Scott Villa

Type of visit: POC

While at the facility conducting the continuation of annual inspection, Licensing Program Analyst (LPA) Delmundo conducted a Proof of Correction (POC) visit for the deficiency section # 87303(a) cited on May 13, 2026. LPA met with Jonabelle Tolentino, administrator (ADM), and LVN-Facility Nurse Olive Manalastas. LPA inspected the bathroom vanities/cabinets in the residents' rooms with Olive Manalastas and observed the vanities and cabinets were replaced with new one. Deficiency is cleared on this same day. Exit interview conducted and copy of this report and POC Letter provided.the state’s words, verbatim · CDSS document, May 22, 2026

Type of visit: Required - 1 Year

On this day, May 13, 2026, at 2:40 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Jonabelle Tolentino, administrator, and Oliive Manalastas, LVN-facility nurse, and informed the reason for visit. LPA toured the facility with Olive Manalastas. LPA inspected the common areas, bathrooms, living/activity room, kitchen, dining area, front, side and backyard. LPA randomly selected 5 residents rooms for inspection. Facility has adequate food supplies for 7 days of non-perishables and 2 days of perishables. Fire extinguishers were observed fully charge with tags showed serviced February 24, 2026. Facility has smoke and carbon monoxide detectors that were tested and observed in operating condition on this day. Hot water temperature in a common bathroom measured at 118 degrees Fahrenheit. Facility conducts fire drills at least every 3 months, and records showed last conducted May 4, 2026. LPA obtained updated/current copies of the following on this same day: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan 4. $3M Liability Insurance certificate .......continued on 809C LPA observed the following: -at 3:10 pm and 3:16 pm, paint of bathroom vanities/cabinets in 2 residents rooms heavily chipped. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil deficiency. Deficiency and plan and correction were discussed with the administrator. Due to time constraint, LPA will come back to continue inspection. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, May 13, 2026

Allegation investigated: Staff did not prevent residents from engaging in a physical altercation.

On this day, January 28, 2026, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegation and close the complaint. LPA met with Jonabelle Tolentino, administrator (ADM) and informed the purpose of visit. The reporting party (RP) indicated that resident, R1, was attacked by another resident, R2, on October 22, 2025. RP further stated that it was reported that the incident was witnessed by residents and staff so RP thinks the incident happened in the common area. .......continued on 9099C Unsubstantiated During the course of investigation, LPA obtained copies of resident roster and staff schedule. LPA reviewed residents' files and obtained copies of including but not limited to the following documents: LIC601 Identification and Emergency Information; LIC602A Physician's Report; LIC625 Appraisal/Needs and Services Plan. LPA interviewed the following: R1, staff (S1) and administrator (ADM) on October 30, 2025; R2 and R5 on January 28, 2026 and obtained additional information from ADM. R1 stated the incident happened inside the facility in the hallway when R1 was going to the bathroom. During interview, LPA didn't observe any bruise in R1's face but scratches on left arm which R1 stated he scratched because his arm was itching. R2 stated R1 was messing up his coffee and his legs so he slapped R1's hand and it happened on the common area inside the facility. R2 was not able to provide the date nor names of staff or other residents who witnessed the incident. R5 stated the incident happened outside in the smoking area of the facility when R1 confronted another resident and R2 intervened. R5 futher stated that R2 turned around to R1 and flailed his hands toward R2 and R2 pushed and slapped R1 on the cheek. R5 stated the facility van arrived and the driver separated R1 and R2. S1 stated not observing any incident between R1 and R2. ADM stated the van driver didn't report the incident. ADM further stated that R1 and R2 came to her on separate occasions regarding R1 staring at R2 and R2 spreading rumor about R1. ADM stated after the report, ADM transferred R1 and R2 to rooms far away from each other. LPA reviewed the facility's camera footage for October 22, 2025 with ADM which covers the inside common areas. LPA didn't observed any incident between R1 and R2 on the alleged date. ADM indicated, and LPA observed the smoking area obstructed from the camera. Based on information gathered, the allegation is unsubstantiated.A finding that the complaint 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. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 15-AS-20251027095801

Allegation investigated: Neglect/lack of supervision: resident (R1) sustained unexplained while in care.

On this day, January 28, 2026, at 12:30 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Jonabelle Tolentino, administrator (ADM) and informed the reason for visit. The reporting party (RP) stated that on January 20, 2025, the facility contacted the hospice agency to report that R1 had a minor scratch on the forehead. RP further stated that on January 21, 2025, hospice nurse discovered two centimeters cut on R1’s forehead and observed bruising around R1’s eyes. During the course of investigation, the Department obtained copies of LIC9020 Register of Facility Clients/Residents, staff roster and LIC624 Unusual Incident Report concerning resident (R1). ....continued on 9099C (page 2) Substantiated Page 2 Copies of including but not limited to R1’s following documents were also obtained: Admission Agreement; LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; Pre-placement Appraisal; LIC9172 Functional Capability Assessment; LIC625 Appraisal/Needs and Services Plan; Unusual Incident Reports; facility notes; doctor's visit notes. Local law enforcement was also involved in the investigation and copy of police report was obtained and reviewed. The following were interviewed: hospice nurse (RN) on February 11, 2025; R1’s family member (FM) on February 11, 2025; R1’s roommate (R2) on June 5, 2025; staff (S1, S2, S3, S4) on June 5, 2025 and June 30, 2025. Documents showed R1 was on hospice, has major neuro cognitive disorder, required full assistance, and was non-verbal. Pre-placement Appraisal indicated R1 needed special observation/night supervision. RN confirmed RP’s statement that the facility called hospice agency on January 20, 2025, and that R1 had a cut on the forehead. RN further stated that RN came to visit on January 21, 2025, and the cut was deeper than what the facility described. The cut did not require hospitalization, but it was red and about two centimeters long, and there was bruising forming around R1’s eyes. RN asked the care staff for an explanation. The care staff believed the incident occurred around Sunday night, January 19, 2025, going into Monday morning, January 20, 2025, but the staff provided no specific time, or explanation for the cause of the unexplained injuries. FM visited R1 at the facility on January 23, 2025 and was informed by the staff that R1 had a cut on forehead and two black eyes. The staff told FM that they think R1 did it to self but when FM saw R1’s condition, FM felt it was unlikely that R1 could have caused the injuries to thyself. .....continued on 9099C (page 3) Page 3 Staff initially believed R1’s injuries were self-inflicted due to R1’s history of restlessness, and staff speculated that R1 may have rolled over and bumped self on the bed rails. R1’s roommate, R2, was also suspected by staff and by the local law enforcement of causing the injuries; however, R2 was interviewed by the Department and police officer and R2 denied any involvement and claimed not to have witnessed anything. Overnight shift staff are supposed to check on residents every one to two hours but based on law enforcement’s review of the facilities’ camera footage, no checks were made by care staff between 0325 to 0723 hours. Staff (S2) was seen entering R1 and R2’s room at 0544 with a broom and again at 0710 with tray of food, but the injury was not discovered until about 0723 hours. Two of the staff (S2 and S3) were inconsistent in their statements. S3 initially reported to the police that she cared for R1 the night of the incident and saw no injuries. However, S3 later recanted and admitted not on duty and later confirmed that it was S1 was the only staff working the overnight shift on the night of the incident. S1 was interviewed by the Department. S1 stated she conducted her rounds every hour during the overnight shift despite camera footage showing no checks were completed between 0325 to 0723 hours. Therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. A $500.00 immediate civil penalty is assessed and will continue for $100.00/day until corrected. An additional civil penalty may be assessed. Deficiency, plan and proof of correction and civil penalty were discussed with the administrator. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 15-AS-20250127122838

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Jan 29, 2026

§1569.269 Enumerated rights; severability: (a)Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency.... ....to meet their needs. -This requirement is not met as evidence by: -Based on interviews and records review, the licensee did not comply with the section when R1 sustained injuries which posed an immediate health, safety and/or personal rights risks to person in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: R1 is no longer at the facility. Administrator to in-service the staff and ensure proper care and supervision are provided to the residents in care. Copy of training topics with attendees signatures to be provided by 1/29/26. A $500.00 civil penalty is assessed.

Type of visit: Required - 1 Year

On this day, 06/05/2025 at 9:00 AM, Licensing Program Analysts (LPAs) David Doidge and Andrew Christy arrived unannounced to conduct an annual required inspection LPAs met with Jonabelle Tolentino, administrator, and informed the reason for visit. LPAs toured the facility including but not limited to common areas, bathrooms, shower room, living/activity room, kitchen, dining area, front, side and backyard. Facility has adequate food supplies for 7 days of non-perishables and 2 days of perishables. Fire extinguishers were observed fully charge with tags showed serviced 02/25/2025. Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in a common bathroom measured at 116 degrees Fahrenheit. Facility conducts fire drills every 3 months, and records showed last conducted 04/28/2025. Emergency Disaster Plan last updated 03/24/2025. LPAs reviewed five (5) residents and five (5) staff files; all were complete. Medications were checked and compared with doctor's orders on file and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources. No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 6, 2025

Allegation investigated: Staff are not distributing a resident's medication as prescribed.

At 1:45 pm on this day, 2/12/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with staff, Adrianne 'Diane' Manalastas. Lulin 'Lucy' Wu, back-up administrator (BUA), arrived at around 2:05 pm. LPA informed the purpose of visit. The reporting party (RP) stated the resident moved-in to RP's facility, and that the staff of Scott Villa could not state when the resident was distributed the last dose of medication and that staff had difficulty understanding questions and finding information on the Medication Administration Record (MAR). RP reported that the med-tech appeared to have no understanding of the medications, what they were for, or any concern for information they were providing. RP further stated that the resident had seizure medication given in morning and that staff stated the medication was last given the day before. However, RP did not provide information who is the resident is and the facility staff and medications. Unsubstantiated LPA obtained copies of LIC9020 Register of Facility Residents for 10/14/24, 12/31/24 and 2/07/25. LPA reviewed and compared the 3 LIC9020s and observed 4 residents (R1, R2, R3, R4) listed on 10/14/24 LIC9020 were no longer on the 2/07/25 LIC9020. LPA reviewed these residents' records and obtained copies of including but not limited to the following: Admission Agreement; LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; Pre-placement Appraisal; LIC625 Appraisal/Needs and Services Plan; facility notes; doctor's orders of medications; Medication Administration Records (MARs); LIC622 Centrally Stored Medication and Destruction Records. Out of these 4 residents, only R1 has seizure medications. The other 3 did not have seizure disorder diagnosis nor seizure medications. LPA interviewed S1, S2 and BUA. S1 and S2 denied receiving calls for R1, R2, R3 and R4 pertaining to medications. BUA stated when Jonabelle Tolentino (administrator) went on vacation, S3 took over the administration of medications from around 12/28/24 through 1/08/25, 1/09/25. BUA also stated that S1 took over the administration of medications when S3 went on vacation up until this day, 2/12/25, which LPA confirmed with S1. LPA reviewed the doctor's order of medications and compared with LIC622 and MAR. Review of records showed S1 has medication training and R1's MAR were properly filled-up. Based on records review and interviews, the allegation of 'Staff are not distributing a resident's medication as prescribed' is closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Feb 12, 2025 · control 15-AS-20250204131826

Type of visit: Case Management - Deficiencies

While at the facility conducting an investigation of a complaint (Control # 15-AS-20250204131826) and upon review of resident's (R1) file, LPA observed R1's medications on the medication bottles were discarded to a container. R1 was discharged from the facility effective 1/29/25. The Medication Destruction page of the LIC622 Centrally Stored Medication and Destruction Record was not completed. Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due date may result civil penalty. Deficiency and plan and proof of correction were discussed with Lulin 'Lucy' Wu, back-up administrator. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Feb 12, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i) · Plan of correction due date: Feb 26, 2025

87465 Incidental Medical and Dental Care (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record ... shall be destroyed in the facility by the facility administrator and one other adult who is not a resident..... -This requirement is not met as evidenced by:the state’s words, verbatim · CDSS document, Feb 12, 2025

Plan of correction: BUA stated she'll conduct in-service training. In addition, BUA to complete the LIC622's Destruction page. Proof to be submitted by 2/26/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87565(i) · Plan of correction due date: Feb 27, 2025

CONTINUATION: -Based on records review, interview and observation, the licensee did not comply with the section above in not documenting on LIC622 the medications of R1 that were to be disposed.the state’s words, verbatim · CDSS document, Feb 12, 2025

Type of visit: Case Management - Health Checks

On this day, January 29, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 2 complaint (Complaint #15-AS-20250127122838). LPA met with Lulin 'Lucy' Wu, back-up administrator (BUA), and informed the reason for visit. LPA obtained copies of LIC9020 Register of Facility Residents. When verified for total number of residents on LIC9020, BUA stated resident (R1) passed away on 1/15/25 in the hospital; however, review of documents and LPA's efaxed folder for the facility revealed no Death Report submitted. LPA also observed Unusual Incident Reports and SOC341 on resident's (R2) file but these documents were not submitted nor received by the Department. Facility did not report to the Department within 2 hours upon knowledge of the suspected abuse. LPA toured the facility inside out with the BUA. LPA inspected the common areas, activity room, dining room, kitchen, ensuite toilets, shower room. LPA randomly selected 6 residents rooms for inspection. LPA observed the following: -at 2:19 pm to 2:21 pm, auditory signal on the exit door in one of the resident's rooms not in working condition. LPA also observed extra hospital bed sideways against the wall and detached baseboard and wall moulding with protruding nail in this room. .....continued on 809C Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation of section 87303(a) within 12 month period. Failure to submit proof of correction by plan of correction due date, may result in additional civil penalties. Deficiencies and plan and proof of corrections were discussed with the BUA. Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Jan 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: Jan 30, 2025

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates ......... -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above in auditory signal not in working conditon which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Corrected. Auditory signal fixed while LPA is at the facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87211(b) · Plan of correction due date: Jan 30, 2025

87211Reporting Requirements (b) Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours....... -This requirement is not met as evidenced by: -Based on records review and interview, the licensee did not comply with the section in not reporting to the agencies includin the Department the suspected abuse which posed an immediate safety and/or personal rights risks to person in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: BAU and licensee to read the Regulations, do the following, and submit POC by 1/30/25: 1. Ensure that reporting is done within the required time frame. 2. Submit self-certification.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 12, 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 is not met as evidenced by: -Based on observation, the licensee did not comply with the section above in extra hospital bed, detached baseboard and wall moulding with protruding nail in the resident's room which pose a potential risks to persons in care. This is a repeat violation.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Corrected. The following were done while LPA was at the facility: 1. Moulding and baseboard fixed/repaired. 2. Extra hospital bed was removed from the resident's room and disposed. The extra hospital bed was removed from the resident's room. A $250.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(A) · Plan of correction due date: Feb 12, 2025

87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified (A)Death of any resident from any cause regardless of where the death occurred.... -This requirement is not met as evidenced by: -Based on record review and interview, the licensee did not comply with the section above in not sending the Death Report for resident (R1) which posed a potential personal rights risk to person in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Corrected. BUA submitted the Death Report to LPA while LPA was at the facility.

Allegation investigated: Staff not affording resident the personal right to leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.

On 6/5/2024 at 1:05 PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with Administrator Jonabelle Tolentino. On the allegation of Staff not affording resident the personal right to leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. Based on record review and interviews the facility has a delayed egress door and alarms that go off when residents with dementia attempt to leave the facility. S1 states that if a residents does not have a diagnosis of Dementia they are able to come and go as they please. R1 does have a diagnosis of Dementia and documentation stating that R1 can not leave the facility unassisted Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 5, 2024 · control 15-AS-20240531102146

Allegation investigated: Facility staff failed to safeguard resident's (R1) personal belonging.

Licensing Program Analyst (LPA) Delmundo arrived unaanounced to investigate the above allegation. LPA met with Jonabelle Tolentino, administrator, and informed the reason for visit. It was alleged that resident's (R1) roommate was wearing R1's jewelry and does not know if the jewelry was stolen or a coincidence that the roommate has it. LPA interviewed R1 who stated the roommate was R1's roommate in the previous private residence where R1 left the jewelries. Based on information provided by R1 that the jewelries and roommate are not in the facility, which the Department does not have jurisdiction, the allegation is closed as unfounded. An unfounded finding means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiency cited. Exit interviewed conducted, and copy fof this report provided. Unfoundedthe state’s words, verbatim · CDSS document, May 10, 2024 · control 15-AS-20240509141643

Allegation investigated: Staff yelled at resident.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegation and close the complaint. LPA met with Jonabelle Tolentino, administrator, and informed the reason for visit. During the course of investigation, LPA obtained copies of staff schedule, LIC9020 Register of Facility Residents, reviewed and obtained copies of residents' records. LPA reviewed facility video footage with the administrator and interviewed 5 residents on 8/17/23 and staff on 8/17/23, 8/18/23 and on this day, 5/10/24. It was alleged that on 8/2023, when R1 questioned S1 when S1 took out R1's personal belongings from R1's drawers in his bedroom to clean and in the process S1 threw out some of R1's personal belongings, S1 yelled at R1. .....continued on 9099C(page 2) Substantiated R1 was interviewed and stated when he was at the dining room on 8/12/23 and asked S3 if S3 has seen his salt and salad dressing in his room, S1 yelled at him. One of the other 4 residents interviewed stated she was yelled at by S1. . Four staff including S1 and S3 were interviewed. Three of the staff denied yelling any residents including R1. One of these staff stated she must be in the laundry room when the incident in the dining room happened. The other staff stated not observing the incident but have observed S1 raising voice on other residents including R1. Although S1 denied yelling at R1, video camera footage of the alleged day of incident was reviewed by LPA and administrator and observed R1 talking to S3 and S1 came to the scene. S1 was observed pointing fingers and moving her hands while talking to R1. Hand movements and facial expressions seemed S1 raising voice which administrator agreed. Based on information gathered, the preponderance of evidence standard has been met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations. and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the administrator. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided. Four staff who were present on the day of the alleged incident were interviewed. Two of the staff denied throwing any of the residents personal belongings. The other 2 staff who did the cleaning stated they threw away only the food items that were expired, rotten and with mold and told R1 they are throwing them away. Four other residents were interviewed including R1's roommate. R1's roommate confirmed that the 2 staff who did the cleaning of their room only threw away the food items that were expired, rotten and with mold and the items that were not expired were not thrown away. LPA observed some food items in the room when LPA conducted inspection on 8/17/23. The other 3 residents stated that none of their personal belongings were thrown away. Based on information gathered, the allegation is closed as 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 occurred. No deficiency cited. Exit interview conducted and copy of this report provided to the administrator.the state’s words, verbatim · CDSS document, May 10, 2024 · control 15-AS-20230815095918

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(1) · Plan of correction due date: May 24, 2024

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. -This requirement is not met as evidenced by: -Based on interviews and review of video footage, the licensee did not comply with the section above when staff yelled at resident which posed a potential personal rights risk to person in care.the state’s words, verbatim · CDSS document, May 10, 2024

Plan of correction: Administrator to in-service the staff and submit copy of training topic with attendees signatures by 5/24/24.

Type of visit: Required - 1 Year

On this day, May 10, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Jonabelle Tolentino, administrator, and informed the reason for visit. Facility has LIC9282 Infection Control Plan. LPA toured the facility inside and out with the administrator. LPA inspected the common areas, bathrooms, shower room, living/activity room, kitchen, dining area, front, side and backyard. LPA randomly selected 8 bedrooms for inspection. Facility has adequate food supplies for 7 days of non-perishables and 2 days of perishables. Fire extinguishers were observed fully charge with tags showed serviced February 26, 2024. Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in one of the ensuite toilets was tested, and measured at 116 degrees Fahrenheit. Facility conducts fire drills every 3 months, and records showed last conducted April 1, 2024. LPA reviewed 5 residents and 5 staff files, and interviewed 3 staff and 3 residents. Medications were checked and compared with doctor's orders on file and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources. LPA observed the following: -at 12:27 p.m., missing drawers and drawer knob in one of the resident's room. -at 12:28 p.m., razor in the ensuite toilet in R5's room. -at 4:45 p.m., quantity of all of R1's 9 medications received by the facility does not match the quantity listed on LIC622. ......continued on 809C (page 2) Page 2 LPA received copies of the following updated documents on this same day: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. Proof of $3M liability insurance coverage Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with the administrator. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, May 10, 2024