Shiloh Retreat

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit to follow up on a complaint investigation that occurred on 6/2/26. LPA met with Staff and explained the purpose of the visit. On 6/2/26, LPA conducted a complaint investigation for complaint 28-AS-20260407090059 on the allegation of lack of supervision, the resident eloped from the facility. LPA cited the facility with California Code of Regulations 87411(a). After reassessing the incident, there appeared to be an absence of supervision when Resident #1 (R1) disappeared from the staff's view, as the resident was walking away from the facility on 4/4/26. Staff could not follow the resident since there were other residents at the facility. R1 ended up at another nearby facility. Therefore, a civil penalty of $500 is being assessed today for the absence of supervision. An exit interview was held. A copy of this report, LIC421IM, and appeal rights were given to Staff Gallardo.the state’s words, verbatim · CDSS document, Jul 9, 2026

Allegation investigated: Due to lack of supervision, resident eloped from the facility.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to deliver findings for the allegation(s) listed above. LPA met with Staff Amalia Ramos and explained the purpose of the visit. On 4/14/26, LPA Chan conducted the initial visit. LPA obtained copies of the staff and resident rosters, documents for Resident #1, and interviewed four (4) staff and five (5) residents. During the visit today, LPA interviewed another staff. The investigation revealed the following: Allegation – Due to a lack of supervision, resident eloped from the facility. LPA interviewed the staff regarding this allegation. The administrator acknowledged that on 4/4/26, Resident #1 (R1) exited the facility independently without staff knowledge or supervision. Staff was assisting another resident when R1 left the facility. Staff heard the alarm on the door and went to check on R1. Substantiated Staff saw R1 walking up the block but could not go after R1 because staff was assisting another resident in the showers. R1 ended up at another facility that was close by and was unharmed. LPA review R1's physician's report, which indicated that R1 cannot leave the facility unassisted. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. A copy of this report and appeal rights were provided to staff Ramos. LPA received and reviewed the incident report that was sent to licensing regarding R1 attacking R2 and ripping off two of R2’s nails. Staff on duty immediately intervened and separated the 2 residents. Staff acknowledged that R1 has been displaying more physical aggression lately. R1 had been seen by the behaviorist and physician regarding the recurring behaviors. LPA interviewed five (5) residents. Residents stated that the staff are always supervising them and will intervene right away when residents become aggressive. Allegation - Staff turned off the alarms on the doors, resulting in resident eloping. Staff interviewed denied turning off the alarms on the doors. Staff stated that when Resident #1 eloped from the facility, staff heard the alarm, which alerted staff to check on the resident. During the visit on 4/14/26, LPA checked the exit doors. The doors will sound loudly when they are open. Staff stated there is a switch to turn off the sound, but they always keep it on for extra security. LPA interviewed five (5) residents, and they all stated that the alarm will sound when someone opens the door. Staff do not turn off the alarm on the doors. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Staff Ramos. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Jun 2, 2026 · control 28-AS-20260407090059

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

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on interviews and record review, R1 left the facility unassisted which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 2, 2026

Plan of correction: Licensee shall conduct an in-service training to ensure staff are providing supervision to residents. ***The inservice log was received during the visit today. POC will be cleared.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual visit using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by Juliana Garcia and explained the reason for the visit. This home is licensed to serve residents ages 60 and over, six (6) ambulatory which six (6) may be non-ambulatory. Facility is approved for six (6) hospice residents. No residents under hospice care during inspection. The home is receiving case management services provided by Eastern Los Angeles Regional Center. Facility Tour & Observations: Personal Rights postings (LIC 613C and Ombudsman), Complaint Poster (PUB 475), and nondiscrimination notice were observed in a common area. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present. Physical Plant The facility is located in a residential area and is a one-story home consisting of six (6) resident bedrooms, two (2) bathrooms, living room, kitchen, laundry room/office, dining area, attached garage, front yard, and backyard. LPA observed five (5) resident bedrooms as one was vacant, and all contained the required furniture (bed, mattress, linens, dresser, chair, and lighting). Cleaning supplies and toxic substances are inaccessible to residents in a locked kitchen cabinet under sink . Bathrooms were clean and equipped with required grab bars in showers and near toilets, as well as non-skid mats; hot water measured in bathroom (1) 110.9°F and bathroom (2) 106.3°F which is within the required 105–120°F. Extra linens and towels were available in the laundry room area. Smoke/carbon monoxide detectors were functional, fire extinguisher was located in the living room near kitchen and second fire extinguisher in the hallway by bedrooms. There were no bodies of water were present. Backyard provided shaded seating. Passageways and exits were observed to be clear and unobstructed. Food Service Refrigerators/freezers were maintained at proper temperatures (refrigerators maximum of 40 degrees°F and freezer 0-degreeºC ) with sufficient supply of 2-day perishable and 7 days non-perishable food. Fresh produce, proteins, and dry goods were stocked. Knives were observed locked in cabinet by front door entrance to the left. Health-Related Services & Records Five (5) residents files were reviewed and contained current required documents Admissions Agreements, Pre-Placement Appraisals, Consents, Needs/Service Plans, Physician’s Reports with TB/ambulatory status and Rights acknowledgments. Five (5) residents’ medications were reviewed; medications were observed to be centrally stored in a locked living room closet. MAR logs were observed to be current. Disaster Preparedness Last fire/earthquake drill was conducted in September 20, 2025, with logs available. LIC 610D Emergency Disaster Plan was available and updated. Emergency supplies (water, food, flashlights, batteries, first aid) were observed. Infection Control Plan was updated. Personnel Records & Training Four (4) staff files to include Administrator file were reviewed and included criminal record clearances, CPR/First Aid, and TB screenings. Required training for staff were not available for review. Insurance Liability insurance was in compliance with an expiration date of February 2, 2026. An exit interview was conducted with Juliana Garcia, House Manager. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. The Administrator was advised of the nature of the deficiency, the regulatory basis, and the required Plan of Correction (POC). The Administrator agreed to submit proof of correction by the due dates specified. A copy of this report, LIC 809D/809C, and appeal rights have been provided.the state’s words, verbatim · CDSS document, Nov 13, 2025

Allegation investigated: Facility is not keeping accurate records of resident medication.

** This report supersedes the original complaint investigation report dated 8/21/2025. The reason for the supersede and the subsequent visit is to change the deficiency for Section 87506 from Type A to Type B, all other findings remain the same.” Licensing Program Analyst (LPA), Bennette Pena conducted a subsequent visit to supersede the report dated 08/21/2025. LPA met with the Administrator, Jesse Quezada and explained the purpose of the visit. The investigation consisted of the following: On 08/21/2025, LPA toured the facility and obtained a copy of the staff & resident rosters. LPA reviewed and obtained Resident #1 (R1) – Resident #2 (R2) pertinent files. LPA also obtained and reviewed the Corrective Action Plan (CAP) issued by Eastern Los Angeles Regional Center (dated 08/07/2025) and interviewed the Administrator. During today’s visit, LPA delivered the superseded report for the allegation listed above. ****CONTINUED ON LIC 9099-C*** Substantiated Allegation: "Facility is not keeping accurate records of resident medication." It is alleged that during an unannounced visit by the Regional Center, they observed that staff members failed to sign the Medication Administration Record (MAR) on the correct date, and there were omissions in signing the MAR altogether. Administrator was interviewed and corroborated the allegation. Administrator stated that in June 25, 2025, Regional Center conducted an unannounced visit and discovered several medication errors for R1-R2, including staff failing to sign the Medication Administration Record (MAR) on the correct date and failing to sign the MAR at all. Regional Center then instructed them to submit an incident report to CCL and Regional Center, which the Administrator submitted on the same day. The Regional Center made an unannounced follow-up visit in July 2025 after reviewing discrepancies in the SIR's submitted for R1-R2. Administrator explained the reasons behind the identified medication issues to the Regional Center. Administrator agreed with the Regional Center’s findings, as stated in the Corrective Action Plan (CAP) dated 08/07/2025, has signed and stated they would comply with it, supporting the allegation. Based on LPA’s interviews and document reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiency cited on the attached LIC9099-D. Exit interview was conducted and a copy of this report was provided to Jesse Quezada, Administrator along with the Appeals Rights.the state’s words, verbatim · CDSS document, Sep 2, 2025 · control 28-AS-20250813145506

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Sep 9, 2025

87506 Resident Records..(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on interviews, records review, the Administrator did not comply with the section cited above in which the staff failed to sign the Medication Administration Record (MAR) on the correct date, and omissions in signing the MAR altogether for R1-R2 which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 2, 2025

Plan of correction: ** This report supersedes the original complaint investigation report dated 8/21/2025 to change the deficiency for Section 87506 from Type A to Type B, findings remain the same.” Administrator shall provide in-service training to all staff on how to properly document the Medication Administration Record (MAR), as well as develop a policy requiring that (2) people verify medication records. Administrator to send a copy of the training log, along with the topics covered, and a sign-in sheet of staff who participated to CCL/LPA by POC due date.

Allegation investigated: Staff mismanaged resident medication. Staff did not follow reporting requirements. Facility is not keeping accurate records of resident medication. Residents medication is not being stored in original container.

Licensing Program Analyst (LPA), Bennette Pena conducted the initial complaint investigation for the allegations listed above. Upon arrival at 9:50am, no one was home to let the LPA in. Administrator was called and informed LPA of their arrival time (1:30pm) at the facility. At 2:00pm, Administrator Jesse Quezada and Co-Administrator, Cynthia Tadeo arrived, met with LPA and explained the purpose of the visit. The investigation consisted of the following: LPA toured the facility and obtained a copy of the staff & resident rosters. LPA reviewed and obtained Resident #1 (R1) – Resident #2 (R2) / SJ MC files such as Face sheet (ID and Emergency Info.), Physician’s report, Medication Administration Records (June-July 2025) and Incident Report (06/25/2025). LPA also obtained and reviewed the Corrective Action Plan (CAP) addressing the above allegations issued by Eastern Los Angeles Regional Center (dated 08/07/2025). Administrator is in agreement with the CAP findings, has signed and will be complying with them. LPA interviewed the Administrator. Staff and clients are out in the community celebrating an event; therefore, not interviewed.****CONTINUED ON LIC 9099-C*** Substantiated The investigation revealed the following: Allegation: “Staff mismanaged resident medication.” It is alleged that during an unannounced visit by the Regional Center multiple discrepancies in medication administration were observed, including missing medications from the blister packs and medication being dropped and replaced with doses from the following day's blister pack without proper documentation. Administrator was interviewed and corroborated the allegation. During Regional Center's initial unannounced visit to the facility on June 25, 2025, Administrator stated that Regional Center discovered discrepancies in medication administration for R1-R2, including missed medications in the blister packs and medications that were dropped and replaced with doses from the following day's blister pack without proper documentation. Following the instructions of the Regional Center, the Administrator stated that they filed an incident report with CCL and the Regional Center on the same day. The Regional Center conducted an unannounced follow-up visit to the facility in July 2025 after reviewing discrepancies in the reports submitted for R1–R2. The Administrator explained to them the reasons behind the identified medication issues via email correspondence. The administrator has agreed with the Regional Center’s findings, as stated in the Corrective Action Plan (CAP) dated 08/07/2025, and has signed and stated they would comply with it, supporting the allegation. Allegation: “Staff did not follow reporting requirements.” It is alleged that the facility failed to report incidents concerning multiple medication administration discrepancies for R1-R2. Administrator was interviewed and corroborated the allegation. Administrator stated that they submitted the incident report to CCLD and the Regional Center following the Regional Center’s instructions during their visit to the facility in June 25, 2025. Administrator indicated that the incident report should have been submitted right after the staff noticed the errors/discrepancies, but they had failed to do so. Based on the interview and the Corrective Action Plan (CAP) dated 08/07/2025 (agreed & signed by the Administrator), the allegation has been substantiated. Allegation: "Facility is not keeping accurate records of resident medication." It is alleged that during an unannounced visit by the Regional Center, they observed that staff members failed to sign the Medication Administration Record (MAR) on the correct date, and there were omissions in signing the MAR altogether. Administrator was interviewed and corroborated the allegation. Administrator stated that in June 25, 2025, Regional Center conducted an unannounced visit and discovered several medication errors for R1-R2, including staff failing to sign the Medication Administration Record (MAR) on the correct date and failing to sign the MAR at all. Regional Center then instructed them to submit an incident report to CCL and Regional Center, which the Administrator submitted on the same day. The Regional Center made an unannounced follow-up visit in July 2025 after reviewing discrepancies in the SIR's submitted for R1-R2. Administrator explained the reasons behind the identified medication issues to the Regional Center. Administrator agreed with the Regional Center’s findings, as stated in the Corrective Action Plan (CAP) dated 08/07/2025, has signed and stated they would comply with it, supporting the allegation. Allegation: "Residents medication is not being stored in original container." It is alleged that during an unannounced visit by the Regional Center, they observed instances of pre-pouring medications prior to administration. Administrator was interviewed and corroborated the allegation. Administrator stated that the Regional Center made an unannounced visit in June 25, 2025 and discovered numerous medication errors for R1-R2, including instances in which medications were pre-poured before being administered. Following the instructions of the Regional Center, the Administrator stated that they filed an incident report with CCL and the Regional Center on the same day. After reviewing discrepancies in the reports provided for R1-R2, Regional Center paid the facility an unannounced follow-up visit in July 2025. The administrator gave them a copy of the email conversation they had in June 2025, explaining the reasons behind the identified medication issues. Administrator agreed with the Regional Center’s findings, as stated in the Corrective Action Plan (CAP) dated 08/07/2025 and has signed and stated they would comply with it, supporting the allegation. Based on LPA’s interviews and document reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies cited on the attached LIC9099-D. Exit interview was conducted and a copy of this report was provided to Cynthia Tadeo, Co-administrator along with the Appeals Rights.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 28-AS-20250813145506

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Aug 22, 2025

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on interview, records review, the Administrator did not comply with the section cited above in which staff missed medications in the blister packs and medications that were dropped and replaced with doses from the following day's blister pack without proper documentation for R1-R2 which poses an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 21, 2025

Plan of correction: Administrator shall conduct an In-Service Training to all staff on appropriate Medication Dispensing Procedures. Administrator to provide/submit a copy of the training log along with the topics discussed, and the sign in sheet of staff name who attended with the date to CCL/LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87506(a) · Plan of correction due date: Aug 22, 2025

87506 Resident Records..(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on interviews, records review, the Administrator did not comply with the section cited above in which the staff failed to sign the Medication Administration Record (MAR) on the correct date, and omissions in signing the MAR altogether for R1-R2 which poses an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 21, 2025

Plan of correction: Administrator shall conduct an In-Service Training to all staff on proper documentation of Medication Administration Record (MAR) and develop a policy to have (2) person verification of medication records. Administrator to provide a copy of the training log along with the topics discussed, and the sign in sheet of staff name who attended with the date to CCL/LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(5) · Plan of correction due date: Aug 22, 2025

87465 Incidental Medical and Dental Care..(h) The following requirements shall apply to medications which are centrally stored:(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Based on interviews, records review, the Administrator did not comply with the section cited above in which there were instances of pre-pouring medications prior to administration for R1-R2 which poses an immediate health, safety or personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Aug 21, 2025

Plan of correction: Administrator agreed to provide in-service medication training to all staff that assist with preparing and administering medications. A copy of the training materials, scheduled date of training and list of participants to be sent to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 27, 2025

87211 Reporting Requirements..(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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 in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Administrator did not comply with the section cited above in which the Administrator did not submit an incident report regarding multiple medication administration discrepancies for R1-R2 which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 21, 2025

Plan of correction: Administrator will conduct an in-service training to all staff regarding Reporting Requirements and sign in sheet of the training. Administrator will also send a self-certification indicating that he read, reviewed and understood Title 22 Regulations, Section 87211. Administrator to submit copy of the In service training and self certification to CCL/LPA by POC due date.

Allegation investigated: Staff did not provide a refund upon resident’s death

*** This licensing report issued on 04/22/2025 supersedes that licensing report dated 04/14/2025. LPA Vaid obtained additional information; however, the investigation findings will remain the same**** On 04/14/2025, Licensing Program Analyst (LPA) Vaid conducted a initial 10-day complaint visit to the facility. Upon arriving at the facility, LPA met with caregiver Elizabeth Taylor allowed entry into facility and contacted the House Manager Cynthia Tadeo who joined shortly after. LPA discussed and explained the purpose of today’s visit. Spoke with licensee Jeese Quezada via phone. LPA toured the physical plant along with Elizabeth Taylor and did not observe any Health and Safety concerns. LPA obtained resident/ staff roster, copy of resident 1 (R1) identification and admissions agreement. Continued on 9099C......... Substantiated Regarding the allegation: Staff did not provide a refund upon resident’s death. It is alleged that the facility has not refunded the remaining prorated amount back to R1’s family upon their death within fifteen (15) days of R1’s death. Three (3) out of three (3) staff interviewed denied this allegation. S1 stated the amount of the refund was processed by the facility licensee on 04/11/2025 and sent out via USPS. The determined amount the facility refunded the prorated amount back to the family. Three (3) out of three (3) residents interviewed could not corroborate this allegation. Witness 1 (W1) stated upon the death of their family member on 11/12/2024, the family cleaned out and vacated R1’s belonging from the facility by 11/12/24. Same day after the death of R1. R1’s lodging for private room and was paid in advance and the contract was effective 10/24/24 to 11/23/24. Payment was agreed and paid in advance for each month on the 24th going forward. Under the Admissions Agreement and Contract page 1 states 'This Agreement shall be in effect from month-to-month, unless and until it is terminated as set forth below'. According to the Admissions Agreement and Contract under section 19, page 10 of the Termination of Agreement states that an RCFE “ this agreement will be terminated immediately upon the death of the resident and payment will be owed until the room is vacated by any and all the residents’ personal belongings. Refunds in case of death will be processed with fifteen (15) days”. R1’s belongings were vacated by family on 11/12/2024. According to W1, facility fees were paid in advance from the 24th of each month to the next. Facility fee payment was made 10/24/24 until 11/23/24. After R1 passed on 11/12/24 and all personal belongings were moved from the facility on 11/12/24. The facility did not determine the refund amount from the monthly advanced payment within fifteen (15) days. According to the admissions agreement the facility is not in compliance its own contract agreement made with R1’s family. Facility to refund the prorated amount to R1’s responsible party/family member for the period 11/13/24 through 11/23/24. Therefore, based on LPA’s, interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D. Exit interview was conducted and copy of this report and appeals rights were left with Jesse Quezada, Administrator.the state’s words, verbatim · CDSS document, Apr 14, 2025 · control 28-AS-20250409100907

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: Apr 14, 2025

Admission Agreements 1569.652 Refund conditions.(c)A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued...to entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. This requirement not met as evidence by: Based on interviews and record review, licensee failed to refundR1's monies with 15 days after R1's belonging were removed and after R1's death.the state’s words, verbatim · CDSS document, Apr 14, 2025

Plan of correction: Licensee to produce proof of entire prorated refund by 04/25/2025.

Allegation investigated: Staff did not prevent resident from developing a stage 4 pressure injury while in care

The purpose of this report 01/06/24 is to remove confidential information from the 9099C dated 12/16/24. Licensing Program Analyst (LPA) Glenn Trueman made an unannounced subsequent visit to the facility and was greeted by Staff Charlene Munoz and explained the reason for the visit. The purpose of the visit is to deliver findings for the above allegation. The initial visit was conducted on 03/06/24 by LPA Mora and was a Health and Safety Check. In regards to the allegation Staff did not prevent resident from developing a stage 4 pressure injury while in care, the Investigations Branch (IB) Investigator Heidy Bendana from the California Department of Social Services conducted an investigation that was completed on 08/09/24. The investigation included interviews with facility staff and residents, and medical records obtained from Eden Hospice, PIH Home Health, Whittier Police Department Incident Report Request and notes and visit notes e-mailed by the House Manager. The investigation provided sufficient evidence to substantiate neglect/lack of care and supervision against Shiloh Retreat. Interviews, notes, home health medical records and hospice medical records indicated Resident R1's pressure ulcers worsened. Substantiated Resident R1 reported that facility staff were not repositioning her every two hours as instructed by PIH Home Health. Per Preplacement Appraisal, Resident R1 had a stage 2 bed sore at the time of admission into the facility. Facility administration and staff knew Resident R1 had a pressure wound because Resident R1 was admitted to the facility with a stage 2 pressure ulcer. Resident R1's pressure ulcers progressively worsened to a stage 4 on 11/6/2023, and small drainage was noted. On 11/10/2023, Resident R1's pressure ulcer was unstageable. Resident R1 was admitted into hospice on 3/7/2024, it was noted that Resident R1 had a stage 4 pressure ulcer in the coccyx and a stage 3 pressure ulcer in the sacral region. Per PIH Home Health medical records, staff S1 told the home health nurse to leave and that caregivers would do Resident R1's care. Staff S2 described R1's wounds as a deep hole that was red. Facility staff knew Resident R1 needed to be rotated every two hours and saw her wounds worsening however it is more likely than not that Resident R1 was not rotated every two hours, as instructed by Resident R1's medical team. PIH Home Health and Eden Hospice noted Resident R1's pain complaints. The facility failed to take appropriate actions to prevent Resident R1's pressure wounds from worsening; therefore, the allegation is substantiated. Based on observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 6 are being cited on the attached LIC 9099D. Civil Penalty Assessed $500. The licensee was informed that a civil penalty might be assessed based on Health and Safety Code 1569.49 (e) Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted .the state’s words, verbatim · CDSS document, Dec 16, 2024 · control 28-AS-20240305101027

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Dec 17, 2024

Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility...: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews and documents reviewed licensee did not ensure R1 was provided medical care in a timely manner after developing a Stage 4 pressure wound which poses an immediate risk to the persons health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Dec 16, 2024

Plan of correction: Administrator will schedule training for staff on procedures, notifying responsible parties, and seeking medical care upon observing wounds in residents by POC due date 12/17/24, and will submit a copy of log, training description and duration of training by 12/31/24. ***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustaining wound while in care. Refer to LIC 421IM*

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Cynthia Tadeo, House Manager for the facility, and explained the purpose of the visit. There are five (5) non-ambulatory residents residing within the home. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control practices were observed. · Infection control plan is on file. Physical Plant/Environment Safety: · The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) residents, six (6) of which may be non-ambulatory, and a hospice waiver approved for two (2) residents. The facility consists of a kitchen with dining area, a living room, an office which contains the facility’s washer and dryer, six (6) resident bedrooms, two (2) bathrooms of which restroom #1 had a hot water temperature of 106.7 Degrees Fahrenheit and restroom #2 had a hot water temperature of 105.2 Degrees Fahrenheit, and therefore the water temperature was within range. The facility also has a backyard that contains a shaded area and a storage shed. The facility was observed to be in good repair. ·The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has two (2) fully charged fire extinguishers in the facility. Operational Requirements: · The Program Design was reviewed. · Fire clearance was approved by LA County Fire Department for a capacity of six (6) residents, six (6) of which may be non-ambulatory, and a hospice waiver approved for two (2) residents. · Care and supervision to meet the clients’ needs was observed. Staffing: · Three (3) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: · Five (5) staff files were reviewed for criminal background clearance and training. · All staff records reviewed have health a health screening with a Tuberculosis clearance, and all staff have First Aid/CPR trainings that are active. · The administrator’s certificate expires on 5/1/2025. Resident Rights/Information: · Physician orders were reviewed for five (5) resident files. · Medications were also reviewed for five (5) residents. Resident Records/Incident Reports: · Five (5) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have an Appraisal/Needs and Services Plan on file. · Staff training was on file. Disaster Preparedness: · Emergency and Disaster Plan was publicly posted and found within the facility. · The last emergency and disaster drill was conducted on 10/1/2024. Planned Activities: · Sufficient Space is provided to accommodate both indoor and outdoor activities. · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs: · There are four (4) residents who are currently receiving hospice services, however currently the facility license is only approved for a hospice waiver of two (2) residents. · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on the LIC809D page. Exit interview held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 10, 2024

Allegation investigated: Staff did not accord resident dignity and respect while in care. Staff does not respond to residents screams for assistance. Staff does not ensure that resident's personal belongings are accessible to the resident.

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation visit for the allegation(s) listed above. LPA Villalobos met with Administrator Jesse Quezada and the purpose of the visit was discussed. On todays visit, LPA conducted the following: Toured the physical plant, Interviewed Staff #1-#4 (S1-S4) and residents #1-#5 (R1-R5), reviewed R1's file and collected documents from R1's related to their care plan. The investigation revealed the following: In regards to the allegation "Staff did not accord resident dignity and respect while in care." it was alleged that S1 had left R1 undressed, exposed without assistance with the door open while completing other tasks. (4) of (4) Staff interviewed denied the allegation. (4) of (5) Residents interviewed could not corroborate the allegation... Continued on LIC 9099-C Unsubstantiated Interview with S1 denies leaving R1 undressed and exposed with their door open. LPA was not provided with proof that R1 was left unexposed with their door open in the facility. Interviews state that R1 is able to communicate with staff and even has a bell ringer to notify staff when they need assistance with anything. Based on interviews conducted, as well as LPA observations there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Staff does not respond to residents screams for assistance." it was alleged that residents scream for assistance and S1 does not respond or assist residents. (4) of (4) Staff interviewed denied the allegation. (4) of (5) residents interviewed could not corroborate the allegation. Interviews show that there was a day, date not provided to LPA, where R1 asked for S1's assistance but S1 was in the process of assisted another resident and could not assist R1 immediately. Interviews state that S1 notified R1 that they would assist them once done with the other resident of the facility. Interviews also state that the only resident who yells out for help is R2 and that is because R2 is blind and gets confused. That is how R2 will call staff over. Staff interviewed denied that resident screams are ignored. Based on interviews conducted, as well as LPA observations there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Staff does not ensure that resident's personal belongings are accessible to the resident." it was alleged that S1 moves R1's portable table away from R1 making it inaccessible to R1. (4) of (4) Staff interviewed denied the allegation. (4) of (5) residents interviewed could not corroborate the allegation. Interviews show that R1 has a personal desk on wheels where they place some of their belongings such as the tv remote. Interviews with staff state that this table is never made inaccessible to R1 and that it is always by their bedside. It is moved to the side when there is care or assistance being provided to R1 so that it is not in the way, but it is put back when tasks are completed. LPA observed the table to be by R1's bedside throughout the visit. Based on interviews conducted, as well as LPA observations there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 28-AS-20231003163348

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator Jesse Quezada and the purpose of the visit was discussed. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has an Infection Control Plan. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance approved for (6) of which six (6) can be non ambulatory. Hospice waiver approved for up to two (2) Physical Plant/Environment Safety: The facility does have a Dementia resident. Facility is a 1-story residential home with 6 resident bedrooms, 2 bathrooms, living and dining room, kitchen,office/laundry room,and a front and backyard. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. Sharps locked and inaccessible to residents On 9/5/23, Emergency Drill conducted. Fire extinguishers Observed Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Personnel Records/Staff Training: Administrator certification observed Staff have criminal background clearance and training. Four (4) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training was observed. Continued on LIC 809-C Staffing: A total of nine (9) staff members provide care and supervision to the clients. Resident Records/Incident Reports: A total of five (5) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records. Complaint poster and Personal rights were observed posted. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar was reviewed Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies observed. Sanitation practices and kitchen cleanliness was observed. Incident Medical and Dental: Five resident (5) centrally stored resident medications were reviewed. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. Residents with Special Health Needs: There are currently (5) residents and (2) are on Hospice and another (2) on Home Health Bed rails for mobility assistance were observed in rooms. Documents on file Per California Code of Regulations, Title 22, NO deficiencies were cited. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 5, 2023