Silver Lining Residential Care

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced site visit to the facility for the purpose of amending Complaint Control Number 22-AS-20260309095814. Upon arrival, LPA met with Staff Mariam Esquivel, explained the reason for the visit, and conducted a health and safety check of the facility. During the visit, LPA provided Mariam Esquivel with a copy of the amended report. An exit interview was conducted, and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 28, 2026

Type of visit: Case Management - Deficiencies

On Friday August 7, 2026 Licensing Program Analyst (LPA) Nancy Guillen conducted an unannounced Case Management- Deficiencies visit. The visit is being conducted in conjunction with complaint control number 22-AS-20260802121030. Administrator(AD) Lacy Faddoul was notified and assisted via telephone. House Manager(HM) Miriam Esquivel assisted LPA during the visit. During the investigation into the complaint, LPA toured the facility, requested documentation and did a health and safety check on the residents in care. At approximately 9:11 am, LPA observed the door leading to the alley on the side of the facility to be locked with a key pad and a security guard door latch. At approximately 9:13 am LPA observed the door leading to the alley parking lot to be locked with the same locking mechanisms. The HM stated all the doors are locked and remain locked. The LPA asked the HM whether the LPA would be able to exit the facility in the event of an emergency. The HM stated that the LPA would not be able to exit without staff assistance and the access code. LPA observed that all four of the facility's exit doors were locked and could not be opened without the required access code or key. AD via telephone instructed HM to unlock all doors and turn on the auditory devices for all exits. At approximately 1:10 p.m., the LPA attempted to exit the facility and observed that the exit door remained locked. The LPA was unable to exit without assistance. Based on the information gathered during the visit, a deficiency is being cited on the attached LIC809-D page. An exit interview was conducted and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Aug 7, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(e)(5) · Plan of correction due date: Sep 4, 2026

(e) Licensees that use... perimeter fence gates shall meet the following...(5) Facility... shall ensure...safety of residents...without violating...Personal Rights of Residents... Additional Personal Rights of Residents in Privately Operated Facilities.This is not met as evidence by: Based on observation and interview, all four facility doors/gates are locked making residents unable to leave the facility without the assistance of staff which poses a potential Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2026

Plan of correction: Licensee has agreed to follow Title 22 regulations regarding locked/unlocked doors. Licensee will contact CCL to submit a request to have the gates locked for the safety of the clients. The gate and the door will remain unlocked until proper approvals have been granted.

Allegation investigated: -Staff did not report a resident's change in medical condition in a timely manner. 2-Staff falsified incident report regarding resident in care. 3-Staff did not seek timely medical attention for resident in care

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced complaint investigation visit to the facility regarding the above-mentioned allegations. Upon arrival, LPA was greeted and granted entry by facility staff. LPA met with Miriam Esquivel and explained the purpose of the visit. The Department received a complaint on 03/09/2026 regarding the above-mentioned allegations. During the investigation, LPA reviewed R1's admission record, Physician Report, Home Health records, Facility Notes, Physical Therapy documentation, responsible party communication notes, Special Incident Report (SIR) documentation, and hospital records concerning Resident 1 (R1)'s hospitalization from 02/10/2026 through 02/20/2026. Regarding the allegation that "Staff did not seek timely medical attention for resident in care," LPA interviewed three staff, and three of three staff denied the allegation. {***CONTINUE9099C***} {***THIS IS AN AMENDED REPORT***} Unsubstantiated Facility records dated 01/31/2026 documented that Home Health assessed R1; reviewed medications; noted mild swelling to R1's left hand; and recommended as-needed pain medication orders. Records dated 02/03/2026 documented that Home Health conducted a follow-up visit and reviewed medications. Records dated 02/05/2026 documented that Physical Therapy attempted an evaluation; however, the evaluation was limited due to R1's inability to communicate or provide verbal consent. Per Staff interview, R’1s responsible party (RP) had been with R1 since the morning and was the one who called emergency personnel. Staff does not recall the time RP called 911. Facility Notes dated 02/10/2026 documented that R1's RP was informed that the physician had been contacted and R1 was transferred to the hospital due to a reported sudden change in mental status. SIR was sent to Licensing. LPA attempted to conduct resident interviews with three of seven residents in care; however, LPA was unable to obtain reliable statements due to the residents' cognitive and mental state. LPA contacted R1's RP, who informed LPA that R1 passed away on 03/08/2026 and did not wish to speak with LPA. Per hospital records, the emergency physician documented that R1 experienced a sudden inability to communicate or move her body at approximately 8:00 AM. Emergency triage records identified 8:00 AM as R1's last-known-well time. R1 arrived at the emergency department by ambulance at 3:30 PM. A stroke alert was initiated. R1 was discharged to a skilled nursing facility on 02/20/2026 at 6:01 PM. The hospital records documented that R1 had a history of a prior stroke in December 2025, with residual left-sided weakness and limited speech. Although R1’s last known well time exceeded 7 hours before medical attention was sought, it remains unclear when R1’s sudden change of condition onset before 9-1-1 was called. Regarding the allegation that "Staff falsified incident report regarding resident in care," LPA interviewed three staff, and three of three staff denied falsifying an incident report regarding R1. LPA reviewed R1's Physician Report, Facility Notes, responsible party communication notes, and SIRs. LPA compared the SIRs maintained in R1's file from January 2026 through March 2026 with the SIR submitted to Community Care Licensing. {***CONTINUE9099C***} {***THIS IS AN AMENDED REPORT***} Hospital records, observations by caregivers, and symptoms observed by witnesses reviewed and obtained by LPA contained additional descriptions of symptoms occurring. The records do not establish what information was known to facility staff when the SIR was prepared or demonstrate that facility staff intentionally altered, fabricated, or knowingly submitted false information. Although additional details were observed not indicated on the incident reports, no false information was observed on the incident reports. Regarding the allegation that "Staff did not report a resident's change in medical condition in a timely manner," LPA interviewed three staff, and three of three staff denied the allegation. Facility records documented multiple Home Health visits; an attempted Physical Therapy evaluation on 02/05/2026, physician contact regarding medication refills, and communication with R1's responsible party. Facility Notes dated 02/10/2026 documented physician follow-up, delivery of the prescription, transfer to the hospital due to a reported sudden change in mental status and submission of an SIR to Community Care Licensing. The hospital records document earlier observations of decreased alertness and neurological changes; however, they do not establish when facility staff first received or recognized those observations, when the physician or responsible party was first notified about the acute neurological change, or whether the occupational therapist's observation was communicated to facility staff. The available facility documentation indicates that the RP was contacted, and an SIR was submitted on 02/10/2026, the same date as the hospital transfer. Therefore, based on interviews conducted, attempted resident interviews, responsible party contact, facility records, and the additional hospital records, the Department does not have a preponderance of evidence to prove that the alleged violations occurred. The hospital records confirm that R1 experienced an acute stroke and document several possible symptom-recognition times; however, they do not establish the precise time facility staff became aware of the acute change, the emergency-response timeline, or that facility staff intentionally falsified information. Therefore, the allegations remain Unsubstantiated. Although the allegations may have happened or could be valid, there is not a preponderance of evidence to prove or disprove the allegations. An exit interview was conducted and a copy of this report was provided to staff. {***THIS IS AN AMENDED REPORT***}the state’s words, verbatim · CDSS document, Jun 12, 2026 · control 22-AS-20260309095814

Allegation investigated: -Faciity not providing activities to residents 2-Facility staff not handling residents medical appointments timely 3-Facility not providing variety of meals 4-residents being overmedicated 5-Facility is over resident capacity 6-Staff does not know how to verbally communicate with residents 7-Facility Staff did not report incident to responsible party 8-Licensee is not responding to responsible party 9-Resident sustained injuries from lack of care & supervision

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility to deliver findings to the above-mentioned allegations. Upon arrival, LPA was greeted and granted entry by office manager, Miriam Esquivel. and explained the purpose of the visit. The Department received a complaint on 03/16/2026, and During the investigation, LPA reviewed records relevant to the allegations, including the complaint report, R1’s 2026 medical records, facility fire clearance,, facility menu, and facility activity calendar. LPA interviewed three staff members. LPA also attempted to interview three residents; however, LPA was unable to obtain relevant information due to the residents’ cognitive ability. . LPA attempted to contact the reporting party on 06/02/2026, 06/04/2026, and 06/12/2026; however, LPA was unable to reach the reporting party. LPA did not leave a voicemail due to the instruction documented in the complaint report, which stated not to leave a voicemail and to call again if the reporting party could not be reached. {***CONTINUE9099C***} Unsubstantiated Regarding the allegation that “Resident sustained injuries from lack of care and supervision,” LPA interviewed three staff regarding this allegation, and three of three staff denied that R1 sustained injuries as a result of neglect, lack of care, or lack of supervision by facility staff. For this allegation, LPA reviewed R1’s 2026 physician report, including skin observation notes, nurse practitioner notes, home health follow-up notes, physical therapy notes, and documented change-of-condition notes. The reviewed records documented that R1 had left eye ecchymosis on 01/19/2026, bumps on the top of the head on 02/06/2026 and 02/21/2026, yellow discoloration to the sides of the face on 03/17/2026, and a raised area to the upper right side of the back on 03/21/2026. The reviewed records also documented that the nurse practitioner was notified, monitoring and follow-up were documented, and the nurse practitioner advised on 03/17/2026 that the yellow discoloration appeared to be a normal healing bruise. The records did not establish that R1’s injuries or skin concerns were caused by lack of care or supervision by facility staff. Regarding the allegation that “Licensee is not responding to responsible party,” LPA interviewed three staff regarding this allegation, and three of three staff denied that the licensee failed to respond to R1’s responsible party. For this allegation, LPA reviewed the complaint report and R1’s 2026 physician report, including documentation related to responsible party communication. Records dated 03/13/2026 documented that facility staff communicated with R1’s responsible party regarding R1’s son’s visit and provided updates regarding R1’s home health and physical therapy services. LPA also attempted to contact the reporting party on 06/02/2026, 06/04/2026, and 06/12/2026; however, LPA was unable to reach the reporting party and did not leave a voicemail due to the complaint instruction not to leave one. Regarding the allegation that “Facility staff did not report incident to responsible party,” LPA interviewed three staff regarding this allegation, and three of three staff denied that facility staff failed to report an incident or change in condition to R1’s responsible party. For this allegation, LPA reviewed R1’s 2026 physician report, including responsible party communication notes, nurse practitioner notification notes, change-of-condition notes, and medical follow-up documentation. Records reviewed documented that the nurse practitioner was notified regarding multiple changes in condition, including entries dated 01/07/2026, 02/06/2026, 02/21/2026, 03/10/2026, 03/17/2026, 03/21/2026, 05/15/2026, 05/21/2026, 05/26/2026, and 06/11/2026. {***CONTINUE9099C***} Records dated 03/13/2026 also documented communication with R1’s responsible party regarding R1’s son’s visit and updates related to home health and physical therapy services. Regarding the allegation that “Staff does not know how to verbally communicate with residents,” LPA interviewed three staff regarding this allegation, and three of three staff denied that staff were unable to verbally communicate with residents. LPA attempted to interview three residents; however, LPA was unable to obtain relevant information due to the residents’ cognitive ability. For this allegation, LPA reviewed R1’s 2026 physician report , including documentation related to R1’s diagnosis, behavior changes, communication with medical providers, and coordination with outside services. The reviewed records documented that R1 had memory impairment and episodes of agitation, yelling, and disrupted sleep. However, records also documented that staff communicated with the nurse practitioner, home health, physical therapy, laboratory services, podiatry, equipment providers, and R1’s responsible party regarding R1’s needs. Regarding the allegation that “Facility is over resident capacity”, LPA reviewed the facility fire clearance and facility census information. The fire clearance documented that the facility is approved for six ambulatory residents and eight non-ambulatory residents. At the time of the visit, there were seven total residents in care. Based on the fire clearance reviewed, the number of residents in care did not exceed the facility’s approved capacity. Regarding the allegation that “Residents being overmedicated,” LPA interviewed three staff regarding this allegation, and three of three staff denied that R1 or other residents were being overmedicated. For this allegation, LPA reviewed R1’s 2026 physician report, including medication review notes, nurse practitioner medication orders, home health medication review notes, and medication change documentation. LPA reviewed R1’s Medication Administration Record (MAR) The records reviewed did not establish that R1 or any other resident was administered medication outside of physician orders. Regarding the allegation that “Facility not providing variety of meals,” LPA interviewed three staff regarding this allegation, and three of three staff denied the allegation. LPA reviewed the facility menu. The facility menu documented planned meals for Monday through Sunday, including breakfast, lunch, dinner, and snacks. The menu reflected a variety of food items, including hot and cold cereal, eggs, toast, pancakes, bacon, muffins, pizza, salad, macaroni and cheese, sandwiches, vegetables, soup, burritos, tacos, spaghetti, turkey, mashed potatoes and steak, LPA also observed residents having breakfast and lunch during this visit, and observed the facility following the menu. Regarding the allegation that “Facility staff not handling resident’s medical appointments timely,” LPA interviewed three staff regarding this allegation, and three of three staff denied the allegation. LPA reviewed R1’s 2026 Facility Notes, including nurse practitioner visit notes, home health records, and change-of-condition follow-up notes. Records reviewed documented nurse practitioner follow-up, home health enrollment and assessment, laboratory services, podiatry services, physical therapy services from 03/09/2026 through 04/29/2026, and equipment follow-up on 03/05/2026. The records reviewed did not establish that facility staff failed to handle R1’s medical appointments or medical follow-up in a timely manner. Regarding the allegation that “Facility not providing activities to residents,” LPA interviewed three staff regarding this allegation, and three of three staff denied the allegation. For this allegation, LPA reviewed the complaint report, R1’s 2026 medical flow sheet, and the facility activity calendar. The facility activity calendar documented planned activities, including morning news, bean bag toss, chair exercise, coffee talk, morning stretch, game day, game show, walk to the park, resident choice days, reading/free time, ice cream social, ring toss, current events, bingo, horse shoes, community center outing, shopping day, movie day, painting/coloring, and hairdresser day. Records also documented that R1 received physical therapy and exercise-related services, including walking with a walker, gait belt-assisted walking, chair exercises, walking on the outside patio, and transfer practice on dates including 03/12/2026, 03/17/2026, 03/19/2026, 03/24/2026, 03/31/2026, 04/07/2026, and 04/23/2026. The records reviewed did not establish that the facility failed to provide activities to residents. LPA also tried to interview R1 regarding all the above-mentioned allegations, but R1 refused to be interviewed. Based on interviews conducted, attempted resident interviews, attempted reporting party contacts, and records reviewed, the Department does not have a preponderance of evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. Although the allegations may have happened or could be valid, there is not a preponderance of evidence to prove or disprove the allegations. No deficiencies were cited during today’s visit. An exit interview was conducted, and a copy of this report was provided Office Manager.the state’s words, verbatim · CDSS document, Jun 12, 2026 · control 22-AS-20260316072225

Allegation investigated: Staff do not ensure adequate care is provided to residents

Licensing Program Analyst (LPA) Samer Haddadin conducted an announced visit to the facility to deliver findings regarding the above-mentioned allegation. Upon arrival, LPA was greeted and granted entry by care staff, Nancy Valdez, and LPA explained the purpose of the visit. At the time of the visit, there were seven residents in care. The Department received a complaint alleging that “Staff do not ensure adequate care is provided to residents.” The complaint alleged general concerns that staff neglect residents, and residents are living under poor conditions. The complaint did not identify a specific resident, staff member, date, time, incident, or specific care need that was allegedly unmet. During the course of the investigation, LPA conducted interviews, reviewed available facility records, and made observations of the facility and residents in care. LPA conducted a comprehensive walk-through of the interior and exterior of the facility. During the walk-through, LPA observed three care staff on duty. LPA checked the hot water temperature, which measured between 114 degrees Fahrenheit and 117.9 degrees Fahrenheit. {***CONTINUE 9099C***} Unsubstantiated LPA also conducted an audit to all current seven residents’ medication and Medication Administration Record (MAR); no discrepancies were noted. Furthermore, LPA also checked the facility’s food supply and observed that the facility had at least a two-day supply of perishable food and a seven-day supply of nonperishable food available. No immediate health and safety concerns were observed during the visit. LPA conducted three staff interviews, and all three staff denied the allegation. Staff interviewed stated that residents’ care needs are being met and denied neglecting residents in care. LPA also conducted five resident interviews. Four out of five residents interviewed denied the allegation and did not report concerns regarding care, supervision, food, facility conditions, or staff assistance. One out of five residents declined to provide a statement. Based on interviews conducted, there was insufficient information obtained to corroborate that residents were not receiving adequate care or supervision. Based on interviews conducted, records reviewed, and observations made, the Department did not obtain sufficient evidence to support the allegation that staff do not ensure adequate care is provided to residents. Although the allegation may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is deemed Unsubstantiated. An exit interview was conducted, and a copy of this report was provided to care staff.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 22-AS-20260519143142

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced site visit to the facility for the purpose of amending Complaint Control Number 22-AS-20260311085816. Upon arrival, LPA met with Staff Mariam Esquivel, explained the reason for the visit, and conducted a health and safety check of the facility. During the visit, LPA provided Mariam Esquivel with a copy of the amended report. An exit interview was conducted, and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 8, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to perform a required annual inspection. Upon arrival, LPA was greeted by House Manager (HM) Miriam Esquivel and granted entry into the facility. LPA explained the purpose of the visit, and the inspection proceeded with HM accompanying LPA throughout the tour of the facility’s interior and exterior. The facility is a two-story house consisting of nine bedrooms, four bathrooms, and an attached garage used for storage. At the time of the visit, 10 residents were present and observed relaxing in their respective rooms. Resident bedrooms were furnished with a bed, chair, clean linens, and adequate storage space, and were free of tripping hazards. Safety equipment, including manual smoke detectors, carbon monoxide detectors, and exit alarms, was tested and found to be operational. Bathrooms were in good condition, equipped with grab bars, and the hot water temperature measured 114.7 degrees Fahrenheit. The kitchen was clean and in good repair. Cleaning supplies and sharp objects were stored securely and made inaccessible to residents. Medications were locked separately, as required. The facility maintained the required minimum two-day supply of perishable food and seven-day supply of nonperishable food. The fire extinguisher was inspected, and the last recorded service date was March 12, 2026 {***CONTINUE 809C***}. The outdoor area was observed to be well maintained, with outdoor furniture in good condition, grounds free of tripping hazards, and ample space for resident activities. Emergency exits were unlocked and free of obstructions. LPA reviewed three resident files and their corresponding medications and noted no discrepancies. LPA also reviewed two staff files and found all required documentation to be present with no issues identified. Facility records confirmed that quarterly fire drills were conducted, with the most recent drill completed on March 7, 2026. No deficiencies were cited during this inspection. An exit interview was conducted with HM Miriam Esquivel, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 10, 2026

Allegation investigated: Staff did not allow resident to return to the facility

Licensing Program Analyst (LPA) Samer Haddadin conducted an announced visit to deliver findings regarding the above-mentioned allegation. Upon arrival, LPA was greeted and granted entry by staff and later met with Licensee Lacy Faddoul. LPA explained the purpose of the visit. It was alleged that “Staff did not allow resident to return to the facility.” During the course of the investigation, LPA reviewed facility records and conducted interviews with staff, residents, the Responsible Party, and the Licensee. LPA reviewed Resident 1’s (R1) Admission Agreement, dated May 8, 2025, which confirmed that R1 was admitted to Silver Lining Residential Care. LPA also reviewed an incident report dated February 23, 2026, which documented that R1 became physically aggressive toward staff and physically assaulted another resident. The report further indicated that R1 was taken by the CAT team on a 5150 hold for 72 hours. {***CONTINUE9099C*** {***THIS IS AN AMENDED REPORT***} Substantiated LPA conducted interviews with four staff members, all of whom corroborated the allegation. Staff stated they feared for their safety if R1 were to return to the facility. LPA also interviewed R1’s Responsible Party, who corroborated the allegation and stated that the facility did not want R1 to return due to R1’s behavior at the facility. In addition, LPA interviewed the Licensee, who confirmed that the facility did not want R1 to return because of concerns for the safety of both residents and staff. LPA also conducted interviews with three residents, all of whom stated they observed R1 behaving aggressively toward another resident; however, they were unable to state whether R1 had been permitted to return to the facility. LPA’s record review further revealed that, pursuant to the Admission Agreement, the facility was required to provide R1 with a written 30-day eviction notice if it intended to evict the resident. However, no written eviction notice was provided. During the interview, the Licensee admitted that no written eviction notice had been issued to R1. Based on the evidence gathered the preponderance of evidence standard has been met therefore the allegation is substantiated. An exit interview was conducted and a copy of the report provided along with appeal rights. {***THIS IS AN AMENDED REPORT***}the state’s words, verbatim · CDSS document, Mar 27, 2026 · control 22-AS-20260311085816

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(c) · Plan of correction due date: Mar 30, 2026

87224 Eviction Procedures (c) The licensee shall, in addition to either serving the required thirty (30) days notice, sixty (60) days notice or... three (3) days notice on the resident, notify or mail a copy of the notice to quit to the resident's responsible person. This requirement was not met as evidenced by: not accepting R1 back to the facility, which poses an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: The licensee agrees to read and review regulation section 87224 on Eviction Procedures. The licensee will send a signed statement of acknowledgement and understanding to LPA by the close of business on the POC due date

Allegation investigated: Facility staff is verbally abusing residents by telling them to shut up and that they are crazy Facility staff is failing to provide care and supervision to residents after 5pm

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator Lacy Faddoul and explained the reason for the visit. During the course of the investigation LPA interviewed staff and residents and reviewed resident records. The investigation into the allegation, facility staff is verbally abusing residents by telling them to shut up and that they are crazy, revealed the following. The Administrator denied the allegation. 5 out of 5 staff interviewed denied the allegation. At the time the complaint was filed 9 residents resided at the facility. 4 out of 9 residents were interviewed. 2 residents refused to be interviewed and 2 residents (diagnosed with Dementia) did not respond to the LPAs questions. 1 resident responded by making random statements. 4 out of 4 residents reported they have never verbally abused in any way. LPA did not observe any evidence to support the allegation. Unsubstantiated Based on the evidence gathered the allegation is deemed unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, facility staff is failing to provide care and supervision to residents after 5pm, revealed the following. 4 out of 9 residents interviewed reported they receive care after 5:00pm. The Administrator denied the report. 5 out of 5 staff interviewed denied the allegation. On August 22, 2023 LPA made a subsequent visit as part of the investigation into to complaint # 22-AS-20230320142719 (same facility) at 8:00pm. During the visit LPA observed staff at the facility providing care and supervision to the residents. Based on the evidence gathered the allegation is deemed unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Oct 15, 2025 · control 22-AS-20220719100645

Allegation investigated: Staff providing care and supervision without criminal record clearance Staff monitor residents via hidden cameras Staff are unqualified to meet residents needs Staff providing care and supervision while intoxicated Staff is financially abusing residents Staff is denying residents' access to make and receive confidential calls

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator Lacy Faddoul and explained the reason for the visit. The investigation into the allegation, staff providing care and supervision without criminal record clearance, revealed the following. It was alleged that Staff 1 (S1) was working at the facility without a valid background clearance. The Administrator reported that S1 was going to be hired pending their background clearance was approved. The Administrator reported that the background clearance was not approved and S1's association to the facility was removed September 15, 2018. The Administrator reported that S1 never worked at the facility. On December 6, 20219 a case management visit was conducted to verify S1 was not at the facility (See LIC809 dated December 6, 2019 for more details). 4 out of 4 staff interviewed reported they never worked with S1. Unsubstantiated Based on the evidence gathered the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, staff monitor residents via hidden cameras, revealed the following. The facility has a ring doorbell camera next to the patio entrance gate which leads into the front patio where the main entrance to the facility is. There is a video camera in the front outdoor patio and the living room. The living room video camera was removed on August 23, 2023. During the initial 10-day visit on August 22, 2023 and a subsequent visit on August 23, 2023, LPAs did not observe any video cameras in residents' rooms. Resident 1 (R1) reported that there was a camera on their TV and they thought it was recording them. R1 has been diagnosed with Dementia. The camera on R1's TV was a photographic camera that did not have the ability to record video. Resident 2 (R2) reported that there was a camera in their room recording them but upon inspection no camera was found. R2 still insisted without any evidence that they were being recorded. 4 out of 4 staff interviewed reported that they were unaware of any cameras in residents' rooms. 5 out 12 residents interviewed reported they did not have any cameras in their rooms. 7 out of 12 residents did not respond to LPAs questions and could not be interviewed. Based on the evidence gathered the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, staff are unqualified to meet residents needs, revealed the following. It was alleged that staff are not properly trained and can't effectively communicate with staff. During both visits by LPAs on August 22 and 23 of 2023 LPAs had no issues communicating with staff. LPAs interviewed 5 out 12 residents who reported no issues with staff. 7 out of 12 residents did not respond to LPAs questions and could not be interviewed. 4 out of 4 staff interviewed reported no issues communicating with residents. LPAs reviewed 5 staff files and verified all 5 staff had the required 20 hours training. LPAs observed at the time the complaint was filed the Administrator had a valid Administrator's certificate and currently has a valid Administrator's certificate. Based on the evidence gathered the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, staff providing care and supervision while intoxicated. Revealed the following. It was alleged that Staff 1 (S1) provided care to residents while intoxicated. 4 out of 4 staff reported that none of the staff have provided care while intoxicated. The Administrator stated no staff member has ever provided care while intoxicated. 5 out of 12 residents reported they are unaware of any staff member providing care while intoxicated. 7 out of 12 residents did not respond to LPAs questions and could not be interviewed. No evidence was gathered that shows S1 ever worked at the facility. Based on the evidence gathered the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, staff is financially abusing residents, revealed the following. It was reported that facility staff financially abused Resident 13 (R13). R13 passed away on March 3, 2020. It was alleged that the Administrator used R13's personal information to secure a loan in R13's name to purchase a car for the Administrator's father. The Administrator denied the allegation. The Administrator's father denied the allegation. It was reported that the Administrator is financially abusing all residents in care. The Administrator denied the allegation. 4 out of 4 staff interviewed denied the allegation and reported they had no knowledge of any financial abuse taking place. 5 out of 12 residents interviewed reported that their families handle their money and they have no monetary issues. 7 out of 12 residents did not respond to LPAs questions and could not be interviewed. LPA interviewed 2 responsible parties for Residents 3 and 4 who reported they handle the residents' money and the facility has no access to their money. The Administrator reported that they are the payee for only one resident who receives SSI. The Administrator reported that Resident 2 (R2) receives the SSI rate and the remainder of their funds is kept in a bank account and in Personal and Incidental (P & I) funds at the facility in cash (kept secured). LPA verified this information through R2's bank records and reviewing their P & I funds. No discrepancies were observed. R2 moved out of the facility on October 24, 2023. No evidence was gathered to support the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, staff is denying residents' access to make and receive confidential calls, revealed the following. It was reported that the Administrator would screen all calls for residents and not allow residents to speak on the phone or would listen in on calls. The Administrator denied the allegation. 4 out of 4 staff interviewed reported all residents are given privacy when they receive a call and have no knowledge of anyone screening or listening in on calls. 5 out 12 residents interviewed reported they have privacy when using the phone and have no knowledge of anyone listening in on calls. 7 out of 12 residents did not respond to LPAs questions and could not be interviewed. The Administrator reported that residents who have the ability to use the phone have their own cell phone and do not use the facility phone for their calls. None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Oct 15, 2025 · control 22-AS-20230320142719

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to perform a required annual inspection. Upon arrival, LPA was greeted by house manager Miriam Esquivel and was granted entry into the facility. LPA explained the purpose of the visit, and the inspection proceeded with house manager accompanying LPA throughout the tour of the facility’s interior and exterior areas. Observations: The facility consists of 9-bedroom, 4-bathroom, two-story house with an attached garage that is being used for storage. During the visit, 10 residents were present and observed relaxing in their respective rooms. Resident bedrooms were furnished with a bed, chair, clean linens, and adequate storage space, and were free of tripping hazards. Safety equipment, including manual smoke detectors, carbon monoxide detectors, and exit alarms, was tested and confirmed operational. Bathrooms were in good condition, equipped with grab bars, and hot water was measured at 114. 9°F.The kitchen was clean and in good repair, with cleaning supplies and sharp objects stored securely and inaccessible to residents. Medications were locked separately, as required. The facility maintained a minimum two-day supply of perishable food and a seven-day supply of non-perishable food, meeting regulatory standards. The fire extinguisher was inspected, with the last service date recorded as March 7th, 2025. Exterior: the facility featured well maintained outdoor furniture, grounds free of tripping hazards, and ample space for resident activities. Emergency exits were unlocked and free of tripping hazards. LPA reviewed three resident files and their corresponding medications, noting no discrepancies. Similarly, two staff files were examined, with all required documentation present and no issues identified. Facility records confirmed facility was not in compliance with quarterly fire drills, in which an advisory note was issued. Findings: No deficiencies were identified during this inspection. LPA conducted an exit interview with House manager and provided a copy of this report.the state’s words, verbatim · CDSS document, Apr 7, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Unlawful eviction Medication not being administered as prescribed

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegations listed above. LPA was greeted and granted entry by staff. Staff called the Administrator and informed her of the visit. LPA met with Administrator Lacy Faddoul. LPA interviewed staff and residents. LPA reviewed facility records. The investigation into the allegation, unlawful eviction, revealed the following. It was alleged the Resident 1 (R1), was unlawfully evicted and not allowed to return to the facility after their hospital stay. On Friday August 30 2024, staff attempted to give R1 a shower and R1 became agitated and hit and scratched 2 staff members. Staff reported R1 was aggressive and yelling so they called 911. The Administrator and family members of R1 were notified. R1 was taken to the hospital. R1 was ready for discharge on September 04, 2024. The Administrator reported that after R1 was assessed they wanted R1 to have a one on one caregiver because of their recent behavior. On September 6, 2024, the Administrator, R1's family members, hospital social worker and the hospital physician who treated R1 had a conference call to discuss admitting R1 back to the facility and R1's plan of care. Substantiated The Administrator reported the facility wanted one on one care for the safety of R1 and the other residents and staff. The hospital social worker, physician and R1's family members did not think one on one care was required. At issue was the hospital's use of Haloperidol lactate injections of 2 mg as needed for delirium. The Administrator reported that she provided a new care plan for R1 to R1's family members but they did not agree to the new care plan. The Administrator reported that after the conference call she was provided with a new physician's report. A review of the physician's reported provided at move in and the one completed at the hospital showed two differences. The new physician's report (dated September 4, 2024) lists R1 as able to dress/groom self and the one provided at move in (dated March 31, 2023) lists R1 is not able to dress/groom self. The physician reported dated March 31 lists R1 as able to administer their own medication and the physician reported dated September 4 lists R1 as not being able to administer their own medication. Neither physician's report lists Haloperidol Lactate 2 mg as a regular medication. The Administrator reported that their concern was the use of Haloperidol Lactate and why was it not being continued if it was being used for the resident at the hospital. R1's family members reported that the physician reported it was no longer necessary and R1 did not require one on one care. On September 10, 2024 R1's family members went to the facility and gathered R1's belongings and informed the Administrator that they have relocated R1. The Administrator reported that they refunded R1's family members for September 2024. A review of records shows R1's family members signed for R1's belongings and for the refund check for $1398.00. R1 was agitated and in distress and needed medical assistance so they were taken to the hospital on August 30, 2024. R1 was treated and the hospital was ready to discharge R1. The facility wanted R1 assessed prior to discharge. The Administrator assessed R1 on September 5, 2024 and sent a revised care plan to R1's family members. A conference call was conducted on September 6, 2024 with all parties regarding R1 returning to the facility and their plan of care. No eviction notice was provided to R1's family members. No action was taken until September 10, 2024 when R1's family members removed R1's belongings from the facility and reported to the Administrator R1 has been relocated. The facility reported they would take R1 back if the the physician's report stated that R1 did not required a one on care. The physician's report dated September 4, 2024 states R1 does not require one on one care. The facility did provide a new care plan but there is no medical documentation to show one on one care was needed. Based on the evidence gathered the preponderance of evidence standard has been met therefore the allegation is substantiated. The investigation into the allegation, medication not being administered as prescribed, revealed the following. It was alleged that R1's was not given the proper amount of medication and that R1 was given medication after is was discontinued. A review of R1's medication administration record (MAR) for August 2024 shows that R1 did not receive 8 different medications on 10 different days. The Administrator reported that the blank spaces on the MAR are when R1 refused to take medication. There is no key on the MAR to indicate what is noted for a medication refusal. There is no indication on the MAR that R1 refused any medications. Based on the evidence gathered the preponderance of evidence standard has been met therefore the allegation is substantiated. An exit interview was conducted and a copy of the report provided along with appeal rights. Based on the evidence gathered the allegations is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Sep 16, 2024 · control 22-AS-20240906145147

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(c) · Plan of correction due date: Sep 17, 2024

87224 Eviction Procedures (c) The licensee shall, in addition to either serving the required thirty (30) days notice, sixty (60) days notice or... three (3) days notice on the resident, notify or mail a copy of the notice to quit to the resident's responsible person. This requirement was not met as evidenced by: Based on interview confirmation and record review the licensee did not ensure the eviction process was followed according to regulation guidelines which poses an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 16, 2024

Plan of correction: The licensee agrees to read and review regulation section 87224 on Eviction Procedures. The licensee will send a signed statement of acknowledgement and understanding to LPA by the close of business on the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Sep 17, 2024

Personal rights of residents in all facilities. To receive or reject medical care or other services. This requirement was not met as evidenced by. A review of records shows R1 did not receive all medication as prescribed which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Sep 16, 2024

Plan of correction: The licensee agrees to read and review regulation section 87468.1 on personal rights of residents in all facilities. The licensee will send a signed statement of acknowledgement and understanding to LPA by the close of business on the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Joseph Alejandre and Edward Kim made an unannounced visit to conduct the required annual inspection. LPAs were greeted and granted entry by staff. LPAs explained the reason for the visit. LPAs met with house manager Miriam Esquivel. LPAs and house manager toured the facility. Facility is a 9-bedroom, 4-bathroom, two-story house with an attached garage that is being used for storage. Lacy Faddoul's Administrator's Certificate expires on May 9, 2024. LPAs observed the See Something, Say Something poster (PUB 475) posted in entrance of the facility. Smoke detectors/carbon monoxide detectors tested operational. The fire extinguisher mounted next to the kitchen is fully charged. LPAs observed the kitchen is clean and organized. The stove lights unassisted. LPAs observed the knives are kept locked and inaccessible to residents. LPAs observed the medication is kept locked in a kitchen drawer. LPAs observed a 2 day perishable and 7 day non-perishable food supply on hand in the kitchen. LPAs observed all 4 bathrooms are clean and operational. Hot water measured between 108.1 and 111.3 degrees Fahrenheit. LPAs toured the resident rooms. All resident rooms had the required furnishings and linens. LPAs and the house manager toured the backyard and garage. The garage is kept locked and used for storage. LPAs observed a shaded seating area for residents to sit outside. LPAs observed the exit gate door knob was broken and non-operational. No bodies of water observed in the backyard. LPAs reviewed 4 out of 5 staff files. 4 out of 5 staff have not completed the required 20 hours of annual training. All 4 staff have completed CPR/First-Aid training. LPAs reviewed resident files. 2 out of 12 residents were missing a current reappraisal. LPAs reviewed resident medications. 1 out of 12 residents did not have all of their medications at the facility. Resident 2 was missing their Chest congestion relief DM SYR liquid which was not at the facility. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Apr 10, 2024

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff would not allow residents provider to visit the resident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. LPA spoke with Administrator/ Licensee Foudil via telephone. During the course of the investigation, LPA interviewed staff, resident, and witness as well as reviewed and obtained pertinent documentation such as sign in logs and physician report. Regarding the allegation that staff would not allow residents provider to visit the resident, the investigation revealed the following: On 02/23/2024 at 12:30 PM, provider stated they arrived for a visit with Resident 1(R1) and was told by staff that the resident was not present at the facility. Provider states being denied entrance. Subsequent information revealed the resident was at the facility during that time frame. Three out of three facility staff deny the incident and state visitors are never denied visitation. The resident's durable power of attorney (DPOA) indicates provider does not come to facility as scheduled nor provide the services they are contracted to do. LPA observed ring footage that did not show the provider at the front door. CONTINUED ON LIC 9099C DATED 03/01/2024 Unsubstantiated Based on interviews conducted and video footage, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Mar 1, 2024 · control 22-AS-20240223151431