Sonnet Hill

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Jasmine Latu. LPA explained the purpose of the visit. LPA toured the facility inside out with ADM which included the 1st floor, 2nd floor and 3rd floor of the facility. LPA randomly toured, but not limited to, bedrooms: 316, 315, 308, 305, 328, 322, 325, 202, 203, 207, 213, 208, 205. LPA tested the delayed egress doors inside the facility. LPA noted the egress doors activated and emitted a sound when trying to open the delayed egress door. There was no obstruction to block the walkways. The front and back of the facility was also inspected. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured at 116 degrees F in resident bathrooms. The facility was equipped with smoke and carbon monoxide detectors. The facility Sprinkler system was last inspected on February 17, 2026. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on March 13, 2026. LPA Provided ADM with CDPH LD Fact Sheet for Administrators and PIN 26-01-ASC LPA reviewed facility records for 5 staff and 5 residents. LPA reviewed 5 resident medications and centrally stored medication records. LPA reviewed resident R1's medication. LPA noted residents R1's Medication, M1, was not listed. This medication has a fill date of February 2026. LPA asked Health and Wellness director Simran Kaur to show LPA if this medication was documented on the centrally stored medication record. Wellness director Simran Kaur confirmed that R1's medication M1 was not listed on the Centrally stored medication record. LPA reviewed Resident R2's medication. LPA noted that 2 bubble packs for medication M2 for R2 were not listed on the centrally stored medication record. LPA asked staff Resident Care coordinator Andrea Maldenado to show LPA if this medication was documented on the centrally stored medication record. Resident Care coordinator Andrea Maldenado confirmed that R2's medication M2 was not listed on the centrally stored medication record. Deficiencies are being cited during today's visit. This report was reviewed with Administrator Jasmine Latu and a copy of the signed report was provided. Appeals rights were provided.the state’s words, verbatim · CDSS document, Apr 1, 2026

Allegation investigated: Licensee does not ensure facility is kept free of pests

Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced complaint investigation visit. LPA announced the purpose of the visit and met with Jasmine Latu, Administrator (ADM). On 02/27/26 the department recieved a complaint with the above allegation. During visit LPA toured 9 random rooms and interviewed 7 staff including ADM and 8 residents. LPA reviewed 3 resident files including but not limited to physicians report, appraisal needs and services. LPA obtained Exterminator inspection report and observation notes. LPA toured room #s on second floor 210, 211, 212, 213, 214, 217 and 219. LPA toured rooms on third floor, 301, 308 LPA did not see any bed bugs in the rooms randomly inspected. LPA and staff inspected the residents bedding and did not observe any bed bugs. page 1 of 2 Unsubstantiated Page 2 of 2 4 out of 5 staff stated he/she has not observed any bed bugs, cockroaches or ants in the facility. 3 out of 5 staff stated they give residents showers, change sheets and bedding, and provide care to residents with ADL's. 1 out of 5 staff stated they observed a bug and reported it to Residential Care Coordinator (RCC). 4 out 5 staff stated they would report if they observed any bed bugs in residents rooms to RCC. 7 out of 8 residents stated they have not observed any bed bugs, cockroaches or ants in their rooms. 1 out of 8 stated he/she has seen a bug but was unable to determine what kind of bug it was. 1 resident stated he/she saw ants but that was when he/she first moved in and the facility promptly took care of the ants and has not seen them since. ADM stated he/she had the facility sprayed by a third party agency for treatment of selected areas and outside of facility for pests. The exterminator report receipt dated 02/11/26 stated the following rooms were inspected 206, 217 and 219. The facility room 210, and 217 is currently unoccupied. The exterminator report stated the selected rooms were inspected and there was no activity of any pests observed. The department has completed its investigation. Based on interviews, the Department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited during today's visit based on California Code of Regulations Title 22. An exit interview was conducted with Administrator Jasmine Latu and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 5, 2026 · control 26-AS-20260227133546

Allegation investigated: Facility staff is not meeting resident incontinent needs Staff are not assisting resident with dressing Facility staff did not provide resident with assistance eating Staff did not dispense medication to resident as prescribed

On 1/30/2026 Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced visit to deliver complaint findings. On 9/19/2025 the Department received a complaint with the above allegations. On 9/24/2025 the Department interviewed Reporting Party (RP). RP states he/she did not have information regarding residents, referred to as R1, being soiled. RP states it was a Witness, referred to as W1, who observed R1 to be soiled. Page 1 of 5 Unfounded Facility staff is not meeting resident incontinent needs On 9/25/2025 the Department conduct a complaint investigation visit and interviewed Administrator (ADM), 2 Staff (S1 to S2) and 4 Residents (R2 to R5) and 2 Witnesses (W1 and W2). ADM states residents are checked every 2 hours, as well as being checked at the start of staff shifts, and after residents have finished meals. On 9/25/2025 the Department interviewed 2 Staff (S1 to S2). 2 Out of 2 Staff state he/she assists residents with his/her incontinent/toileting needs. On 9/25/2025 the Department interviewed 4 Residents (R2 to R5). 2 Out of 4 Residents state he/she does not require assistance with his/her briefs. R4 and R5 state staff assist him/her with his/her briefs, and staff have never left him/her in a wet brief. On 9/25/2025 the Department interviewed 2 Witnesses (W1 to W2). W1 states he/she observed R1 ‘soaking wet’ but did not remember the date of this incident. W1 states he/she did not observe R1 wet, it was RP, and the RP ‘screamed and yelled’ and ‘got it taken care of.’ W1 did not provide additional information regarding this incident. W2 states he/she has no issues or concerns with the care his/her loved one is receiving at the facility. Review of R1’s physician’s report dated 8/5/2025 notes R1 is not incontinent of bladder. Review of R1’s care plan notes R1 to require toileting assistance (3x daily), and Bladder incontinence assistance (0x – As needed). Staff are not assisting resident with dressing On 9/25/2025 the Department interviewed Reporting Party (RP). RP states he/she observed R1 in briefs on 9/10/2025 at approximately 10:00PM and told staff R1 needed to be wearing pajamas ‘to go to bed.’ RP states this is a ‘general preference and it’s not part of R1’s care plan.” On 9/25/2025 the Department interviewed ADM. ADM states staff assist residents with getting dressed. Page 2 of 5 On 9/25/2025 the Department interviewed 2 Staff (S1 to S2). 2 Out of 2 Staff state he/she assists residents in getting dressed. On 9/25/2025 the Department interviewed 4 Residents (R2 to R5). 4 Out of 4 Residents states he/she does not need assistance with getting dressed. R4 states staff offer to help him/her get dressed, but he/she prefers to get dressed on his/her own. On 9/25/2025 the Department interviewed 2 Witnesses (W1 to W2). W1 did not provide additional information. W2 states he/she has no concerns with the care his/her loved one is receiving at the facility. Review of R1’s care plan notes for dressing assistance “2x daily at 6:00AM and 2:00PM.” Facility staff did not provide resident with assistance eating. On 9/24/2025 the Department interviewed Reporting Party (RP). RP states he/she did not observe and does not have any additional information regarding if facility staff did provide R1 with assistance eating. On 9/25/2025 the Department interviewed ADM. ADM states staff assists residents with eating if residents need it. ADM states staff ask residents if he/she need help, or if a resident is not eating his/her food, staff will assist residents with eating. On 9/25/2025 the Department interviewed 2 Staff (S1 to S2). 2 Out of 2 Staff state he/she provides residents with eating assistance. On 9/25/2025 the Department interviewed 4 Residents (R2 to R5). 1 Out 5 Residents state staff help him/her with eating. R3 and R5 state he/she receives their meals on time but did not provide additional information. R4 states ‘maybe once or twice’ he/she was not taken to the dining room but did not provide additional information. On 9/24/2025 the Department interviewed 2 Witnesses (W1 to W2). W1 states a caregiver told him/her that R1 did not receive breakfast on 9/9/2025. Page 3 of 5 W1 states he/she doesn’t know if R1 received breakfast on 9/9/2025. W2 states he/she has no concerns with the care his/her loved one is receiving at the facility. Review of R1’s physician’s report dated 8/5/2025 notes R1 is not able to feed his/herself. Review of R1’s care plan dated 8/19/2025 notes no assistance with eating is noted as part of R1’s care plan. Staff did not dispense medication to resident as prescribed. On 9/24/2025 the Department interviewed Reporting Party (RP). RP states he/she did not observe and does have any additional information regarding if R1’s medications had been given as prescribed. On 9/25/2025 the Department interviewed 2 Staff (S1 to S2). 1 Out of 2 Staff state he/she give residents his/her medications as prescribed. S1 states he/she is not a Medtech and does not assist with resident’s medications. On 9/25/2025 the Department interviewed 4 Residents (R2 to R5). 3 Out of 4 Residents state he/she has no issues with his/her medications. R5 states he/she does not get his/her medications as prescribed or on time. R5 did not provide additional information regarding this incident. On 9/24/2025 the Department interviewed 2 Witnesses (W1 to W2). W1 states facility staff did not give R1’s medications because he/she ‘never saw a caregiver give R1 medications during evening and dinner times.” W1 states he/she visited R1 during the evening hours and did not see staff giving R1 medications. R1 states there were three medications (M1, M2, M3) not being given to R1. W2 states he/she has no concerns with the care his/her loved one is receiving at the facility. Review of R1’s Medication Administration Record (MAR) notes M1 and M2 were administered to R1 on 9/10/2025 to 9/14/2025. M3 was not listed on the R1’s list of medications prescribed by his/her physician. M3 was not listed on R1's Centrally Stored Medication and Destruction Record (CSMDR). Page 4 of 5 This agency has investigated the complaint alleging facility staff is not meeting resident incontinent needs, staff are not assisting resident with dressing, facility staff did not provide resident with assistance eating, staff did not dispense medication to resident as prescribed. We have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. An exit interview was conducted with ADM and a signed copy of this report was provided. Page 5 of 5 END OF REPORTthe state’s words, verbatim · CDSS document, Jan 30, 2026 · control 26-AS-20250919100035

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to conduct a case management visit to follow up on an incident report regarding an elopement. LPA met with Administrator Jasmine Latu and stated the purpose of the visit. On January 5, 2026, the Department received an Incident Report (IR) from the facility. The incident report stated, on January 4, 2026 at 9:55am, a staff member witnessed R1 come down the elevator to the lobby alone. Staff member redirected R1 to the elevator to return R1 to the memory care unit on second floor. On January 5, 2026, LPA Manuel Monter interviewed ADM. ADM stated the elevator in the 2nd floor works once a staff member punches in a code, then they can go down. ADM stated that day, a staff member had punched in a code for a family to go down. ADM stated she was informed afterwards by that family that the resident joined them as they were going in the elevator. ADM stated the staff member who imputed the code should have waited for the door to close before leaving the area, to ensure no memory care resident sneaks in. On January 11, 2026, The Department received an Incident Report regarding R1. The IR stated on January 12, 202, at 5:13am, R1 had eloped from the memory care 2nd floor. Staff heard the alarms from the staircase alerting someone had opened the door at 5:11am. Staff went downstairs and found R1 had made it downstairs and was in the parking lot. R1 was redirected back to the memory care unit. Page 1 Out of 3. On January 12, 2026, the Department received an Incident Report regarding Resident R1. The IR stated on January 11, 2026, at Approximately 4:00pm R1 eloped from the facility. Facility staff searched for R1 when they could not find R1 to take him/her to dinner at 4:00pm. The IR states, “R1 was seen last at the start of PM shift at 3pm. Care staff let movers down at 4:00pm and R1 had got on the elevator and able to make his/her way out of the facility with them.” R1 was found by local Law enforcement at 4:30pm and was found on Meridian and Moorpark. R1 was returned to the facility safely at 4:40pm. On January 14, 2026, LPA Manuel Monter interviewed Staff S1-S5. 5 Out of 5 Staff interviewed stated only the staff know the code. 5 Out of 5 Staff stated once they put in the code, they open the door, which leads to the elevator. 5 Out of 5 Staff stated once the visitors/family is inside, the staff person will close the door and ensure no memory care resident sneaks in/ wanders into the elevator. On January 14, 2026, LPA Manuel Monter interviewed ADM. ADM stated R1 was able to elope because, on January 11, 2026, there was movers, moving in a new residents things to the memory care. R1 was able to go down the elevator with the movers. ADM stated the procedures for the elevator is as follows: the staff member unlocks the door by imputing the code. Staff is supposed to watch who enters the elevator then close the door. ADM stated there are residents who will try to sneak into the elevator as it goes down. On January 22, 2026, LPA Manuel Monter interviewed Former Wellness Director (WD) Ann Lee. WD stated he/she did complete the initial assessment for R1. WD stated the facility was aware of R1's wandering and exit seeking behaviors. WD stated R1 did had elopement attempts at his/her previous facility R1 resided in. On January 22, 2026, LPA Manuel Monter interviewed staff S6 and S7. S6 stated on the day of R1's elopement, he/she didn't know where R1 was because he/she was helping other residents. S6 stated he/she doesn't remember the last time he/she saw R1. S6 stated at 4:00pm, the staff didn't know where R1 was. S6 stated he/she doesn't recall if there was movers coming in and out of the memory care that day. Page 2 Out of 3. S7 stated the day of R1's elopement, he/she wasn't sure what happened. S7 stated the last time he/she saw R1 was when he/she assisted R1 to his/her room. S7 stated he/she then went to assist another resident. S7 stated there was a family moving a residents belongings into the memory care unit that day. S7 stated he/she was not by the elevator that day and doesn't remember opening the elevator door for them. S7 stated around 4:00pm, during dinner time, they could not find R1. S7 stated that was when they discovered that R1 was no in the memory care unit. The Department reviewed R1's Sonnet Hill Observations. Note dated January 11, 2026 states, R1 was adamant about leaving the facility, stood by the elevators, were able to redirect R1 to the community area multiple times. R1 did go to his/her room around 3:00pm. Staff realized R1 no longer in bedroom around 4:00pm and staff searched for R1. R1 came back at 4:30pm, escorted by local law enforcement. Note dated January 12, 2026, at 5:10am, a care giver heard a faint alarm and staff went to see if R1 was in his/her room. When staff checked R1 was not in his/her room. Staff went down the stairs and exited onto meridian and the resident was there at the light. R1 was escorted back to the building at 5:13am. The Department reviewed facility Meeting agenda dated January 8, 2026. Under agenda details, elopement, it states, "be aware of your surroundings in memory care residents could be lurking around the corner waiting to see if they can catch the elevator to leave." The Department reviewed R1's Physician's Report, dated May 14, 2025. The report states R1 cannot leave the facility unassisted and R1 has a neurocognitive disorder. An immediate civil penalty of $500.00 is being assessed against the facility today for violation the absence of supervision, which resulted in R1 eloping from the facility. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. This report was reviewed with Administrator Jasmine Latu and a copy of the report was provided. Appeal Rights was provided. Page 3 Out of 3. END OF REPORT.the state’s words, verbatim · CDSS document, Jan 27, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(e)(5) · Plan of correction due date: Jan 28, 2026

87705 Care of Persons with Dementia (e) (5) Facility staff shall ensure the continued safety of residents if they wander away from the facility ... Personal Rights of Residents in Privately Operated Facilities. This requirement was not met as evidenced by; Based on investigation, on January 11, 2026 R1, who has a neurocognitive disorder, left the facility unassisted and was found by law enforcement unattended. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Administrator stated she will send a written plan of action on how the facility ensures residents with wandering behaviors will be kept safe. ADM stated the facility conducted elopement protocol training's for all staff on 1/19/2026. ADM stated she will send LPA documentation this training has taken place. ADM stated she will send the plan of correction by POC date January 28, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to conduct a case management visit to follow up on a medication error and a incident report regarding an elopement. LPA met with Administrator Jasmine Latu and stated the purpose of the visit. Medication Error On January 5, 2026 the Department received an Incident Report for a medication error of Resident R1 that occurred on January 2, 2026. The incident report states: on January 2, 2026, at approximately 5:21pm, a medtech noticed he/she gave R1, resident R2’s medication M1. The Med tech realized the error and contacted the regional nurse and executive director. Medtech contacted R1's physician and POA. On January 5, 2026 LPA Manuel Monter spoke to Administrator (ADM) Jasmine Latu. ADM stated the medtech made a mistake giving R2's meds to R1, because both of these residents have the same initials. ADM stated the medtech realized the mistake and informed the residents POA and physician. ADM stated the staff member has been retrained. The Department reviewed R1’s Physician’s Report dated September 19, 2025. The physician’s report states R1 is not able to administer his/her own medications and is not able to store his/her own medications. The Department reviewed R1’s ally comprehensive evaluation, dated December 11, 2025. Under medication, the form states, “staff will help the resident with taking their medication.” Elopement On January 12, 2026, the Department received an Incident Report (IR) regarding Resident R3. The IR stated on January 11, 2026, at Approximately 4:00pm R3 eloped from the facility. R3 was found by local Law enforcement at 4:30pm, and was found on Meridian and Moorpark. During today visit, LPA interviewed resident R3, and 4 staff members. At this time, this case in under review and the Department will conduct a follow visit , if warranted. A deficiency is being issued during today's visit, see LIC809D. An exit interview was conducted with Administrator Jasmine Latu and a copy of this report was provided. Appeal rights were also provided.the state’s words, verbatim · CDSS document, Jan 14, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jan 21, 2026

87411 Personnel Requirements - General (a) Facility personnel shall at all times be...competent to provide the services necessary to meet resident needs This requirement was not met as evidenced by Based on interviews conducted, on January 2, 2026, resident R1 was administered residents R2’s M1 medication. This poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 14, 2026

Plan of correction: Administrator stated the facility conducted an in-service for staff on medication training, for the medtech who made the mistake. ADM provided documentation of in-service training conducted on January 4, 2026.

Allegation investigated: Staff did not assist resident with toileting needs in a timely manner. Staff did not ensure resident’s room was maintained in clean condition. Staff did not ensure resident’s showering needs were met. Staff did not dispense medication to resident as prescribed.

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to deliver the findings of the complaint investigation that was received by the Department on 6/16/2025. LPA met with Administrator (ADM) Jasmine Latu. LPA stated the purpose of the visit. On 7/8/2025, LPA Tarin interviewed Reporting Party (RP). RP stated that the facility is not assisting resident (referred to as R1) with toileting needs in timely manner. RP stated he/she has observed R1 soiled while at the facility but did not provide additional information regarding these incidents. On 6/19/2025 and 9/25/2025 the Department conducted complaint visits to the facility and interviewed 5 Staff (S1 to S5), 13 Residents (R1 to R13) and 1 Witness (W1). Page 1 of 4 Unsubstantiated 8 Out of 13 residents state he/she does not require assistance with toileting needs. R5 and R7 states they do not know if staff assist with toileting needs. R6 and R8 state staff assist him/her with toileting needs. R13 did not respond to questions due to neurocognitive disorder. The Department interviewed 5 Staff (S1 to S5). 5 Out of 5 staff state he/she assists residents with their toileting needs. S1 states R1 has had toileting accidents, and staff will clean R1 immediately. S1 states R1’s responsible party was informed about R1’s toileting accidents in late April 2025/Early June 2025, when R1 had a toileting accident. S1 states R1 was cleaned by staff during this incident. The Department interviewed Witness 1 (W1). W1 states he/she does not have any concerns about the care his/her loved one is receiving at the facility. Review of R1’s physician’s report dated 7/7/2023, R1 can care for his/her own toileting needs. Review of R1’s care plan dated 6/18/2025 R1’s toileting assistance is three times per day, morning, noon and evening. Staff did not ensure resident’s room was maintained in clean condition. It has been alleged by the Reporting Party (RP) that R1’s room has ‘dirty laundry’ piled in the room, and staff are not washing the laundry. RP did not provide additional information regarding this incident. The Department interviewed 13 Residents. 7 Out of 13 Residents state the facility staff are cleaning his/her room. 5 Out of 13 Residents states he/she does not know how often staff clean his/her room. 1 Out of 13 Residents states he/she does not require assistance with cleaning his/her room. The Department interviewed 5 Staff (S1 to S5). 5 Out of 5 staff state resident rooms are being cleaned at least once a week, depending on the resident’s care plan. S1 states R1’s room is being cleaned multiple times a week, but it is not listed on R1’s care plan. S1 states R1’s agreement is for cleaning one time a week. Page 2 of 4 The Department interviewed Witness 1 (W1). W1 states he/she does not have any concerns about the care his/her loved one is receiving at the facility. Based on review of R1’s care plan dated 6/18/2025, states R1’s has ‘Spot Checks’ three times a day, morning, afternoon and evening. In addition, R1’s housekeeping and laundry assistance ‘0x, as needed.’ assistance ‘0x, as needed.’ On 9/25/2025 LPAs toured 22 resident rooms and observed all 22 rooms were clean and sanitary. Staff did not ensure resident’s showering needs were met. It has been alleged by the Reporting Party that R1’s showering needs were not met. RP did not provide additional information regarding this incident. The Department interviewed 13 Residents. 6 Out of 13 Residents state he/she does not need assistance with showering. R3, R6, R8 and R11 state staff are meeting his/her showering needs. R5 and R7 stated he/she does not know about showering needs, and R13 did not respond to the questions due to neurocognitive disorder. The Department interviewed 5 Staff (S1 to S5). 5 Out of 5 staff state resident’s showering needs are being met, residents are on a shower schedule. The Department interviewed Witness 1 (W1). W1 states he/she does not have any concerns about the care his/her loved one is receiving at the facility. Based on review of R1’s care plan dated 6/18/2025, states R1’s showering schedule as 1x per week on Monday, Wednesday and Friday. Review of Residents Shower schedule dated 6/6/2025 lists R1 on the shower schedule for Monday, Wednesdays and Fridays. Page 3 of 4 Staff did not dispense medication to resident as prescribed. It has been alleged by the Reporting Party (RP) that R1 was given the wrong medications and dosages for ‘almost 2 years.” RP states ‘for 22 months’ the facility did not update R1’s medications and doses from a third-party agency. The Department requested additional documentation regarding medications for R1, which RP did not provide. The Department interviewed 13 Residents (R1 to R13). 7 Out 13 Residents stated he/she has no concerns with receiving his/her medications. R2, R4, R8 and R9 state he/she does not need assistance with medications. R7 and R13 did not respond to questions due to neurocognitive disorder. The Department interviewed 4 Staff (S1 to S4). 3 Out of 4 staff state residents are receiving medications as prescribed. S4 states he/she is not a MedTech and does not know information about medications for residents. S1 states there was an incident in May 2025 involving a third-party agency for R1 requesting the facility adjusted R1’s medications. S1 states the third-party agency was told R1 needed a doctor’s order for any changes to medications. S1 state an updated medication order was received from R1’s physician after this incident. S1 states this incident was noted on R1’s progress notes. The Department interviewed Witness 1 (W1). W1 states he/she does not have any concerns about the care his/her loved one is receiving at the facility. Review of R1’s progress notes dated 6/19/2025 states on 6/10/2025 a third-party agency for R1 requested the facility change R1’s medication orders. On 6/11/2025 “new orders noted and carried out.” Review of R1’s medication dated 6/01/2025 to 6/30/2025 listed 4 medications updated on 6/11/2025. On 9/25/2025 LPA conducted a random medication audit of 3 residents. LPAs reviewed medication bottles with the centrally stored logs, no discrepancies were noted during the medication audit. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation are UNSUBSTANTIATED.. An exit interview was conducted, and a copy of this report was provided. Page 4 of 4 END OF REPORTthe state’s words, verbatim · CDSS document, Jan 8, 2026 · control 26-AS-20250616083704

Allegation investigated: Facility did not ensure safety of the residents resulting in questionable death(s). Facility staff did not provide care and supervision to residents resulting in injuries. Facility staff is not following infection control plan as required. Facility staff did not ensure that residents needs are met while in care. Facility staff did not maintain comfortable temperature for residents in care. Facility staff is not reporting incidents in a timely manner. Facility staff did not prevent resident from sexually harassing other residents while in care.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced visit to conclude the complaint investigation. LPA Tarin met with the Administrator, Jasmine Latu and stated the purpose of today’s visit. On 8/26/2025, the Department received a complaint with the above allegations. On 8/27/2025, the Department conducted an initial investigation at the facility. An additional complaint visit was conducted on 9/25/2025. It was alleged that the facility did not ensure safety of the residents, resulting in questionable deaths. Page 1 of 6 Unfounded The Department attempted to reach out to the Reporting Party (RP) to obtain additional information. The RP did not respond to the Department’s request for information. On 8/26/2025 the Department reviewed the facility death reports for the months of July and August 2025, with causes of death listed as degenerative disease of nervous system, senile degeneration of brain, cerebrovascular disease. No questionable deaths were noted during review. On 1/8/2025 the Department interviewed Administrator (ADM) Jasmine Latu. ADM states there have not been any questionable deaths for residents at the facility at any time. Facility staff did not provide care and supervision to residents resulting in injuries It was alleged that the facility did not provide care and supervision to residents resulting in injuries. The Department attempted to reach out to the Reporting Party (RP) to obtain additional information. The RP did not respond to the Department’s request for information. On 9/25/2025 the Department interviewed 7 Residents (R1-R7). 6 Out of 7 Residents stated he/she does not have any concerns about the care he/she is receiving. R3 did not respond to questions due to neurocognitive disorder. On 9/25/2025 the Department interviewed 3 Staff (S1-S3). 3 Out of 3 staff state he/she provides care and supervision to residents in care. On 9/25/2025 the Department interviewed 1 Witness (W1). W1 states he/she has no concerns about the care his/her loved one is receiving at the facility. On 8/26/2025 the Department reviewed the facility incident reports for the months of July and August 2025, with no reports that staff did not provide care and supervision to resident resulting in injuries. Page 2 of 6 Facility staff is not following infection control plan as required. It was alleged that the facility staff is not following infection control plan as required. The Department attempted to reach out to the Reporting Party (RP) to obtain additional information. The RP did not respond to the Department’s request for information. On 9/25/2025 the Department interviewed 7 Residents (R1-R7). 5 Out of 7 Residents stated staff wear gloves and masks. R1 states he/she did not know if staff wore gloves and masks. R3 did not respond to questions due to neurocognitive disorder. On 9/25/2025 the Department interviewed 3 Staff (S1-S3). 3 Out of 3 staff state he/she wears personal protective equipment (gloves, masks, gowns) and are following infection protocol. On 9/25/2025 the Department interviewed 1 Witness (W1). W1 states he/she has observed facility staff wearing gloves and masks. LPA Tarin reviewed the facility viral outbreak policy dated May 2022, which states in the event of a viral outbreak, the facility shall follow the Department of Health’s procedures. The policy also states during virus seasons and during a viral outbreak, staff will be wearing PPE which includes a mask, gown, shoe covers and gloves. Facility staff did not ensure that residents’ needs are met while in care It was alleged that the facility staff did not ensure that residents’ needs are met while in care. The Department attempted to reach out to the Reporting Party (RP) to obtain additional information. The RP did not respond to the Department’s request for information. On 9/25/2025 the Department interviewed 7 Residents (R1-R7). 6 Out of 7 Residents stated he/she does not have any concerns about the care he/she is receiving. R3 did not respond to questions due to neurocognitive disorder. Page 3 of 6 On 9/25/2025 the Department interviewed 3 Staff (S1-S3). 3 Out of 3 staff state he/she provides care to residents and assists with toileting, bathing and additional activities of daily living (ADLs). On 9/25/2025 the Department interviewed 1 Witness (W1). W1 states he/she has no concerns about the care his/her loved one is receiving at the facility. Facility staff did not maintain comfortable temperature for residents in care It was alleged that the facility staff did not maintain a comfortable temperature for residents in care. The Department attempted to reach out to the Reporting Party (RP) to obtain additional information. The RP did not respond to the Department’s request for information. On 9/25/2025 the Department interviewed 7 Residents (R1-R7). 6 Out of 7 Residents stated he/she did not have any concerns with the facility temperature. R3 did not respond to questions due to neurocognitive disorder. On 9/25/2025 the Department interviewed 3 Staff (S1-S3). 3 Out of 3 staff states the facility temperature varies depending on residents’ preferences. S1 states the facility temperature is set to 70 degrees, and residents can adjust the temperature in his/her own room. On 9/25/2025 the Department interviewed 1 Witness (W1). W1 states he/she has no concerns about the care his/her loved one is receiving at the facility. On 9/25/2025 the Department toured 22 random resident rooms and observed the thermostat in each room to be at 70 F. Review of the facility Temperature Policy dated 1/1/2025 room temperatures shall be always maintained between 68 F and 85 F, individual residents’ preference shall be considered, residents may request adjustments to their room temperatures as well. The facility will monitor room temperatures using calibrated thermometers. Page 4 of 6 Facility staff is not reporting incidents in a timely manner It was alleged that the facility staff is not reporting incidents in a timely manner. The Department attempted to reach out to the Reporting Party (RP) to obtain additional information. The RP did not respond to the Department’s request for information. On 8/26/2025 the Department reviewed the facility incident reports for the months of July and August 2025, and observed the facility is reporting incident reports per Title 22 regulation. Review of the facility’s “Reportable Events” Policy dated 1/2/2025 lists incidents and reporting time frames for incidents that are immediate (abuse, fire, elopement, etc) and reportable within 24 hours (any unusual incident report made to CCL), investigations. Facility staff did not prevent resident from sexually harassing other residents while in care. It was alleged that the facility staff did not prevent resident from sexually harassing other residents while in care. The Department attempted to reach out to the Reporting Party (RP) to obtain additional information. The RP did not respond to the Department’s request for information. On 9/25/2025 the Department interviewed 7 Residents (R1-R7). 6 Out of 7 Residents stated he/she does not have any concerns about the care he/she is receiving. R3 did not respond to questions due to neurocognitive disorder. On 9/25/2025 the Department interviewed 3 Staff (S1-S3). 3 Out of 3 staff state he/she was not aware of any incident of residents sexually harassing other residents. On 9/25/2025 the Department interviewed 1 Witness (W1). W1 states he/she is not aware of any residents or staff sexually harassing residents. On 8/26/2025 the Department reviewed the facility incident reports for the months of July and August 2025, with no reports of any residents sexually harassing other residents. Page 5 of 6 This agency has investigated the complaint. We have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided. PAGE 6 of 6 END OF REPORTthe state’s words, verbatim · CDSS document, Jan 8, 2026 · control 26-AS-20250826101236

Allegation investigated: Staff did not notify residents and responsible party of possible scabies outbreak.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Heath and Wellness Director (HWD) Ann Lee. On 09/19/2025 and 09/25/2025, LPA conducted investigation visit at the facility. LPA obtained the physician reports and appraisal needs and service plans of residents. LPA obtained the incident reports and the document that the facility notified residents and families of incidents. Continue on LIC9099-C. Page 1 of 3. Unfounded On 09/19/2025, LPA interviewed Executive Director (ED) Jasmine Latu. ED stated resident R1 and R2 lived in the same room in assist living unit. ED stated in May 2025, R1 was found with skin rash. ED stated the facility notified R1's family (FM). ED stated FM took R1 to see dermatologist. R1 was prescribed cream and ointment for the facility staff to apply on R1, it was not scabies. ED stated R2 did not have skin rash or itch. ED stated on 8/19/2025, R1 and R2 were feeling itchy and FM was notified. On 8/26/2025, R1 and R2 were diagnosed with scabies. ED stated R1 and R2 were applied doctor prescribed cream and ointment after diagnosis of scabies. ED stated R1 and R1 were quarantined in their room. ED stated Maintenance Director bought treatment machine for scabies to clean R1 and R2's bed and furniture on 8/26/2025. ED stated the facility washed R1 and R2's laundries and bedding with hot water. ED stated on 8/27/2025, the facility sent a formal notice to notify residents and families that the facility has two residents with scabies in one apartment. ED stated the staff wore PPE before entering R1 and R2's room. ED stated there are no other resident had scabies at that time period. ED stated the census of residents is 42 and the number of scabies positive cases is 2. It is not a outbreak. ED stated after the notice of scabies positive cases, at least 3 families took the residents (R1, R2, R3) to see dermatologist doctor and none of them was diagnosed scabies. LPA interviewed Health and Wellness Director (HWD). HWD stated he/she notified the family member of resident R1 around March 2025 that R1 had skin rash. HWD stated FM took R1 to see dermatologist doctor, and the doctor said it was no scabies. HWD stated the doctor prescribed some different ointments and creams for R1. HWD stated on 8/26/2025, R1 and R2 were diagnosed with scabies. HWD stated the doctor prescribed ointment, cream and pills for R1 and R2. HWD stated R1 and R1 were quarantined in their room. HWD stated there was no other resident had scabies at the time period. HWD stated R1 and R2 were out of quarantine on 09/03/2025. LPA interviewed two caregivers (S1, S2) who took care of R1 and R2. Both stated before 8/26/2025, there was no residents diagnosed with scabies. Both stated residents R1 and R2 were diagnosed scabies on 8/26/2025 and were quarantined at their room. Staff needed to wear PPE to enter R1 and R2's room during their quarantine. Both stated there was no other resident was diagnosed with scabies when R1 and R2 were diagnosed with scabies. Continue on LIC9099-C. Page 2 of 3. LPA interviewed a Med Tech S3. S3 stated before 08/26/25, there was no resident diagnosed scabies. S3 stated on 8/26/2025, resident R1 and R2 were diagnosed with scabies. S3 at that time period, there were no other residents diagnosed scabies except R1 and R2. S3 confirmed he/she only applied the ointment and cream for R1 and R2's scabies. LPA interviewed 6 residents. 6 out of 6 stated they do not have scabies and they do not know any other resident has scabies. On 09/25/2025, LPA interviewed 3 residents. 1 out 3 was unable to answer the questions due to neurocognitive issue. 2 out of 3 residents count not remember if the facility had a scabies outbreak. LPA interviewed a family member who visited the facility who stated he/she visits the facility often but was unaware of the facility had scabies outbreak. Based on the review of the facility incident reports sent to the Department, the facility did report two scabies positive cases of R1 and R2 on 8/26/2025. Based on the review of document and interview, the facility did not have a scabies outbreak and the facility notified the two scabies positive cases to CCL office, and to families. The Department has investigated the above allegations. Based on the investigation, record reviewed, and interviews conducted, the Department found that the above allegations are UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citation noted today. Exit interview was conducted with ED. The report was provided to ED for signature. A copy of the report was provided to ED. Page 3 of 3.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 26-AS-20250909203611

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management visit to amend the findings from unsubstantiated to unfounded for Complaint 26-AS-20250623094647. LPA met with Designated Administrator Johanna Moon. Administrator (ADM) Jasmine Latu is out of the office. No deficiencies were cited during today's visit per California Code of Regulations, Title 22. An Exit Interview was conducted with Designated Administrator Johanna Moon and a signed copy of this report and amended complaint 26-AS-20250623094647 were provided.the state’s words, verbatim · CDSS document, Oct 21, 2025

Allegation investigated: Staff are not following the universal precaution plan

Amended report 10/21/2025 to change finding from UNSUBSTANTIATED to UNFOUNDED Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint investigation visit to deliver the findings on the above allegation. LPA Tarin met with Administrator Jasmine Latu and stated the purpose of the visit. On 6/23/2025 the Department received a complaint alleging staff are not following the universal precaution plan. It has been alleged that the facility did not provide staff with gowns during a viral outbreak that occurred in March 2025. On 6/25/2025 the initial 10-day complaint visit was conducted. LPA Tarin interviewed 7 staff (S1 to S7) and 7 residents (R1 to R7). Unfounded Amended report 10/21/2025 to change finding from UNSUBSTANTIATED to UNFOUNDED All 7 out of 7 staff interviewed stated that the facility is following the facility’s infection control protocol, which includes providing staff with Personal Protective Equipment (PPE) such as gloves, masks and hand sanitizer. 6 Out of 7 staff state he/she is not aware of any viral outbreaks of illnesses at the facility. S7 states there was a viral outbreak of rashes at the facility in March 2025, and the facility did not provide gowns to staff. On 9/25/2025 LPA interviewed 2 additional Staff S8 and S9. S8 and S9 states the facility provides staff with PPE such as gloves and masks. LPA Tarin interviewed ADM. ADM states there were no viral outbreaks of rashes in March 2025. ADM stated in the event of a viral outbreak, the facility will follow the facility’s viral outbreak policy, and staff have access to PPE. LPA Tarin interviewed Residents R1 to R7. 3 Out of 7 residents state he/she has observed facility staff wearing PPE (gloves). 4 Out of 7 residents state he/she does not pay attention to whether staff are wearing gloves or masks. All 7 residents state he/she is not aware of any outbreaks of illnesses at the facility. LPA Tarin inspected 2 supply rooms located on the second and third floor of the facility. LPA Tarin observed 2 Out of 2 supply rooms with PPE supplies to include but not limited to gowns, masks, gloves, hand sanitizer, and shoe covers. LPA Tarin reviewed the facility viral outbreak policy dated May 2022, which states in the event of a viral outbreak, the facility shall follow the Department of Health’s procedures. The policy also states during virus seasons and during a viral outbreak, staff will be wearing PPE which includes a mask, gown, shoe covers and gloves. LPA Tarin reviewed Incident Reports for February to July 2025, and did not observe any reports of a viral outbreak at the facility. This agency has investigated the complaint alleging Staff are not following the universal precaution plan. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 26-AS-20250623094647

Allegation investigated: Facility staff did not properly maintain centrally stored medications. Facility staff did not maintain accurate medication records for residents

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator, Jasmine Latu and stated the purpose of today’s visit. On 6/30/2025, the Department received a complaint with the above allegations. On 7/10/2025, the Department conducted an initial investigation at the facility. Continuation on LIC 9099-C, Page 1 of 3. Substantiated Page 2 of 3. Facility staff did not properly maintain centrally stored medications. / Facility staff did not maintain accurate medication records for residents. It was alleged that the facility staff do not maintain medications. It was alleged that the facility staff do not record resident’s medications on the centrally stored medication log. On 7/10/2025, the Department interviewed 2 staff (S1-S2). Two out of two staff stated there are no issues with properly maintaining centrally stored medications. Two out of two staff stated they have not seen or heard staff express issues with medication management. Two out of two staff stated there are no issues with the residents’ centrally stored medication log. Two out of two staff stated the staff initial their names next to the medication they have logged on the document. Based on review of residents’ records at random, 4 out of 4 resident’s LIC 622 Centrally Stored Medication and Destruction Record were not maintained accurately to document the start date of a medication and/or medication was not recorded. LPA Rai reviewed R1’s LIC 622 and observed 3 out of 4 medications were not recorded accurately, which included start dates were not written to the corresponding medications that were administered to the resident. LPA Rai reviewed R2’s LIC 622 and observed 5 out of 7 medications were not recorded accurately, which included start dates were not written to the corresponding medications that were administered to the resident. LPA Rai reviewed R4’s LIC 622 and observed 10 out of 12 medications were not recorded accurately, which included start dates were not written to the corresponding medications that were administered to the resident. LPA Rai reviewed R3’s LIC 622 and observed 5 out of 12 medications were not recorded accurately, which included start dates were not written to the corresponding medications that were administered to the resident. During the inspection of R3’s room, LPA Rai observed 7 out of 12 medications in the resident’s room, accessible to the resident. Based on review of R3’s Physician’s Report dated 5/19/2025, R3 cannot administer and store medications. S2 was present during the inspection of R3’s room and S2 stated they will assess resident and obtain physician’s order for R3 to administer and store medications. Page 3 of 3. Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. On 7/11/2025, LPA Rai cited deficiencies from California Code of Regulations, Title 22 87465(h)(2) and 87465(a)(4) under Incidental Medical and Dental Care. Plan of Correction was submitted in a timely manner. During today’s visit, LPA Rai cited deficiencies from California Code of Regulations, Title 22 87465(h)(6) under Incidental Medical and Dental Care regarding the facility staff did not maintain accurate medication records, such as LIC 622 Centrally Stored Medication and Destruction Record for 4 out of 4 resident records. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Administrator, Jasmine Latu and a copy of the report was provided. Appeal Rights were provided. Page 2 of 3. Licensee did not ensure sufficient staffing to assist residents with medications. It was alleged that the facility does not have a staff trained to administer medications during the night shift (10pm-6am). On 7/10/2025, the Department interviewed 2 staff (S1-S2). Two out of two staff stated the facility staff assigned to administer and manage medications are called Medication Technicians (Med-Techs). Two out of two staff stated there are 2 Med-Techs in the Am shift (6am-2pm), 2 Med-Techs in the PM shift (2pm-10pm) and 1 Med-Tech in the night shift (10pm-6pm). S2 stated he/she has worked as a Med-Tech to cover shifts and S2 will ensure all shifts are covered. Based on review of staff schedule for 4/1/2025-06/30/2025, there was at least one med-Tech scheduled each day for AM shift, PM shift and night shift. LPA Rai did review S2 covered Med-Tech shifts certain days of the month. Licensee did not ensure staff dispensing medication to residents was appropriately trained. It was alleged that the facility staff are not trained to administer medications. On 7/10/2025, the Department interviewed 2 staff (S1-S2). Two out of two staff stated the Med-Techs are provided 8 hours of theory training and 16 hours of shadow training. S2 stated there is additional training for staff in necessary. On 7/10/2025, LPA Rai obtained staff training records at random for 3 Med-Techs. On 8/27/2025, LPA Rai obtained staff training record at random for additional 3 Med-Techs. Based on review of staff training for 6 staff (S1-S6), 6 out of 6 staff have obtained training necessary for administering medications to residents. The training topics provided to staff included but not limited to “Basics of Medication Management”, “Medication Documentation for California”, “Providing Medication Assistance – California” and “Documenting Medications”. Page 3 of 3. Facility staff did not safeguard the confidentiality of residents’ records. It was alleged that the facility staff did not safeguard the confidentiality of residents’ records which are kept in binders accessible in residents’ rooms. On 7/10/2025, the Department interviewed 2 staff (S1-S2). Two out of two staff stated the resident’s records are in the office which is locked. Two out of two staff stated the electronic medication record (EMR) is updated with all the resident forms. S2 stated the hospice binder is located in the resident’s rooms. On 7/10/2025, LPA Rai toured the resident rooms at random, 2 out of 2 residents under Hospice services had binders in their rooms. LPA Rai reviewed the documents in the binder and they were documents with resident’s information. LPA Rai observed that both rooms were locked. S2 stated the residents’ rooms are locked from the outside and the perspective residents and the facility staff have access to the locks. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator, Jasmine Latu and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 26-AS-20250630103510

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: Sep 3, 2025

87465 Incidental Medical and Dental Care(h)(6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year... This requirement was not met as evidenced by: Based on record review, interview and observation, Licensee did not ensure 4 out of 4 resident records of centrally stoed prescription medications were maintained which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure record of centrally stored prescription medications for each resident is maintained by POC due date. Administrator agreed and understood.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management to address deficiencies observed during today's complaint visit. LPA met with Administrator, Jasmine Latu and stated the purpose of the visit. During today's visit, LPA Rai observed 3 resident rooms (R1-R3) with Health and Wellness Director (HWD) Ann Lee. At 1:03pm, LPA Rai and HWD entered R1's room and observed centrally stored medications and over the counter medications on the kitchenette counter and cabinet below. HWD stated she was not aware of the medications R1 kept in the cabinet. R1 showed medications placed in a 7-day medication storage. Based on review of R1's Physician's Report dated 5/19/2025, R1 cannot administer and store own medication. HWD confirmed R1 does not have physician's order on file to allow R1 to administer or store own medication and facility staff did not assess resident to ensure residents’ safety would not be at risk if allowed access to store own medications. At 1:10pm, LPA Rai and HWD entered R2's room and observed expired prescription topical cream on a bookshelf near the room's entrance. LPA Rai observed PRN medication on another bookshelf near the room's entrance. LPA Rai observed laundry/cleaning solution on the floor near the room's entrance. HWD stated the facilty staff assist with administer resident's medication and R2 should not have access to medication. HWD immediately removed the expired medication and PRN medication. HWD stated Hospice agency aide and family assist with R2's laundry therefore they use the laundry/cleaning solution which is located in the room. HWD stated the laundry/cleaning solution will be kept inaccessible to resident in the resident's room. Based on review R2's LIC 602A Physician's Report dated 6/19/2023, R2 is not able to administer or store own medications. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. At 1:21pm, LPA Rai and HWD entered R3's room and did not observe any medications or chemicals accessible to resident in care. Deficiencies were cited at this time as per California Code of Regulations, Title 22, please see LIC 809-D. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Administrator, Jasmine Latu and a copy of the report was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jul 10, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 11, 2025

87465 Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on observation, record review and interview, the facility staff did not assist R1 with medications as needed when LIC 602A states R1 is not able to administer or store own medication which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure R1 is assisted with medications by POC due date. Administrator agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(4) · Plan of correction due date: Jul 11, 2025

87465 Incidential Medical and Dental Care (h)(4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.This requirement was not met as evidenced by: Based on observation, and record review, the facility staff did not discard R2's medication after expiration date and was still present in R1's room which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure medications are not expired and discarded after date stated on prescription by POC due date. Administrator agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jul 11, 2025

87465 Incidental Medical and Dental Care (h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observation and record review, R2 medications were accessible to R2 who is not able to store own medication which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure centrally stored medications are kept in a safe and locked place inaccessble to residents in care by POC due date. Administrator agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Jul 11, 2025

87309(a)... the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances...which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation and record review, laundry/cleaning solution was observed in R2's room left unattended outside of locked storage which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure cleaning solutions are in locked storage and not left unattended by POC due date. Administrator agreed and understood.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Administrator (ADM) Jasmine Latu. On 7/8/2025, the Department received a death report regarding a resident R1. On 7/9/2025, LPA interviewed ADM. ADM stated resident R1 moved in the facility memory care unit room #206 on 5/16/2025. ADM stated R1 is not on hospice care. ADM stated R1 lives in a single room and without 1:1 private caregiver. ADM stated on 7/3/2025 early morning around 3:24AM, NOC shift caregiver S1 and Memory care Director (S2) were in command station area in memory care unit. ADM stated S1 and S2 heard a big bang. S1 and S2 searched for the source of the big noise, and found R1 was on the floor near the kitchenette in R1's room. ADM stated S1 and S2 called 911 immediately, and R1 was sent to hospital. ADM stated S1 and S2 notified R1's family. ADM stated on 7/6/2025, the facility received a notice from R1's family that R1 died around 7:45AM on 7/6/2025, Sunday, in hospital. FM stated R1's cause of death is internal brain breeding. ADM stated R1 has the disease specified in the physician report dated 4/30/2025. ADM stated on 7/5/2025, R1's family (FM) told him/her the hospital doctor told FM that R1 needs surgery for the internal brain bleeding, but R1 was too weak to go through the surgery. The hospital doctor stated R1 cannot survive more than 24 hours if R1 does not receive the surgery for internal brain bleeding. LPA requested R1's physician report, appraisal needs and service, unusual incident report, and internal incident report. Continue on LIC809-C. Page 1 of 2. LPA interviewed staff NOC shift caregiver S1 and Memory care Director S2. Both stated on 7/3/2025, around 3:24AM, they were in the memory care unit and heard a big bang. They went to resident R1's room and found R1 was on the floor near the kitchenette in R1's room. S1 stated he/she observed R1 had bleeding on the right arn but did not see bleeding on R1's head. S1 called 911 immediately and S2 prepared R1's red folder. R1 was sent to hospital. S1 called R1's family and left message, and notified the facility nurse and ADM. Both S1 and S2 stated this is R1's first fall incident. ADM stated the facility sent R1's incident report to CCL office on 7/3/2025 and R1's death report to CCL office on 7/8/2025. This case needs further investigation. Exit interview was conducted with ADM. The report was provided to ADM for review and signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Jul 9, 2025

Allegation investigated: Staff did not provide medical records to authorized representative

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator, Jasmine Latu and stated the purpose of today’s visit. On 05/24/2024, the Department received a complaint with the above allegations. On 05/31/2024, the Department conducted an initial investigation at the facility. It was alleged a written request by the resident’s authorized representative was submitted to the facility on 4/26/2024 via email. On 5/31/2024, LPA Rai interview Administrator (ADM). ADM stated they received a subpoena request on 05/21/2024 to request the documents requested. ADM stated their management team sent the documents during the requested time frame. Continuation on LIC 9099-C, Page 1 of 2. Substantiated Page 2 of 2. Based on records of email communication between the authorized representative and the facility staff, the initial written request was submitted by resident’s designated representative via email on 4/26/2024 and a follow up email was submitted on 05/3/2024 and 05/9/2024, 5/14/2024, 5/15/2024 and 5/20/2024. On 5/21/2024, the requestor has spoken to Business Office Manager to obtain requested records. On 5/22/2024, the requestor emailed the Business Office Manager and did not receive a response. On 5/24/2024, the requestor emailed the Business Office Manager and notified them of not receiving a response. On 5/28/2024, 7 days later, Business Office Manager responded to the email to give them an update but did not provide the documents requested by written notice. Based on records of email confirmation of submission of documents, the facility staff uploaded the records on 6/6/2024. Based on record of 2nd Follow Up Letter regarding the request of records was sent on 5/31/2024 which asked for facility staff to contact them to confirm they are in the process of preparing the requested documents. Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrator, Jasmine Latu and a copy of the report was provided. Appeal Rights was provided.the state’s words, verbatim · CDSS document, May 15, 2025 · control 26-AS-20240524161555

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: May 22, 2025

87468.2 (a)(2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not met as evidenced by: Based on record review and interview, Licensee did not make available the requested records when resident’s designated representative made a written consent which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 15, 2025

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure records shall reveal or made available confidential information upon the resident’s and/or resident’s designated representative’s written consent by POC due date. Administrator agreed and understood.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit to follow up on subsequent visit made on 7/5/2024 regarding resident (R1) who left the facility and passed away outside of the facility. LPA Rai met with the Administrator, Jasmine Latu and stated the purpose of today’s visit. LPA Rai was investigating R1's death which occurred outside of the facility and was not in hospice services. Based on R1's death certificate, R1's cause of death was probable complication of an existing health condition. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Jasmine Latu and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 15, 2025

Type of visit: Required - 1 Year

On 5/15/2025, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator, Jasmine Latu. LPA explained the purpose of the visit. LPA toured the facility inside and a random sample of resident rooms, common areas, and kitchen area. LPA observed some residents were in the activity rooms. While touring the facility it was observed that the temperature was at 70 deg F. Hot water was also tested in the resident rooms and the temperature was at 105 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Facility has sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are done every month. Six resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA received the following documents, Certificate of Liability Insurance & LIC500. No deficiencies are cited at this time. Report is reviewed and a copy is provided.the state’s words, verbatim · CDSS document, May 15, 2025

Allegation investigated: Facility staff are not providing resident's records to responsible party.

On 1/10/2025, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Health Welness Director (HWD) Dominique Frommo and LPA explained the purpose of the visit. Regarding the Facility staff are not providing resident's records to responsible party, RP stated that he/she is asking for the medication administration record and they are not providing it. They're only providing a list of R1s medication. RP asks the nurse for records of R1s fall but they're not providing it. They're not giving the incident reports. LPA was able to obtain email correspondence between management and RP. The records requested were provided to RP. Based on records review, the department has determined that that the allegation was false, could not have happened and/or is without a reasonable basis, therefore the allegation is UNFOUNDED. Report is reviewed and copy is provided. Unfoundedthe state’s words, verbatim · CDSS document, Jan 10, 2025 · control 26-AS-20231012081055

Allegation investigated: Resident was locked in room. Staff did not administer resident's medication. Resident left in soiled diaper for an extended period of time.

On 1/10/2025, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Health Welness Director (HWD) Dominique Frommo and LPA explained the purpose of the visit. Regarding the allegation of resident was locked in a room, reporting party (RP) stated that the resident (R1) had taken a rapid decline and was locked in his/her room. Not bolt locked, but R1 can’t move without assistance. LPA Donato interviewed HWD and it was stated that the rooms are not locked. Staff lock the doors when residents are out on the floor to prevent other residents from roaming inside the rooms. Residents are also able to lock it themselves if they are cognitive enough to do so. page 1 of 2 Unsubstantiated Regarding the allegation that staff did not administer resident's medication, RP stated that R1 had been given lunch but no lunchtime medication. They had to go around that floor to find someone and they found the floor assistant who had to give my R1 the lunchtime meds at request. LPA interviewed two staff members. Both S1 & S2 mentioned that residents are given medications on a timeframe of at least 2 hours. S1 explained to LPA that in the morning the med pass happens between 7-9am. Around lunch it happens between 11am-1pm. They give the medication during lunch time. In memory care they start lunch at 11. Regarding the allegation of resident left in soiled diaper for an extended period of time, RP shared that R1s diaper had not been changed since the night before. RP is not sure the condition R1s diaper, but it was clear R1 hadn’t been changed properly for the morning. According to S2, they are at least scheduled to do round every 2 hours to check on residents. If in between they notice that residents need changing then they assist the resident. If a resident was left in soiled diapers and the next shift notices it they report it to management so it will be addressed. Based on interviews, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Jan 10, 2025 · control 26-AS-20220207152732

Allegation investigated: Administrator does not designate a substitute during absence from facility. Administrator is not on the premises a sufficient number of hours. Facility is not training staff

On 12/19/2024, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director Jasmine Latu and LPA explained the purpose of the visit. Regarding the allegation of administrator does not designate a substitute during absence from facility, Reporting Party (RP) stated that this facility currently lacks leadership, and the new Executive Director, left for vacation last week and did not designate someone to cover. RP stated that for about a week this facility has been like a "ghost ship", and that the only staff there right now are the caregivers and the concierge person (and someone in accounting) - so - there is nobody providing managerial oversight and handling complaints or would know what to do "if something comes up". page 1 of 3 Unsubstantiated LPA Marrufo was able to interview nine staff members. All mentioned that if the administrator is not in the building then it will be the other directors or managers on duty who will be in charge. S2 mentioned that they would go to the Memory Care Director (MCD), Marketing Director or Business Office Director. It was communicated to S2 in person who to reach out too. S3 stated that they go to their immediate supervisor. S3 also shared that here (the facility) is like a family, when someone is not here, everyone is working together. S5 said that they have always been good, shared that they have never worked a day when the director wasn’t here. It is always a given that someone is here. S4 mentioned that it was never shared to him/her who was in charge of the whole facility when the administrator is gone but did mention that they go to the MCD. During the interviews, there were eight residents that were asked. R1 & R2 mentioned that the current administrator stepped up but they don’t remember if it was communicated to them who’s in charge if there is no administrator. R2 also shared that they have never experienced a time when there was no one in charge of the facility. They always get here. R8 said that there was a change in management but doesn’t know their name. R3, R4, R7 said they don’t know who’s in charge because it has never come up. R5 didn’t want to be interviewed. R6 is not able to answer due to cognitive issues. Based on records review, there were 5 people who has a designation of facility responsibility when Licensee or Administrator is not available. The current administrator was also appointed by the board on July 1, 2022. Regarding the allegation of Administrator (ADM) is not on the premises a sufficient number of hours. During the staff member interviews, seven staff members mentioned that they see the administrator every time they work. S1 said that he/she doesn’t know what time the ADM comes in due to the start time, but when S1 comes in the ADM is already in the facility. There are times when S1 leave and ADMs car is still there. ADM is still available on call in the evenings. If there are issues S1 reaches out and ADM always picks up. page 2 of 3 S2 said that they know ADM works in the mornings. S3 stated that ADMs work schedule is maybe 9 AM until 5 PM. ADM is here almost 5-6 days in a week. I am not completely sure. S4 shared that his/her shifts always used to change. The only time S4 would notice ADM gone would be maybe the weekends, but that was just the weekends. S5 mentioned that ADM is in the facility usually, 9-5. Give or take a few hours. If an emergency or something happens, they are here. When S5 comes here, they are maybe here 30 minutes before. For the allegation that Facility is not training staff, LPA Marrufo was able to obtain staff training records. 5 staff member have current CPR/AED/ First Aid Training, 6 staff showed 4 hours of Dementia Training. During the interviews, S1 shared that when he/she first got hired, the training received from the old nurse was not very much I felt like. Now, S1 is doing the training that should have done months ago, which is through Relias. The whole staff is doing that now. S7 mentioned that they have done first aid, dementia training, and fire drill training. S8 stated that they received hands on training by the old nurse. That was mostly hands on and watching videos. This new nurse just left and told us we had to train on Relias on our downtime because we have been pretty busy and haven’t been able to train. We went through 4 hours of med training where we check the meds 3 times and logging it into point click care after we give the medicine. The people who hand out the meds are supposed to use the point click care systems. If a care giver was trained by the nurse, then the care giver is supposed to be able to use the point click care system. Based on interviews and records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 26-AS-20220718113427

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87467(a) · Plan of correction due date: Dec 20, 2024

87467 Resident Participation in Decisionmaking (a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility. This was not met as evidenced by: Based on records review, 7 out of 7 resident files reviewed does not have a needs and services plan, which poses an immediate health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Dec 19, 2024

Plan of correction: Licensee has already updated all needs and services plans of residents when the new ED took over.

Allegation investigated: Facility staff left a resident outside for an extended amount of time.

On 12/19/2024, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director Jasmine Latu and LPA explained the purpose of the visit. Regarding the allegation of facility staff left a resident outside for an extended amount of time, Reporting party (RP) stated that when he/she arrived at about 3 PM and found resident (R1) outside in the sun slightly unresponsive. RP stated that a staff member (S8) disclosed that R1 was outside on the second-floor porch a little after lunch about 12:30 PM. RP reported that staff came and brought R1 inside to attend to him/her and provided water and medical attention by staff. Additional information was provided by S8 stating that R1 was left outside in the sun from 1pm-3pm due to staff neglect. S8 was unable to provide exact date. page 1 of 2 Substantiated LPA Dolores interviewed eight staff members. S1 mentioned that R1s favorite thing to do is to go in the balcony and sit in the sun. R1 gets cold easily and likes to sit out in the sun. When RP came to visit around 1pm, he/she came and asked where R1 was. They found out R1 was out in the sun for 1 hour and 20 minutes, approximately. Staff member S2 mentioned that they're only supposed to let R1 sit under the sun for 8 - 10 minutes maximum. S4 said that they don’t put R1 outside for more than 15 minutes. S3 shared that he/she doesn’t remember how hot it was but knows it was a hot sunny day. S3 doesn’t know how long R1 was left outside for. From what it looks like, it looked like R1 was outside for an hour. When R1 goes out there he/she is not supposed to be out there for more than one hour. That day no one noticed R1 because he/she was sitting in the rocking chair facing east [next to a pillar] and next to the railing. S6 shared another staff S8 found R1 outside. It was 71 degrees that day and R1 was outside for 45 minutes. S7 stated that usually the direction for R1 to be outside in the sun is about 15 – 20 minutes. The residents sit out in the balcony where you see them. R1 can be under the sun for 15-20 minutes, then they move R1 towards the window where there is more shade. Based on observation, during LPA Dolores’ visit to the facility, the balcony has shade above but parts of the balcony was sunny. LPA observed the area where R1 was found sitting on the balcony, was sunny around 11:00am. Based on the temperature of LPAs apple watch it was 71 – 72 degrees outside. LPA sat under the sun for about 5 minutes and felt very warm and uncomfortable. LPA decided to move to a shaded area. Based on records review, according to WeatherUnderground.com archived records, the recorded temperature on the date of the incident, 10/11/2023 was 73 degF from 11:53am to 3:00pm. Based on interviews and observations, there is preponderance of evidence to prove the alleged violations did occur; therefore, the allegation is SUBSTANTIATED. Deficiencies were cited as per California Code of Regulations Title 22. See LIC9099-D for more information. This report was reviewed a copy of the reports and appeal rights were provided. Page 2 of 2the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 26-AS-20231012081055

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 19, 2024

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: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was not met as evidenced by, based in interviews & records review, R1 was left outside the balcony of the facility for a long period of time exposing R1 to high temperatures, which poses an immediate health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Dec 19, 2024

Plan of correction: Licensee has already corrected this deficiency by updating the needs and services plan of the R1 refelecting minimal sun exposure during the day. Licensee has also advised and reminded staff to be aware of R1s whearabouts inside the facility.

Allegation investigated: Resident sustained a fracture due to staff neglect. Facility staff handled resident in a rough manner. Facility staff forced resident to eat. Facility staff did not shower resident. Facility staff did not assist resident with dressing. Facility staff did not assist resident with dental hygiene.

On 12/19/2024, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director Jasmine Latu and LPA explained the purpose of the visit. Regarding the allegation of resident sustained a fracture due to staff neglect, Reporting Party (RP) stated there are several residents on the 2nd floor who have been "neglected" by staff. Resident (R1) fell and broke his/her hip because staff "allowed R1 to wander". RP stated, "R1 does this (wander) if you don't watch R1". RP noted R1 was in great pain after R1 returned from the hospital when the RP was changing R1s diaper. LPA Chiang interviewed four staff members. Staff (S1) mentioned that he/she saw R1 fall in the hallway to the activity room. S1 stated he/she called Memory care coordinator immediately. S1 stated he/she was near R1 and saw R1 almost falling. S1 stated he/she tried to catch R1 but unsuccessful. page 1 of 3 Unsubstantiated S2 shared that R1 was walking in the hallway to the activity room and fell due to trapping on R1s shoe. S2 stated R1 was active and did not know he/she was unbalanced in walking. S2 stated R1 always likes to walk by himself/herself. S2 also mentioned R1 had a fall in his/her bedroom. R1 had a bed alarm sounded and staff came to check immediately. S2 stated staff called 911 and R1 was sent to hospital. S2 and S4 stated staff check residents every two hours. S3 also mentioned that they set up a bed alarm for R1 after R1s fall in October 2023 and arranged a staff to sit in the second floor (memory care unit) where they can directly monitor R1s bed alarm and the door of R1s bedroom. Based on records review, R1 is an ambulatory resident in memory care. On the facility’s evaluation, it was determined under the criteria of mobility that R1 requires stand by assistance into/out of shower for safety reasons. Regarding the allegations of facility staff handled resident in a rough manner and facility staff forced resident to eat, RP observed that a staff grabbed the resident (R2) by the arm and pulled R2 out of his/her wheelchair and forced R2 to eat. According to staff interviews, S1 stated he/she does not know R2. S1 stated he/she helps to feed residents in dinner. S1 denied that he/she forced resident to eat or handled resident in rough manner. S1 stated usually only 2 or 3 residents need to be fed. S3 shared that there are 4 caregivers in the dining room during the mealtime and always two caregivers to help feed the residents. S3 stated caregivers try to feed residents in a gentle manner but resident might try to approach to the food by themselves while caregivers try to feed residents in an unstable way. S4 stated he/she never saw staff handling residents in rough manner. LPA Chiang also interviewed six residents. R3 stated the facility staff are kind to him/her. R3 stated the facility never handled him/her in a rough manner or force to do anything. R4 and R5 stated that they are able to feed themselves. R8 stated he walks to dining room to eat by himself. All residents mentioned that they did not see or hear staff handling residents in a rough manner. page 2 of 3 Regarding the allegations of facility staff did not shower resident and staff did not assist resident with dressing, RP stated that S5 is the only staff who ever showers and dresses R9. During the resident interviews, R3, R4 and R6 stated they receive 2 showers per week and that caregivers help them dress every day. R6 stated he/she does not need to have more shower per week because he/she does not sweat. R5 stated he/she can have shower whenever he/she wants and has no problem for personal hygiene and staff also helps in dressing. R7 stated he/she has 3 showers per week and needs staff assist for showering. R8 stated that staff helps in dressing every day. According to staff members, S2 and S3 mentioned residents get 2 showers per week. S2 also said that if residents need more showers per week, then either the care level changes or needs extra charge. There is also rotation of assignment among care staff every week, meaning staff will be assigned a different resident to provide care for on a weekly basis. This is to allow staff to get to know all the residents under their care. For the allegations of facility and staff did not assist resident with dental hygiene, RP stated that staff make R10 wait to be fed until everyone else has eaten and then they do not brush the teeth afterwards. RP stated R10 “has gone days with leftover food stuck in his/her teeth”. RP also stated R10 has “swollen, bleeding gums” because of it. Based on records review, R10 did have a medical condition that makes it hard for the resident to open his/her mouth wide and responsible parties are aware and even go to the facility everyday to help assist. Even with this condition, R10 is still provided proper dental hygiene. According to resident interviews, R3, R5 and R8 mentioned that staff helps them brush their teeth. R4, R6 & R7 mentioned that they can brush their own teeth. During staff interviews, S3 mentioned that memory care unit residents get mouth care every day in the morning and assisted living unit resident does not need help for mouth care. S4 stated caregivers provide help for all resident's ADLs. Based on interviews, the department has determined that although the allegations 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 allegations are UNSUBSTANTIATED. Report is reviewed and copy is provided. page 3 of 3the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 26-AS-20231102122245

Allegation investigated: Facility staff were not following infection protocol during the COVID outbreak.

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Health & Wellness Director Dominique Frommo. On August 14, 2024, the Department received a complaint alleging Facility staff were not following infection protocol during the COVID outbreak. It has been alleged facility staff did not wear masks during a covid outbreak. On August 23, 2024 and December 4, 2024, LPA Manuel Monter interviewed Staff S1-S4, S7. All staff interviewed stated the facility is following covid protocols. All staff interviewed stated the facility did the following during a covid outbreak, which included but not limited to, wearing masks, using hand sanitizer, delivering meals to resident bedrooms, isolating covid positive residents and staff. Page 1 Out of 2. Unfounded LPA Monter interviewed ADM. ADM stated the facility provided To go boxes and disposable containers with food, for covid positive residents. ADM stated All staff were wearing masks and automated machines were in the 2nd and third floor. ADM stated Housekeeping, had disinfectant sprays as well. ADM stated they tested the whole community and staff. ADM stated covid positive staff were isolated. ADM stated they Contact family and contact their doctors. ADM stated they Test residents every 3 days. LPA Monter interviewed residents R2-R9. 1 Out of 9 residents (R2) stated he/she doesn’t know what the facility did during a covid outbreak at the facility. 2 Out of 9 residents (R4, R7) stated they did not want to be interviewed. 5 Out of 9 residents (R3, R5, R6, R8, R9) stated they observed staff wearing masks during a covid outbreak. On October 22 & November 12, 2024, LPA Monter interviewed staff S5 and S6. S5 stated the facility provided mask and hand sanitizer. S5 stated staff were masks during an outbreak. S6 stated he/she isn’t comfortable answering the question and stated she does not want to answer. Based on a review of the facility’s infection control plan dated May 2022, the facility shall follow their county’s department of health instructions. The Policy also states staff will wear masks during the virus season/ viral outbreak. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 2 Out of 2. END OF REPORT. On October 22, 2024, LPA Monter interviewed Staff S5. S5 stated he/she was working the night shift when R1 had fallen on August 13, 2024. S5 stated he/she and S6 were assisting a resident on the third floor, who needed assistance. S5 stated later that night R1's family member came to the facility and informed S5 and S6 that R1 had been on the floor for hours. S5 stated he/she ran upstairs to check on R1 and assisted him/her up. On November 12, 2024, LPA Monter interviewed staff S6. S6 stated he/she was working the night shift when R1 had fallen on August 13, 2024. S6 stated he/she could not provide any details on what had occurred that night. S6 confirmed that R1 has the behavior of getting up at night 3-4 times at night. Based on a review of R1’s care plan dated March 18, 2024. states R1 is a moderate fall risk- meaning R1 requires direct interventions that are customized to the identified risk factors. The care plan also states R1 needs standby assist with transferring, and R1 uses a walker to ambulate and has an occasional disturbed sleep pattern. This form states R1 requires status checks every 2 hours at night. Based on a review of R1’s Physicians Report, dated September 20, 2023, R1 has a neurocognitive disorder. R1 is also a risk for falls if unattended. Based on a review of evidenced provided, R1 was last seen by facility staff on August 12, 2024, at 11:21pm. Resident R1 fell on the floor, in his/her bedroom, on August 13, 2024, at 12:19am. Facility staff returned to R1’s bedroom and picked R1 up on August 13, 2024, at 3:47am. The Department has investigated the above allegation. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. This report was reviewed with Health & Wellness Director Dominique Frommo. A copy of the report & appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 16, 2024 · control 26-AS-20240814112117

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 17, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(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 was not met as evidenced by: Based on interviews conducted & evidence reviewed, R1 care plan states R1 requires status checks every 2 hours at night. R1 was last seen on 08/12/24 at 11:21pm and was check on again on 08/13/24 at 3:47am the following day. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 16, 2024

Plan of correction: ADM stated she will send a written letter of understanding, explain how she will ensure the facility will ensure it will meet the care, supervision and services that meet the needs of the residents.

Allegation investigated: Staff are not addressing resident's rash timely.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Executive Director (ED) Jasmine Latu. On 4/15/2024, the Department received a complaint with the allegation that staff are not addressing resident's rash timely. On 4/15/2024, the Department conducted an initial investigation visit. LPA interviewed ED. and 2 staff, 6 residents. Continue on LIC9099-C. Page 1 of 3. Unfounded Staff are not addressing resident's rash timely: On 4/15/2024, LPA interviewed Executive Director (ED) Jasmine Latu. ED stated the facility did not have an outbreak of skin rash. ED stated on 3/25/2024, staff S1 and S2 told ED that they might have rash from resident R1. ED stated he/she told them to see doctor to find out what is the issue. ED stated after S1 and S2 were checked by doctors and found they did not have rash. ED stated R1 was checked by doctor on the week of 3/25/2024, and R1 was found not rash but was allergy. ED stated he/she contacted R1's family member (FM). ED stated FM told him/her that their family members have allergy to laundry detergents. ED stated FM brought doctor prescription over the counter allergy medications and over the counter creams for R1. ED stated FM suggested the facility to use All Free Clear laundry Pod which R1 is not allergy to. ED stated R1 is fine now. ED provided the email communication log with FM. LPA interviewed Director of Medical Service (DMS). DMS denied the facility has outbreak of skin rash. DMS stated resident R1 has allergy but not rash.. LPA interviewed staff S1. S1 stated he/she does not have rash. S1 stated the facility does not have outbreak of rash. LPA interviewed resident R1. R1 was talking something but was unable to answer questions. LPA interviewed R1's roommate R2. R2 stated he/she does not have rash and does not know any one has rash. LPA interviewed another 4 residents, 4 Out of 4 stated they don't have rash and they don't know any one has rash. Based on the review of the facility communication log with R1's family on 3/25/2024, 4/5/2024, and 4/8/2024, the facility did some action to relieve R1's allergy. Based on the interview and records reviewed, The facility conducted some actions for R1 and R1 did not have rash. Continue on LIC9099-C. Page 2 of 3 The Department has investigated the above allegations. Based on the investigation, records reviewed, observation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citations noted at today’s compliant investigation visit. Exit interview conducted with Executive Director (ED). This report was provided to review and for signature. A copy of this report was provided to ED.the state’s words, verbatim · CDSS document, Nov 20, 2024 · control 26-AS-20240411164428

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit at the facility. The purpose of the visit was to follow up on an Incident Report and Death Report of a resident (R1) who left the facility and passed away outside of the facility. LPA Rai met with Health and Wellness Director (HWD) Dominique Frommo and stated the purpose of today's visit. LPA Rai interviewed HWD, 4 staff (S2-S5) and 1 resident (R1). LPA Rai obtained the following copies during today's visit to include but not limited to R1's Physician's Report, R1's Needs and Services Plan and R1's Assessment. LPA Rai determined this case management needs further investigation. Exit interview was conducted with Health and Wellness Director (HWD) Dominique Frommo and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 5, 2024

Allegation investigated: Staff handle resident in a rough manner Staff do not accord dignity in their relationship with a resident in care

On 5/21/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Business Office Manager, Johanna Moon and LPA explained the purpose of today's visit LPA Donato visited the facility and interviewed 3 staff members and 1 resident. LPA attempted to interview other residents but due to cognitive issues, are not able to answer LPAs questions. Regarding the allegation of staff handled resident in a rough manner and staff do not accord dignity in their relationship with a resident in care, reporting party (RP) stated that a staff (S4) agitates a resident (R1). They were physically pushing each other’s hands till they ended up on the floor. Another staff member (S5) witnessed the altercation. RP believes that R1 was confused, and that the staff could no longer deal with him. Page 1 of 2 Unsubstantiated LPA Heberle interviewed the administrator (ADM), and it was mentioned that sometimes a resident is mad because of lost memory. It was another patient (R2), R2 would sometimes grab and shake staff members, but never hit anybody. Does not remember R2 ever hitting other residents but hit staff a month ago. Another resident R1 is violent fairly frequently but has never hit another resident. LPA Donato also confirmed in another interview that R1 has not hit or had an altercation with a staff member. Based on interviews, the department has determined that although these 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 allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. Page 2 of 2 Regarding the allegation of staff mismanage residents’ medication, RP stated that a staff (S1) who works morning shift, prepares the PM medication. Many times, S1 does not have residents multi vitamins, cough syrup, CVD (melatonin), or their pack of medication prepared. Staff (S6) do not always give resident PRN medication. LPA Donato was able to interview S1, and it was mentioned that since the multivitamins are PRNs, if it runs out and responsible parties don’t refill it then they won’t be able to give it to residents. Responsible persons or family members are just advised since it’s a PRN medication and not routine ones. Regarding the allegation of staff not notifying residents representatives of unusual incidents, RP stated that care giving staff was told not to report violent incidents to the residents' responsible parties. Management directed staff to not notify the residents’ family or representatives about the incidents. During the interviews, all three staff members said that they do report the incidents to managers. S2 mentioned that they fill out a form to write what they had witnessed. This is then submitted to the management who does the final report. ADM mentioned too that they have the caregivers write the report as to what they remember. Management are the ones who call the physician (PCP) and responsible parties. Based on incident reports sent by facility, it showed that responsible parties are contacted by the facility to make them aware of the incident. Regarding the allegations of facility does not provide adequate nutrition to residents in care and facility has foul odor, RP stated that the residents do not get snacks or fruit and there was a day when the kitchen smelled like dog. The three staff members mentioned that residents always get snacks. S1 said that there are always snacks provided. Like crackers, fruits and yogurt. Provided 3x or sometimes more when residents ask for second helpings. S3 also mentioned that when snacks are out, they just call the kitchen to provide food. Page 2 of 3 LPA also observed that upon entry in the facility, the lobby has a coffee maker, snacks supply and fruits. On the second floor in memory care, LPA also observed a cabinet that has some snacks and fruit bowl and also a refrigerator where there's custard & drinks. Regarding the allegation of facility has foul odor, RP mentioned that the cook has a dog that is kept in the office which is next to the kitchen. There was a day when the kitchen smelled like dog. LPA observed the facility and it was clean and no smell of odor other than the food being prepped in the kitchen. ADM mentioned that the dog was a small dog that always stays in the office and is not allowed in the kitchen. Based on interviews, records review and observations, the department has determined that these allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is reviewed and copy is provided. Page 3 of 3the state’s words, verbatim · CDSS document, May 21, 2024 · control 26-AS-20230125092006

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Jasmine Latu. LPA toured the facility inside and out with ADM. License, Administrator Certificate, and personal rights posters were observed in the facility. 36 residents and 17 staff were in the facility during LPA's visit. LPA reviewed 5 resident file and 5 staff files. LPA toured the first floor with ADM including the front desk, the offices, multiple purpose room, dining room, kitchen, living room and restrooms. LPA toured the second floor memory care unit with ADM including 22 apartments, dining room, activity room, living room, laundry room, storage room and restrooms. LPA toured the third floor assisted living Unit with ADM including 30 apartments, Med room, activity room, living room, laundry room, chemical storage room and restrooms. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication room, Medication carts, knives closet, and chemical storage room, and laundry rooms were observed locked. Room temperature was at 75 degree F, and hot water temperature was at 110 degree F in facility. The temperature of the refrigerator was at 37 degree F, and the temperature of the freezer was at 0 degree F. Fire extinguisher was serviced on 06/6/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. ADM showed the test report for smoke detector, fire alarm and elevators dated 4/23/2024, and it shows they were working. First aid box and flash lights were observed in the facility. Courtyard was inspected. There was no obstruction to block the walkways. ADM stated the last time the facility conducted the emergency and fire drill was on 4/26/2024. Deficiencies were noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, May 9, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Manuel Monter arrived to the facility unannounced to conduct a case management visit regarding an exception request for resident R1. LPA met with Administrator (ADM) Jasmine Latu. LPA explained the purpose of the visit. LPA requested documents to process the exception request for Resident R1. The facility provided R1's physician report and needs & Services plan. S1 stated R1 is his/her own power of attorney. ADM stated the facility would send LPA a letter of support from R1. ADM stated the reason for the delay was due to staff not being available because of the holidays. ADM also stated the delay was due to staff getting sick as well. LPA advised ADM to collaborate with Community Care Licensing in the future, to process exception requests. No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided. This report was reviewed with Administrator Jasmine Latu and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 17, 2024

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced case management - Legal/Non-compliance visit. LPA met with Administrator (ADM) Jasmine Latu. LPA toured the facility with ADM to include the first floor, second floor, and third floor. LPA reviewed the 7 corrections required during office meeting with licensing on 08/02/2022 to ensure that the facility is currently remaining within compliance. LPA reviewed Administrators qualifications and observed ADM's training documentation to include an up-to-date Administrator Certificate and Technical Support Plan training documentation from January 2023. During review of resident (R1 - R4) files, LPA observed that all admitted residents had complete admissions agreements with responsible party signatures. LPA reviewed eviction training documentation signed by all managerial staff that had attended the meeting dated 07/2022. ADM states a plan to complete an updated in-service training with managerial staff by end-of-week. Facility issued a 30-day eviction notice on 06/29/2023. Eviction notice observed to be in compliance with Title 22 regulations. ADM was unable to produce the staff training documentation regarding resident rights that was completed in July 2022. ADM states a plan to complete the in-service training with all staff and directors before end-of-week. LPA reviewed the facility's plan on submission of incident reports and communication with resident's physician and responsible party. ADM states a plan to complete the in-service training documentation regarding incident reporting and proper communication when there is a change of condition before end-of-week. ADM will send the training documentation to LPA Dolores by end-of-week. SEE LIC809-C. LPA reviewed facility plan of operations and observed addendum stipulating facility's plan to adhere to medication training records, as well as facility procedure for ensuring written confirmation of dosages. Facility's medication plan observed to be contained in both resident and employee handbook. Facility completed a medication in-service training in October 2022. ADM states the nurse completed a more recent in-service training, however, the documentation does not indicate the training topics and date. ADM states they plan to re-train the proper staff to include the updated training documentation. ADM will submit the training documentation to LPA Dolores by end-of -week. LPA Dolores advised ADM regarding the importance of adhering to the facility's corrective action plan that was developed on 08/02/2022, to ensure the facility's stays within compliance of Title 22 regulation. ADM stated understanding. No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided. This report was reviewed with Administrator Jasmine Latu and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 28, 2023