathed on this day. Unsubstantiated Allegation #3 - S1 produced R1's service plan that reveals that R1 has assistance with laundry, assistance with housekeeping and daily tidy and trash pick up on a weekly basis. Based on the information obtained there is not enough evidence that to substantiate the allegation made in this complaint. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left with the facility.the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 56-AS-20251007085858

Allegation investigated: Staff are financially abusing a resident

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Executive Director Pacia and explained the elements of the complaint. Allegation #1 - LPA Prieto interviewed resident #1, in question, who states that he is not aware of any financial abuse occurring that the facility with staff. LPA Prieto interviewed staff #1 (S1), S2 and S3, all stated that they are not aware of any financial abuse occurring with R1 of any other resident at the facility. S4 states that she was made aware of charges made to R1's credit card by R1's responsible party, but did not state that staff were responsible for any of these charges. Based on the information obtained there is not enough evidence that to substantiate the allegation made in this complait. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left with the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 9, 2025 · control 56-AS-20251008124007

Allegation investigated: Staff did not notify residents of a scabies outbreak.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Executive Director Pacia and explained the elements of the complaint. Allegation #1 - Documentation obtained from Executive Director Pacia reveals that 10 residents, at the facility, reported skin irritations and/or rashes. Residence Services Director states that these residents were seen by a Physician and lotions were prescribed to the residents. The diagnosis is not scabies. The facility took precautions on notifying staff and residents. Residents received a newsletter of the health concerns. Each resident received this letter in their mailboxes and posted in the facility lobby area. A copy of this newsletter was obtained for this complaint. Unsubstantiated Based on the information obtained there is not enough evidence to support the allegation made in this complaint. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left with the facility.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 56-AS-20250826125731

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Javier Prieto and LPA Magda Malcore made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Executive Director Pacia and was granted entry to the facility. Licensed capacity is (197) current census (143). LPA was accompanied by Office Manager Danielle Garcia to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, and the CCL complaint poster, were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated office for client/staff files. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. Dishes, cups, and utensils were also stored properly. Culinary Director list residents with special dietary needs and serving the residents according to their dietary needs. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed (10) resident files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed (10) resident medications and (1) hospice files. LPA also reviewed (10) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Business Manager Danielle Garcia.the state’s words, verbatim · CDSS document, Aug 15, 2025

Allegation investigated: Staff make resident stay in their bed for an extended period of time. Staff forced resident to purchase insurance. Staff do not ensure that resident is being provided with activities. Staff are not ensuring that resident's care needs are being met

On 07/30/2025 at 1:30PM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA discussed the purpose of the visit with Exectuive DIrector, Marc Pacia. The investigation consisted of interviews, record review and observation. In regards to the allegation that staff make resident stay in their bed for an extended period of time: LPA interviewed four (4) staff, a relative and a friend of Resident 1 (R1). Staff denied the allegation and stated that R1 would refuse care and or getting out of bed due to pain. Staff stated that they encourage but do not force a resident to accept care. LPA observed the documentation confirming R1's refusal of care/assistance. The relative of R1 stated that R1 could be challenging and refuse care. Based on interviews and record review, this allegation is UNSUBSTANTIATED. In regards to the allegation that staff forced resident to purchase insurance: Staff denied that they forced R1 to purchase insurance. R1 had insurance and was receiving hospice services. Purchasing insurance is not required to become a resident. Both the relative and friend of R1 denied that R1 was forced to purchase insurance. Based on interviews, the lack of information and details to support it, this allegation is UNSUBSTANTIATED. Unsubstantiated In regards to the allegation that staff do not ensure that resident is being provided with activities: Staff stated that a variety of activities are provided for the residents on a weekly basis. LPA observed residents listening to music, a resident was playing the piano, playing Bingo and live music during several visits to the facility. In addition, residents with limited mobility are provided with one-on-one activities in their room. Based on interviews and observation, this allegation is UNSUBSTANTIATED. In regards to the allegation that staff are not ensuring that resident's care needs are being met: Staff stated that based upon their assessment, R1 needed full assistance and they provided this care. R1 was also receiving hospice services. The facility stated that R1 would refuse care and provided documentation to LPA. Based on interviews and record review, this allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted where this report LIC9099 and LIC9099C was discussed and a copy was provided to Executive Director, Marc Pacia.the state’s words, verbatim · CDSS document, Jul 30, 2025 · control 56-AS-20240423152956

Allegation investigated: Staff are not meeting resident bathing needs Staff are not providing adequate food service Staff are not answering resident call buttons in a timely manner Staff do not keep facility free from odor

On 07/29/2025 at 1:00PM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA discussed the purpose of the visit with Executive Director, Marc Pacia. The investigation consisted of interviews, observation and record review. In regards to the allegation that staff are not meeting resident bathing needs: LPA interviewed five (5) staff and ten (10) residents. Staff stated that residents are assisted with showers two (2) times a week and as needed. All ten (10) residents interviewed stated that they are receiving assistance with their showers weekly. LPA observed documentation by the facility detailing Resident 1 (R1) refusal of shower assistance. Based on interviews and record review, this allegation is UNSUBSTANTIATED. In regards to the allegaton that staff are not providing adequate food service: The facility's Admission Agreement states that the facility will provide three (3) meals per day and snacks. LPA observed the kitchen's pantry, refrigerator and freezer to be fully stocked with a variety of food, snacks and beverages. All ten (10) residents stated that they receive meals and snacks. Based upon interviews and record review, this allegation is UNSUBSTANTIATED. Unsubstantiated In regards to the allegation that staff are not answering resident call buttons in a timely manner: Staff stated that they respond to call buttons in a timely manner. All ten (10) residents stated that their call buttons work and staff respond to assist them. LPA observed several staff respond to call buttons during the visit. Based on interviews and observation, this allegation is UNSUBSTANTIATED. In regards to the allegation that staff do not keep facility free from odor: Staff stated that their housekeeping department maintains the facility's common areas, bathrooms and resident rooms. The facility has air fresheners in each of their hallways. Staff take measures to dispose of soiled materials to ensure that the facility's odor remains pleasant. Based upon interviews and observation, this allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted where this report LIC9099 and LIC9099C was discussed and a copy was provided to Executive Director, Marc Pacia.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 56-AS-20250408092644

Allegation investigated: Facility has an aggressive animal on the premises. Residents are left soiled for a long period of time. Facility staff are not properly trained.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conclude a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director Pacia and explained the elements of the complaint. Allegation #1 - During time of investigation, the facility had 2 resident's, each owning 1 small dog. Resident #1 (R1), has a small dog, docile and well tempered. The room was clean and free of odors. R2 has a small dog, docile and well tempered. The room was clean and free of odors. None of the animals showed signs of aggression to LPA or accompanied staff. Allegation #2 - LPA interviewed R1 to R10, none of which stated that they had been left in solied diapers for a long period of time. Unsubstantiated Allegation #3 - Business Manager provided LPA with the latest list of training provided to staff on the topics of mandated in service training, including Resident Rights and Dignity, Mandated Reporting, Understanding Resident's Rights and Staff Responsibilities in Upholding Resident's Rights. Other training topics include Hoyer Lifts, Colostomy bags, HIV, Incontinence care, Transfers, Walking Downstairs, Fire Safety and Skin Integrity. Based on the information obtained there is not enough evidence to support the allegations in this complaint. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left with the facility.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 56-AS-20230524101225

Allegation investigated: Staff do not ensure resident was scheduled doctors appointments. Staff financially abused resident in care.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to concluded a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director Pacia and explained the elements of the complaint. Allegation #1 - Interview with staff #2, reveal that resident #1 (R1), had her pre appraisal on 01/15/2024. Facility appraisal was conducted on 2/23/24. R1 entered the facility on 2/23/24 and moved out, voluntarily, on 03/07/24. No other doctor's appointments were scheduled. Allegation #2 - Allegation of financial abuse relates to payments made by R1 to the facility. LPA obtained financial records for R1 that reveal R1 is her own payee. Authorization and agreement to handle resident funds form was not signed by both parties. Financial records reveal that R1 made a credit card payment as a remaining balance to a Social Security payment for facility rent. Unsubstantiated Based on the information obtained there is not enough evidence to support the allegations made in the complaint. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left with the facility.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 56-AS-20240409080322

Allegation investigated: Resident sustained pressure injury while in care Staff handled resident in a rough manner Residents are not being fed and changed in a timely manner Facility has an infestation of rodents Facility is in disrepair Facility doesn’t have hot water Resident wandered away from the facility due to lack of supervision Facility has insufficient staffing to meet residents’ needs Staff member failed to treat residents with dignity and respect

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Executive Director, Marc Pacia, and informed the purpose for the visit. Regarding allegation #1, resident sustained pressure injury while in care, interviews with the two (2) residents in bedroom #254 deny having pressure injuries. Interviews with four (4) staff deny that residents in room #254 sustained pressure injuries due to staff neglect. The reporting party could not be reached for further information. Regarding allegation #2, staff handled resident in a rough manner, interviews with the two (2) residents in bedroom #101 deny that staff handled them in a rough manner. Interviews with four (4) staff deny handling residents in bedroom #101 in a rough manner. The reporting party could not be reached for further information. Unsubstantiated Based on observations, record review, interviews with residents and staff, the allegations mentioned in this report are Unsubstantiated. An Unsubstantiated finding means 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. An exit interview was conducted where this report was discussed and a copy was provided with appeal rights to Executive Director Pacia at the conclusion of the visit. Regarding allegation #3, residents are not being fed and changed in a timely manner, interviews with four (4) out of six (6) residents deny that they are not being fed or changed in a timely manner. Interviews with four (4) staff deny that residents are not being fed or changed in a timely manner Regarding the allegation #4, facility has an infestation of rodents, LPA conducted a tour of the facility’s common areas and bedrooms and did not observe an infestation of rodents. Interviews with six (6) residents and four (4) staff deny that the facility has an infestation of rodents. Review of facility records reveals the facility is inspected monthly by a professional exterminator for rodents and other pest. Regarding allegation #5, facility is in disrepair, LPA conducted a tour of the facility and observed the sliding doors in six (6) resident (non-ambulatory) bedrooms were working properly. Regarding allegation #6, facility doesn’t have hot water, LPA conducted a tour of the facility and observed the hot water in six (6) resident bedrooms measured at 105- and 106-degrees Fahrenheit. Six (6) residents interviews reveal that they have hot water for showers and/or bathing. Regarding allegation #7, resident wandered away from the facility due to lack of supervision, interviews with six (6) residents and four (4) staff deny knowing a resident with reported name that wandered away from the facility due to lack of supervision. The reporting party could not be reached for further information. Regarding allegation #8, facility has insufficient staffing to meet residents’ needs, LPA record review reveals the facility has sufficient staff to care for the needs of the residents. Four (4) out of six (6) residents deny that staff are not meeting their needs. Four (4) staff interviews deny not meeting residents’ needs. Regarding allegation #9, staff member failed to treat residents with dignity and respect, interviews with five (5) out of six (6) residents deny that staff failed to treat them with dignity at respect. Interviews with four (4) staff deny they fail to treat residents with dignity and respectthe state’s words, verbatim · CDSS document, Jul 29, 2025 · control 56-AS-20230307150845

Allegation investigated: Staff neglect led to resident sustaining pressure injury Staff leave resident in dirty diapers for extended periods

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conclude a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director Pacia and explained the elements of the complaint. Allegation #1 - LPA Prieto interviewed residents #1 through #10 (R1 - R10), all stating that staff has not neglected them while in care. LPA interviewed R11, in question, who also states she has not been neglected by staff and did not sustain any pressure injuries due to neglect by staff. LPA obtained R11's needs and care plan and records reveal R11 did not sustain any pressure injuries at time of this investigation. Allegation #2 - LPA Prieto interviewed residents #1 through #10 (R1 - R10), all stating that staff does not leave them in dirty diapers for long periods of time. LPA interviewed R11, in question, who also states, she has not been left in dirty diapers long periods of time. Unsubstantiated LPA obtained R11's Service Plan which indicates R11 required maximum assistance with toileting and transfers. Based on the information obtained there is not enough evidence to support the allegations made in this complaint. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left at the facility.the state’s words, verbatim · CDSS document, Jul 28, 2025 · control 56-AS-20221222094200

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to have Executive Director Marc Pacia sign amended Complaint Investigation Report (LIC 9099) complaint #56-AS-20230404134825 and complaint #56-AS-20221222094200. The amended reports were signed, along with this Facility Evaluation Report (LIC 809), by LPA Prieto and Exective Director Pacia and a copy of both reports were left with the facility.the state’s words, verbatim · CDSS document, Jul 28, 2025

Allegation investigated: Staff are not meeting a resident's showering needs. Facility is in disrepair. Facility has mold. Staff are not allowing a resident to return to the facility after hospitalization.

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Executive Director, Marc Pacia and informed the purpose of the visit. Regarding allegation#1, staff are not meeting a resident's showering needs, Four (4) staff interviews deny not meeting resident showering needs. Four (4) out of five (5) residents interviews reveal that staff are meeting their showering needs. Regarding allegation#2, facility is in disrepair and allegation#3, the facility has mold LPA conducted a tour of the facility which included but not limited to resident bedrooms/bathrooms, hallways and dining areas and did not observe roof leaks, mold or concaving floors. Regarding allegation#4, staff are not allowing a resident to return to the facility after hospitalization, the investigation reveals that the facility served R1 an eviction notice on 12/16/2023 with an effective eviction date of 01/16/2024. Unsubstantiated In addition, the facility was actively pursuing unlawful detainer action. On 02/29/24, R1 moved to the hospital. Based on observations, record review, interviews with residents and staff, the allegations mentioned in this report are Unsubstantiated; meaning that although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC9099) was discussed, and a copy with appeal rights was provided to Executive Director Pacia at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 25, 2025 · control 56-AS-20240306083921

Allegation investigated: Facility did not allow resident to return to facility after being discharged from a medical facility Resident not receiving medications as prescribed Call button not in working order for months

On 07/24/2025 at 9:15AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA discussed the purpose of the visit with Wellness Director, Liz Banuelos. The investigation consisted of interviews, record review and observation. In regards to the allegation that facility did not allow resident to return to facility after being discharged from a medical facility: LPA interviewed five (5) staff and reviewed records for Resident 1 (R1) and Resident 2 (R2). R1 became a resident of the facility on 11/14/2023 and voluntarily discharged on 03/21/2025. The facility submitted multiple Unusual Incident Reports (SIR) documenting that R1 was admitted to the hospital and in-house notes confirm R1's return to the facility. An interview with the relative of R1 confirmed that R1 was admitted to the hospital several times during their stay and moved out of the facility voluntarily. R2 is a current resident at the facility and LPA did not observe an Eviction letter in their file. Staff denied that the facility did not allow R1 or R2 to return to facility. Based on interviews and record review, this allegation is UNSUBSTANTIATED. Unsubstantiated In regards to the allegation that resident is not receiving medications as prescribed: Licensing Program Analyst (LPA) Renese Howell-Small interviewed (5) staff and ten (10) residents. Staff stated that medical technicians are trained through Relias, monthly in-services, pharmacist and hospice agencies. Staff denied not administering medications as prescribed by a physician. LPA audited the Medication Administration Record(s) (MAR) for Resident 1 (R1), Resident 2 (R2) and Resident 3 (R3). LPA did not observe any errors when the MAR was reviewed. The MAR and the facility's resident notes in the August program, indicate that R1 had a record of refusing medications and although R1 was unable to administer their own medications, kept medications in their room. All ten (10) of the residents stated that they received their medications. Staff also stated that residents may become upset when the physician adjusts their medication and the new medication has changed in appearance. Based on interview and record review, this allegation is UNSUBSTANTIATED. In regards to the allegation that call button not in working order for months: LPA interviewed ten (10) residents. All ten (10) of the residents stated that they have a call button and it is in working condition. LPA observed ten (10) residents interviewed to have a call button and tested random call buttons during the visit in which staff arrived to assist. LPA interviewed five (5) staff and staff stated that each resident is given a call button when hey become residents of the facility. Residents will communicate with staff if their call button is not working. Staff will test the call button and replace the battery when needed. Staff denied that call buttons have not been in working order for months. R1 received a call button but refused it, stating to staff that it was broken. Facility notes confirm that when R1 left the facility on 03/21/2025, R1 turned in their keys/pendant. Based on interviews and record review, this allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where this report LIC9099 and LIC9099C was discussed and a copy was provided to staff.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 56-AS-20240530110755

Allegation investigated: Staff did not ensure resident did not have access to knives Staff did not report incident to CCL or other reporting agencies

Licensing Program Analyst (LPA) Magda Malcore conducted an announced complaint visit to the facility. LPA met with Executive Director, Marc Pacia. Regarding the allegation, staff did not ensure resident did not have access to knives, interviews with staff, resident #2 (R2), and document reveal, on 06/05/2025, resident #1 (R1) pulled out a pocketknife and verbally threaten resident #2 (R2). R2 informed staff. Staff secured the knife from R1 and called law enforcement. R2 stated that there has been no other altercation with R1 since the 06/05/2025 incident. R1 was not at the facility to be interviewed regarding the incident. In addition there is not enough information as to how R1 obtained the pocketknife. Regarding the allegation, staff did not report incident to CCL or other reporting agencies, an incident report was provided to community care licensing regarding the incident that occurred on 6/05/2025 between R1 and R2. As to reporting to other agencies, LPA made attempts to contact outside parties for further clarification and received no response. Unsubstantiated Based on observations, document review, and interviews with staff and resident, the allegation is Unsubstantiated. A finding of Unsubstantiated means 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. An exit interview was conducted where this report was discussed and a copy provided with appeal rights to Executive Director, Pacia at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 23, 2025 · control 56-AS-20250612131659

Allegation investigated: Facility staff left resident in soiled diapers Facility staff did not ensure that resident was fed Facility staff stole from resident

Licensing Program Analyst (LPA) Magda Malcore conducted an announced complaint visit to the facility. LPA met with Executive Director, Marc Pacia. Regarding the allegation, facility staff left resident in soiled diapers, interviews with four (4) staff reveal that residents are not left in soiled diapers and staff check on residents 3-4 times per shift or more depending on their care needs. Five (5) resident interviews reveal that staff have not left them in soiled diapers. Regarding the allegation, facility staff did not ensure that resident was fed, four (4) staff interviews reveal residents are provided meal service in the dining area or a tray is taken to their room. Staff check on residents 3-4 times per shift or more to ensure their care needs are being met. Four (4) out of five (5) resident interviews reveal that staff ensure that they are provided at three (3) meals a day. Regarding the allegation, facility staff stole from resident, four (4) staff interviews reveal they have not stolen from any residents. Four (4) out of five (5) residents interviews reveal that staff have not stolen from them. One (1) resident did not confirm or deny the allegation. Based on observations and interviews with staff and residents, the allegation is Unsubstantiated. A finding of Unsubstantiated means 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. Unsubstantiated An exit interview was conducted where this report was discussed and provided with appeal rights to Executive Director, Pacia at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 23, 2025 · control 56-AS-20240112151013

Allegation investigated: Staff leaves resident soiled for extended periods of time.

Licensing Program Analyst (LPA) Magda Malcore conducted an announced complaint visit to the facility. LPA met with Executive Director, Marc Pacia. Regarding the allegation, staff leaves resident soiled for extended periods of time, interviews with four (4) staff reveal they do not leave residents soiled for extended periods of time and staff check on residents 3-4 times per shift or more depending on their care needs. Five (5) resident interviews reveal that staff have not left them soiled for extended periods of time. Based on observations and interviews with staff and residents, the allegation is Unsubstantiated. A finding of Unsubstantiated means 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. An exit interview was conducted where this report was discussed and provided with appeal rights to Executive Director, Pacia at the conclusion of the visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 23, 2025 · control 56-AS-20250416152027

Allegation investigated: Staff did not refill resident’s medication prescription in a timely manner causing resident to be in pain

Licensing Program Analyst (LPA) Raquel Hernandez conducted an unnannounced visit for the purpose to deliver findings on the allegation listed above. LPA met with Administrator Mark Pacia and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews and facility tour. For the allegation, Staff did not refill resident’s medication prescription in a timely manner causing resident to be in pain. LPA Hernandez conducted (8) resident interviews. 8 out of the 8 stated they have not had any issues regarding medication refills. LPA conducted (4) staff interviews. Staff #4 (S4) stated medication refills are issued by physician. S3 indicated the facility staff will order medication refills 7-8 days prior, however, some residents have a separate pharmacy where family or residents call in for medication refill. Unsubstantiated Based on the evidence gathered during today’s investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Mark Pacia.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 56-AS-20240322091928

Allegation investigated: Staff are not providing adequate care to resident. Facility phone(s) are not being answered. Staff are not responding to Resident's Representative's requests for communication.

Licensing Program Analyst (LPA) Raquel Hernandez conducted an unnannounced visit for the purpose to deliver findings on the allegations listed above. LPA met with Administrator Mark Pacia and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews and facility tour. For the allegation, Staff are not providing adequate care to resident. LPA Hernandez conducted (8) resident interviews. 6 out of the 8 stated the facility staff do provide adequate care to residents in care. Additionally, LPA conducted (4) staff interviews. 4 out of the 4 staff indicated adequate care is being provided to residents in care. Unsubstantiated For the allegation, Facility phone(s) are not being answered. LPA Hernandez spoke with Staff #2 (S2) who indicated the facility phone does go to an automated system where residents are able to leave a voicemail if facility front desk is on another call. LPA conducted (8) resident interviews. 3 out of the 8 indicated they do not have any issues with the facility phone being answered. Additionally, 3 out of the 8 indicated they have not had to call the facility phone as they are given a pendant in the case they may need something. For the allegation, Staff are not responding to Resident's Representative's requests for communication. LPA Hernandez spoke with Staff #1 (S1) and Staff #3 (S3) who indicated all forms of communication are responded to in the event a resident's representative may call the facility. However, S3 indicated due to HIPAA laws, some information may require consent from resident or Power of Attorney documentation for financial or medical before facility releases any information. LPA conducted (8) resident interviews where 7 out of the 8 indicated resident's representative has no issues with contacting the facility or speaking with management. Based on the evidence gathered during today’s investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Mark Pacia.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 56-AS-20220912172452

Allegation investigated: Staff left resident in a dirty diaper for extended periods Staff did not ensure to accommodate resident Staff did not ensure to keep resident’s room clean Staff did not meet resident’s hygiene needs Staff did not ensure to assist resident with transferring from bed to wheelchair and vice versa Staff did not ensure that resident had eaten food

On 07/22/2025 at 9:00AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA discussed the purpose of the visit with Executive Director, Marc Pacia. The investigation consisted of interviews, record review and observation. In regards to the allegation that staff left resident in a dirty diaper for extended periods: LPA interviewed seven (7) staff and ten (10) residents. Staff stated that residents are assisted with their changing needs based upon their needs and services plan and as needed. Staff denied the allegation and confirmed that residents are checked every two (2) hours and they also have a call button/pendant that can be used to call for assistance. Residents stated that their call buttons work and staff assist them with diapering needs when needed. The facility does not provide diaper supplies for residents, these are supplied by family or residents' insurance. Based on interviews, this allegation is UNSUBSTANTIATED. In regards to the allegation of staff did not ensure to accommodate resident: LPA interviewed seven (7) staff and they stated that residents are provided with assistance based upon their needs and services. Resident 1 (R1) ambulated with a wheelchair and was placed on the first (1) level of the facility. Per the Admission's Agreement, staff assisted R1 with baths and toileting, medications and dressing. Staff denied the allegation. The residents interviewed stated that staff assist them with what is needed. Based upon interviews, this allegation is UNSUBSTANTIATED. Unsubstantiated In regards to the allegation of staff did not ensure to keep resident’s room clean: LPA interviewed seven (7) staff and ten (10) residents. Staff stated that rooms are cleaned once a week or more if needed. The facility provided a staff schedule indicating which staff were assigned to clean which rooms and noted if residents refused the service. All ten (10) of residents interviewed stated that their rooms are cleaned often. LPA observed several rooms during the visit to be sanitary. Based upon interviews and observation, this allegation is UNSUBSTANTIATED. In regards to the allegation of staff did not meet resident’s hygiene needs: LPA interviewed seven (7) staff. Caregiving staff assist with resident's hygiene needs and stated that some residents need more assistance than others. The facility does not provide a shower chair but does offer bed baths for residents who can not be assisted safely in the shower. All ten (10) of the residents stated that staff assist them with their hygiene needs or they do so independently. Based upon interviews, this allegation is UNSUBSTANTIATED. In regards to the allegation of staff did not ensure to assist resident with transferring from bed to wheelchair and vice versa : LPA interviewed seven (7) staff. Staff indicated that they are trained to safely transfer residents and assist the residents with transferring as needed. Staff assist with transfers based upon the resident's routine. Residents stated that if they need assistance with transferring or being escorted, staff assists them. Based upon interviews, this allegation is UNSUBSTANTIATED. In regards to the allegation that staff did not ensure that resident had eaten food: Based upon interviews with staff, staff stated that residents are either escorted to the dining area, independently ambulate or are offered meal service. The Admission's Agreement indicates that three meals and snacks are provided. Residents stated that they have their meals in the dining room, are escorted or may have the option of a sack lunch. Staff stated that caregivers will note if a resident is not in the dining area and will request a meal service or a sack lunch for the resident. Based upon interviews, this allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where this report LIC9099 and LIC9099C was discussed and a copy was provided to Executive Director, Marc Pacia.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 56-AS-20240530145847

Allegation investigated: Staff are financially abusing resident

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Executive Director Pacia and explained the elements of the complaint. Allegation #1 - LPA Prieto interviewed resident #1 (R1) who states that there was a discrepancy with her payments to the facility, but did not confirm that abuse was conducted by facility staff. LPA interviewed R2 through R10, none of whom stated that abuse was occurring at the facility. LPA interview Business Manager (S1) who provided payment ledger for R1, and other financial documentation, which reveal account is current with no discrepancies. Based on the information obtained there is not enough evidence that to substantiate the allegations made in this complaint. Therefore, the allegations the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Director Pacia and a copy was left with the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 4, 2025 · control 56-AS-20250603142704

Allegation investigated: Staff failed to treat resident with dignity and respect Staff failed to assist residents in a timely manner

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to concluded a complaint investigation regarding the above allegations. LPA Prieto met Executive Director Pacia and explained the elements of the complaint. LPA interviewed residents relating to this complaint. Allegation #1 - LPA Prieto interviewed residents #1 through #10 (R1 - R10), all stating that staff treat residents with dignity and respect. Residents added they are treated with courtesy and respect by staff at the facility. LPA interviewed R11, in question, who also states staff treat her with courtesy and respect. Allegation #2 - LPA Prieto interviewed residents #1 through #10 (R1 - R10), all stating there are assisted in a timely manner relating to their care and needs at the facility. LPA interviewed R11, in question, who also states staff assist her in a timely manner. Based on the information obtained there is not enough evidence that support the allegations made in this complaint. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and copy was left with the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 14, 2025 · control 56-AS-20221222094200

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to have amended Complaint Investigation Report (LIC 9099) signed. LPA Prieto met with Executive Director Pacia, signed report number 56-AS-20250313125511 and left a copy of this report and LIC 9099 at the facility.the state’s words, verbatim · CDSS document, May 9, 2025

Allegation investigated: Staff do not safeguard resident's personal belongings. Staff does not ensure resident receives incoming mail.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met Executive Director Pacia and explained the elements of the complaint. LPA interviewed staff, residents and gathered pertinent documentation. Allegation #1 - LPA Prieto interviewed resident #1 (R1), in question, who cannot not detail any specific time or dates of any items that were not safeguarded or taken from his room. R1 alleges that staff does not visit him in order to address any missing items. Interviews with R1 and Executive Director Pacia concluded that R1 is visited each morning on a daily basis. LPA interviewed R2 to R8, all who state that they have not had any issues with items not being safeguarded while residing at the facility. Allegation #2 - Interview with R1 states that specific correspondences are not being received, via US mail. R1 states that other items are being received, via US mail and interview with Executive Director concurs that R1 is receiving mail in his facility mailbox. LPA interviewed R2 to R8, all who state that they have not had any issues with receiving mail at the facility. Unsubstantiated Based on the information obtained there is not enough evidence to support the allegations made in this complaint. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left at the facility.the state’s words, verbatim · CDSS document, May 5, 2025 · control 56-AS-20250429103035

Allegation investigated: Facility illegally evicted a resident in care.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met Executive Director Pacia and explained the elements of the complaint. LPA interviewed staff, residents and gathered pertinent documentation. Allegation #1 - Interview with Resident Services Director (S1) and Executive Director Pacia (S2) state that resident #1 (R1), in question, was not evicted from the facility nor given an eviction notice. R1 has not returned to the facility and continues her stay at the medical facility awaiting a proper assessment for an appropriate placement. LPA interviewed R2 to R8, all who state that they have not had any issues with the facility issuing an improper eviction notice or disputed payments relating to their board and care. Based on the information obtained there is not enough evidence that facility illegally evicted a resident in care. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left at the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 5, 2025 · control 56-AS-20250430145827

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Javier Prieto arrived the facility to amend complaint 56-AS-20250218090512. This report was signed by LPA Prieto and Executive Director Pacia.the state’s words, verbatim · CDSS document, May 5, 2025

Allegation investigated: Staff did not ensure the resident had a shower bar in bathroom resulting in falls Due to lack of supervision, resident was left on floor for an extended period of time

Licensing Program Analyst (LPA) Javier Prieto arrived at the facility to conduct a complaint investigation regarding the allegations referenced above. LPA Prieto met with Wellness Supervisor Munoz and provided an explanation of the elements of the complaint. Allegation #1: LPA Prieto conducted a tour of Resident #1's (R1) room and observed that the bathroom is equipped with a grab bar as required. LPA was informed by the wellness supervisor that the facility ordered a new additional grab bar for R1’s shower. There is no evidence to corroborate that R1 had falls due to no grab bar in the bathroom. Unsubstantiated Allegation #2: It was alleged that R1 fell in the shower and remained on the shower for an extended period of time. LPA interview with R1 stated she fell in the shower and immediately reported to Wellness Supervisor (S1), who made an assessment and monitored R1 for any bruising or pain the same day. R1 did not indicate that she waited for an extended period of time. Wellness Director (S2), documented the fall and the followed up with R1 for the next 3 weeks as indicated on R1's Wellness notes that where obtained during the investigation. S1 also provided LPA with R1's activity report related to her call pendant. Records show that R1 did not press her call pendent on the alleged date of 02/18/2025. During interview with R1, she did not express that the call button was pressed nor that he waited for an extended period of time for assistance. Based on the information gathered, there is insufficient evidence to support the claims made in this complaint. Therefore, the allegations are deemed unsubstantiated at this time. This report was signed by LPA Prieto and Executive Director Marc Pacia, and a copy was provided to the facility.the state’s words, verbatim · CDSS document, Mar 18, 2025 · control 56-AS-20250313125511

Allegation investigated: Staff not assisting resident on transferring in and out of a wheelchair Staff not providing three meals to a resident as required Staff left resident in a soiled diaper for hours Staff not safeguarding resident personal belongings

Licensing Program Analyst (LPA) Javier Prieto arrived at the facility to conclude a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director Pacia and explained the elements of the complaint. Allegation #1: LPA interviewed resident #1 (R1), who stated that she does not require assistance from staff for transferring in her wheelchair as she is non-ambulatory and receives services in her room such as bathing, dressing, toileting, and meal delivery. The Resident Service Plan, provided to LPA by Wellness Director (S1), reveals that services performed by staff in R1's room include bathing, dressing, toileting, meal delivery, and medication management. These services do not necessitate transferring R1 in and out of a wheelchair. Allegation #2: In an interview with R1, she confirmed that she receives all three of her meals in her room. The Resident Service Plan indicates that R1 is receiving tray services for all meals from the dining staff, delivered to her room. Unsubstantiated Allegation #3: R1 stated that her toileting needs are routinely addressed by staff, and any additional unscheduled services are also taken care of. The Resident Service Plan reveals that R1 requires full assistance with toileting, including frequent or unscheduled incontinence care. Allegation #4: During the interview, R1 did not report any personal belongings or money missing or taken. LPA observed that R1 has her wallet and bags on her bed, out of reach of staff and other residents. There is no evidence to support the allegation that staff are not safeguarding R1's personal belongings. Interviews with residents 1 through 10 reveal that their needs are being adequately cared for while residing at the facility. Based on the information obtained, there is not enough evidence to support the allegations of staff not assisting residents in transferring in and out of a wheelchair, not providing three meals to a resident as required, leaving a resident in a soiled diaper for hours, or not safeguarding residents' personal belongings. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia, and a copy was left with the facility.the state’s words, verbatim · CDSS document, Mar 6, 2025 · control 56-AS-20240708163311

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Javier Prieto arrive to the facility to have Executive Director Pacia address and sign amended, COMPLAINT CONTROL NUMBER: 56-AS-20231206111059 (LIC 9099) dated 12/08/2023.the state’s words, verbatim · CDSS document, Mar 6, 2025

Allegation investigated: Staff unlawfully evicted the residents while in care

Licensing Program Analyst (LPA) Javier Prieto arrived at the facility to investigate the allegations mentioned above. During the visit, LPA Prieto met with Executive Director Marc Pacia and provided an overview of the complaint. Allegation #1: LPA Prieto reviewed eviction documentation for Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4), provided by Danielle Garcia, Business Office Manager (S1). These residents have either already vacated the facility or are in the process of doing so due to eviction. Proper 30-day notices were issued to R1, R2, and R3 in compliance with Title 22 regulations. The eviction notices were served because of non-payment for care and supervision. Unsubstantiated Supporting documentation, including payment ledgers, collection records, and a timeline of the eviction process, was provided for review. R1, R2, and R3 vacated the premises voluntarily before receiving final eviction notices. Similarly, R4 received an eviction notice under the same process and is currently awaiting a final notice to vacate. Eviction records for R4 were documented in the same manner. Based on the findings, there is insufficient evidence to conclude that staff unlawfully evicted the residents while they were under care. As such, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left with the facility.the state’s words, verbatim · CDSS document, Feb 28, 2025 · control 56-AS-20250227121950

Allegation investigated: Facility staff are not providing medication as prescribed Facility staff do not ensure that residents oxygen is operable

Licensing Program Analyst (LPA) Javier Prieto visited the facility to investigate the allegations mentioned above. During the visit, LPA Prieto met with Executive Director Marc Pacia and outlined the details of the complaint. Allegation #1: LPA Prieto reviewed the Physician's Orders for Resident #1 (R1), the individual involved in this case. The complaint alleged that Insulin was not being administered as prescribed. However, the Physician's Orders for R1 did not include Insulin as a prescribed medication. Wellness Supervisor (S1) confirmed that R1 neither uses nor requires Insulin. Unsubstantiated Allegation #2: S1 and Executive Director Marc Pacia (S2) confirmed that R1's portable oxygen equipment was obtained through a Durable Medical Equipment (DME) provider and is managed by the resident and/or their family. R1's needs and care plan indicate that minimum assistance with the resident's canula is required, but the overall monitor operation or functionality of portable oxygen equipment is the responsibility of the resident and/or family. Based on the evidence gathered, there is insufficient proof to support the allegations that facility staff failed to provide medication as prescribed or to ensure that residents’ oxygen equipment was operable. As such, both allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Javier Prieto and Executive Director Marc Pacia, with a copy provided to the facility.the state’s words, verbatim · CDSS document, Feb 28, 2025 · control 56-AS-20250218090512

Allegation investigated: Staff are not bathing resident Staff are not providing food to the resident Staff are not responding to residents calls for assistance Staff are not taking resident to the dining room

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director Marc Pacia and explained elements of the complaint. Allegation #1 - LPA Prieto interviewed resident #1 (R1) who states that he has been residing at the facility since 02/14/2025 and has been bathed twice since. LPA obtained R1's Resident Care Summary, from facility Wellness Director (S1), that states R1 has a 1 person assist with bathing 1 time per week. R1 was made aware of the bathing schedule and encouraged to press the call button for any additional services relating to bathing. Allegation #2 - LPA Prieto interviewed resident #1 (R1) who states food is being provided to him by either having tray service to his room or escorts to meals in the dining area. Resident Care Summary for R1 indicates he needs full assistance with mobility that includes escorts to meal. S1 provided visual evidence of tray service to R1's room when he was not able to be escorted to the dining area. Unsubstantiated Allegation #3 - Interview with R1 stated that he does have a call pendent and when service is needed, he does press his call button and staff responds promptly. Interview with Executive Director (S2) stated that R1 was reminded that, if service is needed, staff will respond to the call button. R1 confirmed this statement and showed LPA that he does have a call button. Allegation #4 - As indicated in allegation #3, R1 states food is being provide to him by either having tray service to his room or escorts to meals in the dining area. Resident Care Summary for R1 indicates he needs full assistance with mobility that includes escorts to meal. S1 provided proof that R1 was given a tray service meal while in his room when he was unable to be escorted to the dining area. Based on the information obtained there is not enough evidence that staff are not bathing resident, staff are not providing food to the resident, staff are not responding to residents calls for assistance and staff are not taking resident to the dining room. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left with the facility.the state’s words, verbatim · CDSS document, Feb 26, 2025 · control 56-AS-20250225084849

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to further investigate and have Executive Director Pacia signed the amended complaint (56-AS-20241104095010) dated 11/08/2024. The report was discussed with Director Pacia and signed by both LPA Prieto and Director Pacia. A copy of this report was left with the facility.the state’s words, verbatim · CDSS document, Feb 26, 2025

Allegation investigated: Staff does not keep facility clean. Staff does not keep facility free from odor. Staff does not maintain residents hygiene Staff does not feed residents. Staff not putting meals in reaching distance for residents. Staff not responding to resident's call button Staff not assisting residents when requested Staff leave resident in soiled diapers

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Executive Director Pacia and explained the elements of the complaint. Allegation #1 and #2, staff does not keep facility clean and staff does not keep facility free from odor, LPA Prieto toured facility with Executive Director Pacia and found that the common areas, dining areas, lobby and facility corridors were clean, free from obstructions, and odors. Allegations #3, staff does not maintain residents hygiene, LPA Prieto interviewed residents #1 (R1), R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, all state that staff assist with their hygiene needs as required by their needs and services plan. Those residents who are independent state the facility provides amenities to satisfy their hygiene needs. Unsubstantiated Allegation #4 and #5, staff does not feed residents and staff not putting meals in reaching distance for residents. , LPA Prieto interviewed residents #1 thru #10 and R12, all stated that the facility provides three (3) meals a day where they can ambulate to the dinning area to eat. Those residents can ambulate freely or with the assistance of a walking aid, such as a walker or wheelchair. R11 states that tray service is provided and food is place within reaching distance to that resident could easily eat their food. Allegation #6, staff not responding to resident's call button, LPA Prieto interviewed residents #1 (R1), R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, all who stated that staff respond when their call buttons are pressed. Allegation #7, staff not assisting residents when requested, LPA Prieto interviewed residents #1 (R1), R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, all who stated that staff are attentive to their needs and request. Resident also stated that the request range from assistance with their hygiene needs to request to fixing appliances in their rooms. Allegation #8, staff leave resident in soiled diapers, LPA Prieto interviewed residents #1 (R1), R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, all who state that if their needs and care plan requires them to be changed, staff will perform that duties during their shift. Residents have also stated that their call button is use for changing if necessary. Based on the information obtained there is not enough evidence that . Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left with the facility.the state’s words, verbatim · CDSS document, Jan 15, 2025 · control 56-AS-20250106142511

Type of visit: Case Management - Other

Licensing Program Analyst Sarina Ramirez arrived at the facility to amend documents originally delivered on 07/17/24 On 07/17/2024 LPA Ramirez was at the facility to initiate a complaint investigation COMPLAINT CONTROL NUMBER: 56-AS-20240715095448 The amendment was signed by Administrator Pacia and was provided a copy of the amended report at the conclusion of the visitthe state’s words, verbatim · CDSS document, Dec 13, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to have staff resign amended complaint #56-AS-20240916230721. LPA Prieto met with Administrator Pacia, signed report and left a copy with the facility.the state’s words, verbatim · CDSS document, Dec 5, 2024

Allegation investigated: Facility staff do not respond to call buttons in a timely manner Facility staff left resident on the floor for a prolonged period of time

Licensing Program Analyst (LPA) Javier Prieto visited the facility to conduct a complaint investigation regarding the aforementioned allegations. LPA Prieto met with Executive Director Pacia and provided an overview of the complaint elements. Allegation #1: Facility staff do not respond to call buttons in a timely manner LPA Prieto interviewed Resident #1 (R1), who stated that their call button was not functioning properly. LPA Prieto requested R1 to press the call button to confirm its functionality. Approximately two minutes later, a staff member arrived at R1's room, where the interview was being conducted, and manually reset R1's call button. Additionally, LPA Prieto interviewed Residents R2, R3, R4, R5, and R6. All these residents confirmed that their call buttons were working correctly and that assistance arrived promptly after the button was pressed. Unsubstantiated Allegation #2: Facility staff left a resident on the floor for a prolonged period of time LPA Prieto interviewed R1, who reported that a fall occurred in her bathroom on November 2, 2024. R1 stated that she pressed her call button, and approximately two minutes later, staff arrived and transported her to a medical facility. R1 returned the same day with no new orders. Records obtained for R1 indicated that she requires only moderate assistance with transfers and is capable of ambulating independently. Staff #1 (S1) provided discharge papers for R1, which recommended a follow-up with her primary care physician but noted no immediate injuries requiring attention. LPA Prieto also interviewed Residents R2, R3, R4, R5, and R6. These residents reported no issues with falling or with staff failing to arrive promptly when a call button was pressed. Based on the information obtained, there is insufficient evidence to substantiate the allegations that facility staff do not respond to call buttons in a timely manner or that facility staff left a resident on the floor for an extended period. Therefore, these allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia.the state’s words, verbatim · CDSS document, Nov 8, 2024 · control 56-AS-20241104095010

Allegation investigated: Staff did not prevent a resident from sexually abusing another resident

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Executive Director Pacia and explained the element of the complaint. Allegation #1, LPA Prieto interviewed resident #1 (R1), who could not give any details of the alleged incident mentioned in this report. LPA Prieto interviewed R2, who could not recall any such incident occurring pertaining to this allegation. LPA Prieto interviewed R3, R4, R5, R6 and R7 who state that they have not had any inappropriate encounters with other residents at the facility or seen any such inappropriate behavior. LPA interviewed Executive Director Pacia who conducted an internal investigation and could not corroborate the above allegation. Pacia produced an incident report to LPA regarding the alleged incident and cross reported to the appropriate agencies. Unsubstantiated Based on the information obtained there is not enough evidence that staff did not prevent a resident from sexually abusing another resident. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left with the facility.the state’s words, verbatim · CDSS document, Oct 30, 2024 · control 56-AS-20241025092255

Allegation investigated: Staff moved resident to another room without her consent Staff spoke inappropriately to resident

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director Marc Pacia and explained the elements of the compliant. Allegation #1, staff #1 (S1) interview states that resident #1 (R1) in question was moved per family request. Request was asked from R1's family as to S1 due to the location being closer to dining area, as mentioned to R1's family. S1 states R1 was made aware of move by R1's family. R1 states to S1 that R1 cannot transfer to the dining area easy due to her diagnosis and needs and services plan. Needs and service plan was obtained and reveal the R1 is able to transfer independently. R1 no longer resides at the facility to interview regarding this allegation. Allegation #2, it is alleged that R1 stated that staff spoke to R1 inappropriately relating to R1's stay. Staff stated that R1 was made aware that if R1 is not happy at the facility, another facility would be found for her to stay. R1 was not available to interview relating to this allegation. Unsubstantiated Needs and services plan for R1 was obtained and found that R1 is independent with most of her Activities of Daily Living (ADL). Previous interview with R1, with LPA, revealed that R1 was satisfied with the care and stay at the facility and all request for change and modifications were accommodated by Executive Director (S1) at the time. Based on the information obtained there is not enough evidence that staff spoke inappropriately to resident and Staff moved resident to another room without her consent. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Paciathe state’s words, verbatim · CDSS document, Oct 24, 2024 · control 56-AS-20240325083715

Allegation investigated: Staff stole resident’s money.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA met with Business Manager Danielle Garcia and explained the elements of the complaint. Allegation #1, complaint alleges that resident #1 (R1) monies are not being distributed to him as part of his Assisted Living Waiver program (ALW). It is alleged that a stipend of $177 is due to R1 after a cost of rent is paid to the facility through this program. Documentation is obtained from Business Manager Garcia that reveals R1 was approved for the ALW program, paying only for his level of care, hence no stipend of $177 was due to R1. These funds are the resident monies in question. Business Manager states that she is not the payee for R1 and no funds are dispensed through her relating to R1. This agency has investigated the complaint alleging staff stole resident’s money violation. We have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. This report was signed by LPA Prieto and Business Manager Garcia and a copy was left with the facility. Unfoundedthe state’s words, verbatim · CDSS document, Oct 24, 2024 · control 56-AS-20241017154028

Allegation investigated: Facility staff are not properly addressing pest infestation in the facility.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Business Manager Danielle Garcia and discussed the elements of the complaint. Allegation #1, Maintenance Director provided LPA with invoices from Orkin pest exterminators for the treatment and addressing the bug issues the facility may have. The facility is properly addresses this issue by having a monthly treatment service and frequently spot treatments. These spot treatments are made after staff observations or resident inquiries. Last treatment was conducted 13 days prior to this complaint allegation. Maintenance Director also handed LPA the last spot treatment for Rodent control. The facility has a monthly service with BugFree Central Inc, with the latest treament conducted 21 days ago. An invoice was also obtained for this service. LPA interviewed resident #1 (R1) in question, who stated that there is an observation of the pest control treatments being conducted at the facility. Unsubstantiated Based on the information obtained there is not enough evidence that facility staff are not properly addressing pest infestation in the facility. Therefore, the allegations is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Business Manager Garcia and a copy was left at the facility.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 56-AS-20241022143542

Allegation investigated: Unlawful eviction.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA met with Business Manager Danielle Garcia and explained the elements of the complaint. Allegation #1, LPA obtained the eviction documentation for resident #1 in question. Documentation is legal and filed with the Superior Court of California and in order. The eviction is filed and served at the facility for non-payment to resident. LPA Prieto obtained resident #1, detail ledger where non-payment of rent funds totaled $18,669.45. Notice of eviction was posted on the door for resident #1 and resident left the facility on the day of eviction which was October 17, 2024. This agency has investigated the complaint alleging unlawful eviction violation. We have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. This report was signed by LPA Prieto and Business Manager Garcia and a copy was left at the facility. Unfoundedthe state’s words, verbatim · CDSS document, Oct 23, 2024 · control 56-AS-20241017154028

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Office Manager Danielle Garcia and was granted entry to the facility. Licensed capacity is (197) current census (155). LPA was accompanied by Regional Manager Patrick L. Mcadoo Morton, Administrator Marc Pacia and Office Manager Danielle Garcia to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, and the CCL complaint poster, were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated office for client/staff files. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed (15) resident files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed (15) resident medications and (3) hospice files. In addition, LPA audit (10) resident safeguard. The remaining cash balance matched the documentation on the LIC405. LPA also reviewed (10) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. During medication audit, 3 out of the 4 medication carts had lose pills. LPA observed (7) lose pills. LPA requested for the medication to be dispose properly. Medication shall be centrally stored in it's original received container/bubble pack. Based on the observations made during today’s visit, (1) Type A Deficiency were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Marc Pacia and Regional Manager Patrick L. Mcadoo. Along with a copy of Appeal Rights.the state’s words, verbatim · CDSS document, Oct 9, 2024

Allegation investigated: Staff do not ensure the facility is free from bed bugs

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Executive Director Marc Pacia and explained the elements of the complaint. Regarding allegation #1, LPA Prieto interviewed resident #1 (R1), R2, R3, R4, R5, R6, R7 and R8, all saying that they do not have an issues with bed bugs at the facility. Executive Director Pacia and Maintenance Director Tiffany states that recently (09/13/2024), the facility has treated a specific room for bed bugs that was resolved in one (1) day. Copy of the exterminator company was obtained from the facility. Maintenance Director states that one resident from that room moved voluntarily and the second, resident #9 (R9) stayed. R9 added that the issue was not resolved, yet Executive Director produced records (resident's notes) that the issue was resolved when an inspection was conducted. Copies of those notes was obtained during this investigation. The facility also has an exterminator company that will routinely treat the facility, as a preventive measure, for bug and rodents. Those records were also obtained during this investigation Unsubstantiated Based on the information obtained there is not enough evidence that staff do not ensure the facility is free from bed bugs . Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left at the facility.the state’s words, verbatim · CDSS document, Oct 8, 2024 · control 56-AS-20240930124729

Allegation investigated: Staff removed residents’ personal belongings without consent. Licensee does not ensure sufficient staffing to meet residents’ care needs

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA met with Executive Director Marc Pacia and explained the elements of the complaint. Allegation #1, LPA interviewed residents R1, R2, R3, R4, R5, R6 and R7, all who stated that staff does not remove personal belongs nor other items from their rooms without their consent. LPA interviewed staff #1 (S1) and S2 and stated that items are not removed from resident's room without their permission. Staff state that resident #8 (R8) did have some prohibited appliances in the room, but those items were not removed and LPA observed those items in the resident room. Allegation #2, LPA interviewed R1, R2, R3, R4, R5, R6 and R7, all who stated there are sufficient staff to meet their needs. LPA obtained facility roster to show there is sufficient staff to meet clients needs. Unsubstantiated Based on the information obtained there is not enough evidence that staff removed residents’ personal belongings without consent and Licensee does not ensure sufficient staffing to meet residents’ care needs. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left with the facility.the state’s words, verbatim · CDSS document, Oct 7, 2024 · control 56-AS-20241002142602

Allegation investigated: Staff used a resident's bathroom Staff does not prevent a resident from smoking in their room

Licensing Program Analyst (LPA) Javier Prieto arrived at the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Danielle Garcia, Office Manager, and explained the elements of the complaint.Allegation #1: The facility had the water shut off on 09/06/2024 for a two-hour period. Notices were given to all residents, and LPA Prieto obtained a copy of this notice. Kitchen staff were informed to ensure that meals could be prepared and served without interruption. Residents were advised to use the restroom only once until water service was restored. Staff were instructed to use the staff bathrooms located throughout the facility. During interviews, Staff #1 (S1), S2, S3, and S4 confirmed that they do not use the residents' restrooms. Additionally, S2 mentioned that their work crew does not use any residents' restrooms. Unsubstantiated Allegation #2: LPA Prieto interviewed Resident #1 (R1), who was alleged to have been smoking in their room. R1 denied smoking in their room. The facility's policy, which prohibits smoking in any section of the community, including apartments, is clearly posted in the facility lobby and included in each resident's admissions agreement. Based on the information obtained, there is insufficient evidence to support the allegations that staff used a resident's bathroom or that staff failed to prevent a resident from smoking in their room. Therefore, these allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Office Manager Garcia, and a copy was left with the facility.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 56-AS-20240916230721

Allegation investigated: Staff did not ensure facility was free of pests

Licensing Program Analyst's (LPA) LaVette Farlow and (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. (LPA) Farlow and LPA Prieto met with Executive Director Patrick McAdoo-Morton and explained the elements of the complaint. Regarding the allegation that staff did not ensure facility was free of pests to the resident in care; LPA's Farlow and Prieto interviewed resident #1, in question, who states that the facility is not addressing the pest problem and there are roaches in the facility. During the visit LPA's Farlow and Prieto completed a tour of the facility and observed a company name BugFree Central, Inc was present to conduct a weekly pest control. LPA's Farlow and Prieto did complete a visit to R1 room and observed several mouse traps in the room. Unsubstantiated LPA's conducted interviews with several staff. Interview with Staff S1, explained that the facility is currently providing preventative measure to address the pest issues. S1 stated that Orkin comes monthly for treatment at the facility and BugFree Central Inc comes weekly for treatment. Also, the facility has conducted extra cleaning and treatment for those residents that had extra clutter weekly. Documentation was obtained from the Business Manager Danielle Garcia for this report. Based on the information obtained there is not enough evidence that staff did not providing preventative measure to address the pest issue for resident in care. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA's Farlow and Prieto and Business Manager Danielle Garcia and a copy was left with the facility.the state’s words, verbatim · CDSS document, Sep 5, 2024 · control 56-AS-20240827091058

Allegation investigated: Staff are not safeguarding resident's personal belongings. Staff confiscated resident's vitamins. Facility did not ensure that resident was transported to a medical appointment.

On 08/09/2024 at 11:40 AM, Licensing Program Analysts (LPAs) Melody Brown and Raquel Hernandez conducted an unannounced visit to the facility to deliver the findings of the complaint investigations. LPAs Brown and Hernandez were greeted and granted entrance to the facility at the reception area by a staff. Executive Director (ED) Maryann Nevarez was informed of the visit and met with LPAs Brown and Hernandez. LPAs Brown and Hernandez explained the purpose of today's visit. The investigation was conducted by LPA Brown. The investigation consisted of file review and interviews with relevant parties. The first allegation indicates Staff are not safeguarding resident's personal belongings. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with eight (8) of thirteen (13) residents indicated that staffs at the facility are safeguarding residents personal belongings. Interviews with five (5) of five (5) staffs indicated staffs are safeguarding residents personal belongings. Staffs are making sure residents rooms were locked. Per documents review, LPA Brown observed that the facility has Theft Loss Procedures in placed. *** Continuation in LIC9099C *** Unsubstantiated During the facility visit on 06/17/2024, LPA Brown observed that staff at the facility are keeping the resident rooms locked if they are not in their room to keep their belongings safe. The second allegation indicates that Staff confiscated resident's vitamins. Interviews with twelve (12) of thirteen (13) residents indicated that staffs at the facility are not confiscating their medications or vitamins. Interviews with five (5) of five (5) staffs indicated staffs are are not confiscating residents vitamins except if the resident is on medication management and the medications or vitamins in a resident room does not have a doctors order. Per review of Resident #1 (R1) Medication Administration Record (MAR), LPA Brown observed that R1's vitamins reported do not have doctors order. The third allegation indicates that Facility did not ensure that resident was transported to a medical appointment. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with twelve (12) of thirteen (13) residents indicated that staffs at the facility are ensuring that they are transported to a medical appointment. Interviews with five (5) of five (5) staffs indicated resident was transported to a medical appointment. Interviews with staffs revealed that no incident happened at the facility that a staff did not ensure that a resident was transported to a medical appointment. Based on interviews and records review, the allegation Staff are not safeguarding resident's personal belongings (Allegation #1), Staff confiscated resident's vitamins (Allegation #2) and Facility did not ensure that resident was transported to a medical appointment (Allegation #3) are UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, where this report (LIC9099) was discussed and provided to Executive Director Maryann Nevarez.the state’s words, verbatim · CDSS document, Aug 9, 2024 · control 56-AS-20240227125022

Allegation investigated: Staff not providing medication to a resident in care

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Executive Director Maria Nevarez and explained the elements of the complaint. Regarding the allegation that staff not providing medication to a resident in care; LPA Prieto interviewed resident #1, in question, who states that medication was prescribed for an infection. Medication Administration Records (MAR) log obtained for R1 does not indicate that a medication was prescribed on the day of question (07/31/2024), but a medication was given the following day, as prescribed, for the following 5 consecutive days. MAR log indicates that all medications, for resident #1, are being administered as prescribed. Unsubstantiated Based on the information obtained there is not enough evidence that staff not providing medication to a resident in care. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Nevarez and a copy was left with the facility.the state’s words, verbatim · CDSS document, Aug 6, 2024 · control 56-AS-20240731155822

Allegation investigated: Staff are interfering with resident visits

Licensing Program Analyst (LPA) Javier Prieto, LPA Ramirez and LPA Farlow arrived to the facility to conduct a complaint investigation regarding the elements of the complaint. Regarding the allegation that staff are interfering with resident visits; LPAs interview resident #1 (R1) and R2, in question, who state that visiting person was no longer allowed to enter the facility due to an incident that occurred with R2. Staff is aware of the limitation order by law enforcement and is enforcing such order. Unsubstantiated Based on the information obtained there is not enough evidence that staff are interfering with resident visits. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto, LPA Ramirez and LPA Farlow and Business Manager Garcia and a copy of the report was left with the facility.the state’s words, verbatim · CDSS document, Jul 30, 2024 · control 56-AS-20240726093322

Allegation investigated: Staff does not ensure the admissions agreement is being followed Staff does not ensure personal funds are disbursed to resident in a timely manner

Licensing Program Analyst (LPA) Javier Prieto, LPA Ramirez and LPA Farlow arrived to the facility to conduct a complaint investigation regarding thements of the complaint. Regarding the allegation that staff does not ensure the admissions agreement is being followed; LPAs interviewed resident #1 (R1), in question, and confirmed the perameters relating to the facility admisson's agreement is established regarding resident vistation hours. A copy of the admission's report addressing the visiting hours were obtained by LPAs and reveals the facility is following the terms of the agreement. above allegations. LPAs, met with Danielle Garcia, Business Manager and dicussed the ele Unsubstantiated Regarding the allegation that staff does not ensure personal funds are disbursed to resident in a timely manner. Records were from facility Business Manager regarding R1 personal funds which reveal that funds are being dispensed appropriately. Documentation was obtained from the Business Manager for this report. Based on the information obtained there is not enough evidence that staff does not ensure the admissions agreement is being followed and staff does not ensure personal funds are disbursed to resident in a timely manner. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto, LPA Ramirez and LPA Farlow and Business Manager Garcia and a copy of the report was left with the facility.the state’s words, verbatim · CDSS document, Jul 30, 2024 · control 56-AS-20240729092749

Allegation investigated: Staff leave a resident soiled for an extended period of time

Licensing Program Analysts (LPAs) Sarina Ramirez and Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPAs met with Executive Director Patrick Mcadoo-Morton and explained the elements of the complaint. LPAs interviewed staff, resident, and gathered pertinent documentation. Regarding the allegation, staff leave a resident soiled for an extended period of time, Administrator and staff interviewed deny leaving resident in soiled diaper for extended period. Staff interviewed stated that residents are checked every two hours for diaper changes. LPA conducted Six (6) Resident interviews. One (1) Resident stated they are left in soiled diapers for an extended period of time. Two (2) residents stated they are sometimes left wet, but not all the time. Three (3) residents stated they are not left in soiled diapers. There is not enough evidence to corroborate this allegation. Unsubstantiated Based on file review, interviews and observations, the above allegation is Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and a copy with appeal rights was provided to Administrator Patrick Mcadoo-Morton at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 17, 2024 · control 56-AS-20240715095448

Allegation investigated: Staff did not fix the running water timely.

On 06/24/2024 at 11:05 AM, Licensing Program Analyst (LPA) Melody Brown met with Executive Director Patrick McAdoo-Morton at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegation. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentation. The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The allegation indicates Staff did not fix the running water timely. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with seven (7) of eight (8) residents indicated that staffs at the facility fixed the running water issue timely. Interviews with five (5) of five (5) staffs indicated that staffs at the facility immediately contacted the plumbing company to addressed the issue and immediately notified its residents, family members and responsible parties. Residents and staffs interviews revealed that the facility distributed *** Continuation on LIC9099C*** Unsubstantiated gallons of water to their residents to ensure all their residents have water supply. Per documents review, LPA Brown observed the ED McAdoo-Morton immediately address the issue as ED McAdoo-Morton contacted a plumbing company to report the sewer issue at the facility. During the facility visit on 02/29/2024, LPA Brown observed gallons of water on resident rooms. Based on the evidence, the allegation that Staff did not fix the running water timely is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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 at this time. An exit interview was conducted where this report, LIC9099 was discussed and provided to Executive Director Patrick McAdoo-Morton.the state’s words, verbatim · CDSS document, Jun 24, 2024 · control 56-AS-20240226145618

Allegation investigated: Staff did not ensure the facility was free of mold Staff did not ensure the facility was free of odor Staff did not ensure the facility was free of rodents

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above listed allegations. LPA Prieto met with Executive Director Patrick McAdoo-Morton and explained the elements of the visit. Regarding the allegation that staff did not ensure the facility was free of mold; LPA toured the area addressed in this complaint and did not observe mold. Regarding the allegation that staff did not ensure the facility was free of odor; LPA toured the area addresses in this complaint and did not observe any foul odors. The room was at a cool and comfortable. ***continued on LIC 9099C*** Unsubstantiated Regarding the allegation that staff did not ensure the facility was free of rodents; LPA toured the area addressed in this allegation and did not observe any rodents or evidence of rodent droppings. Executive Director McAdoo-Morton produced invoice from their contracted Pest Control indicting that bait traps were placed throughout the facility and no observation of mice activities were observed on the date of pest control visit (5/22/2024). Director also states that issues of mold, odor or rodents were not brought to his attention prior to LPA complaint visit. Based on the information obtained there is not enough evidence that staff did not ensure the facility was free of mold, staff did not ensure the facility was free of odor and staff did not ensure the facility was free of rodents. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director McAdoo-Morton and a copy was left with the facility.the state’s words, verbatim · CDSS document, Jun 21, 2024 · control 56-AS-20240619151040

Allegation investigated: Staff are not assisting residents in a timely manner. Staff are not ensuring residents are provided adequate food service.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director Patrick McAdoo-Morton and explained the elements of the complaint. Regarding the allegation that staff are not assisting residents in a timely manner; LPA Prieto interviewed resident #1 (R1), in question, who states that communication with staff is done by pressing the facility call button, asking for assistance when the med tech staff arrive, asking services from direct care staff and even calling the front office directly from a cellular phone. R1 discussed an incident of a fall when the call button was pressed and assistance from staff arrived immediately. ***continued on LIC 9099C*** Unsubstantiated Regarding the allegation staff are not ensuring residents are provided adequate food service; Interview with staff #1 (S1) states the R1 does dine, with other residents, in the dinning area during meals times. Resident notes reveal the R1 has called to be escorted to the dining area for meals and notes when R1 has refused to be escorted for meals. R1 stated that meals that were refused were by her own accord. R1 added that the meals at the facility are excellent in quality and enjoys the company of facility peers. Based on the information obtained there is not enough evidence that staff are not assisting residents in a timely manner and staff are not ensuring residents are provided adequate food service. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director McAdoo-Morton and a copy was left with the facility.the state’s words, verbatim · CDSS document, Jun 19, 2024 · control 56-AS-20240618110915

Allegation investigated: Staff did not answer residents calls for assistance timely

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Patrick McAdoo-Morton, Executive Director, and discussed the elements of the complaint. Regarding the allegation that staff did not answer residents calls for assistance timely; Resident in question, resided at the facility for 30 days and did not give specific times when calls were made for assistance. Interview with Executive Director McAdoo-Morton states that the signal system for the facility has been in working order and no complaints of residents stating staff are not responding to signal calls have been made. Signal system is located at the from desk where staff monitors throught the day. ***continued on LIC 9099*** Unsubstantiated Three additional monitors are located throughout each wing of the facility and resident's each have call buttons that active signal and viewed on each monitor. Based on the information obtained there is not enough evidence that staff did not answer residents calls for assistance timely. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director McAdoo-Morton and a copy was left at the facility. This agency has investigated the complaint alleging staff contacted social security without residents permission violation. We have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. This report was signed by LPA Prieto and Executive Director McAdoo-Morton and a copy was left at the facility.the state’s words, verbatim · CDSS document, May 21, 2024 · control 56-AS-20240516123507

Type of visit: Case Management - Incident

LPA Javier Prieto arrived to the facility to conduct a case management visit regarding an incident that occurred at the facility on 05/07/2024 regarding resident #1 (R1). The incident was related to R1 and an altercation that occurred with two other staff S1 and S2 and an additional staff (S3) that witnessed the event. LPA spoke with Executive Director McAdoo-Morton, who explained the situation and LPA Prieto interviewed R1, who would not comply with the interview. This report was signed by LPA Prieto and Executive Director McAdoo-Morton and a copy of the report was left with the facility.the state’s words, verbatim · CDSS document, May 9, 2024

Allegation investigated: Facility charging higher amount than state standards allow for SSI. Staff did not do a proper rent increase Staff do not allow residents to have their authorized representative/advocate at facility meetings

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Danielle Garcia, Office Manager and explained the elements of the complaint. Regarding the allegation the Facility charging higher amount than state standards allow for SSI; documentation was obtained of a increase for social security benefits that was sent to all recipients effective January 1st, 2024. Effective January 1st, the rate increased for resident's board and care, which included the increase in social security benefits, not to exceed the amount the resident receives for social security. ***continued on LIC 9099*** Unsubstantiated Regarding the allegation that Staff did not do a proper rent increase; a sample documentation was obtained of a resident who was made aware of an increase in rent November 2023 for the rate increase in January, allowing for the proper amount of time to notify a resident of the increase in rent. A second letter was obtained indicating a rent increase for January 2024, with the letter dated 09/18/2023, exceeding the 60 day notice required by California Law and Title 22. Interview with administrator reveal letters were hand delivered on 09/18/2023. This was also based on the increase in social security benefits. Residents on an Assisted Living Waiver (ALW) also had an increase in benefits where the program also covered the room and board rate and care and supervision rate, not changing what is covered for the facility. The amount received by the recipients did not change. Executive Director Morton-McAdoo stated the residents that have been issued an eviction notice are being evicted due to non-payment and not because the increase rate. Interviews with Resident #1 (R1), R2 and R3 reveal that the they were given a proper eviction notice and eviction was due to non-payment. Eviction records were obtained for R4, R5, R6, R7 and R8 Regarding the Staff do not allow residents to have their authorized representative/advocate at facility meetings; Interview with Executive Director Morton-McAdoo and Business Office Manager Garcia states they do not deny any resident representative an audience regarding admission's to the facility if they are the Power of Attorney (POA) or authorized representative. Advocates are not required to attend facility meeting. Resident Consul was interviewed and states residents do not require advocates to be present during meetings. Based on the information obtained there is not enough evidence that Facility charging higher amount than state standards allow for SSI, Staff did not do a proper rent increase and Staff do not allow residents to have their authorized representative/advocate at facility meetings. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Office Manager Garcia and a copy was left with the facility.the state’s words, verbatim · CDSS document, Apr 29, 2024 · control 56-AS-20240207084938

Allegation investigated: Staff opened resident's luggage without permission Staff changed resident's doctor without permission Staff spoke inappropriately to resident

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Danielle Garcia, Officer Manager, and discussed the elements of the complaint. LPA interviewed staff, resident in question, gathered pertinent documentation. Regarding the allegation that staff opened resident's luggage without permission: Resident #1 (R1) in question states that the luggage was sealed with a small padlock and opened in R1's presence and no attempts to stop staff from cutting the lock. Interviews with staff #1 (S1) and S2 state the lock that was cut was to a lockbox, and cut per R1's request, in the presence of R1, which revealed R1's medication. ***continued on LIC 9099C*** Unsubstantiated R1 added that luggage was opened to retrieve important documents and could not locate the lock's key. Staff added that R1 did not asked to open the luggage, but lockbox with medications. Regarding the allegation that staff changed resident's doctor without permission; R1 was interviewed and states that R1 still has that same doctor and facility staff has not attempted to change her current Physician or medical insurance. Staff #3 (S3) confirmed that R1 continues to have the same Physician and insurance. Regarding the allegation that staff spoke inappropriately to resident; R1 was interviewed and stated that words were said by R1 in a "heated moment". Staff #4 (S4) stated that R1 stated their issues with the facility and S4 stated the options needed to assist, one being to move to another facility as that option was available. Based on the information obtained there is not enough evidence that staff opened resident's luggage without permission, staff changed resident's doctor without permission and staff spoke inappropriately to resident . Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Office manager Garcia and a copy was left with the facility.the state’s words, verbatim · CDSS document, Apr 29, 2024 · control 56-AS-20240424104303

Allegation investigated: Staff does not ensure transportation is available for resident. Staff threatened to evict resident.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Danielle, Officer Manager, and discussed the elements of the complaint. LPA Prieto interviewed staff and resident #1 (R1). Regarding the allegation that staff does not ensure transportation is available for resident; LPA Prieto spoke with R1, in question, who states that transportation to and from the medical facility, where R1 is being treated, has been rectified. R1 concluded that an alternate means for transportation was nessary as facility staff does not transport during early morning hours. ***continued on LIC 9099C*** Unsubstantiated Regarding the allegation staff threatened to evict resident; R1 states to LPA that rent is paid on a timely basis. LPA Prieto confirmed with Business Manager Garcia that rent is being paid on time and in good standing. Garcia confirmed that R1 is not being evicted. R1 confirmed, to LPA, that there is no eviction. R1 added that there is no desire to leave facility. Based on the information obtained there is not enough evidence that staff does not ensure transportation is available for resident and staff threatened to evict resident. . Therefore, the allegations are deemed UNSUBSTANTIATED at this time. 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, Apr 12, 2024 · control 56-AS-20240410121510

Allegation investigated: Resident was left soiled for an extended period while in care. Staff are not meeting resident's hygiene needs.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility conduct a complaint investigation regarding the above allegations. LPA Prieto met with Assistant Business Office Manager Savanna Castro and explained the elements of the complaint. LPA toured the facility, interviewed resident and gathered pertinent documentation. Regarding the allegation that resident was left soiled for an extended period while in care; LPA Prieto obtained resident #1 (R1) service plan which states that R1 is not on an incontinece place, but a bathing plan, with a one person assist, once per week. LPA Prieto obtained shower schedule that shows R1 is bathed once a week. LPA Prieto interviewed R1 who stated that the service plan indicates assistance with toileting 3 times ****continued on 9099C*** Unsubstantiated per day. R1 stated that he ask for assistance, but still has difficulty and would rather use an adult diaper, which is R1 is required to provide and not part of R1's care plan. R1's service plan indicates that there is no special care needs and R1 can self manage. Facility staff has assisted R1 in obtaining incontinence care product in the future. Regarding the allegation that staff are not meeting resident's hygiene needs; R1's service plan states that a minimum assist with dressing. moderate assist with grooming, no special care needs. R1 has a service plan for laundry service once a week. R1 is required provide R1's own care products. Based on the information obtained there is not enough evidence that resident was left soiled for an extended period while in care and staff are not meeting resident's hygiene needs. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Ms Castro and a copy was left with the facility.the state’s words, verbatim · CDSS document, Apr 8, 2024 · control 56-AS-20240404113629

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to the facility to conduct a case management visit relating facility compliance, addressing complaints from residents and also a specific incident that occurred on February 28th, 2024 relating to resident #1 (R1) and the circumstances relating to R1's passing. LPA Prieto met with Administrator McAdoo-Morton and explained the purpose of the visit. During today’s visit, LPA Prieto conducted a facility tour of the facility, dining and common areas. The physical plant was clean and in order with no deficiencies observed. LPA Prieto also interview resident counsel president (RC) who states that issues or concerns relating to the facility are gathered from resident's and are addressed with Executive Director McAdoo-Morton. RC states that those issues are addressed appropriately and timely. RC states that residents had made complaints on their own, which were not brought to RC's attention and even issues that were. LPA Prieto obtained incident reports pertaining to R1 passing, medical reports and follow up documentation relating to grievance services provided to staff, residents and their families. No deficiencies were cited during this visit. An exit interview was conducted with Executive Director McAdoo-Morton and a copy of this report was left with facility.the state’s words, verbatim · CDSS document, Mar 1, 2024

Allegation investigated: Staff dispensed medications not prescribed to a resident. Staff dispensed a medication to a resident that they are allergic to. Resident sustained a pressure injury while in care. Staff did not ensure that a resident is fed while in care.

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Savant of Jurupa Valley to deliver findings of the complaint investigation into the above listed allegations. LPA introduced self and stated purpose of the visit, then met with Executive Director, Patrick McAdoo-Morton. During the investigation, LPA collected records for review, interviewed staff, residents and witnesses, and completed a walk through of the facility. It is alleged that staff dispensed medications not prescribed to a resident. Staff interviewes revealed that the facility does not regulary administer medications of narcotic class to its residents. Staff also completed an investigation of their own which accounted for all resident medications. No medication were determined to be missing. A review, of R1's Medication Administrative Record, (MARS) revelead R1 has missed no medications. It is alleged that staff dispensed a medication to a resident that they are allegic to. A review of R1's Medication Administrative Record, (MARS) revealed that R1 was not dispensed a medication she was allegeric to nor fentanyl or opiates. Which reported to show up on R1's drug screen. Unsubstantiated Based on staff and resident interviews, the allegation staff left a resident in urine and feces is unsubstantiated. This report was signed by LPA Prieto and Executive Director McAdoo-Morton and a copy was left with the facility.the state’s words, verbatim · CDSS document, Feb 27, 2024 · control 56-AS-20240124173434

Allegation investigated: Staff left a resident in urine and feces.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to deliver findings regarding the above listed allegations. LPA Prieto met with Executive Director Patrick McAdoo-Morton and explained the elements of the visit. LPA interviewed staff, residents, and witness. LPA was unable to interview resident (1) due to (R1) no longer residing at the facility. LPA interviewed residents and 8 out of 8 residents revealed they have not been left in urine or feces. LPA interviewed staff, and 5 out of 5 staff denied that resident was left in urine and feces. Resident #1 (R1), in question, vacated the facility on 01/23/2024 and unable to interview. ***continued on LIC 9099C*** Unsubstantiated Based on staff and resident interviews, the allegation that staff left a resident in urine and feces is unsubstantiated. This report was signed by LPA Prieto and Executive Director McAdoo-Moron and a copy was left with the facility.the state’s words, verbatim · CDSS document, Feb 27, 2024 · control 56-AS-20240124173434

From the deficiency page — Deficiency type: Type A · Section cited: HSC 80078(a) · Plan of correction due date: Feb 28, 2024

80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This require was not met as evidenced by: Based on interviews, Administrator did not provide the necessary care and services to meet the needs of all residents. Residents and third party staff report requesting assistance on nurmerous occassion and received no response.the state’s words, verbatim · CDSS document, Feb 27, 2024

Plan of correction: Administrator agrees to meet with all care staff who provide services to residents in care and develop a definitive plan/system for how often residents on "frequent checks" and "regular checks" will be carried out. This plan should include noting who is on frequent checks and what staff will do for these residents. The plan should also include who is on "regular checks" and what staff will do for these residents. This plan should be put in writing and submitted to the Community Care Licensing Office within the next business day.

Allegation investigated: Facility do not ensure that resident hygiene needs are met. Facility did not follow resident modified food diet.

Licensing Program Analyst (LPA) Javier Prieto arrive to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director McAdoo-Morton and explained the elements of the complaint. Regarding the allegation that the facility do not ensure that resident hygiene needs are met; LPA Prieto interviewed resident #1 (R1), in question, who stated that she was offered bathing services by staff and additional bathing services by family members. LPA obtained bathing schedule for R1. R1 believed that the facility would bath R1 everyday for as long as wanted. R1's documentation is identified as independent. Unsubstantiated Regarding the allegation that the facility did not follow resident modified food diet; LPA interviewed R1 who stated the vegetarian diet is a matter of choice. Documentation for R1 was obtained and shows that meals and nutrition care plan shows R1 as independent. Staff has been aware of R1's preference and added additional vegetarian meals to the "always available menu". Based on the information obtained there is not enough evidence that the facility do not ensure that resident hygiene needs are met and that facility did not follow resident modified food diet. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director McAdoo-Morton and a copy of this report was left with the facility.the state’s words, verbatim · CDSS document, Feb 20, 2024 · control 56-AS-20240215113910

Allegation investigated: Staff left resident in a soiled diaper for an extended period time.

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Administrator Patrick L. Mcadoo-Morton and explained the purpose of the visit. The investigation consisted of staff interviews, document reviews, and facility tour. For the allegation, Staff left resident in a soiled diaper for an extended period time. During interviews with residents, all residents informed LPA they have not been left with a soiled diaper for an extended period time. 5 out 8 residents stated the staff will change their brief on time. During interviews with staff, all staff informed LPA they have not left a resident in a soiled diaper for a long period of time. 5 out of the 6 staff stated the facility will have 5 or 6 caregivers per shift. 3 out of the 6 staff stated the facility has a lead staff who will assist with residents calls if other team memebers are occupied assisting another resident. Unsubstantiated In addition, the Administrator stated the facility had upgraded their call system to better assist residents. The facility has screen monitors to inform staff members which residents are calling. The screen monitors provide a facility map, residents name, room number and what time. Staff members are required to have their pagers and walkie-talkie to receive resident calls. LPA observed screen monitors with the information provided and staff members with their walkie-talkie, along with their pager. Based on the evidence found during the investigation, the one (1) allegation listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means 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. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Administrator Patrick L. Mcadoo-Morton along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Jan 29, 2024 · control 56-AS-20240122124542

Allegation investigated: Staff harassing resident of monthly payments. Staff disclosing residents personal information in presence of other residents

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director McAdoo-Morton and explained the elements of the complaint. Regarding the allegation that staff harassing resident of monthly payments; staff #1 interview revealed that a discussion with resident #1, in question, is on a monthly plan, and monies are in the rears. Those monies are due and a discussion of collection of those fees were a necessary discussion. Documentation obtained by LPA Prieto reveal the R1 is in the rears. R1 stated that monies are past due. **** continued on LIC 9099 **** Unsubstantiated Regarding the allegation that staff disclosing residents personal information in presence of other residents; interviews with Executive Director McAdoo-Morton and S1 states that R1 was afforded the opportunity to speak in private and R1 did not want the discussion of payments, or other house rules, to be made in private. R1 understands that there is a need for privacy for discussions, relating to fees, are required, and agrees that those discussions were afforded in relation to privacy. Based on the information obtained there is not enough evidence that staff harassing resident of monthly payments and staff disclosing residents personal information in presence of other residents. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director McAdoo-Morton and a copy was left at the facility.the state’s words, verbatim · CDSS document, Jan 17, 2024 · control 56-AS-20240110151908

Allegation investigated: #1 Staff not giving medication to a resident as prescribed. #2 Staff not assisting resident in a timely manner

Licensing Program Analyst (LPA) Javier Prieto arrived at the facility to initiate a complaint investigation regarding the allegations mentioned above. LPA Prieto met with Executive Director Morton and discussed the elements of the complaint. Allegation #1: LPA Prieto reviewed the Medical Administration Records (MAR) log for resident #1 (R1), revealing that medications are being dispensed as prescribed. An interview with Wellness Director (S1) confirmed that medications are being dispensed as prescribed and that any refusal of medication is documented. During an interview with R1, it was revealed that the medications listed on her Physician's Orders are being dispensed properly. R1 admitted to LPA that she sometimes refuses to take pain medication, even though it is documented in her Physician's Orders. Unsubstantiated Allegation #2: In an interview with R1, it was revealed that she makes calls to the front office from her cellphone when assistance is needed. R1 also mentioned that she uses her room call button for assistance when it is within reach, as her hands are constricted. During an interview with Executive Director Morton, it was concluded that R1 was receiving hourly checks by staff in addition to the medical staff dispensing her medication three times per day. R1 pressed her call button in the presence of LPA, and staff entered the room to address the call within approximately three minutes. LPA conducted interviews with residents 1 through 10, which revealed that staff are dispensing medications as prescribed and providing assistance in a timely manner. Based on the information obtained, there is not enough evidence to support the allegations that staff are not dispensing medication as prescribed and not assisting residents in a timely manner. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Director Morton, and a copy was left at the facility.the state’s words, verbatim · CDSS document, Dec 8, 2023 · control 56-AS-20231206111059

Type of visit: Collateral

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced case management pertaining to the old facility Villa De Anza Assisted Living 331800471 regarding their four (4) complaints. 18-AS-20210719133022 18-AS-20210609144620 18-AS-20210716151500 18-AS-20210706142605 An exit interview was conducted where this report (LIC809) was discussed and provided to Executive Director Patrick McAdoo-Morton.the state’s words, verbatim · CDSS document, Nov 28, 2023

Type of visit: Collateral

On 11/20/2023 at 10:05 AM, Licensing Program Analyst (LPA) Melody Brown arrived at the facility unannounced for a collateral visit on a complaint investigation to interview residents regarding complaint control number 18-AS-20210601164527 and 18-AS-20210601164527. During this visit LPA Brown was met by Executive Director Patrick McAdoo-Morton. An exit interview was conducted, and a copy of this report (LIC809) was discussed and provided to Executive Director Patrick McAdoo-Morton.the state’s words, verbatim · CDSS document, Nov 20, 2023

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced case management pertaining to the old facility Villa De Anza Assisted Living 331800471 regarding their four (4) complaints. 18-AS-20210719133022 18-AS-20210609144620 18-AS-20210716151500 18-AS-20210706142605 During today’s visit LPA received facility documents, toured the facility and confirmed R1 does not reside at the facility. An exit interview was conducted where this report (LIC809) was discussed and provided to Sofia Moreno.the state’s words, verbatim · CDSS document, Nov 1, 2023

Allegation investigated: Staff did not meet resident's medical needs Staff did not assist resident in a timely manner Facility is in disrepair

Licensing Program Analyst (LPA) made an unannounced visit to investigate and deliver findings for the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Executive Director McAdoo-Morton. The investigation consisted of a facility tour, resident interviews, staff interviews, and document review. For allegation, Staff did not meet resident's medical needs : Interviews with resident #1 (R1) and the staff #1 (S1) revealed that the medical needs for R1 is a bed with full rails that R1 does not have a doctor's order for and is requesting the facility to provide. The facility is not required to provide a bed with full bed rails and cannot do so without a doctor's order. Unsubstantiated For allegation, Staff did not assist resident in a timely manner : Interviews with resident #1 (R1) and the staff #1 (S1) revealed the assistance in a timely manner had to do with an allegation that R1 presses the call pendent and staff does not reply in a timely manner. During time of inspection, the pendent was pressed and the staff responded in a timely manner. S1 interview and observation, reveals the pendents are in working order and systems registered calls without fail. For allegation, Facility is in disrepair : Interviews with (S1) and documents obtained revealed that the allegation of the facility being in disrepair, related to smoke detector not being operable. Interview with S1 stated that facility kitchen was alleged to have a fire, but there was no fire, hence the smoke detectors did not come on. Records reveal that the local fire department arrived to inspect the kitchen and required the stove hood to be cleaned. Service was provided and records of the cleaning services were obtained. Overall, there was not enough evidence to collaborate the allegations listed above. Based on evidence obtained during the investigation, the three (3) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means 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. This report was signed by LPA Prieto and Executive Director McAdoo-Morton and a copy was left at the facility.the state’s words, verbatim · CDSS document, Oct 18, 2023 · control 56-AS-20231011155555

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Executive Director Patrick McAdoo-Morton and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (197) current census (140). LPA was accompanied by Facility Administrator, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be at 116.8 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept inside laundry room cabinets inaccessible to clients. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed twenty (20) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Executive Director McAdoo-Mortonthe state’s words, verbatim · CDSS document, Oct 18, 2023

Allegation investigated: #1 Staff neglected resident which resulted in pressure injury #2 Staff left resident unattended with dry feces

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above-mentioned allegations. LPA Prieto met with administrator McAdoo-Morton and explained the elements of the visit. Regarding allegation staff neglected resident which resulted in pressure injury, LPA Prieto obtained resident #1 (R1) charting notes that reveal that R1 was not neglected as R1 was seen every, from the date of this incident on 09/26/2023, until R1's passing on 10/01/23. Staff #1 (S1) interview and records reveal that R1 did not have a pressure injury and indicated on this complaint. Facility administrator provided R1's service plan that indicate R1 diagnosis and R1's plan of care. *** continued on LIC 9099 C *** Unsubstantiated Regarding the allegation staff left resident unattended with dry feces, care records reveal R1 is being attended to regarding his changing and grooming needs. LPA obtained records showing R1 was attended to regarding their changing needs. Care plan reveals that R1 is assessed with a specific care need and feeding as well. Records reveal that R1's diet consist of pureed food and resident narrative notes reveal R1 was fed on the date of this incident 09/26/23. R1 in question was not interviewed on this date as R1 passed away on 10/01/23. Based on the information obtained there is not enough evidence that staff neglected resident which resulted in pressure injury and staff left resident unattended with dry feces. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Administrator McAdoo-Morton and a copy was left with the facility.the state’s words, verbatim · CDSS document, Oct 3, 2023 · control 56-AS-20230927095941