Smith Road Assisted Living

Type of visit: Office

On 6/22/2026, Licensing Program Analyst (LPA) Tremayne Barra, Licensing Program Analyst Manager (LPM) Anthony Perez, and Regional Office Manager (ROM) Reyna Lacey met with Licensee Ma Satchel Lecita and Facility Manager Carisa Estrelles at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office for an Informal Meeting. During today's meeting the following was discussed in regards the licensee's plan for closure of facility H&S Code Section 1569.682 Closure Plan requirements and pre-approval needed Licensee confirmed there is a second managing member. The Department will schedule a separate meeting with this second managing member to review closure requirements. Closure plan will be submitted to the department for approval. An exit interview was conducted where this report, LIC809, were discussed and provided to Licensee Ma Satchel Lecitathe state’s words, verbatim · CDSS document, Jun 22, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Tremayne Barra made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with Assistant, Mercedez De Monteverde. The LPA informed the assistant of the purpose for the visit. The inspection included the following: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility consists of eight (8) resident bedrooms, three (3) bathrooms, a kitchen and dinning area, a living room area, a garage and laundry room, and a patio and yard with sufficient seating and space for activities. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured within regulation. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home and no bodies of water observed. LPA began review of client records. four (4) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed client records to be available and complete. LPA began review of employee records- four (4) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 10/31/2027. LPA observed personnel records to be available and complete. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for knives and sharps in the kitchen. Medications are centrally stored. There is a locked cabinet in the kitchen allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers was serviced on June 05, 2026. Fire drills are conducted quarterly at the facility with the last drill on April 10, 2026. Based on the information received during this visit today in the areas reviewed, there are no deficiency that are being cited per Title 22, Division 6 of The California Code of Regulations. This LIC 809 report was reviewed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Jun 16, 2026

Allegation investigated: Resident wandered from the facility due to lack of staff supervision

Licensing Program Analyst (LPA), Armando Perez and Ahliah Sharp, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Licensee, Ma Satchel Lecita, and explained both the purpose of the visit and the details of the allegation. On August 7, 2024, the Community Care Licensing Division (CCLD) received a complaint alleging a resident wandered from the facility due to lack of staff supervision. It was reported that on July 31, 2024, Resident (R1) eloped from the facility prompting a search and emergency medical intervention. Information obtained through an interview with the Licensee indicated that on July 31, 2024, R1’s visitor arrived at the facility at approximately 11:00 AM and the licensee reported the visitor left between 3:15 and 3:30 PM. The Licensee stated she was informed by staff that R1 was missing at approximately 4:30 PM, which prompted two staff members to leave the facility to search the neighborhood. The Licensee reported the elopement to law enforcement at 5:00 PM. Continued on LIC 9099-C. Substantiated The Licensee reported a Licensing Program Analyst (LPA) was onsite for an annual inspection starting at 3:30 PM and it concluded at 6:00 PM. An interview with the LPA revealed they were onsite at the facility on July 31, 2024, from approximately 2:00 PM to about 6:00 PM. The LPA reported they were not aware a resident had eloped and staff did not disclose the incident during the inspection. Information obtained through a police report dated 07/31/2024, revealed that on July 31, 2024, at approximately 6:16 PM, law enforcement received a request to take a report for a missing person. Telephone contact was made with a facility representative at 6:27 PM and law enforcement arrived at the facility at 7:15PM. Law enforcement learned of R1’s location, which was the hospital, at 7:50 PM. Law enforcement then provided this information to the Licensee. The police report further revealed that a caregiver told law enforcement that R1 was last seen in the living room at approximately 3:30PM. The caregiver then went to start dinner and believed that R1 had gone to their room . The caregiver further reported to law enforcement that R1 had attempted to leave the facility on the same day at approximately 2:30PM. Staff brought R1 back inside of the facility and told R1 to stay inside. The report also revealed paramedics informed law enforcement that they had received a call for service regarding R1 being found laying underneath a car in the driveway and they transported R1 to the hospital. Medical records were obtained and reviewed. The record revealed that vitals were taken of R1 on 07/31/2024 at 3:36PM. This contradicts the staff who reported last seeing R1 at about 3:30PM in the living room. Further noted was that R1 presented at the emergency department after being found unconscious with their head under the bumper of a car. Skin temperature was noted at 107. Medical records show, in the emergency department, with cooling measures, rectal temperature on arrival was 103. R1’s diagnosis was noted as heat stroke, altered mental status and Acute Kidney Injury (AKI). Medical records revealed R1 was admitted to the hospital on 08/01/2024. Facility records were obtained and reviewed. R1’s Physician’s Report with a date of exam as 07/21/2024 revealed a primary diagnosis of Dementia. Under category of Mental Condition, the following was marked “yes”: Confused/Disoriented, Wandering Behavior and marked “no” for Able to Leave Facility Unassisted. The licensee was unable to provide a care plan because one had not yet been developed. R1 was admitted to the facility on 07/30/2024 and the licensee had planned to meet with R1’s family to develop the care plan on 07/31/2024, which was the day of the incident. A Pre Placement Appraisal was reviewed, dated 7/31/2024. Information reviewed does not have elopement concerns. According to Licensee, the Pre Appraisal was completed by responsible party for R1. An interview with a relevant witness reported notifying the Licensee, prior to R1’s admission, of R1’s wandering behaviors. This witness also reported speaking to a staff, but could not remember the name, who informed the witness that R1 had previously attempted to leave the facility on the same day, but was recovered by staff. This witness also reports facility staff admitted to disarming the alarm on the front door because it was annoying. The licensee denies the alarm was ever disarmed. Interviews with staff revealed, there were a lot of guests at the facility on the day R1 eloped and this could have led to staff not noticing R1 leave the facility. Based on interviews and record reviews, the allegation that resident wandered from the facility due to lack of staff supervision is substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalty of $500 is being assessed. The licensee was also informed that an additional civil penalty may be assessed in accordance with H&S Code Section 1569.49. An exit interview was conducted where a copy of this report was provided to Licensee Ma Satchel Lecita along with a copy of the LIC9099-C, LIC9099D, LIC 421IM and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 18-AS-20240807150840

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(e)(5) · Plan of correction due date: Feb 20, 2026

87705Care of Persons with Dementia (e) Licensees that use delayed egress devices on exterior doors and perimeter fence gates shall meet the following…:(5)Facility staff shall ensure the continued safety of residents if they wander away from the facility … in Privately Operated Facilities. This requirement was not being met as evidenced by: Based on interviews and records reviewed, facility staff failed to redirect Elopement risk or to monitor for continued safety. This poses an immediate, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: The facility will conduct an in-service staff training regarding elopement procedures and insuring all exit doors to have functioning alarms. Licensee will provide LPA proof of training by POC date.

Allegation investigated: Facility does not provide modified diet Medical assessment is incomplete and inaccurate

Licensing Program Analysts (LPAs), Armando Perez and Tremayne Barra, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA met with Licensee, Ma Satchel Lecita, where the LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of interviews with staff and relevant parties, observations and file reviews. Regarding the allegation that the facility staff do not provide a modified diet, it was alleged that staff were not following a prescribed diet for Resident 1 (R1). It was further alleged R1 was denied or not offered appropriate alternative meals for their health condition. Interview with Licensee, Ma Satchel Lecita, reported that facility staff are made aware of prescribed diets and will offer meals compliant with diagnosed conditions to the residents in care. Continued on LIC 9099-C. Unsubstantiated .Licensee stated R1 was offered meal options, however, often refused them. The Licensee added that staff made efforts to communicate with R1 to prepare alternative meals; however, R1 refused to collaborate with staff and frequently elected to order fast food. The Licensee reported other individuals would bring R1 bags of groceries and staff were often refused to allow to view or store the groceries. The Licensee reported the observations made about the food identified some of the items as sodas, chips and candy. Information obtained from three of three staff interviews corroborated the Licensee’s statement that they were aware of R1’s prescribed diet but that R1 frequently refused meal options and instead chose to order fast food and snacks to the facility. An interview with R1 revealed R1 reporting that they were not on a prescribed diet, and they chose to monitor their own food selections based on their health conditions. R1 corroborated fast food was their primary source of meals, explaining that facility staff did not provide them with meal options. Information obtained through interviews with other residents revealed 4 of 4 residents reported they were not on prescribed modified diets. These resident interviews also revealed they received their meals and were offered alternative options when requested. Through observations made by the LPA during the visit on February 18, 2025, it was noted that R1 was provided with a lunch that was not consistent with the prescribed modified diet. At that time, R1 was interviewed and reported that the lunch was at their request. Additionally, the LPA observed various snacks in R1’s room, including soda, candy, and potato chips. A review of R1’s physician’s report dated August 2, 2024, revealed R1 was prescribed a modified diet. The LPA also reviewed R1’s consumer notes dated November 2024 through January 2025, which revealed food refusals on approximately 12 occasions. A review of the visitor logs dated November 2024 through January 2025 revealed fast food deliveries for R1 approximately three times. Interview with Administrator stated R1 would instruct delivery drivers to drop off the food in the front and not to sign the visitors log upon request. Regarding the allegation R1’s medical assessment was incomplete and inaccurate, it was alleged staff provided a medical assessment for R1 that included incorrect information, a missing page and discrepancies that led belief the form may be fraudulent. It was alleged a medical assessment for R1 was requested and only pages 4 of 5 were received. The missing page did not allow a determination of the assessment date and the physician who conducted the assessment. An interview with the Licensee was conducted. The Licensee reported they provided the requested medical assessment for R1, and it included 5 of 5 pages. Continued on LIC 9099-C. The Licensee stated they accepted R1 with the medical assessment on file with R1’s previous assisted living facility. The Licensee’s intent was to schedule an updated assessment. The Licensee further reported that R1 did not have a primary physician upon admissions, so they assisted R1 with identifying a physician through R1’s provider. The licensee stated R1 refused follow-up visits. R1 also declined to provide any physician’s name, medical records, or information. The Licensee reported R1 declined to provide the information because R1 maintained the licensee had no right to these details. An interview with R1 could not be conducted to address this allegation. R1 was admitted to the facility on 11/8/2024. A review of R1’s medical assessment dated August 2, 2024 was conducted. The medical assessment consisted of 5 of 5 pages, which included the date of the assessment and the physician who conducted the assessment. LPA Perez made multiple attempts to obtain a review of the medical assessment; however, the physician who conducted the examination did not provide a response. Based on interviews, record reviews, and observations, the allegations have been deemed UNSUBSTANTIATED. A finding that the allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. This report was reviewed on provided to facility representative.the state’s words, verbatim · CDSS document, Jan 16, 2026 · control 18-AS-20250211125221

Allegation investigated: Staff are not providing medication as prescribed

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA met with Caregiver, Veronica Jackson, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation included staff and witness interviews, as well as a review of records. On January 28, 2025, Community Care Licensing received a complaint alleging that staff are not providing medication as prescribed. It was alleged medication was not being dispensed to Resident #1 as prescribed, including at appropriate times and dosage. Interview with Licensee Ma Satchel Lecita stated that R1 denies the medication and staff notated refusals on Medication Logs. The licensee reported she advised R1 to bring a ten-day supply of medication, however, R1 arrived with almost none. The licensee reported R1 did not have a primary physician upon admissions so they assisted R1 with locating a physician through R1’s provider. Continued on LIC 9099-C. Unsubstantiated The licensee further stated that R1 refused follow-up visits and declined to provide any physician’s name, medical records, or information, insisting the licensee had no right to access such details. Interviews with 3 of 3 staff corroborated the licensee’s statements, reporting R1’s consistently refused to take prescribed medication and refused assistance with monitoring vitals to determine appropriate treatment for a restricted health condition, Interviews with staff revealed 3 of 3 emphasized that R1 would refuse medication because R1 thought the medication provided was incorrect. Furthermore, staff reported they complied with R1’s request to bring the medication bottles to R1 for review. However, R1 still continued to refuse. Interview with R1 revealed they admitted to refusing medication, stating they believed it was incorrect. R1 further noted that they would not take medication without observing the dispensing bottle and verifying the medication themselves. R1 also emphasized that they did not recognize the color or shape of the medication, which caused concern and led to refusal. During the interview, R1 reported being advised by a physician not to take any medication prior to medical treatment related to their restricted health condition. R1 declined to provide the physician’s name. An interview with Witness 1 (W1) was completed. W1 reported that R1 claimed facility staff were not providing the correct medication and did not recognize the medication being administered. W1 clarified that they did not personally observe the dispensing of medication and that their account was based solely on R1’s reports. A review of records revealed Medication Administration Records (MAR) were maintained. Medical record logs indicated that R1 consistently refused prescribed medication, with staff recording each refusal. Based on observation, record review, client, and staff interviews, the allegations staff are not providing medication as prescribed is Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided to facility representative.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 18-AS-20250128082056

Allegation investigated: Staff neglect resulted in resident death.

Licensing Program Analysts (LPA), Armando Perez and Robert Campbell, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez spoke with Licensee Ma Satchel Lecita over telephone and explained both the purpose of the visit and the details of the allegation. Licensee authorized for caregiver Edith Campos to review report. The investigation included staff and witness interviews, as well as a review of records. Resident #1 was unable to be interviewed due to their passing. On April 17, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that neglect by facility staff, contributed to the death of R1. It was alleged that facility staff failed to properly administer prescribed medications, resulting in a decline in R1’s health and death, during a subsequent hospital stay. Additionally, it was alleged that actions caused by facility staff led R1 to miss medical appointments essential to their health. Continued on LIC 9099-C. Unsubstantiated In an interview, Licensee Ma Satchel Lecita (L1) denied that the facility neglected Resident 1 (R1) or that such neglect contributed to R1’s death. Licensee revealed that they assessed R1 during a medical treatment session. L1 confirmed R1 was categorized under a restricted health condition and R1 acknowledged they were able to manage their own medication allowed under the regulation requirements under restricted health. L1 noted that after the assessment, they accepted R1 into care, but upon arrival they became demanding and abusive to staff. L1 advised R1 to bring a ten-day supply of medication, however, R1 arrived with almost none. Furthermore, L1 stated that upon R1’s admission, they were unable to confirm whether R1 had established care with a primary physician, therefore, assisted R1 in arranging care with a doctor affiliated with their health provider. L1 further stated that R1 refused follow-up visits and declined to provide any physician’s name, medical records, or information, insisting that L1 had no right to access such details. L1 noted that this lack of disclosure prevented her from securing an alternate medical placement. L1 reported that R1 independently arranged transportation to their medical treatment sessions. L1 noted that R1 refused to inform staff of the treatment location and at times either canceled the scheduled transport or declined to use it after the vehicle had already arrived. Interviews with 3 of 3 staff corroborated L1’s statements. Staff reported R1’s consistent refusal to take prescribed medication, refusal to permit vital sign monitoring necessary to determine appropriate treatment for a restricted health condition, and the abusive behavior toward staff, did not allow staff to care for R1 as needed. Interview with Additional Witness 1 (AW1) revealed that R1 frequently refused medication when unable to verify the prescription, noting that R1 specifically requested to see the medication dispensed directly from the original bottle. AW1 further reported that R1 would deny the medication if its shape or color was unfamiliar or unrecognized. AW1 reported that on January 30, 2025, R1 experienced being locked out of the facility returning from a medical appointment. AW1 alleges that R1 began to miss critical medical appointments due to the fear of being evicted. Interview with Additional Witness 2 (AW2) confirmed that R1 required medical treatment for restricted health condition three times per week. AW2 stated they could not verify how many treatments R1 may have missed. AW2 further confirmed that R1 communicated with a physician shortly after admission to the facility, but was unsure if R1 continued follow-up care. Continued on LIC 9099-C. AW2 also reported that R1 had selected a new physician, though the name was unknown, noting only that the physician’s office was located in San Jacinto. AW2 added that R1 was uncertain about the frequency of visits with this new physician. A review of records indicates that R1’s medical treatment attendance was consistently poor, prior to admission to Smith Road. Documentation obtained shows numerous missed medical treatment appointments aligning with treatment under Restricted Health Condition, with R1 attending only twice during March and April 2024, and completing just nine treatment sessions across May and June 2024. Documentation obtained further revealed following the January 30, 2025 incident in which R1 was locked out of the facility, dialysis attendance further declined missing scheduled treatments on February 1, 6, 13, and 20, and requested early termination of sessions on February 8, 11, 15, 22, and 27. Additional records obtained revealed an independent review was conducted by the Riverside County Elder Abuse Forensic Center. Information obtained indicated that R1’s health was already in decline prior to admission at Smith Road Assisted Living, due to severe deconditioning and multiple medical conditions. Furthermore, it was noted that R1’s health continued to deteriorate during their stay, consistent with their overall medical complexity. Documentation corroborated that R1 repeatedly refused care, medication, and supervision, making it impossible to determine whether the facility’s actions contributed to their death. Report concluded the available evidence does not definitively establish a causal link between the facility's actions or omissions and R1’s eventual death. Based on interviews and record reviews, the allegation that staff neglect resulted in resident death is deemed unsubstantiated. A finding that the complaint is unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report was provided to caregiver, Edith Campos.the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 18-AS-20250417111719

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Armando Perez and Robert Campbell conducted an unannounced visit to the facility for the purpose of issuing citations for deficiencies observed during an unrelated incident. LPA met with Caregiver Edith Campos. During record review, LPA noted that Resident #1 (R1) had been admitted to the facility with a restricted health condition. Further findings indicated that R1 was not enrolled in hospice care and no exception for admitting resident with restricted health plan had been submitted to the Community Care Licensing Division. In addition, R1 had a consistent history of refusing medication and declined staff assistance with monitoring requirements. During an interview with Licensee, Ma Satchel Lecita (L1) stated they relied on R1’s History and Physical Report from his last hospitalization. Additionally, L1 stated R1 did not want to answer many questions during initial assessment. L1 stated R1 did confirm he was diagnosed with a restricted health condition but could manage their own medications. Based on record review and interviews, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809-D. An exit interview was conducted and a copy of this report, 809-D and Appeal Rights was discussed with and provided to facility representative. .the state’s words, verbatim · CDSS document, Dec 16, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87628(a) · Plan of correction due date: Jan 6, 2026

a)The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing…and is able to administer his/her own medication including…injection, or has it administered by an appropriately skilled professional.This requirement was not met as evidenced by: Based on LPA Perez's observation, interview and record review, the licensee did not comply with the section cited above in R1'S medical file observed a restricted health care plan for diabetes and no approved exception was observed for the facility which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 16, 2025

Plan of correction: The licensee will conduct in-house training on the proper care of residents with restricted health conditions. Licensee will also review the regulations governing restricted health conditions and formally acknowledge their commitment to following proper protocol when submitting exceptions for future residents who fall under these regulations. Licensee will email LPA by POC date.

Allegation investigated: Staff did not report an incident involving resident in care as required.

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to deliver findings on the allegation listed above. LPA Abdoulaye was greeted and granted entrance by staff Veronica Jackson. LPA identified himself and discussed the purpose of the visit. It was alleged staff did not report an incident involving a resident in care as required. LPA conducted an interview with the licensee who confirmed they did not report an incident occurring on 07/31/2024, involving Resident 1 (R1), to the Long Term Care Ombudsman (LTCO) within the time frame required by law. A review of the Unusual Incident/Injury Report dated 08/01/2024 revealed the LTCO was notified on 08/19/2024. This corroborates the time frame required by law was not met. Based on interviews and records review, the allegation that staff did not report an incident involving a resident as required was determined to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Pursuant to the California Code of Regulations, Title 22, Division 6, Health and Safety Code, a deficiency is cited on the attached LIC 9099-D. An exit interview was conducted where this report, LIC9099D and appeal rights were discussed and provided to Administrator Ma Satchel Lecita. Substantiatedthe state’s words, verbatim · CDSS document, Aug 8, 2025 · control 18-AS-20240826183736

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(b) · Plan of correction due date: Aug 29, 2025

87211 Reporting Requirements (b)Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above, assuring the incident was reported to the local ombudsman within 2 hours of the incident, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: Licensee stated they will schedule training for themselves and all staff on mandated reporting requirements. Proof of training will be submitted to the Department by the POC due date

Allegation investigated: Staff did not provide food to resident in care Staff denied visitation to resident in care

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with House Manager, Carisa Estrelles, where the LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of interviews with staff and witnesses and file reviews. On December 31, 2024, Community Care Licensing received a complaint alleging facility staff did not provide food to resident in care and denied visitation to resident. Throughout the investigation, LPA interviewed staff and residents and obtained supportive documentation to aid in determining the findings of the noted allegations. The Department interviewed Resident #1; however, the information obtained did not support of the allegations. LPA attempted to conduct a subsequent interview with R1, but R1 passed away in March 2025. No additional information was able to be obtained due to R1’s passing. Continued on LIC 9099-C Unsubstantiated In regards to the allegation that staff did not provide food to resident in care, it was reported that the facility had food available, but would deprive Resident #1 (R1) of food. It was further reported that R1 would only receive food if they behaved themselves. Information obtained from interview with Licensee, Ma Satchel Lecita, denied making the statement. Licensee stated that facility staff would make every effort to provide a variety of food options to R1, however, R1 would refuse. Licensee indicated that R1 preferred to purchase outside food or their own groceries. Information obtained from additional staff interviews corroborated that food, snacks, and alternative options were provided to residents throughout the day and that R1 would refuse. Information obtained from interview with residents stated that they have not experienced being deprived of food and receive their daily meals on time. Information obtained from additional witnesses indicated they received messages from R1 stating they were being denied food and alternatives Through interview with Additional Witness 1 (AW1), It was reported that they reached out to Licensee to obtain further information, during which the Licensee indicated that R1 would be fed when they behave themselves. Information obtained from AW #2 stated they would take groceries to the facility for R1 because R1 advised that they did not prefer the food choices that were served. Additional information revealed that AW2 reported that they had observed food being served to residents and watched R1 decline the food. In regards to the allegation that staff denied visitation to a resident in care, it was reported that R1 had a visitor who was denied entry to the facility. The Department interviewed Witness 3 (W3), who stated that during one of their visits to the facility, R1 expressed a desire to donate personal items. W3 confirmed he was not denied entry to visit R1 but made the decision not to accept the donation. Information obtained from interview with Licensee denied that any visitor was denied entry to the facility. It was advised that the facility does have procedures regarding checking in and allowing staff the time to notify residents and roommates that a visitor is present. Information obtained from additional staff interviews corroborated the information. Interview with AW #1 stated they do not recall a time where they or any other visitors were denied entry into the facility. Information obtained through an interview with AW2 also denied they were denied entry into the facility. It was reported that there was incident when they were delivering groceries to R1 and they had to wait for four minutes before the door was opened. During the investigation, LPA conducted a review of records, which included a visitor’s log. Through record review, a visitor’s log was obtained and there were entries documenting visitation to the facility by W2. Information obtained from additional witnesses did not indicate there were any concerns regarding visitation to the facility. Continued on LIC 9099-C. Based on observation, record review, client, and staff interviews, the allegations that resident was not provided food in care and resident’s visitor was denied entry are Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report was provided to facility representative..the state’s words, verbatim · CDSS document, Jul 31, 2025 · control 18-AS-20241231082009

Allegation investigated: Facility staff hit resident Facility staff are not providing adequate food service Facility staff are not dispensing medications as precribed.

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA met with Administrator, Ma Satchel Lecita, where the LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of interviews with staff and residents, and a review of records. On May 28, 2025, Community Care Licensing received a complaint alleging facility staff hit resident, facility staff are not providing adequate food service and facility staff are not dispensing medications as prescribed. It was alleged Resident 1 (R1) was physically assaulted by a male facility staff member. Resident interviews were conducted. The interviews revealed a male staff entered the room and began striking R1 for being too loud. It was reported there was a witness (W1) to the incident. Continued on LIC 9099-C. Unsubstantiated A name was provided for the staff however, that name did not match any staff employed at the facility. However, based on the description of the staff provided, the LPA was able to determine the allegation involved Staff 1 (S1). An interview with W1 contradicted the account of their witnessing the incident by disclosing they never witnessed any physical abuse by S1 towards R1. This interview also revealed S1 being described as kind and respectful. Resident interviews were conducted where, 4 of 5 indicated no prior observations or experience of physical aggression by S1. The remaining interview, 1 of 5, did not recall a male staff member working. The administrator was interviewed. The administrator reported they learned of the incident and when they spoke to R1, the administrator reports R1 retracted the statement and reported confusion about the incident. The administrator reported that S1 denied physically assaulting R1. S1 was interviewed and reported S1 encountered R1 on the day of the incident. S1 said R1 was yelling, they entered the room and noticed what they described as white foam coming from R1’s mouth. S1 described trying to wipe the foam and R1 moving their head back. S1 denied physically assaulting R1. It was alleged that staff was not providing adequate food service. The allegations included R1 being served last during meal services, not being provided food upon return to the facility and a witness overhearing staff say they ran out of food. Further details about the day R1 returned to the facility and was not provided food included that a third party brought outside food for R1. R1 had already returned to the facility when the third party brought the food. Staff interviews revealed 3 of 3 staff did not recall that specific incident, however, the interviews revealed R1 was provided meals at all meal times. The witness who overheard the statement about the facility running out of food, could not provide details on the staff who made the statement. Residents were interviewed, including R1. R1 reported they had no complaints regarding food service. It was reported meal portions were adequate and they received additional servings when requested. The additional resident interviews were conducted where 5 of 5 affirmed they regularly received meals with adequate portions and noted that staff provided additional servings upon request. It was alleged that facility staff failed to dispense medications according to prescribed instructions. Continued on LIC 9099-C. Administrator stated that 9 of 13 medications were delivered to the facility on April 25, 2025 by R1’s responsible party. The administrator reports speaking to R1’s responsible party who informed them that the remaining medications were pending insurance approval. The conflict arises where it is being alleged that the remaining medications were delivered directly to the facility. However, the administrator denies receiving the additional medications. Interviews with relevant parties did not reveal any corroborating evidence regarding the delivery of the medications. It is unknown which medications or on what date they were delivered. A review of R1’s Medication Administration Record (MAR) showed that 9 medications were dispensed between April 25, 2025, and May 22, 2025. Additionally, the MAR revealed that on May 15, an extra medication was prescribed and added to the nighttime regimen. An interview with R1 confirmed they received their medications as prescribed. Additional resident interviews revealed, 6 out of 6 residents reported receiving medication as prescribed and do not have concerns with dispensing of medication. Based on interviews and record reviews, the allegations staff hit resident, not providing adequate food and not dispensing medications as prescribed is deemed unsubstantiated. A finding that the complaint is unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report was provided to the Administrator, Ma Satchel Lecita.the state’s words, verbatim · CDSS document, Jul 28, 2025 · control 18-AS-20250528091327

Allegation investigated: Facility has failed to provide assistance with bathing and other hygiene needs. Facility does not respond to resident's request for assistance Residents are forced to eat in the dining room

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with Administrator Ma Satchel Lecita, where the LPA explained the purpose of the visit. On February 11, 2025, Community Care Licensing received a complaint alleging the facility does not provide assistance with hygiene needs, facility staff does not respond to resident's request for assistance, and residents are forced to eat in the dining room. The investigation included interviews with staff and residents, and a review of documents obtained. It was alleged facility staff did not provide assistance with hygiene needs, including bathing and toileting, and that the staff did not respond to the resident’s request for assistance. It was reported Resident 1 (R1) would be left with a soiled adult brief and staff would not assist with toileting needs when R1 when requested. Continued on LIC 9099-C. Unsubstantiated The Administrator was interviewed. She reported R1 exhibited verbally aggressive behavior toward staff, including raising their voice and denying staff entry into their room. The administrator said staff made routine attempts to offer assistance throughout the day; however, R1 consistently refused services and responded in an uncooperative and hostile manner. Staff were interviewed, where 2 of 2 revealed R1 would be verbally abusive to staff and would not allow staff to assist them with their daily hygiene needs. R1 was interviewed. R1 reported they would request assistance, and staff would refuse to assist. Additionally, R1 denied being verbally abusive toward staff and denied they would refuse assistance with toileting needs and cleaning. Interviews with other residents were conducted, where 4 of 4 residents reported staff assist with toileting and bathing needs when requested and as needed. A record review of facility daily logs was completed. LPA obtained facility records titled “Diaper Log”. This log documents staff assistance with toileting needs. The log is not specific to a resident but instead documents daily assistance. The log was reviewed for January 2025. The log documented R1 refused assistance with toileting a total of 18 times in that month. The log documented R1 accepted assistance with toileting a total of 15 times in that month. LPA obtained facility records titled “Shower Log”. This log documents staff assistance with showering. The log is not specific to a resident but instead documents when showering assistance was provided. The log was reviewed for January 2025. The log did not reflect any refusals by R1. The log documented R1 accepted assistance with showering a total of 3 times in that month. It was alleged residents are forced to eat in the dining room. It was reported that facility staff implemented a policy requiring residents to eat in the dining area or risk not being served meals. It was reported that the policy was announced and implemented in February 2025. The Administrator was interviewed and reported no such policy was implemented. The Administrator stated the facility accommodates residents who are non-ambulatory by delivering meals to their rooms. Staff were interviewed, where it was revealed 3 of 3 staff corroborated the Administrator’s statement, indicating that at no time had there been a policy mandating all residents to eat in the dining area or risk not being provided with a meal. R1 was interviewed and reported, based on the implemented policy, R1 had to come up with alternative meal arrangements. R1 further reported a facility staff informed R1 that meals would not be provided unless consumed in the dining area. Continued on LIC 9099-C. R1 was not able to identify which staff informed them of the policy. Interviews with 4 of 4 staff members stated that they were unaware of, and had not communicated to residents, of a newly mandated policy requiring meals to be consumed in the dining area or risk not being served. Interviews with residents were conducted, where 4 of 4 residents reported they were not told about this policy. Residents reported they have the option to eat in their rooms without fear of being denied meals. Based on record reviews, and interviews with residents and staff, the allegations that facility does not provide assistance with hygiene needs, facility does not respond to resident's request for assistance, and residents are forced to eat in the dining room are deemed Unsubstantiated. A finding of "Unsubstantiated" means that the allegation may have occurred or is valid, there is not sufficient evidence to prove the alleged violation occurred. An exit interview was conducted, and a copy of the report was provided to the Administrator, Ma Satchel Lecitathe state’s words, verbatim · CDSS document, Jul 24, 2025 · control 18-AS-20250211125221

Allegation investigated: Staff did not ensure that resident's toileting needs were met Staff did not ensure resident's medication was taken as prescribed.

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to deliver findings for the allegations listed above. LPA Abdoulaye was greeted and granted entrance by Caregiver Edith Campos. LPA Abdoulaye Zerbo identified himself and discussed the purpose of the visit. It was alleged that staff did not ensure that resident's toileting needs were met . Concerns were raised that Resident 1 (R1) was left in soiled conditions for extended periods, resulting in rashes. During an interview, R1 reported being changed four to six times daily and whenever additional assistance was requested. Staff interviews confirmed this information. Further details revealed that R1 had appointments three to four times a week from 7 AM to 6 PM. Staff interviews also indicated that R1 was changed before leaving the facility and upon returning. However, it was noted that R1's diaper was not changed while away from the facility, which could explain the rash development. Information obtained from records review of diaper log revealed R1 was changed four to six times a day. Unsubstantiated A review of records corroborated that R1 was picked up by a transportation company contracted with R1’s insurance company for the first ten days of July 2024 and was hospitalized due to a urinary tract infection for the remainder of the month, during which the complaint was received by the department. Information obtained through interviews and records review could not verify R1 was left in soiled condition for a long period of time. It was alleged Staff did not ensure resident's medication was taken as prescribed. Concerns were raised and staff were not providing R1 with their medication, which resulted in R1 having a seizure. LPA conducted interviews with facility representative, and information obtained revealed R1 medication was given as prescribed. Additional information obtained through records reviewed revealed R1 was not on seizure medication. Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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 at this time. An exit interview was conducted where this report, LIC9099 was discussed and provided to Administrator Ma Satchel Lecitathe state’s words, verbatim · CDSS document, Jul 18, 2025 · control 18-AS-20240712211908

Allegation investigated: Facility staff neglect resulted in resident sustaining bed sores Facility staff are not bathing resident Staff are financially abusing residents in care.

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to deliver findings for the allegations listed above. LPA Abdoulaye was greeted and granted entrance by Caregiver Edith Campos. LPA Abdoulaye Zerbo identified himself and discussed the purpose of the visit. It was alleged that facility staff neglect resulted in Resident 1 (R1) sustaining bed sores. Concerns were made that R1 did not receive appropriate care, which resulted in R1 sustaining bedsores. A review of R1’s medical records, facility file, and care logs were completed. The information obtained revealed that R1 is regularly assisted by staff and is changed at least six times a day, as confirmed by staff members. Further information obtained from interviews revealed that R1 arrived at the facility with a spreadable health condition and not bed sores. Facility representatives stated after medical evaluation, it was determined that R1 would go to a Skilled Nursing Facility for further treatment. Facility representatives stated they were not equipped to retain R1 after it was determined the spreadable health condition was contagious. After the treatment, R1 returned to the facility where adequate care was provided. Unsubstantiated It was alleged that facility staff are not bathing R1. Concerns were expressed R1 is not being bathed, according to information obtained, R1 is supposed to be getting bathed once or twice a week. According to interview statements obtained, staff are utilizing body wipes instead of bathing/showering R1. LPA conducted an interview with R1, and information obtained revealed R1 receives a bath once a week on Saturdays, which aligns with the facility’s records. Interviews with staff confirmed that R1 receives baths three times a week, once by facility staff and twice by R1’s nurse aide. Additionally, information obtained through interviews revealed R1 is regularly assisted by staff and is changed at least six times a day, as confirmed by staff members. It was alleged that staff are financially abusing residents in care. Concerns were made that the licensee uses the residents EBT card to make purchases. LPA Abdoulaye Zerbo interviewed several residents regarding their financial management. The information obtained from the interviews revealed that residents manage their own money and for some residents, their money is managed by responsible parties and/or family members. Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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 at this time. An exit interview was conducted where this report, LIC9099 was discussed and provided to Administrator Ma Satchel Lecitathe state’s words, verbatim · CDSS document, Jul 18, 2025 · control 18-AS-20240911142008

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with Administrator Ma Satchel Lecita. The LPA informed the Administrator of the purpose for the visit. The inspection included the following: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility consists of eight (8) resident bedrooms, three (3) bathrooms, a kitchen and dinning area, a living room area, a garage and laundry room, and a patio and yard with sufficient seating and space for activities. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured within regulation. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home and no bodies of water observed. LPA began review of client records. ten (10) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed client records to be available and complete. LPA began review of employee records- four (4) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 10/31/2025. LPA observed personnel records to be available and complete. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for knives and sharps in the kitchen. Medications are centrally stored. There is a locked cabinet in the kitchen allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers was serviced on March 28, 2025. Fire drills are conducted quarterly at the facility with the last drill on April 10, 2025 . Based on the information received during this visit today in the areas reviewed, there are no deficiency that are being cited per Title 22, Division 6 of The California Code of Regulations. This LIC 809 report was reviewed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Jun 18, 2025

Allegation investigated: Licensee is not allowing resident to phone calls. Licensee does not allow resident to have visitors.

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced subsequent visit for additional investigation into the allegations listed above. LPA Abdoulaye was greeted and granted entrance by staff Veronica Jackson. LPA Abdoulaye Zerbo identified himself and discussed the purpose of the visit. It was alleged Staff did not allow resident to make and receive phone calls. Concerns were raised regarding staff not allowing residents to receive or make phone calls. During today’s visit, LPA observed a working phone in the office area and accessible to residents. LPA conducted interviews with multiple residents and information obtained revealed residents are allowed to use the phone and receive phone calls from family members, witnessed by R2 receiving a phone call at 12:45pm. Further information obtained revealed for residents unable to access the phone, staff will take the phone to them when requested. Continued 9099-C..... Unsubstantiated It was alleged Staff does not allow resident to have visitors. LPA reviewed resident’s record, facility file and visitation log. The information obtained revealed the Resident 1 (R1) received visitation for the month of May 2024 and June 2024 but not from a confidential witness. Interviews were conducted and information received revealed the confidential witness refused to sign visitation log and brings food items for R1 who has a modified diet, which constituted a violation of the facility’s visiting policy. Further information received from interviews revealed confidential witness visited the facility about three (3) times between 06-07-24 to 07-07-24 during the R1’ s stay at the facility. During those visits, the confidential witness had altercations with staff members and law enforcement was called on 06-14-24 and the confidential witness was told to vacate the premises by law enforcement officers. LPA conducted interviews with residents and staff and information obtained corroborated that all residents are allowed to have visitors, and the visiting hours are posted on the front door. Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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 at this time. An exit interview was conducted where this report, LIC9099 was discussed and provided to Administrator Ma Satchel Lecitathe state’s words, verbatim · CDSS document, May 21, 2025 · control 18-AS-20240611165807

Allegation investigated: Staff does not ensure residents personal care needs are being met

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced subsequent visit for additional investigation into the allegation listed above. LPA Abdoulaye was greeted and granted entrance by staff Veronica Jackson. LPA Abdoulaye Zerbo identified himself and discussed the purpose of the visit. It was alleged Staff does not ensure residents personal care needs are being met. Concerns were made regarding resident‘s (R1) overgrown toenails and facility not meeting R1’s dental care. LPA conducted interviews and information obtained revealed R1’s insurance coverage did not carry dental care when R1 was admitted at the facility 5-30-24. R1’s Power of Attorney (POA) was informed, and an application was sent by POA to obtain dental insurance. The dental insurance card came on 04-01-25 and an appointment for dental care was obtained on 04-14-25. Further information obtained from record review revealed a pediatrist visited the facility on 08-4-24 to cut R1’s toenails. Continued 809-C.... Unsubstantiated LPA conducted interviews with staff and residents and information obtained revealed the residents have dental appointment when they request it. Based on the evidence, the allegation mentioned above is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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 at this time. An exit interview was conducted where this report, LIC9099 was discussed and provided to Administrator Ma Satchel Lecita.the state’s words, verbatim · CDSS document, May 21, 2025 · control 18-AS-20240806084343

Allegation investigated: Staff do not allow resident to make and receive phone calls.

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to deliver findings on the allegation listed above. LPA Abdoulaye was greeted and granted entrance by staff Veronica Jackson. LPA identified himself and discussed the purpose of the visit. It was alleged staff did not allow resident to make and receive phone calls. LPA conducted resident interviews where 8 of 8 interviews revealed residents are allowed to use the facility phone to make calls and also receive phone calls. A relevant witness interview revealed they called the facility at least twice a month in June of 2024, July of 2024 and August 2024. The witness reported each time they called, they were told R1 was either sleeping or unavailable. R1 was interviewed and reported they have a personal phone to make and receive calls. Continued 9099-C...... Unsubstantiated In addition, R1 reported if needed, they could make and receive calls on the facility’s phone. The licensee denied interfering in R1’s ability to make or receive calls. Additional staff Interview revealed they do not interfere in resident’s ability to make or receive calls. Based on the evidence, the allegation mentioned above is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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 at this time. An exit interview was conducted where this report, LIC9099 was discussed and provided to Administrator Ma Satchel Lecita. This is an amended version of the original report created on 05/21/2025.the state’s words, verbatim · CDSS document, May 21, 2025 · control 18-AS-20240826183736

Allegation investigated: Staff did not notify responsible representative regarding incident involving resident.

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Administrator, Ma Satchel Lecita, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and witnesses and file reviews. On March 10, 2025, Community Care Licensing received a complaint alleging that staff did not notify responsible representative regarding an incident involving Resident. It was alleged that on March 8, 2025, Resident (R1) was transferred to the hospital for medical evaluation and assistance. It further alleged that staff did not report the hospitalization with R1’s designated responsible representative. Information obtained from Administrator, Ma Satchel Lecita stated that R1 did not provide a responsible party during the intake process. Administrator also denied that there was written or verbal instruction to revise documentation designating a responsible party or emergency contact. Continued on 9099-C. Unfounded According to the Administrator, R1 consistently refused to identify a responsible party or share contact information for any additional witness. R1 indicated and documented that they were their own emergency contact and specifically directed staff not to reach out to additional witnesses. Administrator stated they advised R1 to add a responsible party, but R1 consistently refused indicating that they have the ability to make their own decisions. Furthermore, Administrator stated that they had multiple conversations with Additional Witness (AW1) to confirm contact information to report any information pertaining to R1. However, AW1 repeatedly refused to provide the requested information on documents. It was advised that on March 9, 2025, AW1 did visit the facility and was advise that R1 was in the hospital. The notification did abide by the time frame set in place by Title 22 Regulations regarding reporting requirements. Information obtained from an interview with AW1 revealed they had spoken by phone with the Administrator and Staff 2 (S2) around the time R1 was admitted to the facility. AW1 believed that facility staff having the knowledge of their phone contact information was sufficient to assume responsibility for R1. However, AW1 stated they never verbally confirmed nor completed any paperwork designating themselves as R1’s emergency contact. AW1 did corroborate that on March 9, 2025, during a visit to the facility, they were advised of R1’s hospitalization by facility staff. Information from additional witnesses also stated they were not the current or listed responsible party for R1. A review of admission records revealed that the admissions agreement between R1 and the facility did not designate a responsible party. During the intake process, R1 explicitly wrote “none” in the section for a responsible party signature on multiple documents. Additionally, the Emergency Contact Form and Resident Roster did not list a responsible party for R1. R1 was unable to be interviewed regarding the allegations due to the death of R1. Based on interviews, research, and record review, the allegation that staff did not notify responsible representative regarding an incident involving resident in care is unfounded. AW1 was not documented as a responsible party for R1 for the facility to be required to notify of any incident regarding R1. Also, on March 9, 2025, facility staff did advise AW1 that R1 was in the hospital. A finding that the allegation is unfounded meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. This allegation has been investigated and is dismissed An exit interview was conducted where a copy of this report was provided to facility representative.the state’s words, verbatim · CDSS document, May 13, 2025 · control 18-AS-20250310124409

Type of visit: Case Management - Other

On April 28, 2025, LPA Venus Mixson arrived unannounced to conduct a health and safety check regarding another incident. LPA introduced herself and stated the purpose of the visit. Currently at the facility are ten residents and three staff. Two caregivers and a Hospice Nurse. LPA was informed by the Lead caregiver that there are four residents receiving Hospice services and that there are no residents currently who have special diets. LPA conducted interviews with staff and residents, requested and received pertinent documentation, and made observations regarding the health and safety check. Care plans for residents were reviewed, along with residents MARS. There were no noted concerns at the time of this visit. LPA conducted record reviews of staff schedules, resident roster, meals for special diets, (none currently at time of this visit), and care plans for residents, along with Hospice records. There were no observable health and safety concerns currently at the time of this visit. An exit interview was conducted, and a copy of this report was explained and given to Veronica Jackson, Caregiver.the state’s words, verbatim · CDSS document, Apr 28, 2025

Allegation investigated: Licensee wrongfully refused to allow resident to enter the facility

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA met with Administrator, Ma Satchel Lecita, where LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and residents. On January 28, 2024, Community Care Licensing received a complaint alleging that licensee wrongfully refused to allow resident to enter the facility. It was reported that on January 30, 2025, C1 was not allowed entrance into the facility after returning from a medical appointment. LPA conducted interview with Administrator, and it was revealed that Administrator refused C1 entrance into the facility and instructed C1 to contact their responsible party to pick C1 up. According to Administrator, C1 was banging on the front door and yelling explicit language towards staff. The actions of C1 caused the other residents to become agitated. Administrator also stated that law enforcement was contacted for additional assistance. Information obtained from interview with C1 stated that facility staff denied him access to the facility after his medical appointment. Continued on 9099-C. Substantiated Information obtained from a review of documentation corroborated that law enforcement was called to the facility to speak C1 and Administrator. Administrator then allowed C1 to enter the facility and law enforcement escorted C1 back into their room. Based on client and staff interviews and the review of documentation, the allegation that Licensee refused to allow resident to enter the facility has been deemed as substantiated. A substantiated finding indicates the preponderance of the evidence standard has been met. This poses a potential health and safety risk to clients in care. The facility will be cited. An exit interview was conducted. A copy of this report, along with a copy of the LIC9099D, LIC 811, and Appeal Rights were provided. For the allegation that Licensee is not allowing Client to have visitors, it was reported that C1 had their mother denied entrance for a visit. Information obtained from interview with Administrator denied the allegation. Administrator stated that there was an incident were Client’s visitor was knocking rudely on the facility door. Administrator stated when the door was open, the visitor bumped into a staff member who was leaving the facility. Administrator stated the visitor was still allowed to complete the visit. It was advised that the facility maintains a log of all visitors which includes additional details. Interview with Client corroborated the information. Client stated that staff had a verbal altercation with a visitor, but their visitor was still able to meet with Client. Interviews with additional clients and staff corroborated that all clients are allowed visit and no visitors have been turned away. LPA observed the facility did maintain a monthly log for visitors. No concerns regarding visits were advised. Based on the evidence pertaining to the allegations of Licensee not following proper eviction protocols and Licensee not allowing Client to have visitors, the allegations are unfounded. A finding of unfounded indicates that the allegation is false, could not have happened, or is without a reasonable basis. An exit interview was conducted where a copy of this report was provided to Administrator Ma Satchel Lecita. Continuation of Amended report LIC9099-A. It was also reported that when staff would attempt to assist R1 with toileting needs, R1 would refuse assistance. Additional staff interviews were conducted, where 2 of 3 staff reported R1 is verbally abusive and does not allow staff to assist with toileting needs. An interview with R1 was conducted. R1 reported contradicting statements. R1 initially reported staff did assist them with toileting but later in the interview they disclosed that staff do not assist them with toileting. LPA obtained facility records titled “Diaper Log”. This log documents staff assistance with toileting needs. The log is not specific to a resident but instead documents daily assistance. The log was reviewed for January 2025. The log documented R1 refused assistance with toileting a total of 18 times in that month. The log documented R1 accepted assistance with toileting a total of 15 times in that month. Based on interviews and record reviews, the allegation facility staff do not assist with toileting needs is deemed unsubstantiated. A finding that the complaint is unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report was provided to the Administrator, Ma Satchel Lecita.the state’s words, verbatim · CDSS document, Mar 14, 2025 · control 18-AS-20250128082056

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80072(a)(1) · Plan of correction due date: Mar 24, 2025

Personal Rights: Each client shall have personal rights which include, but are not limited to, the following: 1. To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not being met as evidenced by: This requirement was not met as evidenced by: Administrator refused C1 entrance into the facility. This poses an immediate health safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Mar 14, 2025

Plan of correction: The Administrator agreed to conduct personal rights training with staff. Documentation to be submitted to LPA by poc due date. Administrator agreed to send LPA.

Allegation investigated: Licensee wrongfully refused to allow resident to enter the facility

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA met with Administrator, Ma Satchel Lecita, where LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and residents. On January 28, 2024, Community Care Licensing received a complaint alleging that licensee wrongfully refused to allow resident to enter the facility. It was reported that on January 30, 2025, C1 was not allowed entrance into the facility after returning from a medical appointment. LPA conducted interview with Administrator, and it was revealed that Administrator refused C1 entrance into the facility and instructed C1 to contact their responsible party to pick C1 up. According to Administrator, C1 was banging on the front door and yelling explicit language towards staff. The actions of C1 caused the other residents to become agitated. Administrator also stated that law enforcement was contacted for additional assistance. Information obtained from interview with C1 stated that facility staff denied him access to the facility after his medical appointment. Continued on 9099-C. Substantiated Information obtained from a review of documentation corroborated that law enforcement was called to the facility to speak C1 and Administrator. Administrator then allowed C1 to enter the facility and law enforcement escorted C1 back into their room. Based on client and staff interviews and the review of documentation, the allegation that Licensee refused to allow resident to enter the facility has been deemed as substantiated. A substantiated finding indicates the preponderance of the evidence standard has been met. This poses a potential health and safety risk to clients in care. The facility will be cited. An exit interview was conducted. A copy of this report, along with a copy of the LIC9099D, LIC 811, and Appeal Rights were provided. For the allegation that Licensee is not allowing Client to have visitors, it was reported that C1 had their mother denied entrance for a visit. Information obtained from interview with Administrator denied the allegation. Administrator stated that there was an incident were Client’s visitor was knocking rudely on the facility door. Administrator stated when the door was open, the visitor bumped into a staff member who was leaving the facility. Administrator stated the visitor was still allowed to complete the visit. It was advised that the facility maintains a log of all visitors which includes additional details. Interview with Client corroborated the information. Client stated that staff had a verbal altercation with a visitor, but their visitor was still able to meet with Client. Interviews with additional clients and staff corroborated that all clients are allowed visit and no visitors have been turned away. LPA observed the facility did maintain a monthly log for visitors. No concerns regarding visits were advised. Based on the evidence pertaining to the allegations of Licensee not following proper eviction protocols and Licensee not allowing Client to have visitors, the allegations are unfounded. A finding of unfounded indicates that the allegation is false, could not have happened, or is without a reasonable basis. An exit interview was conducted where a copy of this report was provided to Administrator Ma Satchel Lecita. Continuation of Amended report LIC9099-A. It was also reported that when staff would attempt to assist R1 with toileting needs, R1 would refuse assistance. Additional staff interviews were conducted, where 2 of 3 staff reported R1 is verbally abusive and does not allow staff to assist with toileting needs. An interview with R1 was conducted. R1 reported contradicting statements. R1 initially reported staff did assist them with toileting but later in the interview they disclosed that staff do not assist them with toileting. LPA obtained facility records titled “Diaper Log”. This log documents staff assistance with toileting needs. The log is not specific to a resident but instead documents daily assistance. The log was reviewed for January 2025. The log documented R1 refused assistance with toileting a total of 18 times in that month. The log documented R1 accepted assistance with toileting a total of 15 times in that month. Based on interviews and record reviews, the allegation facility staff do not assist with toileting needs is deemed unsubstantiated. A finding that the complaint is unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report was provided to the Administrator, Ma Satchel Lecita.the state’s words, verbatim · CDSS document, Mar 14, 2025 · control 18-AS-20250128082056

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80072(a)(1) · Plan of correction due date: Mar 24, 2025

Personal Rights: Each client shall have personal rights which include, but are not limited to, the following: 1. To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not being met as evidenced by: This requirement was not met as evidenced by: Administrator refused C1 entrance into the facility. This poses an immediate health safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Mar 14, 2025

Plan of correction: The Administrator agreed to conduct personal rights training with staff. Documentation to be submitted to LPA by poc due date. Administrator agreed to send LPA.

Type of visit: Case Management - Other

On February 2, 2025, Licensing Program Analyst Armando Perez and Kathleen Banrasavong conducted a visit to the facility in order to obtain information regarding a request for an eviction. LPAs were granted entry and met with Administrator Ma Satchel Lecita. LPAs conducted interviews with two residents and reviewed pertinent documentation. During the course of the investigation, LPAs observed that the facility had not reported serious incidents to the department. Per title 22, the facility must report all incidents to the department within a 7 day period. A technical violation will be provided. An exit interview was conducted, and a copy of this report was provided to Administrator Ma Satchel Lecita.the state’s words, verbatim · CDSS document, Feb 6, 2025

Allegation investigated: Unlawful eviction.

On 1/31/2025, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to deliver findings regarding the allegation listed above. LPA met with Caregiver, Juana Gonzalez who was informed of the purpose of the visit. Licensee, Ma Satchel Lecita arrived during the visit and was also informed of the purpose of the visit. Regarding the allegation, "Unlawful eviction" it was alleged that Resident 1 (R1) was given an eviction notice for non-compliance of house rules, but was not provided supporting facts of these concerns. Records reviewed indicated R1 was provided with a written eviction notice on 12/30/2024, which did not contain specific required facts including dates, places, witnessess and circumstances related to non-compliance of house rules. Licensee was interviewed and reported the supporting information was not provided to R1 in the eviction notice. Consultation of eviction regulations was provided to Licensee. Licensee has now expressed understanding of the regulatory requirements to evict a resident. Substantiated Licensee reported they will rescind the 12/30/2024 eviction letter provided to R1 by 02/03/2025 and submit proof to the Department by close of business 02/03/2025. Licensee was notified that she is not prohibited from issuing another eviction letter to R1 as long as it met regulatory requirements. Based on interviews conducted and records reviewed, 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, Chapter 8), is being cited on the attached LIC 9099-D. An exit interview was conducted, and a copy of this report was provided. An exit interview was conducted and a copy of this report was reviewed and provided to Licensee along with LIC 9099-D, Confidential Names list (LIC 811), and Appeal Rights.the state’s words, verbatim · CDSS document, Jan 31, 2025 · control 18-AS-20250115150201

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: Jan 31, 2025

(d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement was not met as evidenced by: Based on record review of R1's eviction, the licensee did not provide R1 with specific facts related to the reasons for eviction notice. R1's eviction lacked informative dates, places, witnesses, and/or circumstances related to alleged violations of the house rules. Licensee was interviewed and reported the supporting information was not provided to R1 in the eviction notice. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 31, 2025

Plan of correction: Licensee reported they will rescind the 12/30/2024 eviction letter provided to R1 by 02/01/2025 and submit proof of correction to the Department by close of business 02/03/2025.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA), Stephanie Martinez, continued a required annual inspection at the facility that was started on 06/18/2024. The LPA was allowed entrance into the facility and met with Administrator, Ma Satchel Lecita. The LPA informed the Administrator of the purpose for the visit. The inspection included the following: Physical Plant: The facility consists of eight (8) resident bedrooms, three (3) bathrooms, a garage, an open kitchen and dinning areas, a living room area, an office area, a laundry room, and a patio and yard with sufficient seating and space for activities. There are no bodies of water located on the property. According to Administrator Lecita, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats or strips present. The smoke and carbon monoxide devices were tested by the Administrator and was observed to be in operating condition. The home was kept clean, organized and free of any odors. Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. The facility was not operating beyond the conditions specified on the license. The facility currently has an approved Hospice Waiver for five (5) residents and there is currently one (1) residents in care receiving hospice services. There is a disaster and mass casualty plan in place. Three out of three staff members (S1 - S3) do not have current First Aid training on file. A citation will be issued. Two out of two staff members (S2 and S4) did not have the 20 hours of required annual training (Dementia, Postural Supports, Restricted Health Conditions or Hospice). A citation will be issued. One out of one staff members (S2) does not have the complete 10 hours of initial medication training. S2 only has 2 hours of medication training from 05/30/2023. According to Administrator, S2 started employment on 05/30/2023. A citation will be issued. Five out of five residents (R1 - R5) did not have a written record of care on file. A citation will be issued. Two out of two residents (R1 and R5) have a restricted health condition. According to staff the residents can manage their own treatment/care; however, neither had documentation on file indicating the residents can manage their own health conditions. A citation will be issued. One out of one residents (R6) did not have a hospice care plan on file. A citation will be issued. Medication Review: The LPA inspected resident medications. Medications were observed to be well organized, appropriately labeled and inaccessible to unauthorized individuals. Two out of two residents (R1 and R7) medications were being stored in weekly medication containers. A citation will be issued. An exit interview was conducted with Administrator Lecita in which this report was reviewed and a copy was provided, along with the LIC 811s, LIC 9098, and instructions on appeal rights.the state’s words, verbatim · CDSS document, Jul 31, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility for a required annual inspection. The LPA was allowed entrance into the facility and met with Administrator, Ma Satchel Lecita. The LPA informed the Administrator of the purpose for the visit. The inspection included the following: Food Service: There is a minimum of 2 days supply of perishable foods and 1 week's supply of non-perishable foods available. Sufficient supplies were available for resident's dinning use. The kitchen was kept clean and free of vermin. Due to insufficient time a return visit will have to be completed. This report was reviewed with Administrator Lecita and a copy was provided.the state’s words, verbatim · CDSS document, Jun 18, 2024