Savant of Riverside

Type of visit: Case Management - Other

On May 15, 2026, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility in order to conduct an unannounced Case Management visit. The visit was initiated due to information received via SOC 341, in reference to another matter that was brought to the attention of the Regional Office, and met with the Executive Director, Molly Bowie. LPA introduced herself and stated the purpose of the case management visit. On May 14, 2026, the Adult and Senior Care Department received information pertaining to a staff hitting a resident in care, at the above listed facility. Information obtained from SOC 341 indicated that around 5:30pm on 05/13/2026, their department was called out for a non-injury incident. No medical attention was required, and the resident refused any additional information regarding pressing charges. LPA Mixson conducted a tour of the interior/exterior areas of the facility, along with the Executive Director, and made observations regarding the reason for the visit. LPA observed the Exit signs posted at the exterior doors of the facility on both levels one and two. There was an extra store space for the kitchen’s overflow of food supplies. The Medication area was found to be locked and inaccessible to the residents in care. There were no Health and Safety concerns or challenges observed at the time of this visit. During this visit, additional staff and resident interviews were conducted in reference to the matter listed above. The Executive Director informed the LPA that this incident is currently still pending and that they are not sure at this time the outcome of the situation. An exit interview was conducted, and a copy of this report was reviewed and given to the Executive Director, Molly Bowie.the state’s words, verbatim · CDSS document, May 15, 2026

Allegation investigated: Staff did not administer medication to a resident in care. Staff did not provide meals to a resident in care.

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with Executive Director Molly Bowie, where the LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of interviews with staff and witnesses, file reviews and observations. On March 31, 2026, Community Care Licensing Division (CCLD) received a complaint alleging facility staff did not administer medication to a resident in care and staff did not provide meals to a resident in care. For the allegation that facility staff did not administer medication to a resident, it was reported that Resident 1 (R1) was not receiving their prescribed medications. Attempts were made to interview Additional Witness 1 (AW1) for further information; however, AW1 did not respond to the interview requests. Interview with R1 reported they were not receiving the correct medications and did not recognize some of the medications being dispensed by staff. R1 stated they visited the pharmacy recently and was informed that certain medications were not covered by their insurance. Continued on LIC 9099-C. Unfounded R1 stated they contacted their doctor, but the medication issues persisted. Interview with Wellness Director Olga Morales (WD) indicated that R1 frequently refused medications. WD explained that R1’s doctor instructed staff to continue offering the medications and document all refusals, emphasizing the refusal of medication could lead to increased seizures. Interview with Witness 2 (W2) confirmed that R1’s doctor attempted to adjust R1’s medication regimen, but R1 continued to refuse the changes. W2 reported they had spoken with R1 to encourage medication compliance and had offered assistance with scheduling additional medical appointments; however, R1 refused the offers. Interviews with five out of five residents corroborated that staff administer medications as prescribed and residents had no concerns regarding medication administration. A record review was conducted and revealed R1 refused 55 medications from a sample size from April 1, 2026 through April 7 2026. Additional medication records reviewed from January 2026 through March 2026 had similar results of R1 refusing medication frequently. Additionally, R1 is not under a conservatorship and is listed as self for responsible party indicating they make their own decisions. Regarding the allegation that facility staff did not provide meals to a resident in care, it was reported that R1 was not receiving meals at the facility. Attempts were made to interview Additional Witness 1 (AW1) for further information; however, AW1 did not respond to the requests. An interview with R1 revealed that they receive their daily meals at the facility. R1 was unsure whether they were on a prescribed diet but stated the facility is aware they dislike pork and reported they accommodate his preference. Interview with Executive Director Molly Bowie reported she was not aware of any concerns regarding R1’s meals and confirmed she frequently observed R1 in the dining area. Interviews with two of two staff members corroborated ED statements indicating that R1 has not expressed an issue with the food or that they are not receiving meals. Additionally, Staff 2 indicated that the kitchen staff are aware of R1’s food preferences and make accommodations accordingly. A record review was conducted, and information obtained indicated that R1 is not on a prescribed diet. Additionally, a chart posted in the facility kitchen listing residents' diets and food preferences was reviewed. LPA Perez observed R1’s name on the chart, noting that pork was listed as a food item not to be served. Based on interviews, research, and record review, the allegation that facility staff did not administer medication to a resident in care and staff did not provide meals to a resident in care is unfounded. A finding that the allegation is unfounded meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. Therefore, this complaint is dismissed. An exit interview was conducted. A copy of this report was provided to Executive Director Molly Bowie.the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 18-AS-20260331172227

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with Executive Director Molly Bowie. The LPA informed the Administrator of the purpose for the visit. The inspection included the following: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility consists of one building structure with two floors, Each resident room has grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats present. The building is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. LPA observed a signal pull system in the 10 rooms that were inspected. Facility has Laundry rooms and a locked cabinet is present for storing laundry soap and other chemicals. Various activity rooms were observed. A theater room, salon and club house section was available for resident use. All outdoor and indoor passageways are free of obstruction. There are no firearms at this facility and no bodies of water observed. LPA reviewed client records. Seven (7) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed client records to be available and complete. LPA reviewed employee records- seven (7) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 01/23/2027. LPA observed personnel records to be available and complete. Continued on LIC 809-C. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present in the second floor. There is a location for knives and sharps in the kitchen. Medications are centrally stored. There is a locked room in the second floor allocated for medication storage. Centrally stored medication and destruction logs are maintained and records are digital. Medications reviewed appear to have been dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors are a combined unit, were tested and found to be operational. Fire extinguishers were serviced on 05/22/2025. Emergency drills are conducted quarterly at the facility with the last drill on 03/22/2026. Based on the information received during this visit today in the areas reviewed, there are no deficiencies that are being cited per Title 22, Division 6 of The California Code of Regulations. This LIC 809 report was reviewed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Apr 9, 2026

Allegation investigated: Lack of supervision/neglect resulting in death of resident

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegation. LPA met with Molly Bowie, Executive Director, and informed them of the purpose of LPA’s visit. On 06-09-2025, Community Care Licensing (The Department) received a complaint report with the following allegation. The allegation was lack of supervision/neglect resulting in death of resident. Information received indicated that Resident #1 (R1) did not receive assistance with their oxygen machine from the night shift staff members, resulting in R1’s death. Continued on LIC9099-C.... Substantiated During the Department’s investigation, a comprehensive review of records and interviews with facility residents and staff members was conducted to ascertain the circumstances surrounding the incident. The Department’s review of R1’s resident file revealed that R1 always required oxygen tank and oxygen concentrator. R1 also had cognitive condition that interfered with R1’s ability to perform activities of daily living. R1’s care plan indicated that R1 required maximum assistance with special care needs, such as two (2) hour safety checks and assistance with oxygen use. The Department conducted interviews with two (2) staff members who were on duty on the night of R1’s death. Interview with both staff members revealed R1’s wellbeing was not monitored during the entire night shift. This lack of neglect and supervision was considered a contributing factor in R1’s death. Given R1’s diagnosed conditions and medical needs, regular monitoring of at least two (2) hours was a required standard of care. It is important to note R1’s body was discovered by a staff member who worked the morning shift. The Department’s investigation provided enough information to corroborate the allegation of lack of supervision/neglect resulting in death of resident. Based on interviews conducted and records review, this allegation is substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalty of $500 is being assessed. In accordance with CCR Section 87468.2(a)(4), the determination of additional civil penalties for a violation that resulted in a death of resident, is pending and under review by the Department. An exit interview was conducted where a copy of this report was provided, along with LIC9099C, LIC9099D, LIC421IM, and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Mar 30, 2026 · control 18-AS-20250609123952

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 3, 2026

87468 Additional Personal Rights of Residents in Privately Operated Facilities, (a) In addition to the rights listed in Section 87468.1, Personal Rights... (4) To care, supervision, and services that meet their individual needs... This requirement was not met as evidenced by: Based on interviews conducted and records review, staff's neglect/lack of supervison resulted in death of resident. This posed immediate health and safety risk to resident in carethe state’s words, verbatim · CDSS document, Mar 30, 2026

Plan of correction: Licensee agrees to provide re-inservice all staff to safety/assurance checks, retrain all staff on what assisting oxygen assistance is. Licensee agrees to send proof of training by the POC due date to LPA via email.

Allegation investigated: Staff failed to ensure that the resident’s bed was maintained in proper working condition.

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Business Office Manager, Crystal Maldonado, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and witnesses and file reviews. On January 23, 2026, Community Care Licensing Division (CCLD), received a complaint alleging that facility staff failed to ensure that the resident’s bed was maintained in proper working condition. Interview with Executive Director, Molly Bowie, revealed that the name provided did not match any current or former residents. Interview with Additional Witness 1 (AW1) confirmed the residence of Resident 1 (R1) did not match the facility address. LPA interviewed Witness 2 (W2), and corroborated statements made by ED and AW1 confirming the facility was not the R1’s residence. A review of facility records, including resident rosters, revealed no documented names matching the name reported. Continued on LIC 9099-C. Unfounded Based on interviews, research, and record review, the allegation that facility staff failed to ensure that the resident’s bed was maintained in proper working condition is unfounded due to the listed resident not residing at the facility. A finding that the allegation is unfounded meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. Therefore, this complaint is dismissed. An exit interview was conducted. A copy of this report was provided to Business Office Manager, Crystal Maldonado.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 18-AS-20260123093937

Allegation investigated: Staff do not ensure facility is in good repair. Staff do not ensure the facility is free from pests.

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with Executive Director Molly Bowie, where the LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of interviews with staff and witnesses, file reviews and observations. On August 8, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that staff do not ensure facility is in good repair and staff do not ensure the facility is free from pests. Regarding the allegation that staff failed to ensure the facility was maintained in good repair, it was reported that Resident 1 (R1) experienced ongoing issues with a clogged restroom in their room. Furthermore, it was alleged that the concern was raised with facility management but remained unresolved, continuing to be a problem. Continued LIC 9099-C. Unsubstantiated Attempts were made to interview Additional Witness 1 (AW1) for additional information regarding the allegation above. AW1 did not respond to interview requests and therefore no additional details were obtained. Executive Director (ED), Molly Bowie stated they were not aware of any major restroom repairs being required in resident rooms. Bowie reported being informed that R1 was intentionally clogging their restroom, noting that these incidents became more frequent toward the end of R1’s residency. It was reported that R1 was flushing clothing items or excessive toilet paper. Interview with 4 out of 4 staff corroborated statements made by ED. Additionally, 4 out of 4 reported foreign items found inside the toilet during morning routines. Staff 1 reported walking into R1’s room and observed R1 attempting to do laundry in their toilet and sink. An interview with R1 was attempted; however, R1 was unable to confirm whether the restroom had any issues and chose not to answer further questions regarding the matter. Through direct observation, LPA Perez toured the facility and inspected 10 random rooms to evaluate conditions related to the allegation. 10 out of 10 rooms were observed to have functioning toilets, sinks, and showers. Additionally, a review of maintenance work orders revealed multiple service requests for a clogged toilet inside R1’s room. Documentation indicated that the excessive clog was removed and was consistent with being caused by resident negligence. Regarding the allegation that staff do not ensure the facility is free from pests, it was reported that R1 observed pests inside their room. Attempts were made to interview AW1 for additional information regarding the allegation above. AW1 did not respond to interview requests, and therefore no additional details were obtained. An interview with R1 revealed that they recently entered their restroom and observed a bat inside. R1 emphasized that it was a bat, describing it as black in color with wings. R1 stated they were unsure if anyone else had seen it, noting that the bat appeared only once and flew into a vent. An interview with the ED confirmed that the facility maintains a semi-monthly contract with Orkin for preventive care, with additional services scheduled as needed. ED reported that they have not observed any bats inside the facility, nor have they been made aware of any such sightings. Interview with 4 of 4 staff corroborated that they had never seen a bat inside the facility. Information obtained from additional residents stated that they do not have active concerns of pests being an issue inside the facility. Continued on LIC 9099-C. Through direct observation, LPA Perez toured the facility and inspected 10 randomly selected rooms to assess conditions related to the allegations. 10 out of 10 rooms were noted to be free of pests, including flies, cockroaches, ants, and bed bugs. Additionally, a review of records confirmed that the facility maintains a semi-monthly contract with Orkin Pest Control. Invoices dated January 2025 through August 2025 documented twice-monthly services covering both the exterior and interior perimeter of the facility. Based on interviews, record reviews, and observations, the allegations that staff do not ensure facility is in good repair and staff do not ensure the facility is free from pests have been deemed UNSUBSTANTIATED. A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report was provided to Executive Director Molly Bowie.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 18-AS-20250808114504

Allegation investigated: Facility staff stole money from resident

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with Executive Director Molly Bowie, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and witnesses, and file reviews. On December 1, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that facility staff stole money from resident. It was alleged that a night shift staff member entered the room of Resident 1 (R1), resulting in monetary theft. Interview with R1 reported that on November 18, 2025, while completing their morning routine, they noticed money missing from a bag kept in their room. R1 speculated that staff had entered the room during the night and taken money while they slept.Additionally, R1 acknowledged that they did not see or could not identify any individual involved. R1 emphasized that the allegation was based solely on their recollection that the money was accounted for when they went to sleep and was missing upon waking. Continued on LIC 9099-C.. Unsubstantiated An interview with Additional Witness 1 (AW1) indicated that an investigation had been conducted, which corroborated the statements provided by Resident 1 (R1). AW1 noted that the information obtained was based on speculative events. Interview with Wellness Director (WD), Olga Morales confirmed their involvement in the initial investigation and reported conducting a follow-up interview with R1. During this follow-up, WD identified discrepancies from R1’s initial statement. R1 disclosed that they had provided money to an unknown individual to purchase products but refused to provide further information about the individual. Interview with Witness 1 (W1) revealed that they had not observed staff entering the room during the alleged time frame and had not experienced any missing items in their own room. Interview with S1 confirmed they were assigned to review facility security footage for abnormalities at the alleged location and time frame. S1 reported that the review did not reveal any suspicious activities involving facility staff. Record review indicated that a Special Incident Report was submitted to CCLD regarding the incident, documenting that appropriate steps were taken to support the resident in care. Based on interviews, research, and record review, the allegation that that facility staff stole money from resident has been deemed UNSUBSTANTIATED. A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report was provided to Executive Director Molly Bowie.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 18-AS-20251201093713

Allegation investigated: Staff did not ensure the facility was free of bed bugs

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Executive Director Molly Bowie, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and witnesses, file reviews and observations. On June 24, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that staff did not ensure the facility was free of bed bugs. It was alleged that bed bugs were observed in Resident 1’s (R1) room and facility staff did not take appropriate action to address the issue. Information obtained from Interview with Business Office Manager Crystal Maldonado, confirmed a monthly contract is in place for pest control preventive measures and to address pest related concerns, such as bed bugs. Information obtained from an interview with S1 reported that one room tested positive for bed bugs. However, adjacent rooms or rooms of affected residents were treated as well. Continued on LIC 9099-C. Unsubstantiated S1 stated that all three rooms are currently in the final stages of treatment and are awaiting a final inspection by the pest control technician. LPA interviewed 5 out 5 residents and it was corroborated that they had not seen or had issues with bed bugs themselves and did not have concerns of an active bed bug infestation. Additional Witness 1 (AW1) reported that they have not personally observed any bed bugs within the facility, but became aware of the issue through informal conversations. Additional Witness 2 (AW2) stated that they observed a bed bug on the wall inside of R1’s bedroom and another on R1’s wheelchair. AW2 reported that management was informed and observed staff respond by removing the bed linens, relocating R1, and treating the room with a chemical. On August 11, 2025, LPA conducted a tour of the facility with Staff 1 (S1) and noted observations on 10 out of 10 resident bedrooms. LPA found 10 out of 10 rooms to have no evidence of active bed bugs, pests, rodents, or fly infestations. Additionally, LPA observed three additional rooms were found to be secured and under quarantine for bed bug treatment, with signage posted to restrict entry during the process. LPA confirmed through record review that a semi monthly contract is in place with pest control company Orkin. Through review of invoices, LPA noted that visits were twice a month for service on the exterior and interior perimeter of the facility. LPA obtained an invoice documenting a bed bug treatment conducted on June 13, 2025, which included targeted areas within the bedroom such as the bed frame, restrooms, and doorways. Based on interviews, record reviews, and observations the allegation that staff did not ensure the facility was free of bed bugs has been deemed UNSUBSTANTIATED. A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report was provided to Executive Director Molly Bowie.the state’s words, verbatim · CDSS document, Oct 10, 2025 · control 18-AS-20250624143025

Allegation investigated: Resident hit another resident due to staff neglect

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Wellness Director Olga Morales, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and witnesses, file reviews and observations. On August 25, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that a resident hit another resident due to staff neglect. On August 23, 2025, it was reported that Resident 1 (R1) was awakened by a physical altercation involving Resident 2 (R2). The incident is alleged to have resulted from staff neglect. Multiple interview attempts were made with Additional Witness 1 (AW1) to gather further information, however, AW1 did not respond to the interview request Continued on LIC 9099-C. Unsubstantiated Interview with Resident 1 (R1) reported being attacked with an object in their room. R1 was unable to describe the object, provide the individual’s name, or offer a physical description, stating only that they did not recognize them. Later in the same interview, R1 recalled that the individual may have been in a wheelchair and had a woman’s name, though no further identifying details were provided. R1 stated that they did not press their emergency pendant or call out for staff assistance during the incident, explaining that they were focused on the pain and didn’t think to do so. Despite the alleged event, R1 expressed that they do not feel neglected by the facility staff and affirmed that they do a good job caring for her. Interview with Resident 2 (R2) stated that they entered R1’s room on August 23, 2025. R2 reported calling out to R1 and believed they heard a response granting permission to enter. As R2 moved closer, R1 appeared startled, disoriented, and confused. R2 denied any physical contact with R1 and stated that they exited the room shortly thereafter. R2 expressed that they had no reason to believe their actions would be interpreted as an assault. Interview with Witness 1 (W1) revealed that they did not hear an attack take place and could only acknowledge that R2 was at the entrance of the door. W1 could not determine if R2 entered the room since a covering separates their beds. W1 added that even though their view was obstructed, they did not hear any altercation or attack had occurred. Interview with Executive Director Molly Bowie (ED) reported that staff had not reported any concerns with observed interactions between R1 and R2. ED added that R1 waited until the following morning to report the alleged attack to staff. ED stated that proper procedure was followed, contacting law enforcement and responsible parties. ED stated that the allegation was handled with diligence and investigation did not result in valid concerns. Interview with 5 out 5 staff corroborated that R1 did not have any visual bruising or marks consistent with a physical attack. Additionally, it was supported that R2 is observed to be vocal with their words and not known to have a history of physical aggression towards staff or residents. Continued on LIC 9099-C. On August 29, 2025, Licensing Program Analyst (LPA) Armando Perez conducted observations related to the reported allegation. During the visual assessment of areas reviewed, no injuries or physical markings were observed on R1 that would be consistent with signs of a physical assault. Through record review of staff scheduling records indicated that adequate staffing levels were in place to support proper resident supervision. Additionally, it appears sufficient staff were available to respond to the emergency if R1 had utilized the call system. Based on interviews, record reviews and observations the allegation that a resident hit another resident due to staff neglect has been deemed UNSUBSTANTIATED. A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report was provided to Activities Director Olga Morales.the state’s words, verbatim · CDSS document, Sep 24, 2025 · control 18-AS-20250825145647

Allegation investigated: Facility did not allow a resident visitors.

On 08/21/2025 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the complaint allegation noted above. The LPA met with Crystal Rulas-Maldonado, Business Office Manager and explained the purpose of the visit and the elements of the allegation. The allegation was investigated and consisted of interviews and records review. It was alleged Resident 1 (R1) had visitor that was told they had to leave as the facility’s insurance would not permit for them to be there. It was alleged there was a witness (W) to staff saying this to R1’s visitor. Per an interview with R1, R1 stated that their visitor is only allowed to be in the activities room, and dining room, but not allowed inside their room. R1 states they have the same visitor every other day. However, R1 was interviewed on another date where R1 reported they have never had a visitor denied and the same visitor, visits often. An interview with the witness (W) who was to have allegedly overheard the conversation where staff asked R1’s visitor to leave was conducted. W reported they did not hear the conversation. They observed an interaction where they saw staff approach the visitor, talk to the visitor Unfounded and then the visitor exited the facility. However, W reports they did not overhear what was said. An interview with R1’s visitor was conducted. The visitor reports they visit R1 every day. The visitor reports they have never been asked to leave the facility. Per an interview with Executive Director Molly Bowie, Bowie denied asking R1s visitor to leave and that there no restrictions when it comes to visitation. Per a records review of the facility visitation policy, it revealed that visitation is allowed 24/7. Per Bowie visitation does not include sleeping in resident rooms or common areas. Per interviews conducted with other residents, residents report there have not been any issues with having a visitors, nor are visitors restricted to certain areas within the facility. Therefore, the allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted where a copy of this report was reviewed and provided to Crystal Rulas-Maldonado, Business Office Manager.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 18-AS-20250505154117

Type of visit: Case Management - Other

On 08/21/25 Licensing Program Analyst (LPA) Javina George conducted an unannounced visit to the facility for a case management to deliver amended findings pertaining to complaint control 18-AS-20250505154117 and complaint control number 18-AS-20240802094711. LPA met with Crystal Rulas-Maldonado, Business Office Manager and informed her of the purpose of the visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Crystal Rulas-Maldonado, Business Office Manager.the state’s words, verbatim · CDSS document, Aug 21, 2025

Allegation investigated: Staff leave resident in soiled diapers for an extended period of time Staff are not responding to resident's requests for assistance in a timely manner Staff do not ensure that resident is provided with proper incontinence supplies

On 8/20/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility to deliver findings regarding the allegations listed above. LPA met with Wellness Coordinator, Breanna Jones who was informed of the purpose of the visit. Regarding the allegation, “Staff leave resident in soiled diapers for an extended period of time” it was alleged Resident 1 (R1) is left in soiled/wet diapers consistently for about 45 minutes to an hour. LPA reviewed R1’s physician’s report dated 03/13/2025 and the capacity for self-care subsection, “Able to Care for Own Toileting Needs” is marked “No”. R1 was interviewed and reported they wait approximately one and a half-to-two hours to receive incontinence care on a daily basis after calling the front desk for assistance. Three (3) staff were interviewed and reported R1 is constantly checked on and receives as needed incontinence assistance in a timely manner. One (1) of three (3) staff interviewed reported they check on R1 at least every 30 minutes where R1 will report whether they are soiled/wet and request or decline a brief change. One (1) of three (3) staff interviewed reported R1’s incontinent care refusals are not documented because R1 will initially decline a brief change but later request/agree to a brief change before the end of shift. Staff reported the facility does not document each time a resident receives incontinence care. Substantiated Eight (8) additional residents who were identified to require incontinent care were interviewed. Two (2) of eight (8) residents interviewed denied requiring incontinent care. Three (3) of eight (8) residents interviewed reported receiving incontinent care in a timely manner. However, three (3) of eight (8) residents interviewed reported waiting approximately two (2) to three (3) hours to receive incontinent care from staff after requesting staff's assistance. Based on interviews conducted, this allegation is substantiated. Regarding the allegation, “Staff are not responding to resident's requests for assistance in a timely manner” it was alleged R1’s call light is not working properly so they are forced to call the front desk. LPA reviewed R1’s physician’s report dated 3/13/2025 and the mental condition subsection, “Able to Communicate Needs” is marked “Yes”. R1 was interviewed and reported their call light works properly but facility staff respond approximately forty-five minutes to an hour after R1 activates their call light, which prompts them to call the front desk. Three (3) staff interviewed reported having knowledge R1’s call light works properly. One (1) of three (3) staff interviewed reported they have accidentally activated R1’s call light evidenced by the call light illuminating which required staff to turn it off. A staff interview reported all residents’, including R1’s, call lights have been tested and found to be functioning properly. Nine (9) additional residents were interviewed of which one (1) reported being independent and not using their call light. Four (4) of nine (9) residents interviewed reported activating their call light and receiving timely assistance and waiting up to fifteen minutes. One (1) of nine (9) residents interviewed reported receiving assistance approximately thirty minutes after activating their call light. However, three (3) of nine (9) residents interviewed reported receiving assistance one (1) to three (3) hours after activating their call light for assistance. Administrator, Molly Bowie reported the facility's call light system does not give them the ability to send call log reports or view call light response times. Based on interviews conducted and records reviewed, this allegation is substantiated. Regarding the allegation, “Staff do not ensure that resident is provided with proper incontinence supplies” it was alleged R1’s incontinent supplies are the incorrect size. R1 was interviewed and reported when they moved into the facility, they immediately noticed the briefs provided by the facility were too small because they irritated their skin. Three (3) staff were interviewed and refuted the allegations. Two (2) of three (3) staff interviewed reported although the briefs provided by the facility seemed to be appropriately sized, R1 decided to purchase their preferred brand and size of briefs. One (1) of three (3) staff interviewed reported the brand of briefs the facility uses is sized larger than the standard measurements for that size and accommodates waist sizes greater than R1’s. One (1) of three (3) staff interviewed showed LPA the brand and size of briefs provided to R1, and LPA compared it to the briefs R1 reportedly uses. Based on the brief labels, the briefs R1 uses accommodate waist sizes that are up to twenty-two inches larger than the briefs provided to R1 by the facility. Based on interviews conducted and records reviewed, this allegation is substantiated. An exit interview was conducted and a copy of this report, LIC 9099-D, Confidential Names list (LIC 811) and Appeal Rights were reviewed with Wellness Coordinator, Breanna Jones. Administrator, Molly Bowie called Wellness Coordinator Jones and developed the plan of corrections with LPA.the state’s words, verbatim · CDSS document, Aug 20, 2025 · control 18-AS-20250408113819

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Aug 29, 2025

87625 Managed Incontinence (b)(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by: Based on interviews conducted, four (4) of eight (8) residents reported waiting approximately two (2) to three (3) hours to receive incontinent care from staff after requesting staff's assistance. This poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: Administrator reported the facility will conduct an all staff training on 8/28/2025 regarding providing residents with timely incontinence care. POC will be emailed to LPA by close of business on 9/3/2025 to allow for any contingencies.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 29, 2025

(a) (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interviews conducted, four (4) of nine (9) residents reported wait times ranging from 45 minutes to three (3) hours to receive staff assistance after activating their call light.This poses a potential health/safety/personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: Administrator reported the facility will conduct an all staff training on 8/28/2025 regarding appropriate call light response times. POC will be emailed to LPA by close of business on 9/3/2025 to allow for any contingencies.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(D) · Plan of correction due date: Sep 3, 2025

(a)(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (D) Hygiene items of general use such as soap and toilet paper. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, the briefs R1 uses accommodate waist sizes that are up to twenty-two inches larger than the briefs provided to R1 by the facility. This poses a potential health/personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: Administrator will work with corporate office to develop a practice to obtain appropriate incontinence supplies, if the facility's supply does not meet resident's needs. POC to be emailed to LPA by COB on 9/3/2025.

Allegation investigated: Staff do not ensure that resident is getting medical treatment as necessary

On 8/20/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility to deliver findings regarding the allegations listed above. LPA met with Wellness Coordinator, Breanna Jones who was informed of the purpose of the visit. Regarding the allegation, “Staff do not ensure that resident is getting medical treatment as necessary” it was alleged R1 requested lab work to manage their health care needs and an appointment has not been scheduled on behalf of the resident. LPA reviewed R1’s physician’s report dated 03/13/2025 and neither mild cognitive impairment (MCI) nor dementia are marked. R1 was interviewed and reported they arrange their own medical appointments. R1 further reported they were attempting to gain assistance with the lab work from a home health agency and was experiencing issues with the home health agency, not issues with the facility. R1 reported they did not seek assistance from facility staff to assist with this issue. Therefore, this allegation is unfounded. An exit interview was conducted and a copy of this report and Confidential Names list (LIC 811) were reviewed and provided to Wellness Coordinator Jones. Unfounded Three (3) of three (3) staff were interviewed and reported R1 is transported to the dining room for meals timely or at the time they request. Three (3) additional residents were identified as requiring assistance and be taken to meals. One (1) of three (3) residents were unavailable for an interview. Two (2) of three (3) residents interviewed reported being taken to the dining room in a timely manner or ten minutes before the meal services begin. Therefore, this allegation is unsubstantiated. Regarding the allegation, “Resident is being locked out of their room due to staff neglect” it was alleged R1 does not have a key to their room and is consistently locked out. R1 was interviewed and reported they have a key to their bedroom door leading from the facility’s hallway but their request for a key to their bedroom door leading to the outside of the facility was denied by facility staff. R1 reported they have not been locked out of their room. LPA toured R1’s bedroom and observed one door leads to the facility hallway and the other leads to the outside of the facility. LPA also observed the door leading to the outside of the facility requires a key to gain entry into R1’s bedroom from outside the building and has a lever door handle from inside the bedroom with a push button release, giving R1 the ability to unlock the door from the inside without a key. Three (3) of three (3) staff were interviewed and refuted the allegations. One (1) of three (3) staff interviews conducted reported R1 requested a key to their bedroom door leading to the outside of the facility due to their visitor disliking checking in through the main entrance and signing the visitor’s log. Staff interviews revealed R1’s request for a key to their bedroom door leading to the outside of the facility was denied because it uses a master key that opens eight (8) other resident rooms. If the master key was provided to R1, they would have access to other resident rooms. Additionally, staff carry one (1) master key to be able to assist residents residing in the nine (9) bedrooms to evacuate the building in the event of an emergency. Based on interviews conducted and records reviewed, this allegation is unsubstantiated. An exit interview was conducted and a copy of this report and Confidential Names list (LIC 811) was reviewed and provided to Wellness Coordinator Jones.the state’s words, verbatim · CDSS document, Aug 20, 2025 · control 18-AS-20250408113819

Allegation investigated: Illegal eviction Food service is not provided in a timely manner to residents in care Staff do not ensure residents dietary plan is followed

On 8/20/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility to deliver findings regarding the allegations listed above. LPA met with Wellness Coordinator, Breanna Jones who was informed of the purpose of the visit. Regarding the allegation, “Illegal eviction” it was alleged Resident 1 (R1) was pressured by the facility to sign onto the Assisted Living Waiver (ALW) Program, was informed all the services would be covered, and now received an unlawful eviction notice. LPA reviewed R1’s 30-day eviction notice dated 06/12/2024 issued for nonpayment of the basic services within (10) days of the due date. R1’s eviction notice contained all the required elements. LPA also reviewed R1’s "Payer Detail Ledger" provided by the facility dated 07/08/2024 noting their balance owed. R1 was interviewed and confirmed receiving an eviction notice but refused to provide any other information regarding this allegation. Based on a facility staff interview, LPA received the following information. Staff deny pressuring R1 to participate in the ALW program. Unsubstantiated R1’s admission agreement dated 05/31/2022 was reviewed and revealed R1 was a private pay resident being charged $2500 a month. Staff reported R1 was previously participating in a program that did not continue after the change of ownership. Staff reported that residents participating in this program were given the option to work with the program to identify new facilities contracted with that program so R1 could continue to receive the benefits of that program. Staff report R1 chose to remain in the facility and enroll in the ALW program. LPA reviewed the ALW Patient’s Rights, Freedom of Choice Form, and Amenity Form dated in October of 2023 reflecting R1’s signatures and acknowledging awareness to the ALW participant’s role and responsibility. Due to R1 declining to provide any additional information, LPA was unable to confirm R1’s signature to validate the ALW program consent forms, or to validate if they were pressured to participate in the ALW program. Staff reported R1 was required to pay their portion of the agreed upon rate and the ALW program would pay another portion. Staff reported R1 was not paying their portion of the agreed upon rate. LPA was unable to confirm with R1 if payments were being made or not. LPA received a copy from the facility of an unlawful detainer issued for R1. Therefore, this allegation is unsubstantiated. Regarding the allegation, “Food service is not provided in a timely manner to residents in care” it was alleged food is served late or not at all. LPA made contact with the reporting party who was unable to identify the affected residents nor provide additional details. As a result, LPA conducted an interview with a sample of the population. Facility staff was interviewed and refuted the allegation. Staff reported breakfast is served from 7:30 a.m. to 9:00 a.m., lunch from 11:45 a.m. to 1:00 p.m., and dinner from 4:45 p.m. to 6:00 p.m. Eight (8) residents were interviewed, and eight (8) of eight (8) reported meals are served in a timely manner. Therefore, this allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was reviewed and provided to Wellness Coordinator Jones. Regarding the allegation, “Staff do not ensure residents dietary plan is followed” it was alleged Resident 2 (R2) requires a diabetic diet, and the facility does not accommodate them. R2 was interviewed and corroborated the allegation. However, LPA reviewed R2’s physician’s report and the “Other Conditions” section states, “DM II” but the "Special Diet" subsection is marked "No". A staff interview conducted reported certain residents prescribed diabetes medications may not require a special diet, as some medications require a regular diet to prevent dangerously low blood sugar levels. The staff showed LPA R2’s physician’s orders and reported it listed a prescription medication commonly used to help manage type 2 diabetes. LPA made several unsuccessful attempts to contact the physician listed in R2’s physician’s report to confirm whether R2 required a special diet. Staff reported R2 would tell them, they could not consume sugary foods however, R2 is known to request high-sugar desserts such as chocolate cake with meals. The facility reported they never received an updated physician’s report or medical record to indicate R2 ever required a special diet while they resided in the facility. A staff interview conducted reported R2 has since moved out of the facility and there is no forwarding contact information for them. Therefore, this allegation is unsubstantiated. One (1) of four (4) residents interviewed corroborated the allegation. Three (3) of four (4) residents interviewed reported although they have experienced issues with bed bugs or roaches in their rooms, a professional pest control company treated their rooms promptly. However, LPA reviewed the facility’s pest observations log which noted on 3/8/2024 and 3/27/2024, three (3) resident rooms were identified to have sightings of bedbugs/roaches and the log's “Corrective Actions Taken” column was left blank. LPA conducted a witness interview with Orkin who reported there is no documentation that the three (3) resident rooms identified in the pest observations log and the additional resident room identified during the resident interviews received treatment on or around the reported dates. Administrator Bowie reported during the identified incident time-frames, the facility did not work with any other pest control company besides Orkin. Facility staff was unable to provide documentation to demonstrate the facility took appropriate action to mitigate the pest sightings reported in the specific resident rooms. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore this allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report, LIC 9099-D, and Appeal Rights were reviewed and provided to Wellness Coordinator Jones. Administrator Molly Bowie called Wellness Coordinator Jones and implemented the plan of correction with LPA.the state’s words, verbatim · CDSS document, Aug 20, 2025 · control 18-AS-20240627092850

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 3, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, the facility was unable to demonstrate they took appropriate action to mitigate the pest sightings reported in specific resident rooms. This poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: Administrator reported the facility will conduct an all staff training on 8/28/2025 regarding proper practices to report, document, and follow up on pest signs/sightings. POC will be emailed to LPA by close of business on 9/3/2025 to allow for any contingencies.

Allegation investigated: Staff failed to arrange medical care appropriate to the resident’s condition, which resulted in serious bodily injury and hospitalization.

Licensing Program Analyst (LPA), Valerie Flores conducted an unannounced visit to conclude the complaint investigation regarding the above-mentioned allegation. LPA identified herself and discussed the findings with Wellness Cooridinator, Brianna Jones. It was alleged that the licensee failed to arrange medical care appropriate to the resident’s condition, which resulted in serious bodily injury and hospitalization. The Department’s investigation included multiple unannounced facility inspections and interviews with staff, Wellness Director, resident, and other relevant sources. In addition, the Department reviewed facility records for Resident #1 (R1) [Refer to the LIC 811 Confidential Names List for identification], along with pertinent records from the hospital, hospice agency, and home health agency. (Continue to LIC9099C) Substantiated (Continuation from LIC9099) R1 moved into the facility on October 31, 2023, and was non-ambulatory and spent extended periods either in bed or in a wheelchair. R1 also experienced bowel and bladder incontinence, residual numbness in their lower back and buttocks, and limited mobility. These conditions placed R1 at high risk for skin breakdown. However, the facility file contained no Appraisal/Needs and Services Plan and no other documented plan for monitoring or managing R1’s elevated risk. In March 2024, a Med-Tech (MT1) observed what appeared to be an early-stage pressure injury on R1’s tailbone, describing it as a “black mark.” MT1 indicated that she texted a photo of the pressure injury to Wellness Director Petricia Ward. According to MT1, no treatment or physician follow-up occurred after she elevated R1’s condition. MT1 further reports that R1’s care was not sufficient and left Savant of Riverside due to the ongoing neglect she witnessed. Around the same time, a caregiver (C1) observed a small mark on R1’s tailbone during an adult brief change, which she described as a ‘dot’ or ‘blackhead pimple”. C1 claimed she told one of the Med-Techs but could not recall who. On a subsequent day, the mark appeared larger, prompting her to ask a Med-Tech to re-check it. Another caregiver (C2) recalled the pressure injury starting as a small cut, then worsening and developing a foul smell. C2 reported her observations to Ward and the Med-Techs. C2 noticed that the overnight shift caregivers were not very diligent in changing R1’s briefs through the night as C2 often found R1 soaked upon her arrival at 6:00 AM. C2 added that she reported her observations but does not feel management was as responsive as they should have been. Despite these early reports, no charting or wound care orders appear in the facility’s records until April 7, 2024. Facility LVN (LVN) stated she remembered that one of the caregivers reported R1 had a pressure injury sometime in April. LVN added that she told Ward the wait for R1’s physician to order home health was too long, as the wound had developed odor and suspected infection. (Continue to LIC9099C) (Continuation from LIC9099C) LVN emphasized that Ward did not share her urgency to send R1 to the hospital. LVN shared that she left Savant of Riverside because she had concerns about the overall level of care provided to the residents, which included having insufficient staff to provide care. A Med-Tech (MT2) remembered that R1 was “not well taken care of”. MT2 confirmed being in the room with MT1, who was upset about R1’s wound. MT2 told MT1 to show Ward pictures of the wound. She recalled Ward saying she would handle it, but no follow-up action was observed. On April 15, 2024, a Med-Tech (MT3), learned that R1 had a fever and worsening wound pain. MT3 stated she contacted non-emergency transport to take R1 to the hospital. When R1 initially refused, EMS was called and transported R1 to the hospital ER. MT3 said Ward later admonished her for sending R1 out, indicating that home health was scheduled for the following week. On April 16, 2024, at the hospital ER, R1 was found to have an unstageable, infected pressure ulcer with necrotic eschar at the L-1 to L-3 level. Neurosurgery determined it was unrelated to R1’s prior back incision. On April 17, R1 underwent surgical debridement and a temporary colostomy to manage bowel incontinence, and a wound vacuum was placed. R1 was discharged to the facility on April 24 with orders for home health wound vac and colostomy care. From April 25 to May 13, 2024, a home health agency visited three times per week for wound vac and colostomy care. On May 15, a hospice agency assumed wound care. Hospice records from May 15th show an unstageable medial sacrum wound measuring 11.4 x 6.4 x 2.5 cm with 50% eschar, tunneling, and moderate slough, along with signs of infection including yellow drainage and odor. Hospice documentation notes that facility staff had been asked to increase peri-care frequency, but R1 continued to be found in a “heavily saturated pull-up at each recent visit”. The hospice nurses recorded that the wound was in decline despite antibiotics and recommended urgent consideration of IV antibiotics and surgical debridement to prevent osteomyelitis. (Continue to LIC9099C) (Continuation from LIC9099C) On May 29, R1 was admitted to the local hospital, began IV antibiotics, and underwent two surgeries over a two-day period. R1 was discharged to the facility on June 3rd but returned to the hospital the same day for further IV antibiotic treatment. R1 was later admitted to a skilled nursing facility on June 10th and moved out of the facility July 2nd with the wound unresolved. During the interview, Ward stated she was verbally informed about the wound but denied ever receiving a text message or photo of it from any Med-Tech. She was certain that April 7th was the first date she became aware of the wound and denied having knowledge of it prior to that date. Ward acknowledged, however, that the wound she observed on April 7th had developed before that day, describing it as a ‘black sore.’ She indicated that she immediately requested home health at that time. Ward explained that any reddened area or abrasion should be reported right away, which she said did not occur. She placed blame on the direct caregivers and Med-Techs for failing to report the initial skin breakdown. Ward further agreed that R1 should have been sent to the hospital earlier than April 15th, and that R1 should not have returned to the facility after discharge. She stated that she raised this concern with upper management, emphasizing that nursing staff in upper management make the final decision about whether a resident like R1 can return. Ward clarified that even as Wellness Director, she did not have the authority to decide when a resident should be sent to the hospital. When interviewed, R1 stated that the facility “let it go,” which led to the infection. R1 reported developing a fever of 103 degrees with hot and cold sweats, at which point the facility sent him to the hospital ER for treatment. R1 believes that more prompt action by the facility could have prevented the wound altogether, and that earlier medical intervention might have kept it from progressing to the point of requiring two surgeries. Records reflect that on April 7, 2024, Wellness Director Ward documented for the first time that R1 had a coccyx wound, contacted the resident’s physician, and requested home health. On April 10, a Physician Assistant (PA) examined the resident, charted a sacrococcyx ulcer of approximately one week’s duration, and ordered a STAT wound care referral. Facility records show no evidence of skilled medical care being provided to R1 between April 7th and April 15th. (Continue to LIC9099C) (Continuation from LIC9099C) Ward acknowledged the wound likely existed before April 7th, and agreed the delay in hospitalization should have been shorter. Multiple staff reported systemic issues at the facility, including lack of documentation, inadequate staffing, residents left soiled overnight, and pressure from management to avoid calling 9-1-1. Witness statements were consistent in describing delays in wound care and lack of response to concerns. Medical and hospice records confirmed the wound worsened, resulting in severe infection and multiple surgeries. Based on observations, interviews, and review of records, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. The California Code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. The licensee was advised that a civil penalty is being considered pursuant to Health and Safety Code Section 1569.49(f). An exit interview was conducted and a copy of this report along with Licensee Appeal Rights (LIC 9058 03/22) were provided to Wellness Coordinator, Brianna Jonesthe state’s words, verbatim · CDSS document, Aug 20, 2025 · control 18-AS-20240923133421

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Sep 3, 2025

(a)A plan for incidental medical and dental care shall be developed by each facility...(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This was not met with evidence by: Based on interviews and records review the licensee did not arrange or assist in arranging, for medical care appropriate to the condition of resident #1 which posed an immediate health risk to 1 of 1 persons in care.the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: Wellness Director, Brianna Jones, stated that the facility will hold an in-service training in regard to frequent repositioning of bedridden resident and the process of documenting early stages of pressure injuries. Training will be emailed to LPA via email by close of business on 9/3/2025.

Allegation investigated: Staff does not ensure resident is administered medications as prescribed Staff is mismanaging resident's medications

On 8/18/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering investigative findings into the allegations listed above. LPA Flores identified herself and discussed the purpose of the visit with Administrator, Mollie Bowie. A tour of the facility was conducted and LPA did not observe any health and safety concerns. The investigation consisted of record reviews and interviews. It was alleged staff did not ensure residents were administered medication as prescribed. On the afternoon of 3/18/2024, Staff #1 (S1) documented on the Medication Administration Record (MAR) that Resident #2 (R2) was out of a medication and was needing to be filled. Per the MAR, R2 did not receive the refilled medication until 3/21/2024. Through interviews, information obtained alleged staff are waiting until the medication was out-of-stock until a new order of the medication is submitted causing there to be a delay of when the residents were receiving their medication. (Continuation to LIC9099C...) Substantiated (Continuation from LIC9099) Information received by the pharmacy further corroborated that staff did not place the initial order to fill prior to the medication running out on 3/18/2024. An order to fill was received on 3/20/2024 and medication was refilled/delivered on 3/21/2024. Therefore, the order delay resulted in medication being inaccessible to R2 if and when it was needed. It was further alleged that staff is mismanaging residents’ medication. Through record review, the MAR divulged R2’s medication was “not in cart” on 3/18/2024. Interviews confirmed when staff document that medication is “not in cart”, it means resident finished the medication and a new order is needing to be placed. On the afternoon of 3/19/2024, S1 documented R2 refused the medication. On the morning of 3/20/2024, Staff #2 (S2) documented on the MAR that the medication was “not in cart will follow up”. The afternoon of 3/20/2024, S1 documented on the MAR that R2 was administered the medication. Verbal information received by the pharmacy confirmed that the medication order was placed on 3/20/2024 and filled on 3/21/2024. The previous order for that medication was placed in February of 2024. Therefore, the facility staff did not have medication to offer or provide to R2 as it was previously alleged by S1 on the listed dates. Based on interviews and records review, the allegations of staff do not ensure resident is administered medications as prescribed, and staff is mismanaging resident's medications has been determined to be SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. California Code of Regulations (Title 22, Division 6 & Chapter 3) are being cited on the attached LIC 9099D). An exit interview was conducted and a copy of this report, 9099D, appeal rights, and LIC811-confidential names list were reviewed and provided to Administrator, Mollie Bowie. (Continuation from LIC9099A) The facility does not retain records of residents enlisting and/or changing their pharmacy as it is the decision of the resident and the resident’s responsible party. Per Mollie, the resident and their responsible party are the only people allowed to enroll and/or make changes to the residents pharmacy. If a resident chose to enroll in Market Pharmacy, the resident would have to contact Market Pharmacy directly to enroll. A review of R1’s file was conducted, and it did not contain any documents related to which pharmacy R1 is utilizing. Additional interviews conducted with a relevant party, corroborated that R1 is the only person able to change the pharmacy and changes can be conducted over the phone Based on interviews and records review, the allegation of staff changed resident's pharmacy without resident's consent is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator, Mollie Bowie.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 18-AS-20240419162313

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Sep 5, 2025

Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly...if the following requirements are met: (2) once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:1 out of 1 residents was out of their prescribed medication for multiple days. This poses a potential health, safety and personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Aug 18, 2025

Plan of correction: The Licensee agrees to in-service training on medication administration and timely reordering to delay lapse in medication. This training is to be forwarded to LPA via email by close of business on 9/5/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Sep 5, 2025

Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall... provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange...for medical and dental care appropriate to the conditions and needs of residents. This was not met by: The Licensee did not comply with the above regulation with 1 out of 1 residents. As R2 was not given their medication as prescribed on multiple occassions. This is an immedaite health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 18, 2025

Plan of correction: The Licensee agrees to in-service on proper documentation when completeing the Medication administration record, This training is to be forwarded to LPA via email by close of business on 9/5/2025.

Allegation investigated: Lack of supervision/neglect resulting in resident developing a pressure injury

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegation. LPA met with Molly Bowie, Executive Director and informed them of the LPA's visit. The Department investigation involved interviews with staff, residents, and review of records. On 06-09-2025, Community Care Licensing (CCLD) received a complaint report with the above allegation. It was alleged lack of supervision/neglect resulting in resident developing a pressure injury. Information received stated Resident #8 (R8) had pressure injury that was not treated. LPA’s review of resident file revealed R8 was admitted into the facility in September 2023 and had been under hospice care since March 2024 due to conditions unrelated to the wound care. Continued on LIC9099-C..... Unsubstantiated R8 passed away while receiving hospice care in April 2025 at the facility. LPA conducted review of progress notes documenting routine hospice visits for comfort and wound care. LPA’s review of R8’s hospice records and care plan revealed R8 required assistance with all activities of daily living (ADLs) including repositioning. According to hospice records, facility staff received training on March 3, 2025, for pressure injury management from the hospice agency, including guidance on proper reposition techniques, importance of maintaining strict reposition intervals, and incontinent care routines. Interviews conducted with the Administrator and three (3) staff members assigned to R8 revealed that staff followed hospice-provided instructions regarding wound care, repositioning procedures/routines, and incontinent care. LPA’s review of the hospice agency wound care records indicated R8’s wound was improving. R8 had received routine care from the facility staff, in addition the facility staff confirmed they followed the facility’s procedures such as, routine room checks and repositioning, as well as those from the hospice agency. Based on record review and staff interviews, this allegation is Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means 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 a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 18-AS-20250609123952

Allegation investigated: Facility is not meeting a resident's care needs.

On 08/12/2025 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the complaint allegation noted above. The LPA met Crystal Rulas-Maldonado, Business Office Manager and explained the purpose of the visit and the elements of the allegation. The allegation was investigated and consisted of interviews and records review. Regarding the allegation of facility is not meeting a resident’s care needs, it was alleged that Resident #1’s (R1) feet were in need of care as their feet were observed to be swollen and with a toenail falling off. Furthermore, R1’s electric wheelchair had been in need of repair for months, and R1 requested repair multiple times with no assistance. It was alleged that R1’s feet were observed on or about 03/26/2025. R1 denied seeing the doctor as well as denying having any issues with their feet. The LPA conducted a records review of R1’s Charting Notes dated 03/15/2025 and it revealed that R1 was sent out due to sustaining an injury to their toe. The Patient Visit Information dated 03/15/2025 revealed R1 was seen for Hypertrophic toenail and instructions were provided for finger or toe bruise. Unsubstantiated Regarding R1’s electric wheelchair, R1 could not pinpoint a time frame of when their electric wheelchair had initially broken, but R1 reported it had been broken for some time. The LPA was not able to get a time frame of when the electric wheelchair was broken from the reporting party. The LPA conducted a records review of Charting Notes for R1 and they revealed that on or around 05/19/2025 R1 was informed of the status of options for the replacement of the electric wheelchair. The investigation could not determine if the facility staff responded timely to R1’s request for assistance on repairs to their electric wheelchair. Per an interview with Olga Martinez Wellness Director, R1 was given a manual wheelchair from their hospice agency sometime last year. Therefore the allegation is unsubstantiated, a finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted where a copy of this report was reviewed and provided to Crystal Rulas-Maldonado, Business Office Manager.the state’s words, verbatim · CDSS document, Aug 12, 2025 · control 18-AS-20250505154117

Type of visit: Case Management - Other

On 08/12/25, Licensing Program Analyst (LPA) Debbie Palacios conducted a Case Management visit in reference to complaint control number# 18-AS-20240509101436. LPA met with Executive Director Molly Bowie and explained the purpose of the visit. LPA conducted a tour of the interior/exterior areas of the facility. LPA did not observe any health and safety concerns. During this visit, additional staff and resident interviews were conducted in reference to complaint control number# 18-AS-20240509101436. At this time, an evaluation of information obtained during today’s visit will be assessed to determine if further review is needed. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 12, 2025

Allegation investigated: Facility staff failed to provide supervision to resident in care Staff failed to assist a resident in care with toileting

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Wellness coordinator Breanna Jones and explained the purpose of the visit. Administrator Molly Bowie arrived shortly. The investigation consisted of the following: During the initial visit conducted on 07/25/2025, LPA Martinez conducted a tour of the interior/exterior areas of the facility, conducted interviews, and obtained copies of pertinent documentation. On todays visit LPA Gutierrez interviewed Administrator, Staff #1- Staff #6, and Residents #2 -Residents #9. LPA obtained copies of the following documents: staff roster, resident roster, R1’s admission agreement and physicians report will be emailed to LPA. During today’s visit LPA Gutierrez delivered findings. SEE 9099C Unsubstantiated In regard to the allegation “Facility staff failed to provide supervision to resident in care”, it is alleged that staff “walked off” leaving resident needing help with using the restroom. During interviews with Administrator and staff seven (7) out of seven (7) stated that to their knowledge no staff has ever walked out on a client needing assistance with using the restroom. Staff stated they felt there was enough staff to provide supervision to residents in need. During interviews with residents eight (8) out of nine (9) residents stated no staff has ever walked out on them however they do feel more staff is needed. In regard to the allegation “Staff failed to assist a resident in care with toileting”, it is alleged that resident was left in soiled clothes for multiple days. During interviews with Administrator and staff seven (7) out of seven (7) stated that they have never had a resident left in soiled clothes for multiple days. Staff stated that if a resident had incontinent care needs that they are checked on every two hours or more if needed. During interviews with residents six (6) out of nine (9) residents stated that they have never been left or witnessed any one being left in solid clothes. R2 stated that he/she does have incontinence care and is checked up on every 2 hrs. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given.the state’s words, verbatim · CDSS document, Aug 10, 2025 · control 18-AS-20240723134829

Allegation investigated: Staff are not preventing the use of illegal drugs in the facility Staff are not preventing resident's from smoking cigarettes inside the facility

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Wellness coordinator Breanna Jones and explained the purpose of the visit. Administrator Molly Bowie arrived shortly. The investigation consisted of the following: During the initial visit conducted on 02/11/2025, LPA Perez requested and received pertinent documents and conducted record reviews. During the visit LPA interviewed staff #1. On todays visit LPA Gutierrez interviewed Administrator, Staff #2- Staff #7, and Residents #1 -Residents #9. R7 could not be interviewed. LPA obtained copies of the following documents: staff roster, resident roster, R1’s admission agreement with house rules, R4 R5 R7 warning letters, and R7 eviction notice. During today’s visit LPA Gutierrez delivered findings. SEE 9099C Unsubstantiated In regard to the allegation “Staff are not preventing the use of illegal drugs in the facility”, it is alleged that illegal drugs are being used at the facility. During interviews with Administrator and staff eight (8) out of eight (8) stated that to their knowledge no illegal drugs are being used. All staff stated that they have never physically seen drugs of any kind. During interviews with residents six (6) out of nine (9) residents stated that they have never witnessed illegal drugs being used. R4 did state that they have smelled weed but did not know who was using it. In regard to the allegation “Staff are not preventing residents from smoking cigarettes inside the facility”, it is alleged that some residents are smoking inside of their bedrooms. During interviews with Administrator and staff eight (8) out of eight (8) stated that yes there has been times that they have caught residents smoking in rooms, but they are written up for this. Administrator stated that they are in the process of eviction for one resident because of this matter. Staff state they remind residents that there is a designated smoking area in the back. During interviews with residents four (4) out of nine (9) residents stated that residents do smoke inside there rooms even though there not supposed to and that it is written in the admission agreement. R4 and R5 both stated they had been written up for this and have never done it again. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given.the state’s words, verbatim · CDSS document, Aug 10, 2025 · control 18-AS-20250210135057

Allegation investigated: Neglect/Lack of supervison. Staff are not following resident care plan. Staff is not ensuring resident is being fed regularly, resident appears malnourished. Staff are not responding to emergency call system in resident's room. Staff are allowing resident to become intoxicated while on nurmerous medications. Staff are allowing surveillance cameras in resident's room.

On 07/27/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit and met with Psych Tech Breanna Jones. On 07/26/2025, LPA Regina Cloyd conducted a subsequent visit on to gather information regarding the above allegation(s). LPA met with Edgar Almanza and the purpose of the visit was explained. Business Office Manager Crystal Ruelas joined later. On 07/25/2024, LPA Sara Martinez conducted an unannounced visit to the facility to initiate the investigation into the allegations listed above. LPA met with Wellness Coordinator Olga Morales who was informed of the purpose for the visit. Investigation consisted of the following: On 07/27/2025, LPA Cloyd interviewed three staff (S8 – S10), attempted to interview Witness #1 (W1) over the phone, and obtained Electronic Monitoring Consent Form. On 07/26/2025, LPA obtained staff roster (dated 06/01/2024) and Resident #1 record, June R1’s Medicaid Ledger (2024 and July 2024), R1’s Physician’s Order (as of 07/01/2024), R1’s Hospice Care Plan (07/26/2024) and the Facility’s Program Philosophy and Goals. Continue to LIC9099-C. Unsubstantiated LPA conducted six staff (S1 – S6) and nine resident (R2 – R10) interviews and toured the facility. On 07/25/2025, LPA received five Residents Incident Reports, and Medication Administration Records for four residents. On 07/21/2025. LPA received Resident Roster (dated 05/29/2024) and Staff Roster. On 07/25/2024, LPA Martinez conducted a tour of the interior/exterior areas of the facility, conducted interviews, and obtained copies of pertinent documentation. NOTE: Resident #1 no longer lives at the facility and June 2024 call logs were unavailable. Allegation: Neglect/Lack of supervision. Regarding the allegation, “Neglect/Lack of supervision,” it is being alleged that staff does not provide care and supervision to Resident #1. Record review of Admission Agreement (Basic Services) revealed care and supervision as one of R1’s services. Nine out of nine staff interviews (S1 – S6, S8 – S10) indicated they have not received any complaints that staff neglects residents. Eight out of nine resident interviews (R2 – R10) indicated that staff provides adequate care and supervision. Regarding the allegation, “Neglect/Lack of supervision,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Staff are not following resident care plan. Regarding the allegation, “Staff are not following resident care plan,” it is being alleged that Resident #1 requires activities of daily living but staff does not assist because of R1’s refusal. Record review of Care Plan (dated 07/11/24) revealed R1 requires maximum assistance for bathing, dressing, toileting, transferring, mobility, special care needs (safety checks and assistance with oxygen). R1’s hospice care plan revealed that R1 would receive two skilled nurse visit/week and one PRN visit week one. Services did not include skilled supportive nursing care. R1 was assigned two hospice aide visits (this week). The Hospice Aide Assignment does not indicate the completed tasks. Seven out of seven staff interviews (S1 - S2, S5 – S6, S8 – S10) indicated that they are knowledgeable of resident care plans to deliver services. S1 indicated that the care plan is printed and staff are required to review and sign. Seven out of eight staff interviews (S1, S3-S6, S8 – S10) indicated that staff provides adequate care and supervision. Continue to LIC9099-C. Seven out of seven staff interviews (S1 - S2, S5-S6, S8 – S10) indicated that they try to encourage residents to receive care services or have another caregiver provide the services at a different time. S1 indicated that a care conference is scheduled when a resident refuses services. S1 indicated that a reappraisal may be needed for a higher level of care. Eight out of nine resident interviews (R2 – R10) indicated that staff provides adequate care and supervision. Regarding the allegation, “Staff are not following resident care plan” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Staff is not ensuring resident is being fed regularly. Resident appears malnourished. Regarding the allegation, “Staff is not ensuring resident is being fed regularly. Resident appears malnourished,” it is being alleged that staff Resident #1 declines meal services because of the service cost and supplements with vitamins. Record review of R1’s Admission Agreement (Optional Services. Special Food Service) revealed tray service, a special food service, is charged after two days if the resident is unable, not willing, to come to the dining room. After two days, a fee of $0.00 per tray will be charged. This charge will be itemized at the end of the month. Residents who are unwilling to come to the dining room are not provided two days of tray service without charge. R1’s June 2024 and July 2024 Medicaid Ledger does not reflect food charges. On 07/25/24, interview with S7 indicated that R1 receives tray service for all three meals (breakfast, lunch, and dinner). On 07/26/25, seven out of seven staff interviews (S1-S4, S6, S9 – S10) indicated that alternative meals are offered to residents who decline food. S5-S6, and S8 indicated that staff tries to encourage the resident and come back to offer food two – three times. S1 and S8 indicated that the doctor will be asked to order supplements and if a resident refuses three meals then the resident will be sent to the hospital based on the doctor’s orders. Five out of eight staff interviews (S1, S3 – S6, S8 – S10) indicated that there is not a service cost for food delivery. S2 was unaware. S1 indicated that if the doctor orders food delivery for residents then it is communicated to the kitchen staff and there is no service charge. Five out seven resident interviews (R2 – R6, R8, R10) indicated that there isn’t a service charge for food deliver. R7 and R9 are unaware. Continue to LIC9099-C. Regarding the allegation, “Staff is not ensuring resident is being fed regularly. Resident appears malnourished” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Staff are not responding to emergency call system in resident's room. Regarding the allegation, “Staff are not responding to emergency call system in resident's room,” it is being alleged that Resident #1 fell on 06/14/2024 and did not receive assistance because the system was ineffective. On 07/25/24, an interview with S7 indicated that when R1 pulls the call button, R7 communicates with the care team and they will check on R1. On 07/26/25, nine out nine staff interviews (S1 – S6, S8 – S10) indicated that staff responds to residents’ call system. S1 and S8 indicated that many residents use the phone to call the front desk. Six out seven of resident interviews (R2- R3, R5 – R7, R9 - R10) indicated that staff responds in a timely manner. R6 indicated that R6 uses the phone and it automatically calls the Front Desk. LPA Cloyd tested the phone and the Front Desk answered. R4 and R8 indicated they don’t use the call system. Regarding the allegation, “Staff are not responding to emergency call system in resident's room” based on observation and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Staff are allowing resident to become intoxicated while on numerous medications. Regarding the allegation, “Staff are allowing resident to become intoxicated while on numerous medications,” it is being alleged that staff does not interfere because Resident #1 is independent. Three out three staff interviews (S3-S4, S6) indicated they have witnessed residents with alcohol on the property. S4 also indicated that S4 is unaware of which resident take medication, and that staff would intervene. S2 was unaware. S5 – S6 indicated that they would speak with Supervisor prior to handing out medication. Continue to LIC9099-C. S1 indicated that staff cannot determine if a resident is intoxicated unless the resident tells them. Then staff will call the doctor and ask if they should hold the next round of medication. S8 and S9 indicated they don’t encourage alcohol but will remind residents if they smell it on them or see it that they are on medication. R4 and R8 indicated they have not witnessed residents bringing alcohol into the facility. R6 and R9 have witnessed residents drinking alcohol. R2 - R3, R7 indicated alcohol is not allowed. R5 and R10 are unaware. Regarding the allegation, “Staff are allowing resident to become intoxicated while on numerous medications,” based on interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Staff are allowing surveillance cameras in resident's room. Regarding the allegation, “Staff are allowing surveillance cameras in resident's room,” it is being alleged that Resident #1 installed cameras in R1’s room. The facility does have an Electronic Monitoring Consent Form. S10 indicated that R1 did have a sign posted on R1’s door. S1 and S8 indicated that residents would sign a form or post a notice on their door about video recording. Six out nine resident interviews (R2 – R10) indicated they are unaware if cameras are allowed. Regarding the allegation, “Staff are allowing surveillance cameras in resident's room” based on interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided to the Psych Tech/Wellness Coordinator Breanna Jones.the state’s words, verbatim · CDSS document, Jul 27, 2025 · control 18-AS-20240716112652

Allegation investigated: Staff did not provide a comfortable temperature for resident. Staff did not treat resident with respect.

On 7/27/2025 at approximately 8:30 AM, LPA Alfonso Iniguez conducted a subsequent unannounced complaint visit. LPA Iniguez met with Breanna Jones/Phych Tech. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Culinary Director Interview (A#1), Residents Interviews (R#1-R#10) and Staff Interview (S#1-S#5). LPA obtained and reviewed the following documents: Resident Roster dated: 7/26/25, Staff Roster dated: 7/26/25, copies of (R#1)’s Medication Administration Records (MARs) dated: June 2024 through October 2024 and a Health and Safety check of the facility ( 10 randoms residents rooms: 201, 216, 222, 229, 241, 141, 145, 134, 138 and 137) and the facility elevators and Copies of Facility Staff Trainings regarding residents rights dated:2025. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff did not provide a comfortable temperature for resident. The details of the complaint alleged that the air conditioning on (R#1)’s room was in disrepair. On July 26, 2025, at approximately 4:00 PM, during a health and safety check of the facility, LPA Iniguez observed the former room #201 of (R#1). LPA noted that the air conditioning vent was functioning properly. Additionally, LPA Iniguez inspected (9) other residents' rooms—#216, #222, #229, #241, #141, #145, #134, #138, and #137—and confirmed that the air conditioning units and vents in all inspected rooms were working correctly. On July 26, 2025, at approximately 11:00 AM, during an Interview with the Business Officer Manager (A#1), she stated that all residents’ air conditioning units work correctly, including room 201. On July 25, 2025, at approximately 9:30 AM, LPA Iniguez contacted (R#1) by telephone, but (R#1) did not answer. LPA Iniguez left a voice message. At around 10:30 AM on the same day, LPA Iniguez attempted to reach (R#1) again, but once more, (R#1) did not pick up, and a voice message was left. For a third time, at approximately 11:30 AM, LPA Iniguez called (R#1), who again did not answer, prompting another voice message to be left. On July 26, 2025, at approximately 1:00 PM, during interviews with residents (R#1-R#9), (9) out of (9) stated that their air conditioning unit works properly. On July 26, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#5), (5) out of (5) stated that all residents’ air conditioning units work properly. Evaluation Report continues LIC 9099-C Allegation: Staff did not treat resident with respect. The details of the complaint alleged that the facility staff did not treat (R#1) with respect. On July 26, 2025, at approximately 3:30 p.m., during the records review, LAP Iniguez obtained copies of Facility Staff Trainings regarding residents' rights dated 2025. LPA Iniguez noticed that all facility staff have already taken the training regarding residents' rights this year. On July 26, 2025, at approximately 11:00 a.m., during an Interview with the Business Officer Manager (A#1), she stated that staff are trained in residents' rights annually and upon hire. On July 25, 2025, at approximately 9:30 a.m., LPA Iniguez contacted (R#1) by telephone, but (R#1) did not answer. LPA Iniguez left a voice message. At around 10:30 a.m. on the same day, LPA Iniguez attempted to reach (R#1) again, but once more, (R#1) did not pick up, and a voice message was left. For a third time, at approximately 11:30 a.m., LPA Iniguez called (R#1), who again did not answer, prompting another voice message to be left. On July 26, 2025, at approximately 1:00 p.m., during interviews with residents (R#1-R#9), (9) out of (9) stated that they have never been disrespected by facility staff. On July 26, 2025, at approximately 11:00 a.m., during interviews with facility staff (S#1-S#5), (5) out of (5) stated that they get trained regarding residents' rights mostly every year, and they have never disrespected any resident in care. Evaluation Report continues LIC 9099-C During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. 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, and a copy of the Complaint Report was given to Breanna Jones/Phych Tech.the state’s words, verbatim · CDSS document, Jul 27, 2025 · control 18-AS-20240625083051

Allegation investigated: Facility has bed bugs Resident was forced to relocate due to bed bugs

Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA Peraldi met with the Culinary Manager, Edgar Mendez and explained the reason for the visit. On 08/21/2024, the Riverside Adult and Senior Care Regional Office (RO) received a complaint regarding physical plant and personal rights violations. The complaint alleged that the facility and bedroom of Resident #1 (R1) had bed bugs and that R1 was forced to relocate rooms due to bed bugs. Continued on LIC 9099-C. Unsubstantiated On 08/23/2024, from 2:45pm to 3:45pm, Licensing Program Analyst (LPA), Kathleen Banrasavong, conducted an unannounced visit to the facility to initiate the investigation of the allegations listed above. LPA Banrasavong met with the Executive Director/Administrator Molly Bowie and informed her of the purpose of the visit. The LPA conducted a tour of the interior/exterior areas of the facility, conducted a review of records, and requested copies of pertinent documentation. The LPA interviewed residents and staff. The Executive Director/Administrator was advised that further investigation was needed prior to issuing findings. According to the Executive Director/Administrator, the facility has an ongoing contract with pest control company Orkin to provide routine services to prevent pests. Administrator stated there have been some instances where pests/bed bugs have popped up and they immediately address with the pest control company. The Administrator provided copies of Orkin service reports for service dates of 07/26/2024, 08/09/2024, 08/21/2024, 08/23/2024, 08/26/2024 and 08/27/2024. The administrator also provided the facility protocol for bed bugs and copies of the 08/21/2024 and 08/23/2024 incident reports submitted to Community Care Licensing (CCL). The incident reports document bed bugs were found in R1’s room and four other resident rooms. R1 refused to be temporarily relocated while R1’s room was treated; the other residents were relocated to temporary room assignments while the rooms were treated. R1 no longer resides at the facility. R1 moved out of the facility on 11/18/2024. An attempt to contact R1 was made, however, the phone number was not valid. The facility has demonstrated a proactive approach to pest management and is under a standing contract with Orkin to conduct semi-monthly services to help ensure the facility remains free of infestations. The Department’s investigation did not provide sufficient evidence to substantiate the allegations, therefore the above allegations are deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Jul 26, 2025 · control 18-AS-20240821141334

Allegation investigated: Staff are mismanaging resident’s medication.

Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Peraldi met with the Culinary Manager Edgar Mendez and explained the reason for the visit. On 10/10/2024, the Riverside Adult and Senior Care Regional Office (RO) received a complaint regarding an allegation of staff mismanaging Resident #1 (R1’s) medication. The complaint alleged that staff were refusing to administer R1’s full medication. On 10/15/2024, from 9:00am to 11:35am, Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to the facility to initiate the investigation into the allegation listed above. LPA Martinez met with the Administrator Molly Bowie who was informed of the purpose of the visit. Continued on LIC 9099-C. Unsubstantiated During the visit, the LPA conducted a tour of the facility, conducted interviews, and requested and obtained pertinent documents related to the allegation above. The Administrator was advised that further investigation was needed prior to issuing findings. A review of R1’s care plan, dated 09/24/2024, noted R1 needed assistance with toileting and medication management. R1 needed assistance with mobility, used a wheelchair, was blind in the left eye, and not much vision in the right eye. R1 required a diabetic and renal diet and assistance with glucose monitoring. Safety checks were noted to be one time per shift, medications were noted as four medication passes per day, four injections per day. The care plan also included R1’s need for dialysis, a case manager, and home health services. According to information obtained from the Administrator and facility notes, R1 was scheduled for dialysis appointments on Tuesday, Thursday, and Saturday. R1 would sometimes refuse dialysis appointments or refuse medications. R1 was non-compliant with dialysis and with the diabetic diet. Staff would remind R1 not to eat chocolate, candy, snacks and fast food. Facility notes documented that R1 administered the insulin injection by themselves . “R1 is always asking for the maximum amount of insulin. Asking for the maximum units due to the bad diet. R1 has a sliding scale. Staff set up the insulin and R1 administers.” A review of the physician’s orders and facility medication assistance record (MAR) noted that R1 was to receive a certain number of units of insulin dependent on the sliding scale determined by the blood sugar readings. Per the physician’s orders, the maximum daily dose of Humalog Insulin 100U/ML SOL is 20 units. According to the Administrator, R1 did the blood sugar readings by themselves. There were no blood sugar readings provided, only some of the readings were indicated in the facility notes. The review of Unusual Incident/Injury Reports (SIRs) and facility notes related to R1 revealed that on 10/03/2024, R1’s glucose read high, R1 called emergency medical services (EMS) and was transferred to the hospital. R1 received dialysis and returned to the facility the same day. On 10/05/2024, R1’s dialysis transportation did not arrive, R1 called EMS and was taken to the hospital. R1 returned to the facility 10/07/2024 with no new orders. On 10/11/2024, R1 was transferred to the hospital due to high blood sugar. Continued on LIC 9099-C. On 10/12/2024, the facility progress notes documented that the hospital was contacted for a medical update and the facility was informed that R1 was admitted to the Intensive Care Unit (ICU) due to DKA (Diabetic Ketoacidosis). R1 did not return to the facility. R1 was moved to another facility to be closer to R1’s family. The Department’s investigation did not provide sufficient evidence to substantiate that staff mismanaged R1’s medication. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Jul 26, 2025 · control 18-AS-20241010162139

Allegation investigated: Resident was hit over the head by another resident due to lack of supervision.

Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Peraldi met with the Culinary Manager Edgar Mendez and explained the reason for the visit. On 10/17/2024, the Riverside Adult and Senior Care Regional Office (RO) received a complaint regarding an allegation of lack of supervision. The complaint alleged that Resident #2 (R2) hit Resident #1 (R1) over the head. On 10/23/2024, from 8:15am to 12:15pm, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to investigate the allegation listed above. LPA Romero met with the Administrator, Molly Bowie, who was informed of the purpose of the visit. During the visit, the LPA toured the facility, conducted interviews, and obtained copies of pertinent documentation. Continued on LIC 9099-C. Unsubstantiated The LPA attempted to interview Resident #2 (R2) who refused to be interviewed or speak with the LPA. The Administrator was advised that further investigation was needed prior to issuing findings. A review of R1’s physician report, dated 01/31/2020, listed the primary diagnosis as diabetes type 2, and secondary diagnosis listed as HTN, bipolar I, atrial flutter, and sinus node dysfunction. R1 was able to leave the facility unassisted. No cognitive impairment was noted. R1’s resident assessment, dated 08/21/2024, listed R1 as independent for bathing, dressing, grooming, toileting, transfer and mobility. R1 required use of cane, walker, wheelchair, diabetic diet, and assistance with glucose monitoring. Chronic pain and mental health services were also noted. No cognitive impairment was noted. Behaviors listed as moderate with daily interventions needed due to disruptive, aggressive, or socially inappropriate behavior. Current depression, anxiety, mood disorder. Requires medication assistance, injections 3 times per day, has a psychiatrist and a case manager. A review of R2’s physician report, dated 02/06/2024, listed the primary diagnosis as Schizophrenia, unspecified. No cognitive impairment was noted. R2 was not able to leave the facility unassisted. R2’s resident assessment, dated 07/10/2024, listed R2 as non-ambulatory, having dementia, behavior impairment, confused, agitated, uncooperative and resistant to care assistance. R2 is conserved by the public guardian. According to the Administrator, the medtech reported on 10/02/2024, 2:00am, they heard loud screaming from R1 and R2 in the activity room, came to check, and separate them when R2 hit R1 on the back of head. Riverside Police Department were called and escorted R2 back to their room. There was no visible injury, but R1 complained of pain, and 911 was called. R1 returned to the facility the same day. The Administrator does not recall if R1 had an injury, and does not know the discharge diagnosis as R1 refused to give the facility any paperwork from the hospital. The Administrator stated on 10/02/2024 the facility census was 105 and the overnight (NOC) shift had two team members working. Both the residents’ physicians were notified. R2’s public guardian was also informed of the incident. Continued on LIC 9099-C. The review of Unusual Incident/Injury Reports (SIRs) and facility notes related to R1 revealed on 10/17/2024, R1 called 911 due to experiencing stroke-like symptoms. R1 had a droopy eye, stated they did not feel like themselves, and complained of pain in their temple. The ambulance transported R1 to the hospital. R1 returned to the facility on 10/22/2024 with a new order of Pradaxa and to follow up with their primary care physician. R1 did not provide any paperwork from the hospital to the facility. On 10/23/2024, R1 reported feeling dizzy and called 911, R1 was taken to emergency room and returned to the facility the same day. R1 did not provide any discharge paperwork to the facility. During the course of the investigation, the Department was not able to obtain an interview with R1. Per the Administrator, R1 moved out of the facility on 11/11/2024 and there is no contact information for R1. The information obtained during the Department’s investigation did not sufficiently support the allegation. While R1 was hit on the head during an altercation with R2, the investigation did not provide sufficient evidence to substantiate neglect/lack of supervision by facility staff. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Jul 26, 2025 · control 18-AS-20241017140824

Allegation investigated: Staff did not administer resident’s medication as prescribed. Staff did not provide a safe environment for residents. Staff did not ensure that the facility was in good repair.

On 7/26/2025 at approximately 8:10 AM, LPA Alfonso Iniguez conducted a subsequent unannounced complaint visit. LPA Iniguez met with Crystal Ruelas /Business Office Manager. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Culinary Director Interview (A#1), Residents Interviews (R#1-R#10) and Staff Interview (S#1-S#5). LPA obtained and reviewed the following documents: Resident Roster dated: 7/26/25, Staff Roster dated: 7/26/25, copies of (R#1)’s Medication Administration Records (MARs) dated: June 2024 through October 2024 and a Health and Safety check of the facility ( 10 randoms residents rooms: 201, 216, 222, 229, 241, 141, 145, 134, 138 and 137) and the facility elevators. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff did not administer resident’s medication as prescribed. The details of the complaint alleged that facility staff is not administering to (R#1) their medication as prescribed. On July 26, 2025, at approximately 9:00 a.m., during a records review, LPA Iniguez examined (R#1)’s Medication Administration Records (MARs) from June 2024 to October 2024. LPA Iniguez noted that (R#1) received their pain medications as prescribed by the physician. On July 26, 2025, at approximately 11:00 a.m. LPA Iniguez conducted an interview with the Business Office Manager (A#1). During the interview, (A#1) stated that the Medtech’s are responsible for dispensing medications. They receive training from the pharmacy, supervisors, and through Relias, as well as one-on-one instruction. In addition, (A#1) also confirmed that (R#1) and the other residents in care received their medications as prescribed by their physician. On July 25, 2025, at approximately 9:30 AM, LPA Iniguez contacted (R#1) by telephone, but (R#1) did not answer. LPA Iniguez left a voice message. At around 10:30 AM on the same day, LPA Iniguez attempted to reach (R#1) again, but once more, (R#1) did not pick up, and a voice message was left. For a third time, at approximately 11:30 AM, LPA Iniguez called (R#1), who again did not answer, prompting another voice message to be left. On July 26, 2025, at approximately 1:00 PM, during interviews with residents (R#2-R#10), (9) out of (9) stated that they take medication and they have never missed a dose of their prescribed medications. Evaluation Report continues LIC 9099-C On July 26, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#5), (5) out of (5) stated that the person who administers medication to the residents is the MedTech, and they believe the MedTech’s are trained on how to do their job. Additionally, (5) out of (5) facility staff stated that (R#1) and the other residents in care got their medications as prescribed by their physician. Allegation: Staff did not provide a safe environment for residents. The details of the complaint alleged that facility is not providing a safe environment for (R#1) and the rest of the residents in care. n July 26, 2025, at approximately 4:00 PM, LPA Iniguez conducted a Health and Safety check of the facility, touring the premises with (A#1). During the inspection, LPA Iniguez did not observe any immediate dangers to the residents in care in either the first or second floor common areas. On July 26, 2025, at approximately 11:00 a.m., during an Interview with the Business Officer Manager (A#1), she stated that the facility staff, including herself, provides a safe environment for (R#1) and the rest of the residents in care. On July 25, 2025, at approximately 9:30 AM, LPA Iniguez contacted (R#1) by telephone, but (R#1) did not answer. LPA Iniguez left a voice message. At around 10:30 AM on the same day, LPA Iniguez attempted to reach (R#1) again, but once more, (R#1) did not pick up, and a voice message was left. For a third time, at approximately 11:30 AM, LPA Iniguez called (R#1), who again did not answer, prompting another voice message to be left. On July 26, 2025, at approximately 1:00 PM, during interviews with residents (R#2-R#9), (9) out of (9) stated that they agree the facility staff provides a safe environment for them and the rest of the residents, and they feel safe living here. Evaluation Report continues LIC 9099-C On July 26, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#5), (5) out of (5) stated that they do provide a safe environment for (R#1) and the rest of the residents in care. Allegation: Staff did not ensure that the facility was in good repair. The details of the complaint alleged that two facility elevators were in disrepair. On July 12, 2025, at approximately 4:00 PM, during a health and safety check of the facility, LPA Iniguez observed that the elevators were functioning properly at the time of his visit. On July 26, 2025, at approximately 11:00 AM, during an Interview with the Business Officer Manager (A#1), she stated that the facility has two elevators. When one of the elevators is in disrepair, they contact the technician right away. Additionally, (A#1) stated that the elevators have never been out of disrepair for more than a week. On July 25, 2025, at approximately 9:30 AM, LPA Iniguez contacted (R#1) by telephone, but (R#1) did not answer. LPA Iniguez left a voice message. At around 10:30 AM on the same day, LPA Iniguez attempted to reach (R#1) again, but once more, (R#1) did not pick up, and a voice message was left. For a third time, at approximately 11:30 AM, LPA Iniguez called (R#1), who again did not answer, prompting another voice message to be left. On July 26, 2025, at approximately 1:00 PM, during interviews with residents (R#2-R#9), (9) out of (9) stated that the elevators have never been in disrepair for more than one week. On July 26, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#5), (5) out of (5) stated that there are two elevators at the facility and there are never in disrepair more than one week. Evaluation Report continues LIC 9099-C During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. 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, and a copy of the Complaint Report was given to Crystal Ruelas/Business Office Manager.the state’s words, verbatim · CDSS document, Jul 26, 2025 · control 18-AS-20240625083051

Allegation investigated: Resident developed a pressure injury due to neglect by staff. Facility staff did not seek timely medical attention for residents pressure injuries. Facility staff leave residents in soiled bedding. Facility staff do not respond to residents' call buttons in timely manner.

Licensing Program Analyst (LPA), Debbie Palacios, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA met with Executive Director, Molly Bowie, to explain the purpose of the visit and the elements of the allegations. The investigation consisted of observations, interviews with staff members and residents, and a review of records. It was alleged that Residents R1 and R2 developed pressure injuries due to staff neglect and did not receive prompt medical care. Record review revealed Hospice Care documentation showed that R1 was receiving wound care three times a week. On May 8, 2024, R1 was examined by a physician who assessed the wound and scheduled a follow-up within two weeks. Following a two-week evaluation by a physician, R1 was admitted to Silverado Comfort Care Hospice on May 14, 2024, with medical orders to treat and cleanse wound. Unsubstantiated Hospice records and daily logs from May and June 2024 show that R2 also received wound care two to three times per week, with hospice nurses occasionally making two visits in a single day. Regarding the allegation that staff left residents in soiled bedding, interviews conducted with residents revealed they have not experienced neglect in this regard. Residents reported that when they need prompt assistance, they use their call buttons and get assisted. It was also alleged that facility staff do not respond to resident’s call buttons in a timely manner to respond promptly to call buttons, two out of six residents reported experiencing delays when requesting assistance. Four out of six residents reported that staff respond to the call buttons in a timely manner, approximately within 15 minutes. Staff interviews revealed that telephones had been installed in resident bedrooms to improve emergency communication. During daytime hours, calls are routed to the receptionist; during the night, calls are transferred to the Med-Tech room. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 21, 2025 · control 18-AS-20240509101436

Allegation investigated: Staff did not provide activities to residents in care

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegation. LPA met with Molly Bowie, Executive Director and informed them of the LPA's visit. The Department investigation involved interviews with staff, residents, and review of records. On 06-09-2025, Community Care Licensing (CCLD) received a complaint report with the above allegation. It was alleged that staff did not provide activities to residents in care. LPA observed a large daily activities poster near the main entrance of the facility. The post was for the entire month of July resident activities. LPA observed four (4) to five (5) activities each day, including weekends. LPA conducted interviews with five (5) staff members, all of whom confirmed there are activities every day for the residents. LPA’s interview with seven (7) residents corroborated the staff members’ statements. This allegation is unfounded. A finding of UNFOUNDED means the allegation could not have happened, is false, and/or is without a reasonable basis. Unfoundedthe state’s words, verbatim · CDSS document, Jul 18, 2025 · control 18-AS-20250609123952

Allegation investigated: Staff did not prevent a visitor in the facility from physically abusing resident(s) in care Staff chemically restrained resident(s) in care Licensee retained a resident with a higher level of care needed Staff did not follow physician's instructions regarding resident's diet Staff did not ensure resident(s) were sufficently fed Staff did not ensure that resident's catheter was maintained Staff handled resident(s) in a rough manner Staff left resident in soiled bedding Staff did not assist with toileting as required

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Molly Bowie, Executive Director and informed them of the LPA's visit. The Department investigation involved interviews with staff, residents, and review of records. On 06-09-2025, Community Care Licensing (CCLD) received a complaint report with the above allegations. It was alleged staff did not prevent a visitor in the facility from physically abusing resident(s) in care. Information received indicated that a visitor physically abused Resident #5 (R5) and another resident. LPA’s interview with Resident #5 (R5) revealed the visitor in question is R5’s spouse. R5 denied experiencing any physical abuse from anyone, including the spouse. LPA interviewed five (5) staff members and seven (7) residents, all of whom denied witnessing or being aware of physical abuse. This allegation is unsubstantiated. Continued on LIC9099-C... Unsubstantiated It was alleged staff refused to allow resident the ability to collect their personal belongings after eviction. Information received indicated that Resident #7 (R7) came to the facility to get their belongings, but the management did not allow R7 to do so. LPA’s records review revealed R7 was lawfully evicted on 10-24-2024. LPA verified the eviction via court documents provided for review. Per the court document, the landlord is responsible for the safe keeping of tenant’s property for fifteen (15) days from the date of eviction. Per the Administrator, R7 never came back to the facility to claim their personal property. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means 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 a copy of this report was provided. It was alleged staff chemically restrained resident(s) in care. Information received indicated that staff intentionally administered extra medication to keep residents sedated. LPA’s file reviews revealed both Resident #1 (R1) and Resident #4 (R4) had been on hospice care plan. Both R1 and R4 passed away. LPA conducted interviews with five (5) staff members and seven (7) residents, all of whom denied witnessing or being aware of chemically restraining a resident. Both the Administrator and medication technician stated medication dispense is strictly followed by residents’ physician’s orders. LPA’s review of medication records for both R1 and R4 did not find any corroborating evidence of over medication or medication errors. This allegation is unsubstantiated. It was alleged Licensee retained a resident with a higher level of care needed. Information received indicated that staff retained a resident who should have been placed in a memory care facility. LPA’s review of records revealed Resident #6 (R6) was non-ambulatory who had been under hospice care. LPA’s review of resident file revealed R6 did not have dementia diagnosis or wandering behavior. LPA’s review of physician’s report and facility’s assessment did not find any corroborating evidence that R6 required higher level of care. This allegation is unsubstantiated. It was alleged staff did not follow physician’s instructions regarding resident’s diet. Information received indicated that Resident #3 (R3)’s food was to be pureed. LPA’s review of records revealed R3 is currently at a hospital and required special diet per the resident’s physician’s order. The physician’s order stated R3’s meal must be mechanical sort chopped with thin liquids. Administrator and wellness director stated the kitchen staff always provide any special diet in the resident’s care plan and physician’s order. LPA’s interview with kitchen staff corroborated the statement from the Administrator and wellness director. This allegation is unsubstantiated. It was alleged staff did not ensure resident(s) were sufficiently fed. Information received indicated that staff did not bring food to Resident #4 (R4). LPA’s records review revealed R4 was non-ambulatory and required a Hoyer lift for transfers. R4 passed away in April 2025, while receiving hospice care. The Administrator stated R4 was receiving tray service where meals were delivered directly to the resident’s room, at no additional cost. This accommodation was made due to R4’s limited mobility and care needs. The Administrator stated R4 consistently received meals in accordance with their admission agreement and dietary requirements. Tray service was provided three times daily, and staff were instructed to ensure meals were delivered and consumed as appropriate. Continued on LIC9099-C.... LPA interviewed five (5) staff members. All staff members affirmed that residents are provided with three meals per day, and that additional snacks or special dietary accommodations are made based on individual needs. LPA interviewed seven (7) residents currently residing at the facility. All residents confirmed they receive three meals daily and denied any instances of missed or insufficient meals. Based on the review of records, staff and resident interviews, there is no evidence to support the allegation that residents were not sufficiently fed. All findings indicate that residents receive regular meals in accordance with their care plans and admission agreement. Therefore, this allegation is unsubstantiated. It was alleged staff did not ensure that resident’s catheter was maintained. LPA’s review of records revealed Resident #3 (R3) is currently at a hospital due to conditions unrelated to the catheter. R3 is under hospice care plan and requires use of catheter. LPA conducted an interview with the Administrator. The Administrator explained that facility staff are limited in the scope of catheter care they can provide. Specifically, staff are permitted to drain the catheter bag and clean the surrounding area, but full catheter maintenance, including insertion, replacement, and clinical assessment, is the responsibility of hospice care personnel. The Wellness Director confirmed the Administrator’s statement, emphasizing that catheter maintenance falls under the duties of licensed hospice staff, not facility caregivers. LPA interviewed five (5) staff members. All staff reported that incontinence care, including draining catheter bags, is performed every two hours or as needed, depending on the resident’s condition. LPA interviewed seven (7) residents. All residents stated they receive appropriate and timely incontinence care. Based on the review of records, staff and resident interviews, and clarification of care responsibilities, there is no evidence to support the allegation that the resident’s catheter was not properly maintained. According to record reviews and interviews conducted, catheter care was routinely managed by hospice personnel, and facility staff perform their assigned duties within scope. Therefore, this allegation is unsubstantiated. It was alleged staff handled resident(s) in a rough manner. Information received indicated that staff would handle residents in a very rough manner. LPA interviewed five (5) staff members. All staff members denied having witnessed or engaged in any rough handling of residents. They reported that care practices are conducted in accordance with facility rules, emphasizing safety, dignity, and respect. LPA interviewed seven (7) residents currently residing at the facility. All residents denied experiencing or observing any rough handling by staff. Each resident stated that staff consistently provide care in a respectful and gentle manner. During the investigation, LPA observed staff interactions with residents during routine care and facility activities. Continued on LIC9099-C.... Staff were seen assisting residents with attentiveness and professionalism, using appropriate techniques for mobility and personal care. Based on consistent statements from both staff and residents, as well as LPA’s direct observations, there is no evidence to support the allegation that residents were handled in a rough manner. Therefore, this allegation is unsubstantiated. It was alleged staff left resident in soiled bedding. Information received indicated that staff do not change catheter for Resident #3 (R3), and it will overflow. LPA’s records review revealed R3 is currently at a hospital. LPA’s interviews with five (5) staff members revealed incontinence care and bedding changes are provided every two (2) hours or as requested, depending on the residents’ needs. Three (3) of the seven (7) residents interviewed stated they required incontinence care and stated the staff have provided incontinence care and bedding change promptly. Based on the absence of corroborating evidence and consistent statements from both staff and residents confirming appropriate care practices, this allegation is unsubstantiated. It was alleged staff did not assist with toileting as required. Information received indicated that staff would not provide incontinence care for Resident #8 (R8). A record review conducted by LPA revealed Resident #8 (R8) passed away in April 2025 while receiving hospice care. Interviews conducted by LPA with five (5) staff members indicated that incontinence care is provided every two hours or upon request, based on the individual needs of residents. Of the seven (7) residents interviewed, three (3) reported requiring incontinence care and affirmed that staff have provided such care in a timely manner. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means 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 a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 18, 2025 · control 18-AS-20250609123952

Allegation investigated: Staff does not ensure resident has electricity.

On 07/14/2025 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation noted above. LPA met with Executive Director (ED) Molly Bowie, where LPA explained the purpose of the visit and the elements of the allegation. The allegation was investigated, and the investigation consisted of interviews and records review. On 08/02/2024 Community Care Licensing received a complaint alleging staff did not ensure resident had electricity. It was alleged Resident 1 (R1) returned to the facility to find their room had no electricity. The LPA was unable to determine the date of occurrence. LPA attempted to interview R1 but was unsuccessful. The ED was interviewed and reported they had never been informed that R1 was without electricity. The ED further reported they had an exterminator company providing services which consisted of electrical outlet covers being removed to allow for powder to be inserted. However, at no time was the electricity turned off. The LPA obtained a copy of a document titled “Bedbug Conventional Treatment Preparation Checklist” from the ED. The checklist gave instructions on what to do before and after the service has been rendered. The checklist did not note anything concerning the electricity. The LPA received a video and it was reviewed. The video depicted a dark room. It appeared the individual filming was using a cell phone with the flashlight on. In the background was a nightstand which held a white rectangular shaped box that had a green light illuminating from it. An interview with the individual who made the video could not be conducted. Unsubstantiated The LPA conducted a random sampling of interviews with other residents. These residents occupied the same floor as well as other areas of the facility. These interviews revealed that 4 of 4 residents reported they never were without electricity. Based on interviews and records review, the allegation of staff did not ensure resident had electricity is 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 violation did occur. An exit interview was conducted where a copy of this report was reviewed and provided to Molly Bowie Executive Director. The LPA reviewed the document titled “Commercial Services Agreement” dated 07/18/2023. The agreement was for the exterminator company to come out two times a month. The Service Report dated 07/13/2024 indicated bed bug activity was found in room 265 and the room was treated. R1 resided in room 265. An Odd Job form was reviewed dated 08/23/2024 which indicated treatment to room 265 and no bed bug activity was found. Another Odd Job form dated 08/26/2024 indicated multiple rooms were inspected, including room 265, and no live activity was found. The exterminator company made a recommendation to remove all infested furniture from all the rooms. Per an invoice dated 10/01/24, the facility disposed of the items on 09/14/24, and 09/28/24. The LPA was unsuccessful in interviewing R1. The LPA was unable to determine how long the bed bugs had been in the room prior to the treatment on 07/13/2024. Staff disturbing resident’s sleep. It was alleged construction in the facility was being done at all hours of the night, disturbing the sleep for the residents. The facility was undergoing construction which included painting, replacing carpet and tile flooring, hanging art and replacing furniture. The ED was interviewed and reported the time frame for the construction was June of 2024 through February 2025. She reported that during that time frame, there were two overnight projects that were approved to be completed. She further reported the approved projects did not restrict resident movement nor did it consist of loud noises. Bowie could not recall receiving any noise complaints from residents. Bowie further stated that the only noisy/loud part was when the tiles in the dining room were replaced and that project was only completed during the day from 9am-2pm. R1 was unable to be interviewed. Other resident interviews were conducted where 4 of 4 reported they did not have their sleep disturbed nor did they hear complaints from any other residents regarding the construction. Staff isolating residents. It was alleged that staff told residents to stay in their rooms to benefit the facility, because the facility was short staffed. The ED denies residents were asked to isolate. She also denied being short staffed. She stated there are 3 shifts. The AM shift consists of 2 med techs and 4 caregivers, the PM shift consists of 2 med techs and 2-3 caregivers and the NOC shift consists of 1 med tech with 1-2 caregivers. R1 was not available to interview. Other resident interviews were conducted where 4 of 4 reported they were not told to isolate or stay in their rooms. Therefore the allegations are unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted where a copy of this report was reviewed and provided to Molly Bowie Executive Director.the state’s words, verbatim · CDSS document, Jul 14, 2025 · control 18-AS-20240718105822

Allegation investigated: Staff illegally evicted resident.

On 07/14/2025 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegations noted above. LPA met with Crystal Rulas-Maldonado, Business Office Manager, where LPA explained the purpose of the visit and the elements of the allegations. The allegations were investigated, and the investigation consisted of interviews and records review. It was alleged staff illegally evicted Resident 1 (R1). R1 was issued an eviction notice on 05/21/2024, for failing to pay. A review of the eviction notice revealed that it met Title 22 regulatory requirements. It was further alleged that R1 was denied access to their room upon their return to the facility. Staff reported R1 was out of the facility from 07/20/2024 through 08/03/2024. Upon R1’s return to the facility, R1 was relocated to a model room, because their room was being treated for pests. R1 was then moved back into their original room on or around 08/27/2024. A review of the facility’s Acknowledgement of Discharge form dated 11/11/2024, revealed R1 vacated the facility on 11/11/2024. On that date R1’s responsible person removed all personal belongings. The form was signed by R1’s responsible person. Unsubstantiated It was further alleged staff called local law enforcement regarding R1’s eviction. Staff deny calling the police on R1 for an eviction. A review of charting notes for R1, revealed that local law enforcement was contacted and it involved R1, however, that call was done on 08/05/2024. This occurred after the date this complaint was received. This complaint was received on 08/02/2024. Furthermore, the reason for the call to local law enforcement on 08/05/2024, according to the charting note, was for something other than an eviction. LPA attempted to interview R1, however R1 no longer resides at the facility. Attempts to contact R1 via telephone were unsuccessful. Based on insufficient evidence to corroborate or refute the allegation, the allegation of staff illegally evicted a resident is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted, and a copy of this report was reviewed and provided to Crystal Rulas-Maldonado, Business Office Manager. Regarding the allegation of staff withheld resident's personal belongings. It was alleged that facility staff withheld R1’s personal belongings and valuables: TV, laptop, dresser, 2 night stands, linens, hygiene products, and all personal clothing. A records review of R1s Personal Property and Valuables List dated 04/04/2021, was reviewed which revealed it was not completed as there was a line through the form, the form did not include any updates of items purchased throughout the duration of R1’s placement at the facility. A review of the facility’s Acknowledgement of Discharge form dated 11/11/2024, revealed R1 vacated the facility on 11/11/2024. On that date R1’s responsible person removed all personal belongings. The form was signed by R1’s responsible person. There is no documentation of the specific items picked up. LPA conducted an interview with a resident witness (RW). RW reported the laptop was given to them directly from R1 a few months before R1 discharged from the facility. RW also reported on the day R1’s responsible person was collecting R1’s belongings in November of 2024, RW was given R1’s TV, 2 night stands and decorative pillows. RW stated they were close with R1 and it was already agreed upon that R1 would give those items to RW. LPA attempted to interview R1, however R1 no longer resides at the facility. Attempts to contact R1 via telephone were unsuccessful. It was alleged R1 was informed by previous Executive Director Morgan Williams that their bed was infested and that it would be replaced with a new one. During the investigation, the facility did not have a record available for LPA to review, proving that a new bed was purchased for R1. LPA attempted to interview R1, however R1 no longer resides at the facility. Attempts to contact R1 via telephone were unsuccessful. Based on observations and interviews the allegations are unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was reviewed and provided to Crystal Rulas-Maldonado, Business Office Manager.the state’s words, verbatim · CDSS document, Jul 14, 2025 · control 18-AS-20240802094711

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Armando Perez conducted an unannounced visit to the facility for a case management in regards to complaint control # 18-AS-20250206161754. LPA met with Executive Director Molly Bowie and informed ED of the purpose of the visit. The purpose of the visit was to deliver the amended report and obtain the necessary signature. LPA and ED reviewed and discussed the previously delivered report and the amended report and LPA delivered the amended report to ED. An exit interview was conducted, and a copy of this report was provided to facility representative.the state’s words, verbatim · CDSS document, Jul 2, 2025

Allegation investigated: Licensee did not follow proper eviction protocols with resident in care.

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA met with Executive Director, Molly Bowie, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of observations, interviews with staff members and residents, and a review of records. On February 6, 2025, Community Care Licensing received a complaint alleging Licensee did not follow proper eviction protocols with resident in care. The complaint alleged Client 1 (C1) was not given adequate time to relocate and secure new housing before the eviction date. LPA interviewed Additional Witness who stated, that although C1 had received all necessary eviction notices, they believed there was a verbal agreement with Executive Director (ED), Molly Bowie to extend the eviction date. However, during an interview with the ED, ED confirmed a conversation with additional witness days before the eviction, but denied offering any extension. Continued on 9099-C. Unfounded ED clarified that the eviction process was under the jurisdiction of the court system, which was beyond their authority to influence. LPA attempted to interview C1, but was unable to obtain relevant information, as C1 could not answer or recall the questions posed. A record review indicated that the eviction process began on September 25, 2024. The 30 day eviction notice issued to C1 on September 25, 2024 included all the required information per Title 22 regulations. On January 7, 2025, the Superior Court of Riverside formally approved the eviction. Information obtained from a deputy sheriff, who executed the court-ordered eviction, confirmed the eviction complied with legal procedures and was not viewed as unlawful. Based on interviews, research, and record review, the allegation that licensee did not follow proper eviction protocols with resident in care is unfounded. A finding that the allegation is unfounded meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. This allegation has been investigated and is dismissed An exit interview was conducted where a copy of this report was provided to Administrator Molly Bowie. *This is an amended version of an original report created on 4/16/2025.the state’s words, verbatim · CDSS document, Apr 16, 2025 · control 18-AS-20250206161754

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with Executive Director Molly Bowie. The LPA informed the Administrator of the purpose for the visit. The inspection included the following: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility consists of one building structure with two floors, Each resident room has grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats present. The building is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured in 10 rooms and all measured within regulation. LPA observed a signal pull system in each room and was tested. Staff responded in a timely manner. Facility has 1 Laundry room and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. There are no firearms at this facility and no bodies of water observed. During inspection of room 138 LPA observed a basket with cleaning supplies. Administrator stated it belonged to the resident and it is not prohibited in their care plan or restricted by a physician and they do not have Dementia. LPA confirmed regulation 87309(b) allowed access for such items for personal use with certain limitations. LPA began review of client records. Ten (10) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed client records to be available and complete. LPA reviewed employee records- Ten (10) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 01/23/2027. LPA observed personnel records to be available and complete. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present in the second floor. There is a location for knives and sharps in the kitchen. Medications are centrally stored. There is a locked room in the first floor allocated for medication storage. Centrally stored medication and destruction logs are maintained and records are digital. Medications reviewed appear to have been dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors are a combined unit, were tested and found to be operational. Fire extinguishers was last serviced on 07/26/2024. Fire drills are conducted quarterly at the facility with the last drill on 04/02/2025 . Based on the information received during this visit today in the areas reviewed, there are no deficiencies that are being cited per Title 22, Division 6 of The California Code of Regulations. This LIC 809 report was reviewed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Apr 16, 2025

Allegation investigated: Staff are not allowing resident to return to the facility due to their stage 4 pressure injury

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA met with Business Office Manager Crystal Maldonado, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of observations, interviews with staff members and residents, and a review of records. On December 17, 2024, Community Care Licensing received a complaint alleging that staff are not allowing resident to return to the facility due to their stage 4 pressure injury. It was reported that the resident was not allowed to return to the facility until the pressure injury was downgraded to stage 2 or 3. Information obtained from interview with Administrator stated that the level of care for stage 4 pressure injury was a restricted health condition and would require hospice enrollment for the additional care. This is in accordance with Title 22 regulations. Information obtained from interview with the resident stated that they were not denied returning back to the facility, but was registered for hospice care for the care of the stage 4 pressure injury. Unfounded Additionally, LPA observed resident to be living at the facility during the visit on December 23, 2024 and obtained a Hospice Admissions letter from Hospice of the IE and OC dated December 20, 2024. Based on interviews, research, and record review, the allegation that staff are not allowing resident to return to the facility due to their stage 4 pressure injury is unfounded. A finding that the allegation is unfounded meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted where a copy of this report was provided to Business Office Manager Crystal Maldonado.the state’s words, verbatim · CDSS document, Jan 16, 2025 · control 18-AS-20241217150653

Allegation investigated: Personal Rights

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to the facility to initiate the investigation into the allegation listed above. LPA met with Executive Director Molly Bowie who was informed of the purpose for the visit. LPA's investigation consisted of a tour of the facility, records review, and interviews. Regarding the allegation "Personal Rights", LPA conducted a record review of the facility's resident roster for Resident One (R1) during the visit. Record review of the roster revealed R1 was not listed as a current resident receiving care and supervision at the facility. LPA conducted an interview with Executive Director Molly Bowie during the visit to inquire about R1's residency status at the facility. Executive Director Bowie reported R1 is not a resident at this facility. LPA conducted interviews with relevant parties who confirmed R1 was not admitted to this facility but was admitted to a different licensed residential care facility for the elderly. Unfounded The Department will conduct a follow up with the licensed residential care facility for the elderly. This agency has investigated the complaint alleging "Personal Rights". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to Executive Director Bowie.the state’s words, verbatim · CDSS document, Nov 18, 2024 · control 18-AS-20241117090019

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

On 10/23/2024, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to investigate the allegation listed above. LPA met with Administrator, Molly Bowie who was informed of the purpose of the visit. It was alleged there are bugs and mice in Resident 1's (R1's) room. LPA reviewed the resident roster, which did not list R1 as a current resident. Administrator Bowie was interviewed and reported R1 is not a resident at the facility and there are no reports of bugs or mice observed in any of the residents' rooms. Administrator Bowie explained the facility has an ongoing contract with pest control company "Orkin" to provide routine services to prevent pests. LPA contacted Orkin who reported they provide ongoing treatment on a semi-monthly basis and additionally as needed. Administrator Bowie provided LPA copies of the pest service reports noting routine services have been completed and there are no reports of pests sightings or activity that would require additional treatments. LPA made contact with R1 who confirmed they have never resided at this facility. Unfounded Five (5) residents were also interviewed and reported they have not observed mice or bugs in their bedrooms or anywhere else in the facility. Two (2) staff were also interviewed and reported they have not observed mice, mice droppings, or bugs in any of the resident rooms or common areas throughout the facility. Two (2) staff interviewed added they have not received reports of pest activity/sightings and are not aware of any residents observing mice, bugs, or pests in their bedrooms. This agency has investigated the complaint alleging "Facility staff are not properly addressing pest infestation in facility". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to Administrator Bowie along with Confidential Names list (LIC 811).the state’s words, verbatim · CDSS document, Oct 23, 2024 · control 18-AS-20241018143509

Allegation investigated: Staff spoke inappropriately to resident

Licensing Program Analyst (LPAs) Sara Martinez and Debbie Palacios conducted an unannounced facility to initiate the complaint investigation regarding the allegation above. LPAs conducted a tour of the facility, staff and resident interviews, and requested pertinent documents related to the investigation. Regarding the allegation "Staff spoke inappropriately to resident", it was reported a staff member had yelled and threatened Resident One (R1) in the facility courtyard with other residents present and threatened to call the police on R1. LPAs conducted interview with R1 who reported Staff One (S1) did not threaten R1 but had yelled and embarrassed R1 in front of the other residents who were present. Interviews conducted with four (4) residents who were reportedly present during the interaction between R1 and S1 denied S1 yelling at R1 and denied S1 threatening to call the police on R1. LPAs conducted an Interview with S1 who denied yelling at R1 and denied telling R1 they were going to contact the police. Unsubstantiated Interview with Staff two (S2) who was reportedly present during the interaction with R1 and S1 denied S1 yelling at R1 and denied S1 threatening to call the police. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Executive Director Bowie.the state’s words, verbatim · CDSS document, Oct 2, 2024 · control 18-AS-20240927120949

Allegation investigated: Staff did not release resident records upon request from resident's authorized person

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to the facility to initiate the investigation into the allegations listed above. LPA met with Executive Director Molly Bowie who was informed of the purpose for the visit. The complaint investigation consisted of interviews and records reviewed. Regarding the allegation “Staff did not release resident records upon request from resident's authorized person”, it was reported records for Resident One (R1) was requested on 08/21/2024 and the facility has not provided the requested documents to R1’s authorized person. Staff One (S1) reported the facility received a letter requesting medical records for R1 dated 08/16/2024. S1 sent the requested documents to upper management and their legal department to review the documents before sending the requested documents to R1’s authorized representative. Records review of an email reveals S1 sent R1’s requested documents to upper management on 08/21/2024. During today’s visit, LPA Martinez confirmed with R1’s authorized representative they have not received the requested documents. Substantiated Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. An exit interview was conducted and a copy of this report, LIC 9099-D, LIC 811- Confidential Names, and appeal rights was provided to Executive Director Bowie.the state’s words, verbatim · CDSS document, Sep 16, 2024 · control 18-AS-20240909182812

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Sep 27, 2024

87468.2 Additional Personal Rights of Residents...(a) In addition to the rights listed in Section 87468.1... residents in privately operated residential care facilities...shall have(19)... prompt access to review all of their records...provided within two business days... This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by not providing R1 records to R1 representative as required which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2024

Plan of correction: Licensee will ensure requested documents will be sent to R1's authorized responsible party before the plan of correction date 09/27/2024.

Allegation investigated: Licensee is not properly addressing pest issue in the facility.

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation in regards to the allegation noted above. LPA met with Executive Director Molly Bowie and explained the purpose of the visit and the elements of the allegation. On 7/16/24 Community Care Licensing received a complaint alleging the licensee is not properly addressing the pest issue in the facility, specifically rats, termites and cockroaches. LPA conducted a review of a special service agreement from the local exterminator company, which revealed that the licensee entered into a contract with the local exterminator company on or around 10/16/23. The service agreement lists the following pest coverage: (rats, mice, cockroaches, rolly pollies, crickets, common ants, pincher bugs). LPA reviewed a recent service contract dated 7/13/24 that notes that bed bug inspection and treatment was performed in a resident bedroom. Per interview with Executive Director Molly Bowie, the room that was treated had the following items discarded and replaced (mattress and box spring), all the clothing and bedding was removed and washed. The resident was relocated to another room while room their room is Unfounded being treated. A follow up visit is also noted be made today 7/17/24. Per the service report dated 2/15/24 there were two rooms that were both treated for bed bugs and German cockroaches. On 2/27/24 an inspection was conducted the same two rooms that were treated on 2/15/24 and there was no activity found. In addition there was nothing documented on the pest control invoices to support that the facility has or had termites, or rats. Per Executive Director Molly, there have not been any reports or observed activity for the alleged pests (termites and rats). The local exterminator comes to the facility on a semi monthly basis, but will come if needed for any additional reports of pests in between scheduled service dates. Service reports were reviewed and revealed that the exterminator does come to the facility on a consistent basis. For this year (2024) the following visits were made 1/19, 1/29, 1/30, 2/15, 2/27, 3/8, 3/22, 4/10, 4/26, 5/10, 5/25, 6/20, 6/28, 7/13 were provided and details the service that was performed on that day, Based on interviews and record review the allegation of Licensee is not properly addressing pest issue in the facility is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was reviewed and provided to Molly Bowie, Executive Director.the state’s words, verbatim · CDSS document, Jul 17, 2024 · control 18-AS-20240716141532

Allegation investigated: Staff is retaliating against resident. Staff is refusing to accept resident's rent money.

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation in regards to the allegations listed above. LPA met with Executive Director Morgan Williams, where LPA explained the purpose of the visit and the elements of the allegations. The allegations were investigated which included observations, interviews and records review. On 5/22/24 Community Care Licensing received a complaint alleging staff is retaliating against resident and that staff is refusing to accept resident's rent money. Regarding the allegation of staff is retaliating against Resident #1 (R1). R1 was issued an eviction notice on 1/19/24, per an interview with Executive Director Morgan Williams, an internal review of records was conducted and it was discovered that the facility did not remove R1 from auto pay, and R1s rent payment for the originally signed ACH amount was paid in January 2024. The facility issued a refund January's rent in February 2024. A DEMURRER (tests the legal sufficiency of a pleading complaint) was filed against the unlawful eviction that was dismissed on 4/16/24. Per Morgan after consulting with corporate and the facility's attorney, it was agreed that all the Unsubstantiated necessary credits for any partial payments had been given and that R1 should have the 30 day notice to pay or quit reissued on 5/21/24, as the facility still wants to move forward with the eviction of R1 for the failure to pay rent. Based on interviews and records review the allegation of staff is retaliating against resident is unsubstantiated. Regarding the allegation of staff is refusing to accept resident's rent money. The facility was reissued a new license as there was a change in ownership. Residents are to sign new contracts but R1 is reported by Executive Director as refusing to do so. Per an interview with R1, R1 believes that they would not qualify for the ALW program, and does not want to be responsible or their loved ones to have to pay anything after their passing after being apart of the program. In addition the facility under went a change in management in July 2023, R1 was issued a 30 day notice to pay rent or quit. R1 resolved that matter in September 2023. Per Executive Director Morgan all residents were informed via the notice dated 10/1/23 and via town hall meeting that was held in or around August 2023 informing that Arlington will accept and retain residents who are either private pay or ALW program recipients, as the contracts with third party services had been terminated. If the residents that are not apart of the ALW program, and considered to be private pay, would be charged $4,500 which was indicated in the letter on dated 10/1/23 and is what R1 was expected to pay beginning 1/1/24. R1 opted to sign up for auto pay to have their rent automatically drafted/paid in September 2023. R1s rent payment for the originally signed ACH amount was paid in January 2024. The facility issued a refund for the amount that was paid in February 2024. The facility is not accepting R1s rent as R1 is not paying the expected amount based on being defined as a private pay resident. Based on interviews and records review the allegation of Staff is refusing to accept resident's rent money. is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted and a copy of this report was provided to Morgan Williams, Executive Director.the state’s words, verbatim · CDSS document, May 29, 2024 · control 18-AS-20240522083240

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility for the purpose of conducting a Pre-Licensing visit for Change of Ownership. Analyst met with Applicant Adam Zenou and Administrator Morgan Williams, who LPA Colvin informed of the purpose of today's visit, and toured the facility with the Administrator. ACTIVITIES: Inside and outside, there are areas for residents to use for their leisure. Activity room has activities for residents such as puzzles, books, and television. There is additionally planned activities schedule posted at the entrance and a staff member stationed at the room to aid residents. FOOD SERVICE: The kitchen area was observed for the ability to serve food and cleanliness. Dishes, utensils and glasses are present and in good condition. Facility has both perishable and non-perishable supply of food to satisfy the 2 day and 7 day requirements. Refrigerator was observed to be at 40 degrees and the walk-in freezer was 0 degrees. EMERGENCY PREPAREDNESS: Facility has an emergency exit plan in place a posted in plain view at the facility and in each hallway. Facility was found to have operational smoke detectors and carbon monoxide detectors, and fire extinguishers. Applicant has completed and submitted a Mitigation Plan for Infection Control for the facility as well. Facility is equipped with generator to provide electricity in case of an emergency. LPA Colvin observed emergency disaster supplies (including food and water) in a designated locked storage room. ADMINISTRATION/MEDICATION: A locked medication room with additionally locked medication carts are present and where all medication is stored. Records are additionally maintained in the locked medication room along with first aid supplies. PHYSICAL PLANT: Fire Clearance was granted for 222 non-ambulatory residents and 10 bedridden residents on 2/22/24 by the Riverside City Fire Department. The facility is set-up with resident bedrooms and bathrooms, kitchen, dining room, activity rooms, offices, laundry rooms, and lounges/common areas. Exits to the outside were observed to be unlocked for clients' and staff's use in case of emergency, and there are no locked gates around the facility restricting emergency exit. LPA Colvin tested the facility's hot water in multiple rooms and observed it to be measuring at 86, 108.5, 103.6, 106.5, 90.3, 107.7, and 109 degrees. Administrator had maintenance increase the temperature on the water heater during today's inspection, and LPA Colvin retested the rooms with the lowest water temperature. LPA Colvin observed some rooms to be reaching 105 degrees, but others remained below 105. LPA Colvin observed required accommodations in residents' bedroom and bathrooms, including beds, linen, storage furniture, and lamps. Trash bins located in resident bedrooms were observed to not have tight-fitting lids, and LPA Colvin observed that some of these residents require assistance with incontinence, as evidenced by presence of diapers and wipes. Smoke detectors and carbon monoxide units are all operable, as observed by LPA Colvin when LPA Colvin tested them. Common areas such as dining and living rooms were observed to be clean and in good condition. REQUIRED POSTINGS: LPA Colvin observed the facility to have informational postings for residents in two main areas of the facility. LPA Colvin observed postings included Residents Rights, Resident Counsel, Theft and Loss Policy, information for Long-Term Care Ombudsman, "See Something, Say Something" Complaint Poster for Community Care Licensing. LPA Colvin did not observe a posted Admissions Agreement, which Administrator Morgan Williams stated was available upon request. AREAS REQUIRING CORRECTION: LPA Colvin noted the following items which need to be fixed prior to the completion of the change of ownership of this facility and issuing of a new license: · Trash bins in resident bedrooms were not observed to have tight-fitting lids · Water temperature was reading below 105 degrees in multiple resident bedrooms Analyst will inform Centralized Applications Bureau (CAB) about the Pre-Licensing visit and Applicant being ready to proceed with the licensing process once corrections have been made. Applicant may self certify to LPA Colvin when corrections have been made. An exit interview was conducted with Applicant Adam Zenou and Administrator Morgan Williams, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 14, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 236 Census (if any clients in care): 150 COMP II Participants: Adam Zenou (Corporate Board Member) & Morgan Williams (Administrator) Interview Method: Virtual interview via Microsoft Teams On February 27, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Feb 27, 2024