Serra Highlands Senior Living

Allegation investigated: Staff do not ensure the facility is properly maintained

On May 20, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced 10-day complaint visit. LPA met with Administrator, Joshua Lambengco and explained the purpose of the visit. Regarding the allegation, staff do not ensure the facility is properly maintained, according to the reporting party, a vacant resident was observed with two ventilation ducts, one of which was blocked with what appeared to be either a portion of a ceiling tile or a complete ceiling tile which can pose a potential danger to residents as the other ventilation duct was observed not to be working. During the investigation, LPA toured a random sample of resident rooms, made observations, and interviewed staff. Based on observations, LPA observed 1-2 ventilation ducts in each room, in addition to either a window or a sliding door. According to staff interviewed, the facility has a central heating and cooling conditioning system that comes out the ventilation ducts. LPA observed at least one and/or both ventilation ducts to be working in the resident rooms observed. According to staff and resident interviewed, the only reason the ventilation ducts are closed is if residents request for it to be closed. Based on observations and interviews conducted, the department has determined that although the above allegation may have happened or is valid, there is no a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is UNSUBSTANTIATED. Report is reviewed with administrator and a copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 20, 2026 · control 14-AS-20260518120834

Allegation investigated: Staff do not ensure the facility is free of odor

On April 28, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit. LPA met with Administrator, Joshua Lambengco and explained the purpose of the visit. Regarding the allegation, staff do not ensure the facility is free of odor, according to the reporting party, Resident 1's (R1's) room had a strong odor consistent with urine. During the investigation, LPA toured and observed R1's room. R1's room smelled like urine and LPA observed stains on R1's carpet. Based on observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. A civil penalty of $250.00 is being issued during the visit for a repeat citation within 12 months. Deficiency was cited on 2/18/26. This report is reviewed and discussed with the Administrator; a copy is provided. Report is reviewed with Administrator and a copy is provided with appeal rights. Substantiated Regarding the allegation, staff do not ensure the residents toileting needs are met and staff refused to assist resident with dressing, according to the reporting party, R1 did not have available diapers in his/her personal supply bag, and the diapers present were not appropriately sized for R1. Staff were asked for assistance in dressing R1 prior to discharge, however staff declined stating R1 was able to dress himself/herself. I requested staff assistance in helping Mr. Hill dress prior to discharge; staff declined, stating that he was able to dress himself. During the investigation, LPA interviewed staff, reviewed R1's file and attempted to interview R1's responsible party. LPA was unable to interview R1 as R1 is no longer a resident at the facility and R1's responsible party was not responsive. Based on R1's physician's report dated 3/11/25, R1 is able to dress himself/herself and care for his/her own toileting needs. According to R1's service plan dated 10/23/25, R1 is independent with dressing and toileting tasks. Based on staff interviews, R1 was assisted with dressing and changing of his/her diaper as R1 would wet himself/herself. Staff indicated if a resident is independent with toileting and dressing, however a resident needed assistance, staff would always help. In addition, staff indicated, there were always extra diapers at the facility and previous staff were in charge of ordering it for R1. Regarding the allegation, staff did not ensure resident wound care needs were met and staff did not ensure resident's hygiene needs were met, according to the reporting party, during hygiene care at R1's new facility, staff observed significant physical concerns, including large open wounds on R1's back, scabbing and wounds present on ears, overgrown toenails, and fingernails with visible debris underneath. R1's hair and facial hair were overgrown, and his/her overall presentation was consistent with poor hygiene. During the investigation, LPA interviewed staff, reviewed R1's file and attempted to interview R1's responsible party. LPA was unable to interview R1 as R1 is no longer a resident at the facility and R1's responsible party was not responsive. Based on R1's physician's report dated 3/11/25, R1 is able to bathe and groom himself/herself. According to R1's service plan dated 10/23/25, R1 is one persons assist with showers and received showers every Monday and Friday in the PM. Based on staff interviews, staff were not aware of any wounds that R1 had while at the community. Staff indicated that R1 would receive showers 1-2x a week, however at times R1 would refuse. Based on documents reviewed and interviews conducted, the department has determined that although the above allegations may have happened or is valid, there is no a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is UNSUBSTANTIATED. Report is reviewed with administrator and a copy is provided.the state’s words, verbatim · CDSS document, Apr 28, 2026 · control 14-AS-20260226120348

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 5, 2026

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by Based on observations, R1's room smelled like urine and LPA observed stains on R1's carpet which poses a potentional health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 28, 2026

Plan of correction: Based on observations made during complaint visit on 4/28/26, the carpet was replaced with hardwood floors and the room was aired out and no longer smelled like urine. Deficiency cleared and corrected. A civil penalty of $250.00 is being issued during the visit for a repeat citation within 12 months. Deficiency was cited on 2/18/26.

Type of visit: Required - 1 Year

On April 28, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced annual inspection. LPA met with Administrator, Joshua Lambengco and explained the purpose of the visit. LPA toured the facility inside and outside including but not limited to; a random sample of resident rooms, communal bathrooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a two story facility. Resident rooms were observed to be clean and in good repair. Resident bathrooms and communal bathrooms were observed to be equipped with paper towels and liquid soap. LPA toured main dining room and kitchen. LPA observed 2 days perishables and 7 days non-perishables. LPA observed medication room on the first floor to be locked and inaccessible to residents. Communal areas and were observed clean and free from tripping hazards. Water temperature throughout the facility measured between 111-114 degrees F. Medication, sharps, and chemicals are locked and inaccessible to residents in care. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of May 2025. Emergency drills are logged and done every 3 months. LPA reviewed 5 resident records and 5 staff records. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with administrator and a copy is provided.the state’s words, verbatim · CDSS document, Apr 28, 2026

Allegation investigated: Staff are not properly trained

On March 13, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Resident Services Director, Anne Dasmarinas and explained the purpose of the visit. Regarding the allegation, staff are not properly trained, according to the reporting party, there have been multiple medication administration errors occurring during the NOC shift after a care staff members was assigned to perform Med-Tech duties without documented medication training. During the investigation, LPA interviewed the Resident Services Director and reviewed training records for all 7 med-techs. According to the Resident Services Director, she reviewed med-techs training records. On 3/6/26, after she discovered Staff 1 (S1), who is a med-tech, did not complete their initial training to assist residents with self-adminisration of medications, she pulled S1 off the schedule. On 3/11/26, after the Resident Services Director discovered Staff 2 (S2), another med-tech, did not complete their initial training to be able to administer medications to residents, she pulled S2 off the schedule. (continue to 9099C) Substantiated Based on training records reviewed, there are 7 med-techs in total and both S1 and S2 did not complete their 16 hours of initial training prior to administering medications to residents in care. In addition, based on training records reviewed, LPA did not observe med-techs receiving their annual on-the-job training in relation to policies and procedures regarding medications on top of their initial required training to be able to administer medication to residents in care. The facility was unable to provide me any documentation to show med-techs are receiving their annual on-the-job training. Based on information collected and files reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Resident Services Director and a copy is provided with appeal rights. LPA conducted a medication count for R1’s Levothyroxine. LPA observed the amount of medications in the bottle corresponded with the start date of the medication listed on the centrally stored medication record. In addition, according to staff interviews, R1 does not take alendronate. LPA confirmed that alendronate is not on the R1’s prescribed medication list and MAR. Based on documents reviewed, information collected, observations, and interviews conducted, the department has determined that although the above 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 above allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Mar 13, 2026 · control 14-AS-20260227122349

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.69(a)(1) · Plan of correction due date: Mar 14, 2026

§1569.69 Employees assisting residents with self-administration of medication; training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 16 hours of initial training... This training shall consist of eight hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medication which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by: Based on training records reviewed, S1 and S2 did not have their initial 16 hours of training documented prior to administering medication to residents in care which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 13, 2026

Plan of correction: Licensee/administrator shall submit a plan in writing on how to ensure all med-techs complete their initial 16 hours of training. Plan shall include, documented how many hours it took to complete the training.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(c)(3)(D) · Plan of correction due date: Mar 14, 2026

87411 Personnel Requirements - General: (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (3) The training shall include, but not be limited to, the following:(D) Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4). This requirement is not met as evidenced by: The facility was unable to provide LPA documentation to show med-techs have been receiving their annual on-the-job training. LPA did not observe any annual trainings in med-techs files during file review.the state’s words, verbatim · CDSS document, Mar 13, 2026

Plan of correction: Licensee/administrator shall submit a plan in writing on how to ensure all staff receive their annual on-the-job training. Plan shall include; who will be conducting the training, when it will be conducted, keeping track of staff that require their annual training, maintaining documentation of the training, etc.

Type of visit: Case Management - Deficiencies

On March 13, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit in relation to complaint control: 14-AS-20260227122349. LPA met with Resident Services Director, Anne Dasmarinas and explained the purpose of the visit. During a complaint investigation, LPA requested to review personnel training records, however the facility was unable to provide LPA training records for the requested staff members. Deficiency was observed during the visit and cited from the California Code of Regulations, Title 22 and Health and Safety Code. See LIC809-D. Report is reviewed with Resident Services Director, Anne Dasmarinas and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Mar 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c) · Plan of correction due date: Mar 20, 2026

87412 Personnel Records: (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Based on 7 personnel records reviewed, LPA did not observe any staff training records in the files. In addition, facility was unable to provide it to LPA during the complaint visit on 3/5/26 which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 13, 2026

Plan of correction: Licensee/administrator shall submit a plan in writing on how to ensure personnel files are maintained at the facility and each personnel file contain the documents/information as listed on CCR 87412.

Allegation investigated: Staff do not provide adequate food service

On March 5, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced 10-day complaint visit. LPA met with Resident Services Director, Anne Dasmarinas and explained the purpose of the visit. Regarding the allegation, staff do not provide adequate food service, according to the reporting party, the med-tech requested assistance from the caregiver to check on Resident 1 (R1) who had not eaten his/her breakfast, however the caregiver stated that R1 did not want to get up. According to the reporting party, the med-tech had to go to R1’s room to assess R1 and bring him/her down to the dining room. Furthermore, reporting party stated, R1 was hungry and wanted to go to the dining room. During the investigation, LPA interviewed R1, staff and reviewed R1's service plan. Based on R1's service plan, R1 is independent for meals and food trays are delivered to his/her room for every meal. According to staff interviewed, R1 eats meals in his/her room because he/she likes to be in his/her room. LPA interviewed R1 who indicated he/she received his/her meal this morning and has not had an issue with meal service. Based on documents reviewed and interviews conducted, the department has determined that although the above allegation may have happened or is valid, there is no a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 5, 2026 · control 14-AS-20260227161900

Type of visit: Case Management - Other

On March 5, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit. LPA met with Resident Services Director, Anne Dasmarinas and explained the purpose of the visit. On 3/1/26, LPA was made aware via email of an eviction status for Resident 1 (R1). On 3/2/26, LPA emailed the Special Operations Director asking when the eviction notice was issued to the resident as based on LPA's records review, CCLD did not receive a copy of the eviction notice provided to R1. According to the Special Operations Director, the eviction is in collections and with the facilities legal department. Special Operations Director provided LPA with a copy of the unlawful detainer. LPA reviewed the document and observed a copy of a 30-days eviction notice signed by Staff 1 (S1) dated 10/28/25 addressed to R1 for nonpayment of the rate for basic services. During the visit, LPA reviewed documents. S1 no longer works at the community so LPA was unable to confirm if the eviction notice for R1 was sent to CCLD or not. The facility was unable to provide documentation to show that a copy of the 30-day eviction was submitted to CCLD. LPA reviewed CCLD records and was unable to find a copy of the 30-day eviction notice. Deficiency was observed during the visit and cited from the California Code of Regulations, Title 22 and Health and Safety Code. See LIC809-D. Report is reviewed with Resident Services Director, Anne Dasmarinas and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Mar 5, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(f) · Plan of correction due date: Mar 12, 2026

87224 Eviction Procedures: (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by: Based on record review, the facility was unable to provide LPA documentation to show that a copy of the 30-day eviction for R1 was submitted to CCLD. In addition, based on CCLD's record, a copy of the eviction notice was not observed which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 5, 2026

Plan of correction: Facility shall develop a plan of correction to ensure compliance with Sec.87224(f). Licensee shall provide proper notice to CCLD if/when a resident is being issued an eviction notice.

Allegation investigated: Staff did not properly maintain the residents rooms

On February 18, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Community Support Nurse, Shannon Metcalfe and explained the purpose of the visit. Regarding the allegation, staff did not properly maintain the residents room, according to the reporting party, Resident 1's (R1's) room reeked of urine and the floor was dirty and Resident 2's (R2's) bedroom floor is dirty and sticky. During a complaint visit conducted on 12/12/25, LPA observed R1 and R2's room. Although, R2's room was observed to be clean and odor-free, LPA observed R1's room to have a urine odor. Based on observations made, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiency of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiency may result in civil penalties. Report is reviewed with Community Support Nurse and a copy is provided with appeal rights. Substantiated Regarding the allegation, staff do not ensure a resident is being properly fed, according to the reporting party, staff do not get R2 up for breakfast. During the investigation, LPA interviewed R2 and interviewed staff. According to staff interviewed, there are a couple residents who wake up later than other residents or prefer to have meals in their rooms. If residents don't come down to the dining hall for their meals, caregivers will go check in on the resident and ask if they want their meal delivered to their rooms. According to the previous Cullinary Director, the kitchen has a meal attendance tracking form that helps kitchen staff keep track of residents who have received their meals and residents who have not received their meals. If residents do not come down to the dining hall for the meals, the kitchen staff will notify the caregivers and the caregivers will go check on the resident. Regarding the allegation, staff do not meet a resident's planned activity, according to the reporting party, there is no one at in the facility that will help her walk daily. During the investigation, LPA observed and reviewed the activities calendar for the month posted on the first floor hallway and interviewed staff. According to staff interviewed, activities are provided to residents everyday and residents have a say on what goes on the activity calendar, however the facility can't accommodate one resident and what they want because there are other residents in the facility. LPA observed the activities calendar to have "walking for fitness" at least 3-4x a week. According to the activities director, walks are either inside the facility or outside the facility, depending on the weather and if the residents want to walk outside or inside. The activities director indicated, there are 3-4 residents who like to walk outside everyday and tries her best to take them on walks. Regarding the allegation, staff did not afford the residents privacy, according to the reporting party, Resident 4 (R4) stated that staff talk to him/her about being sexually inappropriate. In addition, the reporting party indicated caregivers enter residents rooms without knocking and would linger when there are visitors visiting residents in their room. During the visit, LPA interviewed residents and staff. According to R4, he/she does not remember saying or having sexual conversations with staff. According to R4, at times he/she can have memory issues but would remember if staff were having inappropriate conversations with him/her. According to staff and residents interviewed, staff are required to knock and wait for residents response prior (continue to 9099C) to entering a residents room. According to the residents interviewed, staff always knock on their doors before entering. If there are visitors in the resident's room, staff ask if they are allowed to stay and do what is need or if they should come back when the visitors are gone. Based on documents reviewed, information collected, and interviews conducted, the department has determined that although the above 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 above allegations are UNSUBSTANTIATED. Report is reviewed with Community Support Nurse and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 14-AS-20251203122307

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 25, 2026

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by: Based on LPA's observations, R1's room to have a urine odor which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 18, 2026

Plan of correction: Licensee/administrator shall submit a plan in writing on how to ensure resident rooms are clean and odor-free. Plan shall include, increasing housekeeping services.

Allegation investigated: Staff use profanity towards resident.

On January 27, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Regional Sales, Ruth Ocon and explained the purpose of the visit. Regarding the allegation, staff use profanity towards resident, according to the reporting party, Staff 1 (S1) cursed at Resident 1 (R1). During the investigation, LPA interviewed R1, staff and attempted to interview S1. According to R1, S1 says the F word or use other profanity towards him/her several times. LPA reached out to S1, however was unable to interview S1. According to staff interviewed, he/she witnessed S1 cursing at R1. Based on information collected and file reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Regional Sales and a copy is provided with appeal rights. Substantiated During the investigation, LPA interviewed R1, interviewed S2 and reviewed S2's personnel file. According to R1, when he/she pressed his/her call button, S2 came to R1 and turned the call button off and leave.S2 indicated that he/she has never turned off any residents call button and does not assist residents with care as that is not his/her job and is not trained for it. According to S2, he/she does not have access to the call button system nor does he/she keep a radio in their office. Based on S2's personnel record, LPA confirmed that S2 does not have any caregiving training. Regarding the allegation, staff not providing a comfortable room temperature for resident(s), according to the reporting party, there are some areas in the facility that are cold and staff are not providing a comfortable room temperature. During the investigation, LPA toured the facility with the maintenance director. A comfortable temperature of 69-72 degrees F is maintained throughout the facility and LPA observed thermostats to be in good working condition. In addition, the maintenance director indicated that most residents have portable space heaters in their rooms. Based on documents reviewed, information collected, and interviews conducted, the department has determined that although the above 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 above allegations are UNSUBSTANTIATED. Report is reviewed with Regional Sales, Ruth Ocon and a copy is provided.the state’s words, verbatim · CDSS document, Jan 27, 2026 · control 14-AS-20260109164112

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Feb 3, 2026

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff... This requirement is not met as evidenced by: Based on interviews, R1 indicated that S1 says the F word or use other profanity towards him/her several times. According to staff interviewed, he/she witnessed S1 cursing at R1 while assisting S1 with providing care to R1 which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Licensee/administrator shall conduct an in-service training regarding personal rights of residents, including but not limited to treating residents with dignity and respect

Type of visit: Case Management - Incident

On January 27, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management in relation to an incident that occurred on 1/8/26. LPA met with Regional Sales, Ruth Ocon and explained the purpose of the visit. The Licensee reported on 1/8/26 at 10:40am, Resident 1 (R1) asked the front desk to call a cab to go to T-Mobile to purchase a new phone. At 12am, the regional sales asked the front desk to call T-Mobile to let them know that R1 was there and tell them that if R1 needed help to get a cab back to the facility, to call the facility and they would send the bus driver to pick R1 up. At 12:30pm, the regional sales sent the bus driver to R1's area to see if the bus driver could find R1 and offer him/her a ride back, however the bus driver was unable to locate R1. At 4:30pm, R1 was still not back to the facility, the facility notified R1's responsible party and the regional sales went to where R1 was dropped off to see if she could find him/her. Regional sales drove around for an hour and then went to the police department to file a report. At 6:30pm, a good samaritan called the facility and notified the facility that R1 is in front of the police department and found R1 walking around Daly City. R1 came back to the facility at 7pm. During the investigation, LPA reviewed R1's file, reviewed sign in/sign out log at the front desk, and interviewed staff. Based on R1's file reviewed, R1 is not able to leave the facility unassisted. According to the staff interviewed, they were not aware that R1 could not leave unsupervised. In addition, staff indicated that R1 has left the community unsupervised many times. Deficiency was observed during the visit and cited from the California Code of Regulations, Title 22 and Health and Safety Code. See LIC809-D. Report is reviewed with Regional Sales, Ruth Ocon and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Jan 27, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 28, 2026

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on R1’s file reviewed, R1 is unable to leave the facility unassisted, however, R1 left the facility unassisted on 1/8/26 at around 10:40am and did not return back to the community till 7pm when R1 was found by a good samaritan. Staff indicated they were not aware that R1 was not allowed to leave the facility unsupervised which poses an immediate health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Licensee/administrator shall conduct an in-service training with staff regarding elopement risk/wandering behavior. Regional sales indicated there is a book with the receptionist at the front desk to show which residents that are ABLE to leave unassisted and residents that are UNABLE to leave unassisted.

Type of visit: Case Management - Incident

On January 16, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit in relation to an incident that occurred on 12/18/25. LPA met with Special Operations Director, Kathy Valencia and explained the purpose of the visit. The Licensee reported, on 12/12/25, Resident 1's (R1's) physician changed R1's medication for Pregabalin from one 50mg capsule in the morning to one 75mg capsule in the morning. R1 is with the VA and the facility did not receive the new medication bottle until 12/17/25. On 12/18/25, the med-tech on shift, administered one 50mg capsule in the morning instead of the 75mg capsule. The error was discovered on 12/19/25 by another med-tech. During the visit, LPA reviewed R1's file, including but not limited to; physician's orders for medication, medication list, medication administration record (MAR), and R1's medication bottles. Based on R1's medication list, R1 was required to take one tablet of Pregabalin (75mg) medication daily every morning, and one 75mg tablet at bedtime, however the med-tech administered one 50mg capsule instead. The facility failed to provide R1's medication as prescribed by the physician. According to the Community Support Nurse, the med-tech that administered the wrong medication is no longer employed with the facility and they were unable to get a statement prior to the med-tech leaving. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Special Operations Director, Kathy Valencia and a copy is provided.the state’s words, verbatim · CDSS document, Jan 16, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 17, 2026

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on R1's medication list, R1 was required to take one tablet of Pregabalin (75mg) medication daily every morning, and one 75mg tablet at bedtime, however the med-tech administered one 50mg capsule instead. The facility failed to provide R1's medication as prescribed by the physician.the state’s words, verbatim · CDSS document, Jan 16, 2026

Plan of correction: Licensee/administrator shall conduct in-service training with med-techs to ensure residents are receiving their medication as prescribed.

Allegation investigated: Staff do not ensure resident's record is up to date.

On June 17, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Administrator, Shayan Gheisar and explained the purpose of the visit. Regarding the allegation, staff do not ensure resident's record is up to date, according to the reporting party, Resident 1 (R1) has not seen his/her primary care physician (PCP) in 3 years and records are not up to date. During the investigation, LPA reviewed R1’s file and observed R1’s physician’s report to be from 9/2021. R1 does not have an updated physician’s report as according to the administrator, R1 has not seen his/her PCP or seen a physician since 2021. Based on information collected and file reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Administrator and a copy is provided with appeal rights. Substantiated During the visit, LPA interviewed the administrator and med-tech. According to the administrator and med-tech, it’s the residents and responsible parties responsibility to schedule the medical appointments. In addition, administrator and med-tech indicated that once responsible parties or residents schedule medical appointments, they should notify the front desk so that transportation can be arranged in advance. Regarding the allegation staff are not properly trained, according to the reporting party, he/she spoke to a med-tech (name unknown) that was not sure who was filling R1's medications and did not know much about R1. During the investigation, LPA reviewed 5 staff training records. LPA concluded that based off the records of staff training, staff are being trained regularly throughout the year. Staff records are complete and training logs are being maintained and audited every month. Regarding the allegation, staff do not ensure facility restrooms have adequate toiletry supplies, according to the reporting party, the communal bathrooms at the facility does not have toilet paper, liquid soap, and paper-towels. During the visit, LPA interviewed housekeeping staff and observed the communal bathrooms. According to the housekeeping staff, the bathrooms are checked and toiletries are restocked in all communal bathrooms at the start of their shift in the morning and then checked 3x throughout the day. During the investigation, LPA observed the two communal bathrooms on the first floor and the communal bathroom on the second floor and observed all three bathrooms to be equipped with liquid soap, paper towels, toilet seat covers, and paper-towels. Regarding the allegation, staff is retaining a resident that required a higher level of care, according to the reporting party, R1 has advanced dementia based on the medications R1 is taking for Alzheimer’s dementia, however there is no memory care services at the facility. During the investigation, LPA observed R1’s file and medication list. Although R1 is taking two alzheimer's dementia medications, the facility does not have anything in writing indicating that R1 has dementia. According to the administrator, the facility has tried several times to reach out to R1's responsible party to schedule an appointment for R1 to be reassessed, however R1's responsible party is non-responsive. Based on documents reviewed, and interviews conducted, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed with the administrator and a copy is provided.the state’s words, verbatim · CDSS document, Jun 17, 2025 · control 14-AS-20250514093527

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(h) · Plan of correction due date: Jun 24, 2025

87463 Reappraisals: (h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by: Based on records reviewed, R1 has not received an annual routine visit since 9/2021 which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: Licensee/administrator shall ensure all residents are receiving annual visits and documentation is maintained in each resident's file. In addition, administrator/licensee shall ensure if residents refuse annual appointments or responsible parties fail to be responsive, it gets documented.

Type of visit: POC

On 4/24/2025 , Licensing Program Analyst(LPA) Grace Donato arrived at the facility to conduct a Plan of Correction(POC) visit with regards to citations given to the facility on 4/17/2025. LPA met with Resident Services Director Jonamar Pascua and explained the purpose of the visit. As of today deficiencies have been cleared. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Apr 24, 2025

Type of visit: Required - 1 Year

On 4/17/2025 LPA Grace Donato conducted an unannounced annual visit to the facility. LPA met with Administrator Shayan Gheisar and explained the purpose of the visit. LPA toured the facility including a random sample of resident rooms, common areas, and kitchen . LPA observed some residents were at the dining room having breakfast. While touring the facility it was observed that the temperature was at 69 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Carbon monoxide monitor is working properly. All fire extinguishers is due for April evaluation. Facility has a scheduled maintenance for these extinguishers on 4/17/2025. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Food supply delivery is scheduled on this day. Emergency drills are done quarterly. Six resident records and six staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Administrator certificate has expired but renewal has already been submitted and pending evaluation. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. Hot water was tested in random rooms and 7 out of 9 showed a temperature of between 99-103 deg F. During the review of staff roster, it was found out that 4 staff members does not have criminal background clearance. LPA received copy of the following: LIC610E - Emergency Disaster Plan Personnel Report Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Apr 17, 2025

Type of visit: Office

**** NOTE ORIGINAL SIGNATURE IS ON FILE WITH THE PACIFICA SENIOR LIVING UNION CITY FACILITY***** **** NOTE ORIGINAL SIGNATURE IS ON FILE WITH THE PACIFICA SENIOR LIVING UNION CITY FACILITY*****the state’s words, verbatim · CDSS document, Apr 4, 2025

Allegation investigated: Resident's dresser is inaccessible Staff did not maintain a comfortable temperature for a resident in care.

On March 7, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Shayan Gheisar and explained the purpose of the visit. Regarding the allegation, residents dress is inaccessible, according to the reporting party, Resident 1's (R1's) bed is pushed against the dresser and R1 is unable to use it to put his/her clothing inside of it. During the investigation, LPA observed R1's room and observed R1's dresser against R1's bed and LPA was unable to fully open the dresser. Regarding the allegation, staff did not maintain a comfortable temperature for a resident in care, according to the reporting party, it was reported that there is no heat in R1's room since being admitted in December of 2024. (Continue to 9099C). Substantiated During the investigation, LPA toured the facility and R1's room. Based on observations, there was no functioning heating unit in R1's room and there were no space heaters that were provided. In addition, during the facility tour, LPA observed that the second floor communal area had no functioning heating units, however there were space heaters in the room. LPA observed space heaters in certain residents rooms due to no functioning heating unit. According to the administrator, there has been issues with some of the HVAC units and facility currently looking for repairs. Based on information collected and observations conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Administrator and a copy is provided with appeal rights. During the investigation, LPA interviewed staff. According to staff interviewed, R1 was asked multiple times if he/she wanted to go to the hospital and if he/she wanted the facility to call 911, however R1 refused and didn't want his/her family members to know. Regarding the allegation, staff did not transport resident to a medical appointment, according to the reporting party, R1 had an appointment on 2/10/25 for his/her pain, however the staff did not take R1 because his/her appointment was too far. During the investigation, LPA interviewed the Administrator and reviewed the transportation log located at the front desk. According to the administrator, if a resident has an appointment, they are required to notify the front desk 72 hours in advance to ensure a drive is available for transportation. In addition, according to the administrator R1 did not notify the facility on his/her appointment until the morning of her appointment. Based on the transportation log, LPA did not observe R1's name listed on the log for 2/10/25. Furthermore, LPA reviewed the resident handbook that is provided by the facility which indicates, to reserve a ride with the front desk receptionist at least 72 hours in advance. Based on documents reviewed, and interviews conducted, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed with the administrator and a copy is provided.the state’s words, verbatim · CDSS document, Mar 7, 2025 · control 14-AS-20250211164016

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(13) · Plan of correction due date: Mar 14, 2025

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (13)To have access to individual storage space for private use. This requirement is not met as evidenced by: LPA observed R1's room and observed R1's dresser against R1's bed and LPA was unable to fully open the dresser which poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Mar 7, 2025

Plan of correction: Deficiency is cleared during the visit. LPA observed R1's room and observed R1 to have access to dresser.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b) · Plan of correction due date: Mar 7, 2025

87303 Maintenance and Operation: (b) A comfortable temperature for residents shall be maintained at all times. This requirement is not met as evidenced by Based on interviews and observations, the facility does not have working heating units in some parts of the facility. According to the administrator, there has been issues with some of the HVAC units and facility currently looking for repairs, however for the meantime, residents are being provided space heaters as an alternative option.the state’s words, verbatim · CDSS document, Mar 7, 2025

Plan of correction: Licensee/Administrator shall submit a plan in writing indicating how to ensure a comfortable temperature is maintained at the facility. Plan shall include repairing heating units.

Allegation investigated: Three resident's eloped due to lack of supervision

On February 24, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Administrator, Shayan Gheisar and explained the purpose of the visit. Regarding the allegation, three residents eloped due to lack of supervision, according to the reporting party, four residents have eloped from the facility due to lack of supervision. During the investigation, LPA interviewed administrator and staff. According to administrator and staff, there was a resident (R1) who did leave the facility unassisted once and was found by a caregiver and redirected back to the facility. Based on R1's physician's report reviewed, it was noted R1 had a diagnosis of dementia and is unable to leave the facility unassisted. Family was informed and facility helped family move R1 to a memory care facility. Based on information collected and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Failure to correct said deficiencies may result in additional civil penalties. An immediate $500.00 is issued due to absence of supervision. Report is reviewed with Administrator and a copy is provided with appeal rights. Copy of civil penalty is provided. Substantiated During the complaint visit, LPA observed R1's toilet to be in good working condition. Based on interview conducted with R1, the facility replaced his/her toilet with a new toilet. According to the administrator, the facility was having plumbing issues throughout the facility, however it has been fixed as all the toilets are in good working condition. Regarding the allegation, facility does not meet residents' nutritional needs, according to the reporting party, the facility's food quantity and quality are not adequate to meed the nutritional needs of the residents and the facility does not give the residents enough food to meet those nutritional needs. In addition, the reporting party indicated, the facility sometimes runs out of food. During the investigation, LPA interviewed residents, observed the facility's food menu and observed the facility's food supply. LPA observed 2 day perishables and 7 day non-perishables present at the facility. LPA observed one weeks food menu and observed that the facility provides several entree options each meal with additional daily items and snacks to choose from. Kitchen staff have record of resident dietary restrictions with notation of restrictions labeled on the menu for each individuals' diet. Upon interviews with residents, LPA received inconsistent information regarding food taste but was found that the facility provides 3 meals a day with a variety of nutritious food options. Regarding the allegation, staffing levels do not meet the needs of residents in care, according to the reporting party, staffing levels present are not enough to meet the needs of residents by not responding to residents timely and providing the actual services when appropriate. During the investigation, LPA reviewed staff schedule, 5 residents response times. According to the administrator, there are 6 caregivers for 70 residents during the morning and afternoon shift, 11 of which are independent resident. LPA reviewed 5 residents call buttons within the last months, and on average the response time is 7 minutes. Regarding the allegation, staff are not trained to meet the needs of residents in care, according to the reporting party, staffing levels present are not enough to meet the needs of residents and the staff are not trained properly to meet those needs by not responding to residents timely and providing the actual services when appropriate. (Cont to 9099C). During the visit, LPA reviewed 5 staff files and observed training records. Staff records are complete, with training logs that have met the basic requirement. On going staff training is provided monthly regarding the following topics; infection control, proper transferring, incontinence care, skin checks, first-aid, etc. Regarding the allegation, facility is not notifying residents and families of changes taking place in licensee or corporate structure, according to the reporting party, there are changes being made on the corporate level, or ownership level, and those changes are not being communicated to residents and the families of the residents. During the investigation, LPA interviewed responsible parties, administrator, business office manager, and reviewed documents. The administrator and the business office manager denied this allegation and indicated that a letter was sent to residents and family members on October 1, 2024 notifying them that there will be a change in management company. Administrator provided LPA a copy of the letter for review. According to residents interviewed, it was indicated that they did receive letters from the facility notifying them of the change of management. Based on observations, documents reviewed, and interviews conducted, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed with the administrator and a copy is provided.the state’s words, verbatim · CDSS document, Feb 24, 2025 · control 14-AS-20241120141233

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 25, 2025

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on staff interviews, there was a resident (R1) who did leave the facility unassisted once and was found by a caregiver and redirected back to the facility. Based on R1's physician's report reviewed, it was noted R1 had a diagnosis of dementia and is unable to leave the facility unassisted which poses an immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Feb 24, 2025

Plan of correction: Licensee/administrator to conduct in-service training regarding elopment risks and how to ensure there is adequate supervision. Immediate Civil Penalty of $500.00 is being assessed today 2/24/25 for absence of supervision.

Allegation investigated: Facility faucets used by residents for personal care do not deliver hot water

On December 4, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Administrator, Shayan Ghesiar and Business Office Manager, Natice Coles and explained the purpose of the visit. Regarding the allegation, facility faucets used by residents for personal care do not deliver hot water, according to the reporting party, the facility has failed to provide adequate bathing shower water temperature above 86 degrees. During the visit, LPA measured water temperature which includes faucets and showers in 5 resident rooms on the first floor and 5 resident rooms on the second floor. Water temperature throughout the facility measured between 105-107.2 degrees F. Based on observations conducted, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed with Administrator and a copy is provided Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 4, 2024 · control 14-AS-20241125161351

Type of visit: Case Management - Annual Continuation

On May 15, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced continuation visit for an annual inspection that was conducted on 4/23/2024. LPA met with the administrator and explained the purpose of today's visit. During today's visit: A review of (6) resident files was conducted and noted on the LIC 858. A review of (7) staff files was conducted and noted on the LIC 859. LPA also conducted staff and residents interviews. No deficiency cited. This report is reviewed and discussed with the administrator. A copy is provided.the state’s words, verbatim · CDSS document, May 15, 2024

Type of visit: Required - 1 Year

On April 23, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with the administrator and explained the purpose of today's visit. LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA observed the indoor and the outdoor passageways are free of obstruction. This is a two story facility; LPA observed sufficient lighting and comfortable temperature is maintained throughout the facility. LPA toured the first floor of the facility and observed residents having lunch in the dining room. LPA toured the kitchen located on the first floor and observed 2 day perishable and 7 day non-perishable. Sharps and chemicals were observed to be locked and inaccessible to residents. LPA observed medications/med cart locked in an office on the 1st floor next to the elevator. A tour of the rooms were conducted on the 1st and the 2nd floor and observed to be spacious and included all required furnishings. Staff room was observed on first floor to be a break room. Second floor common area and some of the vacant resident rooms are currently undergoing construction. LPA will return on another day to complete the inspection. No deficiency cited today. This report is reviewed and discussed. A copy is provided.the state’s words, verbatim · CDSS document, Apr 23, 2024

Type of visit: Case Management - Other

On April 9, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 3:00 pm to conduct an unannounced Case Management visit to investigate a death that occurred in January 2024. LPA Calandra was greeted by Shayan Gheisar, Executive Director and explained the purpose of his visit. LPA Calandra requested the following documents: -Assisted Living Schedule -Training records LPA Calandra interviewed 1 staff member. No deficiencies were cited during today's visit. This report was reviewed with Executive Director, Shayan Gheisar, and a copy of the report left at the facility.the state’s words, verbatim · CDSS document, Apr 9, 2024

Allegation investigated: - Licensee not ensuring that infection control practices are maintained - Facility is malodorous

LPA Jeung met with business office director and resident services director (RSD) and reviewed Infection Control Plan and related staff training. Administrator participated by phone. Based on this investigation--which included observations of supplies of PPE and plastic garbage bags and interviews with staff--these allegations are determined to be unsubstantiated. Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur. It cannot be determined that caregivers wear the same gloves when caring for more than one resident, nor that shortage of plastic garbage can liners resulted in offensive odors due to absence of trash can liners. During review and discussion of Infection Control Plan (LIC9282), it is noted that the current Infection Control Preventionist is RSD. Administrator agreed to submit revised ICP and proof of infection control training from a medical professional for RSD. LPA also recommended that documentation of 40 hour new hire training include infection control, as per CCR 87470 Infection Control Requirements. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 27, 2024 · control 14-AS-20240108140600

Type of visit: Case Management - Other

On March 19, 2024 at 1:21 PM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a Case Management in regards to a death that occurred on January 20, 2024. LPA Calandra met with Shayan Gheisar, Executive Director and explained the purpose of his visit. LPA Calandra asked for the following documents: 1. Resident and Medical file for R1 2. Staff schedule for January 2024 3. Staff training 4. 6 Staff files LPA Calandra reviewed 6 staff files and staff training records. LPA Calandra also interviewed 2 staff members. No deficiencies were cited during today's visit. This report was reviewed with Shayan Gheisar, Executive Director and a copy of the report left at the facility.the state’s words, verbatim · CDSS document, Mar 19, 2024

Allegation investigated: - Staff does not ensure residents are spoken to in an appropriate manner - Staff do not ensure residents are served food of good quality and quantity - Staff do not ensure a clean safe environment is provided for residents in care

On 02/07/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver fidingings in regards to the allegations received. LPA met with Shayan Gheishar and explained the purpose of today's visit. During the investigation LPA made observations and conudcted interviews. LPA observed the areas under construction dnd did not observe any power tools or supplies in the hallways or walkways of the facility. The facility is renovating some rooms on the second floor. Those rooms are observed to have the doors closed. There was no dust in the hall or walkways the rooms are attached to. The facility kept the doors closed to prevent dust from exiting the rooms. LPA did not smell or observe any toxic items being used during the renovation process and was told that the items being used are legal and approved for such building projects. LPA did not observe any construction dust in the hallway outside of those rooms. No dust was observed on shoes or rails. The city's building and permitting department inspected the construction and found no anomolies and provided suggestions on how to add additional measures to help. Continued on next page. Unsubstantiated Page 2 - LIC9099 Food services and meals are served per menus and suggested serving sizes and USDA recommendations. Residents with modified diets, prescribed diets, or adjusted diets due to health conditions are provided those meals based on those needs. Additionally if residents do want more food they are allowed to request additional servings depending on availability. Interviews conducted cannot provide evidence to show that residents are being spoken to in inappropriate ways. Communications may have been perceived as being dismissive, or being spoken to inappropriately, but LPA does not have a preponderance of evidence to show that did take place in the manner in which it was described. These allegations are unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report is reviewed with Shayan Gheishar.the state’s words, verbatim · CDSS document, Feb 7, 2024 · control 14-AS-20231207160004