Silverado Senior Living - The Huntington

Allegation investigated: Staff do not ensure that residents are able to enter and exit the facility.

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced 10-day complaint visit to investigate the above-mentioned allegation. LPA met with Elizabeth Cruces, Office Services Manager, and the reason for the visit was explained. Rochelle Carpio, Administrator, arrived thereafter and continued to facilitate the investigation. The investigation consisted of the following: LPA, obtained copies of staff and resident rosters, toured the facility with a particular focus on inspecting the front door and interviewed Staff 1 – Staff 5 (S1-S5). LPA attempted to conduct interviews with residents at random; however, was unable to obtain information regarding the allegation. *Note: the facility serves cognitively impaired elderly residents. The investigation revealed the following: ***Continues on LIC 9099-C*** Unsubstantiated Regarding: Staff do not ensure that residents are able to enter and exit the facility. It is alleged that the front door is locked at random times and no one can get in or out without a buzzer. It is also alleged that sometimes the wait is over ten minutes during the day, making it hard to deliver and creating a fire hazard. Interviews with (5) out of (5) staff revealed that the front door is not locked at random times and it is not a fire hazard. Staff indicated that although the facility is a “closed facility” due to being full Memory Care, there are protocols in place for people to come in and out of the facility during normal business hours and evening shifts to ensure the safety of residents in care. Staff further stated that all residents living in the facility are not restricted from entering and exciting the facility; however, could only leave the premises with a chaperon after being signed-out at the front desk as part of the safety measures the facility has in place. Interviews with Staff 1 – Staff 3 (S1-S3) revealed that the front desk always has staff monitoring the door Monday – Friday, 8:00 a.m. to 7:00 p.m. and Saturday and Sunday, 9:00 a.m. to 6:00 p.m. to “buzz” people in and out of the facility when the “doorbell” in the front door is triggered. Visitors coming in and out of the facility after business hours must follow the same protocol of using the front “doorbell” to alert staff. Nurses working the PM shifts have portable phones which are alerted when visitors trigger the “doorbell” by the front door to gain access into the building. Staff stated that service providers who may come to the facility after hours can call the facility’s main phone line if they need access to facility. Staff indicated that the front door is locked from the outside, but not from the inside because the door is equipped with a delay egress system which triggers an alarm after 30 seconds after the door is opened to alert staff of a possible elopement. Staff indicated that their food and medical equipment vendors do not deliver after hours because they have a set schedule that they follow for deliveries to be made during regular business hours. Shipping retailers leave packages outside of the main entranceway and do not request access to the inside of the building when delivering packages. Staff indicated that although there have been times in which visitors have waited several minutes to be provided with access into the facility by staff, wait times do not exceed ten minutes. Staff further indicated that they have not received any reports regarding people not being able to get in or out of the facility or having to wait for more than ten minutes to be granted access inside. LPA inspected the front door and observed the delay egress system to be working properly. The “buzzer” in the front desk was also tested and found it to be operational. Interviews and observations could not corroborate the allegation that staff are not ensuring that residents are able to exit and enter the facility. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Rochelle Carpio, Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 13, 2026 · control 28-AS-20260806151134

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Galarza conducted an unannounced case management visit to address new information obtained for complaint control # 28-AS-20260528120044. The purpose of the visit was explained to Director of Health Services Arienne Ghammangne. The facility is instructed to comply with deceased resident (R1's) representative and produce the requested records within 10 business days. Exit interview was held with Arienne Ghammangne. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 30, 2026

Allegation investigated: Staff are not providing medical records to authorized representative.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the above allegation. The purpose of the visit was discussed with Director of Health Services Arienne Ghammangne. Administrator Rochelle Carpio arrived later. The investigation consisted of: The interior and exterior facility grounds were toured. Record review was completed. Copies of resident (R1's) file documents and staff and resident rosters were obtained. Staff (S1- S7) and residents (R2 - R8) were interviewed. Resident (R1) is deceased and was not interviewed. A family member/visitor was interviewed. *Note the facility serves cognitively impaired elderly residents. Report continues on LIC 9099C. Unsubstantiated Allegation: Staff are not providing medical records to authorized representative. It is alleged the facility ignored or refused a request to obtain and review deceased resident (R1’s) facility records that an alleged post-death beneficiary sent on February 5, 2026, and was received by the facility on February 6, 2026. The complaint alleges the facility was provided proper documentation establishing authority and beneficiary status of the alleged representative and never issued a lawful written denial of records access to the alleged post-death beneficiary. According to the complaint a letter of “enforcement and production” was sent to the facility and none of the requested documents were provided to the alleged post-death beneficiary. Administration staff were interviewed. Per staff interviews, the facility was not provided Letters of Testamentary appointing the alleged post-death beneficiary as executor, which would make them the representative of the estate. Administration staff stated the alleged certified mail request was not received. Based on record review, resident (R1) died on January 22, 2026. The resident was never under a conservatorship during their lifetime. Decision-making authority through Durable Power of Attorney (DPOA) was delegated to another individual. The findings indicate the requestor did not provide the facility with a court order that acknowledges their authority and the validity of the trust. The facility must verify the requestor’s authority through official documentation e.g., Letters of Administration or court order. The findings indicate the facility has not failed to release records to the requestor absent a court order. Therefore, there is insufficient information to support the 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 with Administrator Rochelle Carpio. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 28-AS-20260528120044

Allegation investigated: Staff did not seek timely medical care for resident Staff did not follow the Universal Precautions Protocol staff did not notify authorized representatives of an outbreak

Licensing Program Analyst (LPA) Alberto Lopez made a subsequent unannounced visit to deliver findings for the above-mentioned allegations. LPA met with Jadelyn Pazcoguin - Family Ambassador and discussed the purpose of the visit. 01/21/2026 Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to investigate the above-mentioned allegations. LPA met with Rochelle Carpio, Administrator, and discussed the purpose of the visit. The investigation consisted of LPA reviewing and obtaining copy of staff and resident rosters, interviewed six (6) staff, S#1 – S#6, six (6) residents R#1 – R#6, attempting to interview R#7, reviewing email response from Department of Public Health to facility, R#7 Hospital visit records, three (3) incident reports, R7 progress notes from 12/28/2025 to 01/21/2026. (continued on 9099C) Unsubstantiated (continued from 9099) The investigation revealed regarding allegation: Staff did not seek timely medical care for resident. It is alleged that medical attention was not provided to resident in timely manner. LPA interviewed six (6) staff, and all six staff denied the allegation. One staff member (nurse) stated that staff noticed a resident wobbling while walking on January 3, 2026, around 10:00am and immediately assessed resident. Resident was observed with acute distress and generalized weakness, congestion and episodes of dry cough and paleness. Staff called 911 and resident was transported to Huntington Hospital at the time. LPA interviewed six (6) residents, and all six (6) residents could not corroborate the allegation. Several residents stated that facility staff provide medical attention right away and are happy with the services provided to them. There is insufficient evidence to support this allegation. Allegation: Staff did not follow the Universal Precautions Protocol. It is alleged that facility did not follow proper infectious control protocols that resulted in a respiratory illness outbreak. LPA interviewed six (6) staff and five (5) of six staff denied the allegation. One (1) staff refused to answer. LPA interviewed six (6) residents, and all six residents could not corroborate the allegation, and all stated that they were not aware of any kind of illness outbreak and all six (6) stated they had not recently been ill. Facility provided the department with an infection control plan and LPA took tour of facility common areas and did not observe any staff or residents with symptoms of a respiratory illness. LPA observed facility to be clean and observed staff following infectious disease protocols by wearing masks and gloves while assisting residents. There is insufficient evidence to support this allegation. (continued on 9099C) (continued from 9099C) Allegation: Staff did not notify authorized representatives of an outbreak. It is alleged that facility did not notify authorized representatives of an outbreak at the facility. LPA Interviewed six (6) staff and all six staff denied that there was an outbreak of any kind at facility. LPA Interviewed six (6) residents and all six residents could not corroborate the allegation. Staff stated that they had three (3) residents diagnosed with Pneumonia this month and they had returned to facility after a short stay at hospital. Facility reported one resident with Pneumonia on 01/03/2026, one resident on 01/07/2026 and a third resident on 01/17/2026 . All three residents were diagnosed over 72 hours apart. This does not meet the definition of an outbreak. At the time of this visit, the facility had reported three (3) total residents and zero (0) staff infected. The Department of Public Health could not confirm that an outbreak has occurred at the facility. There was no outbreak to report to authorized representatives, however facility did notify the authorized representatives on the incident(s) on the day it was reported to the department. Facility took precautions immediately after the first infection, notified Public Health, responsible parties, and the Department. There is insufficient evidence to support this allegation. Based on interviews and records reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was discussed and provided to facility Jadelyn Pazcoguin - Family Ambassadorthe state’s words, verbatim · CDSS document, Jan 31, 2026 · control 28-AS-20260112121705

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to deliver deficiency citation. LPA met with Rochelle Carpio Administrator and discussed purpose of visit. During the investigation of complaint #28-AS-20250219161002 One resident showed inappropriate sexual behaviors on 01/28/2024, 03/08/2024, 03/09/2024, 04/27/2024, 05/01/2024, 05/06/2024, 05/09/2024, 06/26/2024, 08/10/2024. and 07/14/2024. Facility did not report these incidents to the department as required, Citation and plan of correction issued. Exit interview conducted with staff, copy of report, 809D and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 28, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 4, 2025

87211(a)(1)(D) 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 evidenced by: R1 showed inappropriate sexual behaviors on 01/28/2024, 03/08/2024, 03/09/2024, 04/27/2024, 05/01/2024, 05/06/2024, 05/09/2024, 06/26/2024, 08/10/2024. and 07/14/2024. Facility did not report these incidents to the department as required.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Administrator will read section 87211 and send a signed letter via fax or mail stating that Administrator has read and understands section 87211. Also, Administrator will create and send incident reports when resident had inappropriate sexual behaviors for the dates of 01/28/2024, 03/08/2024, 03/09/2024, 04/27/2024, 05/01/2024, 05/06/2024, 05/09/2024, 06/26/2024, 08/10/2024, and 07/14/2024 and fax or mail to the department by plan of correction date which is 11/04/2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Gabi Rodriguez, receptionist and Rochelle Carpio Administrator and Director of Health services Arienne Ghammangne who assisted with the visit. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan. Facility observed to very clean. Operational Requirements: A current Plan of Operation was reviewed. The facility serves residents 60 years and older, and a Hospice Waiver for ten (15) resident is approved. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. A surety bond is not applicable. Facility does not handle resident's money. Physical Plant/Environment Safety: The facility consists of a 2-story building with resident rooms on both floors. The main floor has a lobby, library, bistro area, dining room, kitchen, administrative offices, and spacious outdoor patio. The 2nd floor consists mainly of resident rooms and a dining room. There are no swimming pool or bodies of water on the premises. There are no firearms or weapons stored at the facility. LPA selected six random rooms to inspect and measure the hot water temperature. (continued on 809C) (continued from 809) The water temperature measured between 102.3 – 120.0 degrees F which is not the required range of 105-120 degrees F. The supply of dishes/cups is adequate. The facility smoke detectors are hard-wired. Carbon monoxide detectors were observed throughout the facility. Fire alarm system was tested during visit. The fire extinguishers were fully charged and in compliance. The grounds of the facility are well landscaped with a ramp that leads to the entrance. A shaded area with chairs is provided in the patio area. The facility is equipped with a centralized sprinkler system. The south side fire door was tested and did not operate properly; it did not open after 30 seconds. One door in the lobby is not working and does not open after 30 seconds. Staff provided work order for Wandering Gate Upgrade proposal from West Mills Communications Corporation and stated that work is to be completed next week. LPA asked facility to report to Fire Department and CCL and facility agreed. Staffing: There appears to be always sufficient staffing in the facility. With night staff that is trained and able to assist in care and supervision of the residents in case of an emergency. Personnel Records/Staff Training: Staff have criminal record clearance, some staff have current First-Aid training along with training in medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 6 staff files with no deficiencies observed. Administrator Rochelle Carpio certificate expires on 01/21/2027 Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman near the entrance. A total of six (6) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment, and emergency information. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. LPA observed activities during visit. (continued) Food Service: Sufficient food supply is stored in the kitchen and storage areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. (continued) (continued from 809C) Incident Medical and Dental: Six (6) centrally stored resident medications were reviewed. Medication is given according to doctor’s orders. Some medications did not have labels and staff promptly corrected that by placing labels on the medications. Medical and dental transportation is provided by family, transportation services, or staff. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last fire/disaster drill was on 09/08/2025 Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. Facility admits residents with dementia and staff have all required training documented within personnel files. Per California Code of Regulations, Title 22, deficiencies were cited. Technical Advisories provided. Exit interview was conducted with staff. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Oct 28, 2025

The state marks this report as 8 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provide a resident access to a walking device Staff authorized change in a resident's medical needs without proper consent Staff did not prevent a resident from causing harm to another resident while in care Staff left a resident unattended Staff did not properly report an incident involving a resident Staff did not safeguard a resident's personal belonging

Licensing Program Analyst (LPA) Alberto Lopez made a subsequent visit to the facility to deliver findings of the above allegations. LPA met with Elizabeth Cruces, Business Manager, Vanessa, Rodriguez, Clinical Staff Manger and discussed the purpose of the visit. On 05/20/2025 Licensing Program Analysts (LPAs) Alberto Lopez and Elena Mallett conducted the initial visit for the allegations listed above. LPAs arrived unannounced and met with Director of Health Services Arienne Ghammangne. The purpose of the visit was explained. During the visit today, LPA obtained copies of the staff and resident roster. Progress notes for R1, Prescription for R1 dated 08/15/2024. R1 Clothing Assessment Forms (3). R1 MAR for time R1 was at facility, R1 file, and Communication log for time R1 was at facility. The investigation consisted of LPA reviewing and obtaining staff and resident roosters, interviewing six (6) staff (S#1-S#6) and five (5) residents (R#2-R#6). R#1 has moved out of facility and is not available for interview and cannot answer questions due to cognitive impairment. R#7 could not answer questions due to cognitive impairment. LPA attempted to contact S#7 and S#8 several times but was unsuccessful. (cont) Unsubstantiated (continued) The investigation revealed: 1) Allegation Staff did not provide a resident access to a walking device. It is alleged that the facility took away R1 cane and provided R1 with a walker and that the facility did not provide R1 with instructions for use. LPA interviewed six (6) staff and six (6) of (6) staff denied the allegation. S6 stated that the safety of the residents is the facility primary responsibility, and that R1 was combative and a strap on R1 cane was tearing R1 skin. R1 was provided with a walker to prevent R1 from striking other residents with the cane and to assist her in ambulating. The facility did not provide physical therapy to R1, on how to use the walker because it was not ordered by physician or required according to staff assessment completed by staff. One staff member stated that R1 was able to use walker just fine and that R1 was eventually given cane back when facility was sure R1 would not strike other residents. LPAs interviewed five (5) residents and five (5) of five (5) residents could not corroborate the allegation. Five (5) of (5) residents stated that the facility has never taken away their canes or walkers. There is insufficient evidence to support this allegation. 2) Allegation: Staff authorized change in a resident's medical needs without proper consent. It is alleged that facility pressured resident’s family members into giving anti-psychotic to resident. LPA interviewed six (6) staff, and all six (6) staff denied the allegation. LPA interviewed five (5) residents, and all five (5) residents could not corroborate the allegations. R1 was admitted on 07/20/2024 and moved out on 08/18/2024. According to S3, R1 was prescribed an anti-psychotic for aggression and being combative on 08/15/2025. S3 stated S3 never personally administered the anti-psychotic due to her schedule. S1 stated physician is always consulted first and that the family/responsible party along with resident’s physician make the final decision for any new medication(s). Record reviewed showed that R1 physician ordered the anti-psychotic, and family/responsible party agreed, for agitation with start date of 08/16/2024. There is no evidence that family was pressured into authorizing anti-psychotic for resident. 3) Allegation: Facility staff do not intervene when resident's engage in physical altercations. It is alleged that R1 had an altercation with another resident and the staff did not intervene. LPA interviewed six (6) staff, and all six (6) staff denied the allegation. No staff witness any altercation between residents. One staff stated resident was found on floor by staff on duty and SIR submitted to the department. LPA interviewed five (5) residents and five (5) of five (5) residents could not corroborate the allegation. All five (5) residents stated they have never witnessed resident on resident violence at facility. There is not enough evidence to show that staff allowed aggressive behavior between residents. (continued) (continued) 4) Allegation: Staff left a resident unattended. It is alleged that resident was left unattended. LPA interviewed six (6) staff, and all six (6) staff denied the allegation. One staff member stated that the resident was not left unattended, that a staff member was present and assisting another resident when the staff found resident on the floor outside in the hallway. Five (5) of five (5) residents could not corroborate the allegation and one resident stated that staff are always “watching us” and provide us with good service. Staff stated that facility checks on residents every 2 hours. There is insufficient evidence to support this allegation. 5) Allegation: Staff did not properly report an incident involving a resident. It is alleged that facility did not report what happened involving resident incident to family on 08/17/2024. Facility reported that R1 was found on the floor in the hallway by staff on duty. Family member stated that contracted staff (S7) contacted the family and left voice mail on family member phone telling family member that resident was pushed to the ground by another resident and taken to hospital due to complaining of pain in left hip area. Also, S1 stated S1 contacted family the next day. One staff member stated that the facility reported the incident as reported by the staff (S8) who found R1 on the floor. S7 left the message, however S7 was contracted staff. Facility Administrator (S6) stated that S7 was authorized to provide information to the family but that S7 may have interpreted the facts differently since S7 did not witness the incident. LPA was unsuccessful in reaching S7 that left the message and the staff (S6) that found the resident on the floor after several attempts to do so. Neither staff are employed by the facility nor provide service to facility any longer. The evidence shows that facility staff (S7) contacted the family on the day of the incident and family acknowledged that fact, but family felt that it was not an official contact since “permanent” staff did not contact them right away. There is insufficient evidence to support this allegation. 6) Staff did not safeguard a resident's personal belongings. It is alleged that the facility never returned resident’s phone charger after she left the facility. LPA interviewed six (6) staff, and all six (6) staff denied the allegation. LPA interviewed five (5) residents and five (5) of five (5) residents could not corroborate any lost or stolen items. One staff stated staff completes an inventory list when residents move in, and record review of resident personal property inventory form showed no phone charger on the list. Staff stated the facility does everything they can to safeguard residents personal property, but things do get separated from residents from time to time. S6 stated S6 personally handed the charger to R1 responsible party. There is insufficient evidence to support this allegation. 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 Elizabeth Cruces, Business Manager, Vanessa, Rodriguez, Clinical Staff Manger A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 13, 2025 · control 28-AS-20250515142610

Allegation investigated: Staff did not prevent resident from inappropriately touching himself in front of other residents in care.

Licensing Program Analyst (LPA) Alberto Lopez conducted a subsequent visit to deliver findings. LPA arrived unannounced and met with Ruth Thuku, Charge Nurse and assisted with the visit. Administrator Rochelle Carpio was on the phone during the visit and reading of the report. The purpose of the visit was explained. The investigation consisted of: On 02/19/2025, LPA toured the facility, obtain copies of the staff and resident roster, and conducted a health and safety check. On 02/25/2025, LPAs interviewed five (5) staff and six (6) residents, reviewed, and obtained Resident #1-#4(R1 -R4) pertinent documents, Alhambra Police Department incident number and name of officer, copy of email dated 02/18/2025, Nurses progress notes from 2/19/2024 to 02/20/2025, R2 face sheet, Physician’s Report for Residential Care Facilities for the Elderly (RCFE), R1 Medication List, R1 progress notes from 01/24/2024 to present. R1 service plan dated 02/25/2025. Incident report dated 02/21/2025 regarding R1 and R2. R1 Behavior Mapping dated 02/18/2025. R1 Power of Attorney dated 04/19/2024. R1 California Probate Code Section 4701 dated 08/13/2018. R1 client interest intake dated 12/23/2023. R1 mini mental dated 07/22/2024. R1 Diet Request Form. (Continued on 9099C) Substantiated (continued from 9099A) The investigation revealed: Regarding Allegation: Staff did not prevent a resident from inappropriately touching self in front of other residents in care. It is alleged that the resident was inappropriately exposing self in front of the other residents. LPA interviewed six (6) staff and four (4) of six (6) staff corroborated the allegation by stating to have observed R1 masturbating multiple times, Staff were aware of R1’s tendency to masturbate in R1’s room, and that R1 was placed on medication to assist with behavior. Due to cognitive skills, R1 and R2 were not able to be interviewed. Per documents reviewed, R1 was admitted to the facility on 12/23/2023. Progress notes show on the following dates R1 showed inappropriate sexual behaviors; 01/28/2024, 03/08/2024, 03/09/2024, 04/27/2024, 05/01/2024, 05/06/2024, 05/09/2024, 06/26/2024, 08/10/2024. On 07/14/2024, R1 made an inappropriate sexual comment towards R1’s roommate and their visitors. On 09/24/2024, Facility contacted R1’s physician and was provided with medication to assist with inappropriate sexual behaviors. On 2/18/2025 Facility staff observed R1 on top of their roommate, with R1’s pants down. At 8:33am, staff #4(S4) emailed the facility’s nurses and management team regarding R1’s inappropriate behavior towards roommate (R2). Per records reviewed the facility Administrator was aware of R1’s behavior between January of 2024 to August of 2024. It wasn’t until 9/24/2025 that the facility staff contacted R1’s physician to seek assistance with behaviors. The facility staff did not protect the personal rights of the residents in care by providing assistance sooner and/or providing a private space for R1. Therefore, there is sufficient evidence to support this allegation. 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 LIC9099D. An exit interview was conducted. A copy of this report, Plan of Correction, and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Aug 23, 2025 · control 28-AS-20250219161002

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2 · Plan of correction due date: Aug 24, 2025

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on documents reviewed and interviews, licensee did not ensure R1’s inappropriate sexual behavior disturbed other residents in care which poses an immediate risk to the personal rights, health, or safety of the persons in care.the state’s words, verbatim · CDSS document, Aug 23, 2025

Plan of correction: Licensee will create a plan to deal with inappropriate behaviors showing steps, documentation, and considerations of privacy, will train facility staff on the plan and provide a copy to the department by POC date 08/24/2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(h)(3) · Plan of correction due date: Aug 24, 2025

87405(h)(3) Administrator - Qualifications and Duties (h) The administrator shall have the responsibility to: (3) Develop an administrative plan and procedures to ensure clear definition of lines of responsibility, equitable workloads, and adequate supervision. This requirement is not met as evidenced by: Based on interviews and documents reviewed, licensee did not ensure the administrator seek appropriate intervention for R1 in the course of (eight) 8 months which poses an immediate risk to the personal rights, safety, and health of the persons in care.the state’s words, verbatim · CDSS document, Aug 23, 2025

Plan of correction: Licensee will ensure Administrator is aware and/or takes the necessary continue education to address inappropriate behaviors in a timely manner to be able to plan and train staff to address the behaviors and will submit a copy of education obtained by POC due date 8/24/2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Resident was denied the right to visit the facility prior to residence. Medication is not given as prescribed.

**The is an amended LIC 9099/LIC 9099C to reflect the allegations to show on the report** Licensing Program Analyst(LPA) Nicol Wesley Licensing Program Analyst (LPA) Nicol Wesley conducted an Amended complaint visit to investigate the above allegations. LPA met with Adminstrator Rochelle Carpio and Arienne Ghammangne to discuss the purpose of today’s visit. LPA Wesley requested copies of: resident #1 file, a copy of the staff and resident roster, LPA Wesley also visited the medication room, interviewed residents, interviewed staff, interviewed with resident #1, and interviewed the POA. Regarding allegation: Resident was denied the right to visit the facility prior to residence. LPA Wesley interviewed the wellness Director Arienne Ghammangne who stated prior to admission resident #1 and their POA came to visit the facility. LPA Wesley spoke to the POA who confirmed that they visited the facility and saw the facility prior to the resident residing there. LPA Wesley spoke to resident #1 and he said that he saw continued on LIC 9099C. Unsubstantiated the facility prior to moving there. Regarding allegation: Medication is not given as prescribed. Regarding resident #1 receiving anti-psychotic medication, LPA Wesley visited the medication room and reviewed a list of medication for resident #1 and did not see any type of anti-psychotic medication for resident #1. LPA Wesley asked the Administrator, the Director of Health services and the LVN if they pressure the family, so they could give anti psychotic medication and they answered no. LPA Wesley asked the POA for resident #1 if the facility pressured him to issuing resident #1 anti-psychotic medication and he said no, the physician is the one who orders medication and sends it to the pharmacy/facility. LPA Wesley did observed that one of resident #1's medication was increased, but it was not a anti-psychotic medication. The Administrator said the residents are seen by the doctor(s) and evaluated, sometimes the doctor decreases medication and sometimes the medication is increased, depending on the situation. The LVN(Charge Nurse), said they refer to the Physician orders when filling and refilling the medication, it has nothing to do with family members. Based on the interviews conducted with staff, residents, review of residents medical files and facility records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation(s) are UNSUBSTANTIATED. Exited interview conducted.the state’s words, verbatim · CDSS document, Apr 15, 2025 · control 28-AS-20250211120232

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Alberto Lopez and Sakinah Madyun made a subsequent visit. The reason for the subsequent visit is to change the deficiency Type from A to B for the citation issued on 2/25/25 for Section 87309(A). LPAs met with Arienne Ghammangne Director of Health Services and discussed purpose of visit. According to Section 87309(a), items that could pose a danger to residents are to be kept in a locked storage and not left unattended if outside the locked storage. The three pairs of scissors in question were behind an unlocked door, yet it could not be established based on the preponderance of the evidence that these items were left unattended as required. In consideration of these facts, the citation appears to be a potential risk to residents and not an immediate risk. On 02/25/2025 conducted a subsequent visit to investigate two complaints. LPAs arrived unannounced and met with Arienne Ghammangne Director of Health Services and Rochelle Carpio Administrator arrived a short time later and assisted with the visit. The purpose of the visit was explained. During a tour of facility at 9:50am with Arienne Ghammangne, Director of Health Services, LPAs observed the wellness room door unlocked on the second floor across from the elevator and dining area. Inside the room were three (3) pairs of sharp scissors in the unlocked room which are accessible to 32 residents in dementia care facility. This poses an immediate risk to the health, safety, or personal rights of the persons in care. Deficiency cited on 809D, exit interviewed conducted with Arienne Ghammangne Director of Health Services and copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 11, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Feb 26, 2025

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This deficiency is evidenced by: Based on observation by LPAs and Director of Health Services during tour of facility licensee did not ensure staff locked up 3 pairs of scissors left unattended in the unlocked wellness room at 9:50AM on the second floor of dementia care facility which poses a potential risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Apr 11, 2025

Plan of correction: Citation previously cleared at the time of the visit on 2/25/25. ***no further action necessary***

Allegation investigated: Staff retained resident against the resident's will Staff do not provide daily activities for resident

Licensing Program Analysts (LPAs) Alberto Lopez and Luis Deleon conducted an initial visit to investigate the allegations listed above. LPAs arrived unannounced and met with Arienne Ghammangne Director of Health Services. The purpose of the visit was explained. The investigations consisted of LPAs interviewing five (5) staff and six (6) residents, One witness (W1) whicbh is family member, reviewing and obtaining staff and resident rosters, activity calendar and POA for health care for R1. The investigation revealed: Allegation: Staff retained resident against the resident's will. It is alleged that resident is being held against there will even after the resident has expressed the desire to leave. (continued on 9099C) Unsubstantiated (continued on 9099C) LPAs interviewed five (5) staff and five (5) of five (5) staff denied the allegation. LPAs interviewed six (6) residents and six (6) of six (6) residents were not able to corroborate the allegation. R1 stated R1 is not being held against R1 will and stated R1 enjoys being at facility and feels safe. LPAs spoke with W1 who family member is who has POA authority. W1 stated that W1 agrees with all the facility is doing in caring for R1. W1 stated to LPAs that the allegation is false. W1 stated that police visited her a few days ago at 8:30pm to investigate abuse allegation. W1 stated police arrived with rifles in hand and in full gear and cause W1 undo distress. W1 stated that it was her son who lives out of state that made the abuse allegations. There is insufficient evidence to substantiate this allegation. Allegation: Staff do not provide daily activities for resident. It is alleged that R1 is being denied activities, specifically exercise by walking. LPAs interviewed five (5) staff and five (5) of five (5) staff denied the allegation. LPAs interviewed six (6) residents and six (6) of six (6) residents were not able to corroborate the allegation. R1 stated R1 is always busy and has things to do. LPAs observed R1 walking around the facility grounds with W1. LPA observed facility residents participating in activities through the entire visit. The facility has an activity calendar posted and staff stated they included residents in the decision-making process for activities. All residents stated the facility has more than enough activities and are encouraged to participate. There is insufficient evidence to substantiate this allegation. 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. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Mar 25, 2025 · control 28-AS-20250317170026

Allegation investigated: Staff are harassing residents to ingest resident's prescribed medications. Staff does not ensure resident's medication records are updated. Staff are withholding resident's mail.

Licensing Program Analysts (LPAs) Alberto Lopez and Sakinah Mudyun conducted a subsequent visit to removed identifiers from report. LPAs met with Arienne Ghammangne Director of Health Services and discussed the purpose of the visit. Nothing else has changed and findings remain the same. On 03/25/2025 Licensing Program Analysts (LPAs) Alberto Lopez and Luis Deleon conducted an initial visit to investigate the allegations listed above. LPAs arrived unannounced and met with Arienne Ghammangne Director of Health Services The purpose of the visit was explained. The investigations consisted of LPAs interviewing five (5) staff and six (6) residents one (1) witness (W1), reviewing and obtaining staff and resident rosters, one resident’s face sheet, medication orders dated 01/02/2025 and 01/06/2025. Progress notes for one resident for month of January 2025, POA for health care for one resident. List of medications for one resident. Fax from Omnicare dated 01/06/2025 . Unsubstantiated (Continued from 9099) The investigation revealed: Allegation: Staff are harassing residents to ingest resident's prescribed medications. It is alleged that staff are withholding food from residents unless they take their medications. LPAs interviewed five (5) staff and five (5) of five (5) staff denied the allegation. LPAs interviewed six (6) residents and six (6) of six (6) residents were not able to corroborate the allegation. One resident stated food is never withheld from resident regardless of if resident takes medication or not. LPAs toured the upper and lower dining rooms during lunch time and all residents were provided their meals and observed nurse providing medications to some residents and no resident was refusing to take the medications. Nurses denied hiding the medications in the food or withholding food. W1 stated that food is not withheld from resident if resident refuses medications. There is insufficient evidence to substantiate this allegation. Allegation: Staff does not ensure resident's medication records are updated. It is alleged that there is no evidence of discussion between one resident’s physician and facility staff. LPAs interviewed five (5) staff and five (5) of five (5) staff denied the allegation. LPAs interviewed six (6) residents and six (6) of six (6) residents were not able to corroborate the allegation. W1 stated W1 is aware of all medication changes and in agreement with them. An order from one resident’s physician for alteration of medication was sent to facility on 01/06/2025. On 01/06/2025 family took resident to medical appointment. New prescription was discussed between resident’s physician and the family. The new prescription was approved by family. A new prescription order was created and sent to pharmacy on 01/06/2025. One resident stated resident not familiar with what this allegation means. LPA reviewed one resident’s progress notes for month of January 2025. On 01/13/2025 and 01/17/2025, Resident record was updated and shows progress note updating resident’s medical records. Resident’s medication records were updated on 01/07/2025 and 01/14/2025. S1 stated family took resident to physician on 01/06/2025 and physician recommends changes and family approves the recommendations. There is insufficient evidence to substantiate this allegation. Allegation: Staff are withholding resident's mail. It is alleged that mail for one resident is being withheld by facility. LPAs interviewed five (5) staff and five (5) of five (5) staff denied the allegation. LPAs interviewed six (6) residents and six (6) of six (6) residents were not able to corroborate the allegation. One resident stated resident always gets mail. One resident stated resident does not want one family member involved in resident’s affairs or to have any kind of contact with resident as it becomes too stressful for resident. One resident stated resident would prefer if one family member be left out of resident’s medical and personal business completely. There is insufficient evidence to substantiate this allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Mar 25, 2025 · control 28-AS-20250317120524

Allegation investigated: Staff confiscated resident's personal items.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Business Office Manager Elizabeth Cruces. Administrator Rochelle Carpio arrived later. The investigation consisted of: A tour of the facility was conducted with special focus on nursing office, resident rooms, library, and common areas. Staff (S1-S5), and residents (R1- R10) were interviewed. Record review of Admission Agreement, Personal Property Disclaimer Appendix H, and Individual Service Plan was completed. Resident Identification and Emergency Information Worksheets and Clothing Assessment Forms of residents who wear eyeglasses and reading glasses were obtained. The Wellness Nrusing Office was toured. A hearing aid charging area, and drawer containing labeled eyeglasses/reading glasses, and bathroom storage cabinet where dentures are kept was observed. All the residents in the building are cognitively impaired. Unsubstantiated Allegation: Staff confiscated resident's personal items. The complaint alleges facility staff have confiscated the reading glasses of a resident (name unknown), and are keeping them locked in the nursing office. According to information obtained, the reading glasses are only accessible at limited times during the day, which infringes upon the personal rights of the resident. Complaint details state the unknown resident has a newspaper subscription they have been unable to read because the resident cannot find their reading glasses. Since the complaint does not name the resident. Residents that use reading glasses were randomly selected for interviews. A total of 10 residents were interviewed. None of the residents interviewed reported staff confiscate their eyeglasses or reading glasses. During room inspections, reading glasses were observed in the residents room and/or drawers. A total of five (5) staff were interviewed. Staff stated that some resident personal items i.e., dentures, hearing aids, and glasses are taken to the Wellness/Nurse office after they are put to bed as a safety precaution, and in order to prevent residents who wander from taking them from resident rooms. This procedure is only done for the less independent more cognitively impaired residents. Each morning staff take back the reading and/or eyeglasses to the residents rooms. Upon admission to the facility, reading and eyeglasses are labeled and added to the inventory list in order to ensure the residents personal belongings are safeguarded. If and when a resident requires frequent reminders to wear glasses, it is added to their Service Plan and staff are instructed to remove the glasses from their rooms after bedtime. Copies of current inventory of resident's personal effected and valuables were reviewed and obtained. Per staff interviews, there are approximately 5 residents that use reading glasses and enjoy reading the newspaper. LPA interviewed residents who utilize reading glasses and regularly read. During room inspections, reading glasses were observed in the resident rooms on top of tables or inside drawers. The Wellness Nursing office has a drawer where resident's glasses are stored at night, a hearing aid charging area, and bathroom medicine cabinet for denture storage. Facility staff are following procedures put in place to ensure health and safety of the individual resident or other residents. There is insufficient evidence to corroborate the 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. An exit interview was conducted and a copy of this report was discussed and provided to facility Administrator Rochelle Carpio.the state’s words, verbatim · CDSS document, Mar 20, 2025 · control 28-AS-20250314140716

Allegation investigated: Staff are retaliating against residents for filing a complaint. Staff are not allowing residents to have packages delivered.

Licensing Program Analysts (LPAs) Alberto Lopez and Sakinah Madyun conducted a initial visit to investigate the allegations listed above. LPAs arrived unannounced and met with Arienne Ghammangne Director of Health Services and Rochelle Carpio, Administrator who arrived a short time later and assisted with the visit. The purpose of the visit was explained. The investigation consisted of LPAs taking tour of common areas of facility, obtaining, and reviewing staff and resident roster, spread sheet showing mail distribution for residents, POA for R1. and LPAs interviewed five (5) staff and six (6) residents. The investigation revealed: Allegation: Staff are retaliating against residents for filing a complaint. It is alleged that staff are retaliating against residents for complaining. (Continued on 9099C) Unsubstantiated (continued from 9099) LPAs interviewed five (5) staff and five (5) of five (5) staff denied the allegation. LPAs interviewed six (6) residents and six (6) of six (6) residents were not able to corroborate the allegation. The complaint did not specify which residents were being retaliated against. LPAs observed staff caring for residents and did not observe any kind of abuse during the day long visit. Staff were observed to be kind and caring as they cared for residents. There is not enough evidence to substantiate this allegation. Allegation: Staff are not allowing residents to have packages delivered. It is alleged that staff is not giving residents their mail and packages. LPA interviewed five (5) staff and five (5) of five (5) staff denied the allegation. LPAs interviewed six (6) residents and six (6) of six (6) residents were not able to corroborate the allegation. All six (6) residents stated they receive their mail and packages and some residents stated that it is acceptable for their family to receive their mail. The facility has a tracking log for all residents and which explains the distribution of mail to the appropriate residents and/or their authorized representatives. R1 stated his son FM2 and spouse FM3 is authorized to open R1 mail. R1 also stated R1 does not want one (1) family member FM1 to obtain R1 mail. There is not enough evidence to substantiate this allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Feb 25, 2025 · control 28-AS-20250218112908

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Alberto Lopez and Sakinah Madyun conducted a subsequent visit to investigate two complaints. LPAs arrived unannounced and met with Arienne Ghammangne Director of Health Services and Rochelle Carpio Administrator arrived a short time later and assisted with the visit. The purpose of the visit was explained. During a tour of facility at 9:50am with Arienne Ghammangne, Director of Health Services, LPAs observed the wellness room door unlocked on the second floor across from the elevator and dining area. Inside the room were three (3) pairs of sharp scissors in the unlocked room which are accessible to 32 residents in dementia care facility. This possess as an immediate risk to the health, safety, or personal rights of the persons in care. Deficiency cited on 809D, exit interviewed conducted with Rochelle Carpio Administrator and copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 25, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Feb 26, 2025

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This deficiency is evidenced by: Based on observation by LPAs and Director of Health Services during tour of facility licensee did not ensure staff locked up 3 pairs of scissors left unattended in the unlocked wellness room at 9:50AM on the second floor of dementia care facility which poses a immediate risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Feb 25, 2025

Plan of correction: Staff removed the scissors and made them inaccessible to residents in care. ***No further action required***

Allegation investigated: Staff retaliated against resident from authorized representative made a complaint Staff are not giving the resident mail/packages Staff do not safeguard residents personal belongings Due to lack of supervision, resident fell and received injuries

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to investigate the above allegations. LPA met with Administrator Rochelle Carpio and discussed the purpose of the visit. At today's visit 02/04/25 Staff and Resident Roster were submitted. File of Resident R1 was reviewed and Physician's Report, Identification and Emergency Information Worksheet, Personal Property Disclaimer and Inventory List were submitted, Interviews were conducted with the Administrator and Staff S1 and S2. Resident's R1-R5 were interviewed. LPA took a tour of common areas and Resident R1's room. In regards to the allegation Staff retaliated against resident from authorized representative made a complaint, based on interviews conducted and information gathered it was revealed during a tour of Resident R1's room LPA observed a television, mouse, mouse pad and calendar. Interview with Resident R1 who stated that he gets all his packages and nothing is missing. Stated that staff are terrific. Said his belongings are safe. Unsubstantiated Staff stated that they never heard of Resident R1 having belongings kept away from him and stated they never would retaliate and resident has personal rights. Items are often misplaced at times. Said Resident R1 walks around with a bag of his belongings and that items alleged missing are in his room. Resident's R2- R5 stated staff is very professional and always assist and are very accommodating and helping all residents. 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 Staff are not giving the resident mail/packages, based on interviews conducted and information gathered it was revealed by Resident R1 who stated that he gets all his packages. Resident's R2-R5 all stated that they receive their mail/packages. Staff stated that they now will give packages and mail unopened to residents. Said previously they needed to know what may be in the mail or packages to protect residents safety. Said this allegation was just addressed 01/28/25 and now the process has changed. It should be noted that Substantiated findings were delivered 01/28/25 regarding the allegation Facility staff are interfering with residents mail and packages. 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 do not safeguard residents personal belongings, based on interviews conducted and information gathered it was revealed by Resident R1 that his belongings are safe and he also has his belongings in a bag he carries around. Stated he gets all his belongings and none have been taken from his room. Resident's R2-R5 stated that their belongings have always been safe and they haven't had any items taken from their room. Spoke with Staff who stated that they had never heard of missing items from any residents room. Said that items may be misplaced, but they look for it and often find it. During a tour of Resident R1's room LPA observed a television, mouse, mouse pad and calendar. 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 Due to lack of supervision resident fell and received injuries, based on interviews conducted and information gathered it was revealed by Resident R1 that he hit his head in the bathroom and staff assisted him right away in going to the emergency room when they noticed his cut at breakfast. Resident's R2- R5 all stated that staff are great and assist them with all medical concerns. Staff stated that when Resident R1 came to breakfast they noticed blood on his head. Said the Resident R1 said he hit it on the ceiling and then said he hit it on the shower knob. Also stated they will do rounds every 2 hours and it was not noticed during those visits. 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. An exit interview was conducted with Administrator.the state’s words, verbatim · CDSS document, Feb 4, 2025 · control 28-AS-20250203091750

Allegation investigated: Facility staff are interfering with residents mail and packages

License Program Analyst (LPA) Alberto Lopez made unannounced initial visit to investigate the above allegations. LPA met with Rochelle Carpio, Administrator and Arienne Ghammangne, Director of Health Services and discussed the purpose of the visit. The investigation consisted of LPA taking a tour of common areas, interviewing six (6) staff (S#1-S#6), six (6) residents (R#1-R#6), Interviewing one (1) witness who is family member, reviewing and obtaining staff and resident rosters, R1 Physician’s Report for Residential Care Facilities for the Elderly (RCFE), Email from POA with medication list and Physician’s Admission orders dated 12/12/2024, POA for Health Care dated 11/12/2022, Physician’s orders dated 01/10/2025 for Super B Vitamin, R1 Information and Emergency information worksheet, R1 Preplacement Appraisal Information dated 12/06/2024, R1 client interest Profile dated 12/06/2024, R1 Resident Emergency/Transfer Information, New Prescription dated 01/06/2025 to increase current prescription signed by Physician electronically, and, R1 Service plan dated 12/23/2024. (Continued on 9099C) Substantiated The investigation revealed. Allegation Facility staff are interfering with residents mail and packages. It is alleged that facility staff is opening resident’s mail. LPA interviewed six (6) staff and four (4) of six (6) staff denied the allegation. S3 and S5 stated they do open the resident's packages to make sure residents do not get dangerous items and to inventory the items. LPA interviewed six (6) residents and three (3) of six (6) residents stated that their mail is opened by facility staff. Staff stated they want to make sure the residents do not get a medication or over the counter item that they may be allergic to and that is why they open the mail. Opening the resident’s mail is a clear violation of the resident’s rights. There is enough evidence to substantiate this allegation. Based on interviews conducted, 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), is being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Correction was reviewed and developed with the Administrator. A copy of this report and appeal rights were provided. (continued from 9099) The investigation revealed. LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegation. LPA interviewed six (6) residents and six (6) of six (6) residents could not corroborate the allegation. LPA reviewed R1 medication list, and all medications are ordered by R1’s physician and are administered according to physician’s orders. W1 who is POA for health care for R1 is aware and in agreement of the medications facility is providing to R1. LPA observed R1 to be alert during the entire visit. There is insufficient evidence to substantiate this 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. An exit interview was conducted with Administrator. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 28, 2025 · control 28-AS-20250121144404

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(15) · Plan of correction due date: Jan 31, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (15) To send and receive unopened correspondence in a prompt manner. This requirement has not been met as evidenced by: S3 and S5 stated that resident's correspondence is opened and screened before giving it to resident which poses an immediate risk to the health, safety, or personal rights to the persons in care.the state’s words, verbatim · CDSS document, Jan 28, 2025

Plan of correction: Administrator will read section 87468.1 and send a written statement to LPA stating she has read and understands the section. Also, facility staff will not open any correspondence belonging to residents and will provide it to residents promptly and unopened.

Allegation investigated: Facility staff are not ensuring resident's medication is being administered as prescribed Facility staff do not intervene when resident's engage in physical altercations Facility staff did not safeguard resident's personal items

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to investigate the above allegations and met with Arrienne Ghammange. LPA discussed the purpose of the visit. The investigation consisted of LPA reviewing and obtaining staff and resident roosters, interviewing four (4) staff and five (5) residents (R#2-R#6). R1 has moved out and not available for interview. LPA reviewed R1 file and medication list, Property/Clothing list of R1, Face sheet of R1, Medication list for R1, SIR dated 08/22/2024 regarding un-witnessed fall of R1. Release of liability arising from lost items signed by responsible party, e-MAR for R1 08/2024. The investigation revealed: Allegation: Facility staff are not ensuring resident's medication is being administered as prescribed. It is alleged that facility pressured R1 family members into giving anti-psychotic to R1. (Continued on 9099C) Unsubstantiated (Continued from 9099) LPA interviewed four (4) staff and all four (4) staff denied the allegation. LPA interviewed five residents and all five (5) residents were not able to corroborated the allegations. R1 was admitted on 07/20/2024 and moved out on 08/18/2024. According to S3, R1 was prescribed an anti-psychotic for aggression and being combative. S3 stated S3 never personally administered the anti-psychotic due to her schedule. S1 stated that family is always consulted first and make the final decision for any new medication(s). Record reviewed showed that R1 physician ordered the anti-psychotic for agitation with start date of 08/16/2024 and was administered according to doctor's orders. There is no evidence that family was pressured into authorizing anti-psychotic for R1. Allegation: Facility staff do not intervene when resident's engage in physical altercations. It is alleged that resident had an altercation with another residents and staff did not intervene. LPA interviewed four (4) staff and all four staff denied the allegation. S1 stated R1 was found on floor by staff on duty and SIR submitted to the department. LPA interviewed five (5) residents and five (5) of five (5) residents could not corroborate the allegation. All five (5) residents stated they have never witness resident on resident violence at facility. There is not evidence that staff allowed aggressive behavior between residents. Allegation Facility staff did not safeguard resident's personal items. It is alleged that facility failed to safeguard resident's phone charger and is lost. LPA interviewed four (4) staff and all four (4) staff denied the allegation. LPA interviewed five (5) residents and five (5) of five (5) residents could not corroborate any lost or stolen items. S2 stated S2 completes an inventory list when residents move in, Reviewed of R1 personal property showed no phone charger on the list. S2 stated the facility does everything they can to safeguard residents personal property but things do get separated from residents from time to time. There is not enough evidence to substantiate this allegation. 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 Arrienne Ghammange. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 5, 2024 · control 28-AS-20241030153735

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Director of Health services Arienne Ghammangne and Administrator Rochelle Carpio arrived a short time later and assisted with the visit. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan. Operational Requirements: A current Plan of Operation was reviewed. The facility serves residents 60 years and older, and a Hospice Waiver for ten (10) resident is approved. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. A surety bond is not applicable. Facility does not handle resident's money. Physical Plant/Environment Safety: The facility consists of a 2 story building with resident rooms on both floors. The main floor has a lobby, library, bistro area, dining room, kitchen, administrative offices, and spacious outdoor patio. The 2nd floor consists mainly of resident rooms and a dining room. There are no swimming pool or bodies of water on the premises. There are no firearms or weapons stored at the facility. LPA selected random rooms - (rooms #157, #159, #161, #204, #203, and #223) to measure the hot water temperature. The temperatures measured between 93.7-122 degrees F which is not the required range of 105-120 degrees F. The supply of dishes/cups is adequate. During today's visit. The facility smoke detectors are hard wired. Carbon monoxide detectors were observed throughout the facility. The fire extinguishers were fully charged and in compliance. The grounds of the facility are well landscaped with a ramp that leads to the entrance. A shaded area with chairs is provided in the patio area. The facility is equipped with a centralized sprinkler system. The north fire door was tested and does not operate. LPA asked facility to report to Fire Department and CCL and facility agreed. Staffing: There appears to be always sufficient staffing in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records/Staff Training: Staff have criminal record clearance, current First-Aid training along with training in medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 5 staff files with no deficiencies observed. Administrator Rochelle Carpio certificate expires on 01/21/2025 Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman near the entrance. A total of five (5) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. (continued) Food Service: Sufficient food supply is stored in the kitchen and storage areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Incident Medical and Dental: Five (5) centrally stored resident medications were reviewed. Medication is given according to doctor’s orders. Medical and dental transportation is provided by family, transportation services, or staff. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. LIC610 needs to be updated when all staff are trained on shut of utilities. Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. Facility admits residents with dementia and staff have all required training documented within personnel files. Per California Code of Regulations, Title 22, deficiencies were cited. Technical Advisory provided. Exit interview was conducted with staff. A copy of the report and appeal rights were issued. Civil penalties issued for repeat violation.the state’s words, verbatim · CDSS document, Sep 16, 2024

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Lack of supervision resulting in unsafe environment for residents.

Licensing Program Analyst (LPA) Alberto Lopez conducted a subsequent visit to investigate the allegation listed above. LPA was greeted by Elizabeth Cruzes, Receptionist and LPA discussed the purpose of the visit. LPA met with Staff Arienne Ghammange who assisted with the visit. The investigation consisted of LPA taking a tour of facility, interviewing nine staff including Administrator S#1-S#9 (S1-S9) and 5 residents R#1 - R#5 (R1-R5), three witnesses W#1-W#3 (W1-W3) reviewing and obtaining copies of R1, R2 and R3 Physicians Report and other pertinent information. The investigation revealed: (Continued on 9099C) Unsubstantiated The investigation revealed: Allegation: Lack of supervision resulting in unsafe environment for residents. It is alleged that a resident threw a ceramic plate and it shattered into pieces that could have harmed the residents. R#1 stated she witness the incident and that the maintenance man came in and swept it up right away. R#1 stated she grabbed a broken piece of the cup (for evidence) and took it to her room. S5 stated she went to sweep it up it up, but it was already cleaned up by another staff by the time she got there and just ran a mop over it. No resident was ever in harm’s way during entire incident. No resident was harmed. Residents interviewed could not collaborate the allegation. R1 was asked to return the broken piece more than once to discard it and refused to hand it over. She finally did hand it over to police who discarded the piece and left without investigating. There is no evidence that lack of supervision is making it unsafe for residents. Therefore, this allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jan 4, 2024 · control 28-AS-20231030143019

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80072(a)(b)(1) · Plan of correction due date: Jan 18, 2024

80072(a)(b)(1) (a) In addition to Section 80072, the following shall apply. (b) The licensee shall insure that each client is accorded the following personal rights. (1) To visit the facility with his/her relatives or authorized representative prior to admission. Facility failed to insure that resident/family or authorized representative visit facility prior to admission.the state’s words, verbatim · CDSS document, Jan 4, 2024

Plan of correction: Administrator will send written plan on how they will avoid this in the future and train admitting staff to insure that residents are accorded all personal rights and send sign roster of staff who attended the training by POC date.

Type of visit: Case Management - Deficiencies

During the course of a complaint investigation, Licensed Program Analyst (LPA) observed that R1 did not have updated LIC602. Last one was dated 10/12/2022 which poses/posed a health and safety Hazard to resident in care. Deficiency cited, please see 809D for details. Exit interview conducted with Director of Resident Engagement. and copy of report, 809D and appeal rights provided. .the state’s words, verbatim · CDSS document, Nov 7, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Nov 14, 2023

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Resident#1 did not have a current physician report on file. Based on file review, Administrator did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 7, 2023

Plan of correction: Administrator would obtain an updated phyisican report LIC 602 and provide a copy of the physician report to Licensing by POC due date.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to finish the annual inspection. LPA met with Director of Resident Engagement, Cathy Huo, and explained the reason for the visit. During the visit today, LPA completed the remainder of the inspection and the following were reviewed: Staffing: The facility has sufficient staffing to meet the needs of the residents. There are awake staff providing night supervision. Personnel Records-Training: LPA reviewed 4 Staff files. The administrator's certificate expires on 1/21/25. Staff have fingerprint clearance and associated to the facility. 2 out of 4 staff files are missing the health screening form. Staff have appropriate dementia care training. Resident Records-Incident Reports: LPA reviewed 5 resident files. The files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, and care plan. The physician's report for 3 residents (Residents #1, #2, and #4) are not current. Resident Rights-Information: Information for appropriate reporting agencies are posted at the facility. Residents' rights are respected and implemented by staff. Residents with SHN: Facility accepts and retain residents with dementia. Staff are ensuring that incontinence residents are changed often and the facility remains free of odor from incontinence. No smoking-Oxygen in use signs are posted where appropriate. Deficiencies are issued on the LIC809D. An exit interview was held with Cathy Huo. A copy of this report along with appeal rights are given to staff.the state’s words, verbatim · CDSS document, Nov 7, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 10/26/23. LPA met with the Director of Health Services, Arienne Ghammangne, and explained the reason for the visit today. The facility is licensed to serve 62 bedridden residents ages 60 and above and provides dementia care. The hospice waiver is approved for 10 residents. LPA conducted the inspection using the Compliance and Regulatory Enforcement (CARE) Tools. The following were observed: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff continue to clean and disinfect daily and more often for high touched surfaces. Facility has sufficient PPE supplies and had submitted the Infection Control Plan. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 52 residents residing at the facility. The facility has the sufficient amount for liability insurance covering injury to residents and guests. Physical Plant & Environment Safety: The facility consists of a 2 story building with resident rooms on both floors. The main floor has a lobby, library, bistro area, dining room, kitchen, administrative offices and spacious outdoor patio. The 2nd floor consists mainly of resident rooms and a dining room. There are no swimming pool or bodies of water on the premises. There are no firearms or weapons stored at the facility. LPA selected random rooms - (rooms #121, #119, #157, #163, #216, #221, #256, #260) to measure the hot water temperature. 4 out of the 8 rooms had temperatures between 136-137 degrees F which is over the required range of 105-120 degrees F. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Incidental Medical & Dental: The medications are centrally stored in the wellness office. The facility uses an electronic Medication Administration Record (MAR) log to document medications given. LPA reviewed 5 residents' medication and they are being administered as prescribed by the physician. A deficiency is being issued today. An exit interview was held and a copy of this report along with appeal rights were given to administrator Carpio.the state’s words, verbatim · CDSS document, Oct 26, 2023