Sonrisa Villa

Allegation investigated: Neglect resulted in resident sustaining a fall with injury. Facility staff acted physically aggressive with resident resulting in bruising.

Licensing Program Analyst (LPA) David Roman conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified himself and discussed the purpose of the visit with Med Tech, Galeed Quintana. On Janurary 09, 2026, Community Care Licensing Division (CCLD) received a complaint alleging neglect resulted in resident sustaining a fall with injury and facility staff acted physically aggressive with resident resulting in bruising. During the investigation, LPA D. Roman collected pertinent facility records, conducted interviews with residents, staff, and outside sources. Interviews revealed contradicting information regarding the allegations mentioned above. Based on evidence obtained, the preponderance of evidence standard was not met, therefore, the allegation was unsubstantiated. (Cont. on 9099-C) Unsubstantiated An exit interview was conducted with Med Tech, Galeed Quintana, to whom a copy of this report and Licensee/Appeals Rights (LIC 9058) were provided.the state’s words, verbatim · CDSS document, Mar 25, 2026 · control 08-AS-20260109155322

Allegation investigated: Staff do not administer resident's medications as prescribed. Licensee did not address bed bug issue.

Licensing Program Analyst (LPA) David Roman conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified himself and discussed the purpose of the visit with Medtech, Galeed Quintana. On November 08, 2021, Community Care Licensing Division (CCLD) received a complaint alleging staff do not administer residents’ medication as prescribed and licensee did not address bed bug issue. During the investigation, the department was not able to reach R1 for interview, records review revealed that approximately (16) sixteen residents did not have medication. Regarding the allegation of licensee did not address bed bug issues, during an unrelated complaint visit on January 07, 2026 the Department observed pillowcases, bedsheets, and bed linen with observable bedbug detritus and blood stains. Interviews with staff revealed that they had recently removed mattresses in an attempt to remedy the situation. The facility provided receipts of fumigation services however, bedbugs extermination was not included in the services provided. (Cont. on LIC9099-C) Substantiated Based on the evidence obtained, the preponderance of evidence standard was met, therefore, the allegations are Substantiated. The deficiencies are cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and is noted on the attached LIC 9099-D. A plan of correction was jointly formulated with new Administration. An exit interview was conducted with Medtech, Galeed Quintana, to whom a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058) were provided. Their signature on this report acknowledges the receipt of this report and their rights.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 08-AS-20211108113110

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.2(c) · Plan of correction due date: Feb 11, 2026

Health and Safety Code section 1569.2(c) provides: (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with... taking medications. The requirement was not met as evidenced by Department observations & interviews. Medication servies were not rendered to to 16 of 76 residents in care which posed a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: On 01/10/2026 the Department issued a Temporary Suspension Order and installed a Temproary Manager to oversee operations. TM reported medications have been refilled for residents in care and re-trained Medtech staff.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80087(a) · Plan of correction due date: Feb 25, 2026

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by the Department's observations & interviews. The facilities bedbug infestation posed a health and safety risk to 76 of 76 persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: On 01/10/2026 the Department issued a Temporary Suspension Order and installed a Temproary Manager to oversee operations. TM reported fumigation services for the extermination of bedbugs have been initiated.

Allegation investigated: The facility is in financial distress. Licensee charging residents above SSI rate. The Licensee does not ensure residents receive Personal and Incidental Needs Allowance.

Licensing Program Analyst (LPA) David Roman conducted an unannounced complaint visit to deliver findings on the above-mentioned allegations. LPA was met by Staff, Veronica Valadez, and discussed the purpose of the visit. It was alleged that the licensee was in financial distress. The Department’s investigation consisted of a tour of the facility, interviews with staff, and review of records. The Department’s investigation revealed that based on the records provided, it appears the licensee is paying most bills late, with disconnection notices being sent out for two of the three utility bills reviewed. Bank records provided showed low and inadequate cash reserves; with a total of 11 overdraft fees between the four bank accounts submitted; indicating insufficient funds available from the bank accounts to cover their expenses. It should be noted the licensee had not maintained sufficient cash reserves to cover any unforeseen expenses, with monthly ending balances less than $200.00 for 12 of the 16 months of the bank statements reviewed. The licensee did not have a financial plan required by law to ensure the residents’ care and supervision would not be interrupted. (Cont. on LIC9099-C) Substantiated It was alleged that the licensee charged residents above the SSI rate. The Department’s investigation included review of records and interviews with staff. Investigation revealed that staff provided a signed notice to residents dated December 13, 2025, notifying them of an increase in the monthly rate, which would become effective on January 1, 2026. The notice included an increase in the monthly rate to $1626.07. This was in excess of the maximum allowable rate of $1444.07 for SSI/SSP residents. Interview with the Administrator yielded contradictory statements as the Administrator denied signing the notice or that it was provided to residents. This was inconsistent with other staff interviews which corroborated the allegation. It was alleged that the Licensee did not ensure that residents were provided with their Personal and Incidental funds. Investigation revealed that residents received SSI, which includes an amount which must be provided to the recipient as a Personal and Incidental (P&I) Needs allowance. Interviews with staff, including the Administrator, yielded conflicting statements regarding how the cash is maintained and disbursed but revealed that P&I funds were received via direct deposit and/or paper checks and were deposited into a bank account. Review of facility records revealed that P&I ledgers were not consistent with cash on hand. Interviews with residents revealed some residents were unaware that P&I was received by the licensee for their disposal. The Department has investigated the above-mentioned allegations and has found that based upon the evidence obtained during the investigation, including record review, interviews, and observations, there is sufficient evidence to prove or corroborate the allegations. Therefore, these allegations have been deemed substantiated. Deficiencies have been cited in accordance with California Code of Regulations, Title 22. An exit interview was conducted with Medtech, Veronica Valadez, and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to Veronica Valadez. Their signature on this form acknowledges receipt of these rights.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 08-AS-20251231112845

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Feb 11, 2026

The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records... This requirement was not met as evidenced by the Department's records review observation & staff interviews. The Licensee's financial plan was insufficient which posed a health & safety risk to 76 of 76 persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: On 01/10/2026 the Department issued a Temporary Suspension Order (TSO) and installed a Temporary Manager to oversee facility operations.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Feb 11, 2026

Additional Personal Rights of Residents in Privately Operated Facilities (a) ...residents shall have all of the following personal rights:(8) To be free from neglect, financial exploitation... This requirement was not met as evidenced by the Department's observations & interviews. The facility's mismanagement of P&I funds and record keeping posed a health & safety risk to 76 of 76 persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: On 01/10/2026 the Department issued a Temporary Suspension Order and installed a Temporary Manager to oversee the facility operations.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.65(c) · Plan of correction due date: Feb 11, 2026

Increase in fee rates for elderly residents; 90 days’ written notice... If a licensee increases rates...Welfare and Institutions Code, the licensee shall meet the requirements for SSI/SSP rate increases, as prescribed by law. This requirement was not met as evidenced by the Department's observations and interviews. The Licensee attempted to increase fee rates which posed a health & safety risk for 76 of 76 persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: On 01/10/2026 the Department issued a Temporary Suspension Order and installed a Temporary Manager to oversee facility operations.

Type of visit: Case Management - Other

Licensing Program Analyst’s (LPAs) Carmen Lopez and David Roman conducted an unannounced case management visit at the facility. LPA’s identified themselves and were granted entry by the Receptionist. LPA stated the purpose of the visit and reviewed the basic elements of the visit with caregiver Veronica Valadez. The Department had obtained control of the facility in January 2026 due to discrepancies found and has assumed the responsibilities with a new management team. Since January 2026, the new Management Team as found resident medications have not been given as prescribed and an inventory of medications was complete and the following was discrepancies were found: During 12/21/25, three residents had a total of 4 medications missing and had not been refilled or available. The new management team was able to have it filled and delivered by 01/21/2026. During 12/27/2025, there were 10 residents who had a total of 17 medications that were either missing, not filled, or pending refill. The new management team has filled some medications and others were pending to be filled. During 01/21/2026, there were two residents who were missing 2 medications. The new management team was able to fill the medications. During today’s visit, deficiencies were cited and can be found on the LIC809-D page of this report. An exit interview was conducted with Veronica Valadez, medication technician and a copy of this report, LIC 811 and Licensee/Appeal Rights (LIC 9058 3/22) were provided to the caregiver at the conclusion of the visit. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Feb 11, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 12, 2026

87465 Incidential Medical and Dental: (4) The licensee shall assist residents with self-administered medications as needed... This requirement was not met as evidence by: Based on records review, the facility did not assist resident with obtaining their requireed medications and posed a health risk to 15 of 76 residents in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: On 01/10/2026, the Department issued a Temporary Suspension Order and installed a Temporary Manager (TM) to oversee operations. TM reported medication management and initiated orders. This is deemed cleared during today's visit.

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

Licensing Program Analyst, David Roman arrived on February 11, 2026, for an unannounced inspection to follow up on a substantiated complaint allegation. The purpose of the visit was discussed with Licensee, Kamran Shirizi, via Teams (online meeting), who granted entry to the facility. On January 8, 2026, the Department concluded a complaint investigation regarding the following allegations: staff did not properly report an incident involving a resident (R1). The Licensee was cited for Health and Safety Code § 1569.317 Absentee Notification Plan for Missing Residents. At the time of the complaint visit on January 8, 2026, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation. This is evidenced by facility staff not following the absentee notification plan and failing to report R1’s disappearance for an extended period of time, which resulted in a substantial risk of death of R1. (Cont. LIC809-C) Today February 11, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on January 8, 2026, the amount of the civil penalty issued today will be $9,500. An exit interview was conducted with facility representative, a copy of the report issued, and appeal rights provided to Medtech, Galeed Quintana. Their signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Feb 11, 2026

Allegation investigated: Licensee did not follow the admission agreement Fire doors were obstructed

On January 29, 2026, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted a telephone conference with Med Tech, Veronica Valadez, to present investigative findings. The Department’s investigation included a facility tour, record review, and interviews with staff. On February 13, 2025, Community Care Licensing (CCL) received a complaint alleging that the licensee did not follow the admission agreement. Specifically, it was alleged that facility staff would issue a new admission agreement with a revised fee schedule whenever the resident’s rate increased. A review of the admission agreement and fee schedule did not disclose any violations of Title 22 regulations. According to Title 22, the licensee is required to issue a new admission agreement whenever the terms of the agreement change. The facility also notified residents and responsible parties of rate changes as required by regulation. (Continue at LIC9099C) Unsubstantiated (Continue from LIC9099) The complaint also alleged that the facility's fire doors were obstructed. The investigation did not yield evidence to support this allegation. During interviews, staff indicated that they did not recall observing any obstruction of fire doors or hallways. During the facility visit conducted on January 10, 2026, no obstructions of hallways or any other areas of the facility were observed. The investigation included a review of images provided by an outside source, which showed facility hallways cleared of any obstruction and doors wide open. The images did not indicate any obstructions or violations of Title 22 regulations. Additionally, the date and time of the images were not provided, limiting the ability to corroborate the complaint. The review of the sample of admissions agreement did not disclose any violations. Based on the investigation, including record review, staff interviews, and observation, there was insufficient evidence to substantiate the allegations. Therefore, the allegations are deemed unsubstantiated. An exit interview was conducted with Med Tech, Veronica Valadez. A copy of this report and the Licensee Appeal Rights (LIC 9058 03/22) were mailed to the licensee of record and emailed to sonrisavillainc@gmail.comthe state’s words, verbatim · CDSS document, Jan 29, 2026 · control 08-AS-20250213144936

Allegation investigated: Staff did not meet resident's care needs

On January 29, 2026, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted a telephone conference with Med Tech, Veronica Valadez, to present investigative findings. The Department’s investigation included a facility tour, record review, and interviews with staff. On February 12, 2025, Community Care Licensing (CCL) received a complaint alleging that staff did not meet a resident’s care needs. Specifically, it was alleged that a resident living at the facility repeatedly called out for help and that staff did not respond. The identity of the resident and the specific dates of the alleged incidents were not disclosed during the investigation. (Continue at LIC9099C) Unsubstantiated (continue from LIC9099) The investigation included a review of evidence provided, which consisted of images of a room door labeled “109” and video recordings of a person yelling for help and requesting that 911 be called. However, this evidence was insufficient to substantiate the allegation. The source and legitimacy of the recordings could not be confirmed, and it could not be verified that the individual yelling was the resident living in room 109. Additionally, the date and time of the incident depicted in the images and videos were not provided, further limiting the ability to corroborate the complaint. Based on the investigation, including record reviews and staff interviews, there was insufficient evidence to substantiate the allegation. Therefore, the allegation is deemed unsubstantiated. An exit interview was conducted with Med Tech, Veronica Valadez. A copy of this report and the Licensee Appeal Rights (LIC 9058 03/22) were mailed to the licensee of record.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 08-AS-20250212162345

Type of visit: Case Management - Health Checks

Licensing Program Analyst, David Roman (LPA D. Roman) conducted an unannounced case management visit to check on the health and safety of residents in care. LPA D. Roman gained access to the facility, identified himself, and met with Receptionist, Edward Nunez to discuss the purpose of today's visit. LPA D. Roman met with Temporary Manager, Robert Centoria. LPA D. Roman's visit consisted of briefly speaking with residents concerning their health and safety, touring the bottom and top floor of the facility, and obtaining additional information about the residents care. LPA D. Roman did not observe any immediate health and/or safety violations and after speaking with residents did not receive any complaints about their health. A tour of the kitchen area was also completed in which there was sufficient food for residents. An exit interview was conducted with Receptionist, Edward Nunez, to which a copy of this report along with Licensee/Appeal Rights was provided to them whose signature below confirms receipt of this report and their rights.the state’s words, verbatim · CDSS document, Jan 20, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst, David Roman (LPA D. Roman) conducted an unannounced case management visit to check on the health and safety of residents in care. LPA D. Roman gained access to the facility, identified himself, and met with Direct Support Staff, Gabriel Zamora to discuss the purpose of today's visit. LPA D. Roman inquired on the Temporary Manager, Robert Cantoria. LPA was informed that the Manager was purchasing food items for the facility. LPA D. Roman's visit consisted of briefly speaking with residents concerning their health and safety, touring the bottom and top floor of the facility, and obtaining additional information about the residents care. LPA D. Roman did not observe any immediate health and/or safety violations and after speaking with residents did not receive any complaints about their health. A tour of the kitchen area was also completed in which there was sufficient food for residents. An exit interview was conducted with Direct Support Staff, Gabriel Zamora, to which a copy of this report along with Licensee/Appeal Rights was provided to them whose signature below confirms receipt of this report and their rights.the state’s words, verbatim · CDSS document, Jan 12, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst's (LPA's) Carmen Lopez, and Jose De La Cruz conducted an announced case management visit to observe the health and safety of the residents in care. LPAs were greeted, granted entry into the facility, and met with temporary Administrator Robert Cantoria. On January 10, 2026, the RM and LPM met with the Licensee. The Department issued a Temporary Suspension Order (TSO) to the former administration, and a temporary Administrator was contracted to assume facility's operation for a period of 90 days. During today’s visit, LPAs Lopez and De La Cruz toured the facility and verified the health and safety of residents in care. The LPAs also met with staff to explain the TSO and answer questions. LPA's toured the facility,and conducted a health and safety check for the residents in care. LPA's requested and obtained relevant information. An exit interview was conducted, and a copy of this report, along with Licensee Rights (LIC 9058, 03/22), were provided to temporary Administrator Cantoria at the conclusion of the visit. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Jan 11, 2026

Allegation investigated: Facility staff not properly addressing bed bugs in the facility

Licensing Program Analyst (LPA) Jose De La Cruz conducted an unannounced visit to follow up and deliver findings related to a complaint investigation. LPA Jose De La Cruz was met by Staff member Israel Rocha, and was granted entry into the facility. The purpose of the visit was discussed. During the visit, LPA Jose De La Cruz conducted a tour of the interior and exterior of the facility and briefly interacted with residents. On September 27, 2024, Community Care Licensing (CCL) received a complaint alleging that staff did not adequately address a bed bug infestation within the facility. Ongoin complaints regarding the same issue from different sources support the above allegation. (continue at LIC9099C) Substantiated (continue from LIC9099) On January 10, 2026, LPA Jose De La Cruz conducted a follow-up visit to deliver and close the complaint investigation regarding the above allegation. Based on interviews and records reviewed during the investigation, there was sufficient evidence to substantiate the allegation. Therefore, the allegation is determined to be substantiated. One deficiency was cited by the California Code of Regulations, Title 22 (refer to the LIC809-D page). No Civil Penalty was assessed. Plan of Correction was jointly developed with Staff member Israel Rocha. An exit interview was conducted with Staff member Israel Rocha, to whom a copy of this report, the LIC 809-D pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit. (continue from LIC9099) On January 10, 2026, LPA Jose De La Cruz conducted a follow-up visit to deliver and close the complaint investigation regarding the above allegation. Based on interviews conducted and information obtained during the investigation, there was insufficient evidence to substantiate the allegation. Therefore, the allegation is determined to be unsubstantiated, and the complaint is closed. This report was discussed with Temporary Manager Robbie Centoria. A copy of this report, along with Licensee/Appeal Rights, was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 10, 2026 · control 08-AS-20240917083116

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80087(a)(1) · Plan of correction due date: Jan 23, 2026

The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. The licensee shall take measures to keep the facility free of flies and other insects. Based on records reviews, staff did not address the bug infestation on 1 out of 79 residents in care which posed a potential health risk to 1 of 79 residents in care.the state’s words, verbatim · CDSS document, Jan 10, 2026

Plan of correction: Facility threw mattressess and cleaned rooms with chemichals.

Allegation investigated: Staff is interfering with a resident's visitations

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to follow up and deliver findings related to a complaint investigation. LPA Garcia-Centeno was met by Manager, Gabriela Zamora, and was granted entry into the facility. The purpose of the visit was discussed. During the visit, LPA Garcia-Centeno, along with facility staff, conducted a tour of the interior and exterior of the facility and briefly interacted with residents. On July 24, 2025, Community Care Licensing (CCL) received a complaint alleging that facility staff interfered with a resident’s (R1) visitations. During the investigation, specific details regarding dates or instances of denied visitation were not obtained. (continue at LIC9099C) Unsubstantiated (continue from LIC9099) On January 10, 2026, LPA Garcia-Centeno conducted a follow-up visit to deliver and close the complaint investigation regarding the above allegation. Based on interviews conducted and information obtained during the investigation, there was insufficient evidence to substantiate the allegation. Therefore, the allegation is determined to be unsubstantiated, and the complaint is closed. This report was discussed with Medication Technician, Nidia Gutierrez A copy of this report, along with Licensee/Appeal Rights, was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 10, 2026 · control 08-AS-20250724103520

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

Regional Manager (RM) Jerry Romero, Licensing Program Manager (LPM) Lizzette Tellez, Licensing Program Analyst (LPA) Marisela Garcia-Centeno, Licensing Program Analyst (LPA) Carmen Lopez, Licensing Program Analyst (LPA) Amy Domingo, and Licensing Program Analyst (LPA) Jose De La Cruz conducted an unannounced Case Management–Legal/Non-Compliance visit. RM, LPM, and LPAs were greeted, granted entry into the facility, and met with Administrator Teresita Reyes. On January 10, 2026, the RM and LPM met with the Licensee. A Temporary Suspension Order (TSO) was issued, and a temporary manager was contracted to assume facility operations for a period of 90 days. On today’s date, LPAs Garcia-Centeno, Domingo, Lopez and De La Cruz toured the facility and verified the health and safety of residents in care. The LPAs also met with residents, staff, and responsible parties to explain the TSO and answer questions. An exit interview was conducted, and a copy of this report, along with Licensee Rights (LIC 9058, 03/22), was provided to the Licensee, Kamran Shirazi. The Licensee’s signature below acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jan 10, 2026

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Amy Domingo and Natasha Persaud conducted an unannounced case management other visit. LPAs identified themselves and were granted entry. LPAs met with Facility Manager, Gabriela Zamora, and discussed the purpose of the visit. A review of records revealed that on 12/2/25, the facility received a past due notice indicating that the utilities would be shut off on 12/17/25, due to non-payment; however, no notice of termination was sent as required. Based on the Foreclosure Protection Act of 2011 and per HSC § 1569.686(a)(5), the licensee was required to provide notice to the Department, State Long Term Care Ombudsman, all residents, and if applicable, their legal representatives within two business days of receipt of a notice of intent to terminate electricity, gas, or water service within 15 days of the notice. Despite the requirement to notify all parties that the utility was at risk of shut off by 12/17/25, no notice was ever sent. Therefore, a civil penalty of $100 per day is being assessed per HSC § 1569.686(c) commencing 12/2/25, totaling [$100 x number of days (or) the maximum penalty of $2,000]. Upon review of facility records, it was observed that the licensee failed to pay their required annual licensing fee timely. The Department has not received payment as of today and the facility has an outstanding balance. Failure to pay the annual licensing fee is a violation of HSC §1569.185 and may result in forfeiture of the facility’s license. LPAs were away from the facility for approximately one hour between 3:00pm - 4:00pm Continued on LIC809C (Continued from LIC809) The facility currently has eighteen (18) residents receiving hospice services. A review of records reflected the facility failed to obtain hospice care plans for all eighteen (18) residents. Deficiencies were observed during today's inspection and cited per Title 22 regulations and the Health and Safety Code on the attached LIC 809-D. An exit interview was conducted with House Manager, Gabriela Zamora, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Their signature below confirms receipt of these documents. The report was discussed via telephone while at the facility with Licensee Kamran Shirazi.the state’s words, verbatim · CDSS document, Jan 9, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.686(a)(5) · Plan of correction due date: Feb 9, 2026

(a) A licensee shall notify the department, State Long-Term Care Ombudsman, all residents, and, responsible party in writing, within two business days... (5) A utility company has sent a notice of intent to terminate utility service on the property within not more than 15 days of the notice. This requirement was not met, as evidenced by Based on record review, the licensee did not notify the required agencies regarding terminiation of utiliyt services for 79 out 79 [R1-R79] residents which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 9, 2026

Plan of correction: Licensee paid the utility bill and agreed to notify all required agencies in the event of utility services are interrupted or terminated. Licensee agreed to provide proof of paid utility bills for the month of January 2026.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.185(a)(1) · Plan of correction due date: Feb 9, 2026

Failure to pay the required annual licensing fee shall constitute grounds for forfeiture of the license (a)(1) An application fee adjusted by facility and capacity shall be charged by the department for the issuance of a license to operate a residential care facility for the elderly. After initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license. This requirement was not met, as evidenced by Based on record review, the licensee did not pay the annual licensing fee which poses a potential health and safety risk to 79 out of 79 residents.the state’s words, verbatim · CDSS document, Jan 9, 2026

Plan of correction: Licensee agreed to pay balance of the annual licensing fee by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(a)(4) · Plan of correction due date: Feb 9, 2026

(a)The licensee shall be permitted to accept or retain residents…(4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each resident. This requirement was not met evidenced by: Based on record review, the licensee did not maintain hosice care plans for 18 out 18 [R1-R18] residents, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 9, 2026

Plan of correction: Licensee agreed to obtain and maintain current hospice care plans for each resident receiving hospice services by POC.

Allegation investigated: Staff did not properly report an incident involving a resident

Licensing Program Analysts (LPAs) Natasha Persaud, Amy Rodgers, Amy Domingo, Licensing Program Maanger (LPM) Lizette Tellez, and Regional Manager, Jerry Romero conducted an unannounced visit to deliver findings in the above complaint allegation. The purpose of the visit was discussed with Licensee, Kamran Shirazi and Administrator, Teresita Reyes. On May 22, 2025, Community Care Licensing (CCL) received a complaint alleging facility staff did not contact emergency personnel after Resident #1 (R1) was found to be missing. Details of the allegation state that on May 20, 2025, R1 left the facility unassisted at 11:34am and did not return for lunch. According to R1’s Physician’s Report dated March 9, 2025, R1 is allowed to leave unassisted, has mild-cognitive impairment and is ambulatory. Interview with Facility Manager established that R1 had a change in condition roughly three months before this incident but had not developed wandering tendencies. Interview with R1’s responsible party established that they were concerned about R1’s recent memory loss and was diagnosed with mild cognitive impairment with onset of dementia. Continued on LIC 9099C. Substantiated Interview with multiple staff revealed that R1’s daily routine included leaving the facility for daily walks but would regularly return for meals or by 2:00pm for their afternoon coffee. Staff revealed that they were then instructed to search for R1 inside and outside of the facility but did not find them. Records collected reveal that facility’s absentee notification plan states the facility staff will contact emergency personnel after 30 minutes of residents being noted missing. Emergency department records collected revealed that facility reported R1 missing on 5/20/2025 at 6:13pm, roughly six hours after identifying R1 missing. Records also revealed that facility manager stated they had not contacted emergency personnel because they were hopeful staff would find R1. On 5/21/2025 at about 12pm, R1 was found deceased in a canal roughly six (6) miles away from the facility. Death records confirmed that R1’s manner of death was accident with a sub manner of death as drowning. Based on interviews conducted, review of records, including outside sources records, a preponderance of evidence exists to support the allegation. Therefore, the allegation was substantiated. A deficiency was cited per the Health and Safety Code (refer to the attached LIC 9099-D). The Department has determined this violation resulted in death to the resident in care. An immediate Civil Penalty of $500.00 is charged and is noted on the LIC421IM. Currently, per Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of Community Care Licensing Division. An exit interview was conducted with Licensee, Kamran Shirazi. and a Plan of Correction was jointly developed. A copy of this report, LIC811, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Licensee, Kamran Shirazi, signature on this form confirms receipt of documents. It was also alleged that staff did not prevent R1 from wandering while in care. Based on records collected, there were no medical limitations to prevent R1 from leaving the facility unassisted and R1’s walking away from the facility was normal behavior. Interview with multiple staff revealed R1 would always return from such daily walks. Interview with the party responsible corroborated such information. Based on records and interviews conducted by the Department, there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Licensee, Kamran Shirazi, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 8, 2026 · control 08-AS-20250522100402

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.317 · Plan of correction due date: Jan 9, 2026

Absentee notification plan for missing residents. Every residential care facility...issues that arise when a resident is missing from the facility...Section 1569.80. The plan shall include... requirement that an administrator of the facility, or his or her designee, inform the resident’s authorized representative when that resident is missing from the facility and the circumstances in which an administrator of the facility, or his or her designee, shall notify local law enforcement when a resident is missing from the facility. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not follow their Absentee Notification Plan for 1 out of 79 [R1] residents, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 8, 2026

Plan of correction: Licensee will have staff trained regarding Absentee notification plan for missing residents by a vendor. Licensee will submit proof of scheduled training date by POC due date. In addition, the training will be submitted within 2 weeks. An immediate civil penatly was assessed.

Allegation investigated: Conduct Inimical

Licensing Program Analysts (LPAs) Natasha Persaud, Amy Rodgers, Amy Domingo, Licensing Program Maanger (LPM) Lizette Tellez, and Regional Manager, Jerry Romero conducted an unannounced visit to deliver findings in the above complaint allegation. The purpose of the visit was discussed with Licensee, Kamran Shirazi and Administrator, Teresita Reyes. On June 9, 2025, Community Care Licensing (CCL) received a complaint alleging Staff 1 (S1) was under the influence of narcotics while providing care to residents. Details of the allegation state that on June 1, 2025, S1 began their caregiving shift, at approximately 3:00pm. During S1’s break, they were observed by multiple staff retrieving an item from a car and returning to work with swollen and inflamed eye lids and partially closed eyes. Staff reported that S1 was not responding to their instructions. According to Staff #2 (S2) and Staff #3 (S3), S1 became unresponsive and cardiopulmonary resuscitation was initiated by S3 inside the facility. Emergency response records collected revealed that emergency personnel arrived at the facility at roughly 5:08pm to assist with an unresponsive staff. Continued on an LIC 9099C. Substantiated Such records also revealed S1 was administered a rapid reversal opioid medication to assist with narcotic overdoses. Medical records confirmed S1 was diagnosed with an apparent overdose on fentanyl. Based on interviews conducted, review of records, including outside sources records, a preponderance of evidence exists to support the allegation that S1 was under the influence of narcotic drugs while providing care. The allegation was substantiated. A deficiency was cited per the Health and Safety Code (refer to the attached LIC 9099-D). An exit interview was conducted with Licensee, Kamran Shirazi, and a Plan of Correction was jointly developed. A copy of this report, LIC811, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Licensee, Kamran Shirazi, signature on this form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 8, 2026 · control 08-AS-20250609082218

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.58 · Plan of correction due date: Jan 9, 2026

Persons prohibited from being a licensee, owning beneficial interest in licensed facility, or holding certain positions... for reinstatement. Engaged in conduct that is inimical to the health...welfare, or safety...receiving services from the facility, or ...State of California This requirement is not met as evidenced by: Based on interviews and record review, the licensee's staff engaged in conduct inimical in 1 out of 30 [S1] staff, which posed an immediate health and safety risk to evident in care.the state’s words, verbatim · CDSS document, Jan 8, 2026

Plan of correction: Staff was terminated. POC corrected.

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs), Amy Rodgers, Amy Domingo and Natasha Persaud, Licensing Program Manager (LPM), Lizzette Tellez and Regional Manager (RM), Romero conducted an unannounced Case Management - Other. The purpose of the visit was discussed with Facility Manager, Gabriela Zamora, Licensee, Kamran Shirizi, and Administrator, Teresita Reyes On January 8, 2026, the department visited the facility to commence a Health and Safety check. During the visit, Guardian Background Clearance System was reviewed. It was discovered some staff were not fingerprint cleared or associated to the facility. Staff #1 (S1), is the current Administrator and has a current administrator certificate posted inside the facility. S1 has an active background clearance; however, S1 is not associated to the facility. It was also discovered Staff #2 (S2) and Staff #3 (S3) and Staff #4 (S4) do not have fingerprint clearances and are not associated with the facility. During the facility tour, the department observed that the oven in the kitchen was inoperable. Staff confirmed the oven has been inoperable for approximately three (3) months. The department also reviewed the posted menu and discovered that the facility is not following their posted menu. Also, the facility did not have the required two (2) day non-perishable food supply. (Continued on LIC809C) (Continued from 809) On 1/8/26, During review of facility personnel records, it was observed that the facility failed to keep required personnel records. LPA requested and reviewed 4 personnel files for staff employed. Deficiencies observed included: Missing or incomplete job application/resume and employment references for 4 staff. Missing health screening (physician’s report) and/or TB test results for 4 staff. Missing First Aid/CPR certificates for 4 staff providing direct care. Missing orientation/training documentation (including personal rights, emergency procedures, dementia/wandering if applicable) for 4 staff. Missing proof of criminal record clearance and association to the facility for 4 staff. Based on records reviewed the licensee failed to maintain complete and current personnel records as required by regulation. Deficiencies were cited on the attached LIC 809(d) and Civil Penalties assessed and noted on the LIC421BG. A plan of correction was jointly developed with the licensee. An exit interview was conducted with Licensee Kamran Shirazi, and a copy of this report along with Licensee/Appeal Rights were provided at the conclusion of the visit. Their signature on this report acknowledges receipt of these reports and licensee rights.the state’s words, verbatim · CDSS document, Jan 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Jan 9, 2026

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility (3) Request a transfer of a criminal record clearance... This requirement was not met as evidenced by: Based on record review, the licensee did not ensure that a criminal record clearance transfer was complete for 1 of 30 staff members prior to working in the facility, which poses an immediate health, safety and personal rights risk to 79 of 79 residents in care.the state’s words, verbatim · CDSS document, Jan 8, 2026

Plan of correction: Licensee agreed not to allow staff to work or be present in the facility until S1 - S4 have been fingerprinted and associated to the facility. Provide proof of Guardian Association by POC date. A civil penalty was assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Feb 9, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on record review, the licensee did not ensure that the oven in the facility kitchen was working in the facility, which poses an potential, safety and personal rights risk to 79 of 79 residents in care.the state’s words, verbatim · CDSS document, Jan 8, 2026

Plan of correction: Licensee agreed to ensure the oven is operable by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Feb 9, 2026

General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents.... All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by: Based on record review, the licensee did not ensure that the oven in the facility kitchen was working in the facility, which poses an potential, safety and personal rights risk to 79 of 79 residents in care.the state’s words, verbatim · CDSS document, Jan 8, 2026

Plan of correction: Licensee purchased a 2 day supply of perishable food on 1/8/2026. Licensee will send weekly photos of purchased food items along with receipts by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: Feb 9, 2026

Personnel Records(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement was not met as evidenced by: Based on record review, the licensee did maintain personnel records, which poses an potential, safety and personal rights risk to 79 of 79 residents in care.the state’s words, verbatim · CDSS document, Jan 8, 2026

Plan of correction: Licensee agreed to ensure all staff records are current and maintained by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Manager (LPM) Lizzette Tellez conducted an unannounced case management visit to address deficiencies observed during a complaint visit. LPM identified herself and was granted entry. LPM met with Facility Manager, Gabriela Zamora, and discussed the purpose of the visit. On today's date, LPM visited the facility to commence a complaint visit. Upon attempting to enter the facility, LPM observed the facility entrance/exit door to be locked. Facility staff engaged an unlocking mechanism from the front desk and allowed LPM entry into the facility. Upon attempting to exit the facility, a button located at approximate shoulder level needed to be engaged in order to unlock the door. Review of facility records revealed that the licensee did not obtain approval from the Fire Authority or licensing agency prior to use of the locking mechanism. A deficiency was cited in accordance with California Code of Regulations, Title 22. Additionally, a civil penalty in the amount of $500 was assessed. An exit interview was conducted with Facility Manager, Gabriela Zamora. A copy of this report, and Licensee's Rights (LIC 9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Jan 7, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Jan 8, 2026

CARE OF PERSONS WITH DEMENTIA The licensee shall ensure that the fire clearance includes approval of locked exterior doors or perimeter fence gates and that facility staff on all shifts have access to, and know how to use, equipment needed to unlock exterior doors or perimeter fence gates. This requirement was not met as evidenced by: Based on observations and record review, the licensee did not ensure approval was obtained prior to locking exterior doors. This poses an immediate safety risk to 79 of 79 residents in care.the state’s words, verbatim · CDSS document, Jan 7, 2026

Plan of correction: Facility manager deactivated the locked exterior door during today's visit. Facility manager stated a written plan would be provided to CCL regarding disposition of removal or application of fire authority. A civil penalty in the amount of $500 was assessed. POC due to CCL by POC date.

Allegation investigated: Staff forced residents to move to other rooms in the facility. Staff did not ensure the facility was kept free of pests. Staff did not provide proper medication assistance to residents in care. Staff exposed residents to an unknown chemical causing discomfort to residents in care. Resident rooms are not kept clean.

Licensing Program Analyst (LPA) David Roman conducted an unannounced visit to conduct a complaint investigation. LPA D. Roman identified himself and discussed the purpose of the visit with Facility Manager, Gabriela Zamora. On November 05, 2025, Community Care Licensing Division (CCLD) received the above complaint allegations. During the investigation, LPA D. Roman reviewed pertinent facility records, conducted interviews with residents, and staff. LPA D. Roman along with facility staff conducted a tour of the interior and exterior of the facility. Interviews revealed scheduled, timely, and adequate care for residents. Proper medication support services. Interviews also disclosed no pest infestations however, interviews reported pest control services being provided. LPA observed no pest infestations, LPA observed housekeeping services, medication support services and care being provided. Unsubstantiated Based on evidence obtained, the preponderance of evidence standard was not met, therefore, the allegations are unsubstantiated. An exit interview was conducted with Facility Manager, Gabriela Zamora, to whom a copy of this report and Licensee/Appeals Rights (LIC 9058) were provided.the state’s words, verbatim · CDSS document, Nov 14, 2025 · control 08-AS-20251105082952

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) David Roman conducted an unannounced Case Management Inspection. LPA D. Roman identified himself to Gabriela Zamora, and discussed the purpose of the visit. LPA D. Roman reviewed the resident records, intake assessment. The residents records illustrated admissions to the facility on 10/07/2025, with no SI, no SH BX's. Resident received EMS due to his on going behaviors of self harm. Staff reported the resident was to be sent to a crisis center in San Diego. LPA D. Roman along with facility staff toured the interior and exterior of the facility and inspected bedrooms and bathrooms. LPA D. Roman observed the residents bedroom where the incident occurred. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents, medication cart is locked. No pools or bodies of water on the premises. An exit interview was conducted with Facility Manager, Gabriela Zamora.the state’s words, verbatim · CDSS document, Nov 14, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) David Roman conducted an unannounced Case Management Inspection. LPA D. Roman identified himself to Facility Manager, Gabriela Zamora, and discussed the purpose of the visit. LPA D. Roman reviewed the resident records and intake assessment which identified the resident entered the facility with a fractured tibia or fibula on 01/09/2025. LPA D. Roman conducted staff interviews which revealed the resident fell in the dinning area and refused to receive medical treatment on 10/12/2025. LPA D. Roman along with facility staff toured the interior and exterior of the facility and inspected bedrooms and bathrooms. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. LPA D. Roman observed the dining area where it was reported that the resident fell to be free of obstruction. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. An exit interview was conducted with Facility Manager, Gabriela Zamora. A copy of this report, along with Licensee/Appeal Rights, was provided to them at the conclusion of the visit. Their signature on this form acknowledges the receipt of this report and their rights.the state’s words, verbatim · CDSS document, Nov 4, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Roman conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Facility Manager, Gabriela Zamora. According to the facility’s license, the facility has a maximum capacity of 175 residents, of whom all may be non-ambulatory and 30 of which may be bedridden/hospice. LPA D. Roman toured the interior and exterior of the facility and inspected random rooms. The facility was sanitary, and in decent repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings, closet and night stand. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas. Water temperature was measured at 110 degrees F. No pools or bodies of water on the premises. Per Gabriela Zamora, no firearms or ammunition are kept at the facility. Smoke alarms and carbon monoxide detectors tested during the month of August 2025, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present and serviced on 02/28/2025. First aid kit(s) were complete and readily accessible. Resident and employee records reviewed had required documentation. An exit interview was conducted with Facility Manager, Gabriela Zamora, to whom a copy of this report and the Licensee/Appeal Rights were provided during the visit.the state’s words, verbatim · CDSS document, Sep 29, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) David Roman conducted an unannounced case management inspection visit. LPA D. Roman identified himself to Facility Manager, Gabriela Zamora, and discussed the purpose of the visit. LPA D. Roman along with facility staff toured the interior and exterior of the facility and inspected resident bedrooms. LPA D. Roman interviewed the resident and staff. The facility was sanitary, and in decent repair. LPA inspected the bedroom of the resident in question in which the pathways appeared to be obstructed by ripped linoleum floor covering. LPA D. Roman informed Facility Manager, Gabriela Zamora that the ripped linoleum floor should be removed to avoid future falls for residents in care. Facility Manager, Gabriela Zamora contacted maintenance employee to remove the exposed/ripped linoleum. Pathways throughout the facility were free of obstruction and slip hazards. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. LPA D. Roman completed records review of the resident in question. The resident is receiving medication support services, hospice care, and the resident has a follow up visit with PCP on 08/20/25. An exit interview was conducted with the Facility Manager, Gabriela Zamora to whom a copy of this report and the Licensee/Appeal Rights were provided during the visit.the state’s words, verbatim · CDSS document, Aug 15, 2025

Allegation investigated: Staff did not ensure that residents have access to laundry services. Staff did not administer medication as prescribed.

Licensing Program Analyst (LPA) David Roman conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified himself and discussed the purpose of the visit with Facility Manager, Gabriela Zamora. On March 18, 2025, Community Care Licensing Division (CCLD) received a complaint alleging facility staff did not ensure that residents have access to laundry services and staff do not administer medication as perscribed. During the investigation, LPA D. Roman collected pertinent facility records, conducted interviews with residents, and staff. Interviews revealed contradicting information regarding the above allegations. Based on the evidence obtained, the preponderance of evidence standard was not met, therefore, the allegation was unsubstantiated. (Cont. 9099-C) Unsubstantiated An exit interview was conducted with Facility Manager, Gabriela Zamora, to whom a copy of this report and Licensee/Appeals Rights (LIC 9058) were provided.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 08-AS-20250318152937

Allegation investigated: Facility staff did not seek timely medical treatment for resident.

Licensing Program Analyst (LPA) David Roman conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified himself and discussed the purpose of the visit with Facility Manager, Gabriela Zamora. On April 03, 2025, Community Care Licensing Division (CCLD) received a complaint alleging facility staff did not seek timely medical treatment for a resident. According to the allegation R1 did not receive timely medical treatment for internal bleeding. During the investigation, LPA D. Roman collected pertinent facility records, conducted interviews with residents, staff, and outside sources. Interviews revealed contradicting information regarding timely medical treatment for the resident. Based on evidence obtained, the preponderance of evidence standard was not met, therefore, the allegation was unsubstantiated. An exit interview was conducted with Facility Manager, Gabriela Zamora, to whom a copy of this report and Licensee/Appeals Rights (LIC 9058) were provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 10, 2025 · control 08-AS-20250403152420

Type of visit: POC

Licensing Program Analyst, David Roman (LPA D. Roman), conducted an unannounced facility visit to verify Plan of Corrections. The plan of corrections visit is pertinent to an in service training for Personal Rights. LPA D. Roman introduced himself, identified, and discussed the purpose of the visit with Facility Manager, Gabriela Zamora. Facility Manager, Gabriela Zamora, reported that facility staff attended the Personal Rights training held by Coordinator, Karla Flores, from Imperial County Long Term Care Ombudsman Program. An exit interview was conducted with Facility Manager, Gabriela Zamora. No deficiencies cited today. Their signature acknowledges the receipt of this report and licensee rights.the state’s words, verbatim · CDSS document, Jun 26, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst, David Roman (LPA D. Roman) conducted an unannounced case management visit to obtain additional information on an unusual incident report made on 06/23/2025. LPA D. Roman conducted an interview with Administrator, Gabriela Zamora. LPA D. Roman also reviewed the residents file and toured the facility along with facility staff. No deficiencies were cited during today's visit. An exit interview was conducted with Administrator, Gabriela Zamora, to whom a copy of this report and the Licensee/Appeal Rights were provided during the visit. Their signature acknowledges the receipt of this report and their rights.the state’s words, verbatim · CDSS document, Jun 24, 2025

Allegation investigated: Unlawful Eviction Licensee did not afford resident a choice in making decisions.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to initiate an investigation in the above-mentioned allegations. LPA met Manager Gabriela Zamora and discussed the purpose of the visit. On January 27, 2025, Community Care Licensing (CCL) received a complaint alleging R1 was issued an unlawful eviction notice and R1 was not afforded the right to make personal choices in their daily life. According to the allegation on January 26, 2025, R1 was unlawfully asked to leave the facility but Resident 2 (R2) prevented R1 from being evicted. Interview with R1 revealed R1 was not asked to leave the facility and was not issued an eviction notice. Interview with the Administrator revealed R1 was not issued an eviction notice and has no intent on issuing one to R1. Interview with R2 revealed R2 was issued the eviction notice due to non-payment. Unsubstantiated Records collected corroborated that R2 was issued such notice for non-payment. Interview with outside source did not reveal any corroborating information to prove R1 or R2 were issued an unlawful eviction notice. It was also alleged that R1 was forced by staff to move rooms within the facility. Interview with R1 revealed R1 was not forced but asked by staff if R1 wanted to move rooms and R1 declined such move. Interview with Administrator revealed that R1 was asked if R1 wanted to move rooms to distance R1 from R2, but R1 declined. Interview with outside source corroborated that Administrator was trying to protect R1 from R2. LPA observations on today’s date revealed R1 is still in original room. Based on interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Manager Gabriela Zamora, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 08-AS-20250127105040

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted a case management visit to deliver an amended report. LPA met with Manager, Gabriela Zamora, and informed her of the purpose of the visit. Today's visit is to deliver an amended report from complaint visit conducted on 11/19/2024. The amended report was reviewed with Manager, Gabriela Zamora and signatures were obtained. An exit interview was conducted, Appeal Rights (LIC 9058 03/22) along with a copy of this report was provided to Zamora at the end of the visit.the state’s words, verbatim · CDSS document, Jan 16, 2025

Allegation investigated: Facility staff interfered with resident receiving packages

Licensing Program Analyst (LPA), Natasha Persaud conducted a complaint investigation visit. LPA met with Manager, Gabriela Zamora and discussed the allegation listed above. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff and residents. It was alleged facility staff interfered with resident receiving packages. It was reported Resident #1 (R1) ordered some items online in February 2024 and September 2024 that were not delivered promptly. Records reviewed regarding package delivery to the facility was confirmed and signed by staff for both occasions. The manager's interview revealed the staff working the front desk, signs for the package then it's placed in designated areas located behind the front desk. Residents will either come to the front desk to retrieve the package or staff will deliver the package to the resident. A package was delivered on 02/12/24 for R1 but not received by R1. According to R1, the package contained medications and they had to reorder and pay again for the medications. Staff interviews revealed they were not aware of that package. Continued on an LIC 9099C. Substantiated On 09/19/24, records revealed another package was delivered to R1 and signed by facility staff as received. Staff interviews confirmed they sign for the packages for residents and once it slows down they deliver the package to the resident or the resident stops by the front desk to obtain the package. Staff were not aware of the whereabouts of the package delivered on 09/19/24. R1's interview revealed asking the front desk staff on 09/19/24 for the package, once receiving the delivery message and again each day until delivered. Staff denied being asked for the package on any of the days. The manager's interview stated after talking with staff it was discovered the package was located behind a large air conditioning unit, which was hard to see located at the front desk. On 09/25/24, the package was accidentally delivered to another resident with the same first name. The other resident opened the package and realized it was not their package and it was returned to the front desk. Staff observed the package was opened and used to tape to seal the package back up. On 09/25/24, R1 sent an email to the facility regarding the package still not being delivered, then two (2) hours later that same day, staff delivered R1's package to them. The regulation states the resident has the right to receive unopened correspondence in a prompt manner. Even though there was an issue with the facility providing the package to the incorrect resident. R1 received an opened correspondence seven (7) days late, which was not in a prompt manner. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Manager, Gabriela Zamora whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Oct 2, 2024 · control 08-AS-20240926094605

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(15) · Plan of correction due date: Oct 30, 2024

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To send and receive unopened correspondence in a prompt manner. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure 1 out of 100 [R1] resident received their correspondence unopened and in a prompt manner, which posed a potential Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: The Manager stated they will be using a package delivery form and have residents sign once they obtain their package. The Manager also stated she will conduct in-service training on the form and ensure packages are delivered unopened and in a prompt manner. Manager will submit proof of training. POC due date 10/30/24.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident visit. LPA met with Manager, Gabriela Zamora and discussed the purpose of the visit. On 09/30/24, the facility self reported an incident involving Resident #1 (R1). The Incident Report stated a on 09/26/24, a resident alerted facility staff at approximately 10:30am that R1 was walking in the middle of the road. At approximately 10:40am staff went to search for R1 but R1 was gone. R1 returned to the facility at approximately 2pm with no injuries. The Manager explained R1 leaves the facility on a regular basis and signs out and signs back in using their facility log. Manager stated R1 is capable of being in the community unassisted and knows the area well. The Manager also stated R1 has a cell phone but refuses to answer it when staff call. The facility also has R1's friend's contact information and will get a hold of R1's friends to verify R1's location. There have never been any issues with R1 being in the community. Manager believes R1 is able to be in the community unassisted and will discuss the issue with R1's Physician to update the Physician's Report that currently indicated R1 is not allowed to leave unassisted. Once the facility was made aware R1 was out of the facility and didn't return they followed their Absentee Notification Plan. The facility cannot force a resident to remain in the facility. The facility acted appropriately by following their absentee plan. No deficiencies were issued. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Manager, Gabriela Zamora whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Oct 2, 2024

Allegation investigated: Facility is in disrepair Staff do not intervine when there are resident on resident altercations

Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Manager Gabriela Zamora and discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside agency. It was reported to CCL that facility is in disrepair and staff do not intervene when there are resident on resident altercations. [Continued on LIC 9099] Unsubstantiated [Continued from LIC 9099] Regarding the allegation that facility is in disrepair, it was reported that there is water damager to the facility and the facility is “falling apart”. LPA observations revealed that LPA did not observe any water damage or leaks in the facility. LPA observed room 202 to be under construction with debris on the floor, but was vacant and inaccessible to residents. Interview with Outside Source (OA) reported having concerns for the facility grounds such as cracks in the pavement in the outside/patio area and reported no knowledge of anyone getting injured from cracks. Interviews with facility staff revealed no concern for facility being in disrepair. Interview with residents revealed no concern for the buildings/grounds. Regarding the allegation that facility staff do not intervene when there are resident on resident altercations, it was reported that there was an incident where R1 & R2 got into an argument that involved one resident shoving the other, one resident breaking the other’s cane and one resident had a knife. interviews with facility staff revealed that staff will redirect residents when there is an altercation and will call the police if there is a physical altercation. Facility staff revealed there was a verbal argument between two residents and facility staff stood in between them and asked them to separate. Staff stated that residents separated, denied that the argument got psychical and stated that none of the residents were seen with a knife. Staff also reported that residents were issued warnings regarding the incident. LPA’s review of records confirmed that warnings were issued to the residents. Interviews with residents revealed conflicting statements on whether or not a resident had a knife. Interview with R1 revealed that they have only been involved in minor disagreements and denied ever engaging in a physical altercation. R1 also denied that they have seen any residents with weapons. Interview with resident revealed that during the incident staff tried to verbally calm down R1 &R2. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Manager Gabriela Zamora. A copy of this report along with licensee rights (LIC 9058) was provided to Manager whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, May 22, 2024 · control 08-AS-20240419093531

Allegation investigated: Resident rooms do not have a working auditory signal system. Lack of sufficient staffing to meet residents' needs

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Manager Gabriela Zamora and discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside agency. It was reported to CCL that resident rooms do not have a working auditory signal system and there is lack of sufficient staffing to meet resident’s needs. [Continued on LIC-9099 C] Unsubstantiated [Continued from LIC 9099] Regarding the allegation that resident rooms do not have a working auditory signal system, LPA conducted a walk through of the facility and observed working signal systems in rooms that were toured. LPA observed some empty rooms that were being renovated that did not have signal systems although there were no residents residing in those rooms. Interviews with staff revealed that signal systems are in working order and are in all resident bedrooms. Interviews with residents did not avail any concern in regards to signal system. Regarding the allegation for lack of sufficient staffing to meet resident’s needs, it was reported that there is a staff shortage and residents are not getting proper assistance. Interviews with facility staff revealed no issues with care and supervision. Interviews with residents revealed no concerns for residents not getting their needs met. Interview with Outside Source (OA) revealed concerns for lack of staffing. Insufficient evidence to substantiate allegation due to conflicting statements in regards to staffing. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Manager Gabriela Zamora. A copy of this report along with licensee rights (LIC 9058) was provided to Manager whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, May 22, 2024 · control 08-AS-20231205162201

Type of visit: Required - 1 Year

Licensing Program Analyst’s (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. Facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Manager Gabriela Zamora. The facility is currently licensed for a maximum capacity of one-hundred seventy (175), of which all may be non-ambulatory. During today’s inspection, there was a total of one-hundred and four (104) clients in care. LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected resident bedrooms. The facility was clean and sanitary. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Extra linens, hygiene supplies were present and personal protective equipment were present. Hot water temperature was compliant in part of the building while a portion of the building did not have hot water. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water on the premises. Per staff no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) and first aid kit was present. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and reviewed multiple staff and client records/files. The files which LPA reviewed contained required documents. Deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Plans of Correction was jointly developed with the Manager. An exit interview was conducted with Manager, to whom a copy of this report, the LIC 809-D and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, May 22, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Manager Gabriela Zamora. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 02/01/2024). According to the LIC624: on 01/31/2024, Resident #1 (R1) left the facility on foot. [See LIC 811 Confidential Names List for a description of select person identifiers used.] Facility staff followed R1, but were initially unable to redirect R1 back, leading staff to call 911. R1 returned with staff to the facility about an hour later, unharmed. During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying that they were indeed safe and unharmed. LPA tested auditory staff alert devices on the facility’s six exterior exit doors. LPA also collected copies of and reviewed pertinent care records and interviewed relevant staff. According to their latest LIC602 Physician’s Report (dated 02/24/2022), R1 was diagnosed with bipolar disorder. R1 was not diagnosed with Dementia or Mild Cognitive Impairment (MCI). R1’s physician determined that R1 was ambulatory, independent in Activities of Daily Living (ADLs), not confused/disoriented, able to follow instructions, able to communicate needs, and able to leave the facility unassisted. The latest LIC625 Appraisal/Needs and Services Plan (dated 01/13/2022) which Licensee performed on R1 corroborated the above points. [CONTINUED ON LIC 809-C, 1 of 2] [CONTINUED FROM LIC 809] During today’s visit, R1 declined to be interviewed by LPA. However, staff interview showed R1 had a history of refusing medications which were prescribed by their assigned psychiatrist; this was also true during the time of the incident. On 01/31/2023 around 4:00 AM, R1 was hallucinating and claimed to have seen a man inside their bedroom. R1 became troubled and left the facility on foot via the lobby's front doors. Staff #1 (S1) saw R1 as they exited and followed them, trying unsuccessfully to redirect them back to the facility and calling 911. R1 walked around three blocks to the local fire department’s station, where personnel there helped convince R1 to return to the facility. R1 then walked with S1 back to the facility, under the observation of a sheriff’s deputy who arrived later. R1 was unharmed. During today’s visit, LPA observed (and manager interview confirmed) that the facility’s fire extinguishers had not been serviced within the last twelve (12) months, as was required for Licensee to maintain ongoing compliance with its prior approved Fire Clearance (issued by the local fire authority). Per manager interview: a) The facility’s lobby front desk is not usually staffed between the hours of 10:00 PM and 6:30 AM; and, b) on the date of LPA’s visit, there were around thirty-one (31) residents in care diagnosed with dementia. During today’s visit, LPA observed: For five of six exterior doors, staff alert devices were present and intact, but staff had them turned off (i.e., deactivated) during the daytime. These doors were not continuously visually monitored by staff. Also, one of two sensors associated with the facility’s lobby entrance doors was not working, effectively allowing the front door to be opened from the inside without triggering a staff alert. Licensee had constructive knowledge of the faulty sensor needing repair since mid-August 2023. Based on a review of records and confirmed by manager interview, Licensee did not have a current and signed Admissions Agreement for R1, as was required. [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809-C, 1 of 2] Three (3) deficiencies were cited per California Code of Regulations, Title 22 (see the LIC 809-D pages). Since one of the deficiencies was also a violation of the facility’s fire clearance, an immediate civil penalty of $500 was assessed (see the LIC 421-IM page). Plans of Correction was jointly developed with the licensee. LPA also issued Technical Assistance (TA) regarding conducting a reappraisal of R1, and regarding an infection control requirement (see the LIC 9102-TA pages). An exit interview was conducted with Zamora, to whom a copy of this report, the LIC809-D pages, the LIC9102-TA pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Feb 5, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Feb 6, 2024

87202 Fire Clearance: “(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.” This requirement was not met, as evidenced by: Based on LPA observation and manager interview: Licensee did not maintain ongoing compliance with its prior-approved fire clearance, which posed an immediate safety risk to 100 of 100 residents (R1 through R100) in care.the state’s words, verbatim · CDSS document, Feb 5, 2024

Plan of correction: During today’s visit, Licensee contacted a vendor to schedule service for the facility’s fire extinguishers. Licensee agreed to E-mail the completed vendor invoice and a photograph of one of the updated extinguisher service tags to LPA, by 03/05/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(j) · Plan of correction due date: Mar 5, 2024

87705 Care of Persons with Dementia: “(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.” This requirement was not met, as evidenced by: Based on records and interviews, during today’s visit, Licensee did not have continuously active auditory devices or other staff alert features to monitor exits, which posed a potential safety risk to 31 of 100 residents (R2 through R34) in care.the state’s words, verbatim · CDSS document, Feb 5, 2024

Plan of correction: During today’s visit: Licensee activated (turned on) the auditory alarms at each exterior door (other than the lobby front door). Licensee agreed to retrain its staff to: a) keep all such alarms activated 24/7, and b) remind residents that such doors are to be used as emergency exits only. Licensee also contacted a vendor to repair the faulty front door alarm sensor; the appointment is scheduled for 02/08/2024. Licensee agreed to send a copy of the staff training sign-in sheet, a copy of the vendor's completed invoice, and a video of the front door alarm in action (both left and right sides) to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87505(a) · Plan of correction due date: Mar 5, 2024

87505 Admissions Agreements: “(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.” This requirement was not met, as evidenced by: Based on LPA observation and staff interview, for 1 of 100 residents (R1), licensee did not complete an individual written admission agreement, which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 5, 2024

Plan of correction: Licensee agreed to coordinate with appropriate persons, as needed, to complete an Admissions Agreement for R1. Licensee agreed to E-mail a copy of the Admissions Agreement to LPA, by the POC due date. Licensee agreed to conduct an internal audit to ensure that all current residents have a signed Admissions agreement. Licensee agreed to review their internal policies/procedures, to ensure that the signed Admissions Agreement is treated as a required document at time of move-in.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit to deliver findings from a completed case management investigation. LPA met with Manager Gabriela Zamora and explained the reason for this visit. During today's visit, LPA shared the investigation findings with the facility representative. The Department conducted an investigation after Licensee self-reported an incident which had occurred on 04/16/2022, in which Resident #1 (R1) jumped out of a second-story window at the facility. [See LIC 811 Confidential Names List for identification of R1.] The incident resulted in serious bodily injury to R1. CCLD initially had concerns regarding staff supervision. The Department's investigation involved multiple interviews with staff and outside sources, along with review of facility and medical records. The evidence showed: Prior to admission, R1 had been medically evaluated as stable and ready for discharge to an assisted living facility. R1 was ambulatory, independent with all activities of daily living, and able to communicate their needs. No additional care or supervision provisions were noted on written appraisal records. Staff had observed R1 approximately thirty minutes prior to the incident, and there were no indications that R1 was in distress or required assistance. Based on the preponderance of evidence obtained, the Department did not determine that there was a lack of staff supervision in regard to this incident. No deficiencies were issued during today's case management visit. An exit interview was conducted with Zamora, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit. Zamora's signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Feb 5, 2024

Allegation investigated: Facility did not have hot water

Licensing Program Analyst (LPA) Ramon Serrano, conducted an unannounced Complaint Visit. LPA introduced himself and discussed the purpose of the visit with Med-Tech Evelyn Reyes. It was alleged that the facility did not have hot water. It was reported that the entire east wing on the second floor did not have hot water as well as some of the residents on the first floor. LPA conducted random water temperature checks throughout the facility escorted by Med-Tech Evelyn. The first floor common area bathroom had a water temperature reading of 118 degrees Fahrenheit. Room #101 on the first floor had a (bathtub) water temperature reading of 117 degrees Fahrenheit. Room #221 on the second floor had a (bathtub) water temperature reading of 111 degrees Fahrenheit. Room #240 on the second floor had a (sink) water temperature reading of 116 degrees Fahrenheit. Unsubstantiated Title 22 regulation states that faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid. An exit interview was conducted with Evelyn Reyes. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Evelyn Reyes whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Dec 28, 2023 · control 08-AS-20231222113947

Allegation investigated: Lack of supervision resulted in residents being absent without leave. Licensee did not follow reporting requirements.

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to follow up on the above allegations. LPA met with facility Manager Gabriela Zamora and reviewed basic elements of the complaint. During today's visit, LPA reviewed records, interviewed staff and then delivered findings. On 12/5/2023, it was alleged that facility has lack of supervision resulted in residents (R1 & R2) being absent without leave (AWOL) and Licensee did not follow reporting requirements. [Continued on 9099-C] Substantiated [Continued from 9099] Interview with Staff 1 (S1) revealed that resident 1 (R1) & Resident (R2) often leave the facility to go out in the community unassisted. S1 reported witnessing R1 & R2 leave the facility on Friday 12/1/2023 and then left as their shift ended. S1 stated that upon returning to the facility the next day (12/2/2023) they noticed that R1 & R2 had not returned to the facility. S1 admitted that they did not call the police or notify the Manager of the missing residents, as required, and was not able to provide a reason for this. S1 said they searched the local area for R1 & R2 on Saturday (12/2/2023) and Sunday (12/3/2023). S1 admitted that no one reported to any outside agency about the incident. Interview with Manager revealed that she does not work on the weekends and S1 is in charge on weekends. Manager reported that she is always available by phone and has instructed staff to notify her if there is an emergency, including missing residents. Manager stated that she has verbally told staff what to do in the event there is a resident missing. This includes search the facility grounds, immediately call her, search the local area and immediately call the police. Manager reported that she became aware of situation on Monday 12/4/2023 when she did not see R1 & R2 as she typically does. Manager asked staff about the whereabouts of R1 & R2 and she was notified that they had been missing since Friday. Manager immediately called the police to report residents missing, called responsible parties and searched the town. Manager admitted that she did not notify Community Care Licensing and did not submit an incident report until requested to do by Community Care Licensing. Review of client records revealed that according to R1 and R2’s most recent physician’s reports they are unable to leave the facility unassisted. Based on evidence obtained during visit, both allegations are substantiated. Deficiencies are cited on LIC 9099-D, per CCL Title 22 regulations. Plans of correction were jointly developed with Manager Zamora, and a paper copy of this report was provided along with Licensee Rights.the state’s words, verbatim · CDSS document, Dec 6, 2023 · control 08-AS-20231205162201

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87211(a)(1)(D) · Plan of correction due date: Jan 5, 2024

A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence........(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. Based on interviews and records review, the Licensee did not submit an incident report to the Department regarding AWOL of R1& R2. This poses an potential safety risk to 101 of 101 residents in care.the state’s words, verbatim · CDSS document, Dec 6, 2023

Plan of correction: Manager will provide training to staff about reporting requirements and wil submit proof of training to LPA Ramirez by POC due date.

From the deficiency page — Section cited: HSC 87464(f)(1)(c) · Plan of correction due date: Dec 6, 2023

Basic services shall at a minimum include: Care and supervision ... "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement was not met as evidenced by: Based on interviews, R1 and R2 eloped due to facility staff’s lack of supervision. This posed an immediate safety risk to two residents in care.the state’s words, verbatim · CDSS document, Dec 6, 2023

Plan of correction: Manager will create an absentee notification plan and provide training to staff about absentee notification plan. Manager will submit proof of training to LPA Ramirez by POC due date.

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