South County Retirement Home

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management - Incident visit to follow up on a visit made on 11/19/2025 regarding an Incident Report the Department received on 11/18/2025. LPA Rai met with Administrator, Sam Apostol, and stated the purpose of the visit. On 11/18/2025, the Department received an LIC 624 Incident Report stating on 11/17/2025 resident R1 was found unconscious and staff called 911 in response and R1 was transported to the hospital. Administrator Sam Apostol was informed R1 passed away at the hospital the same day. On 11/19/2025, the Department conducted a visit at the facility to follow up on the Incident Report. LPA Rai received information from Administrator, Sam Apostol and two staff members. Three out of three staff stated on 11/17/2025 staff heard R1 fall in the bathroom and observed R1 on the floor unconscious. The facility staff called 911 and paramedics transported R1 to the hospital. ADM stated R1 passed away at the hospital due to cardiac arrest. During this investigation, Death Certificate was not able to be released to the Department due to Health Insurance Portability and Accountability Act (HIPPA). LPA Rai contacted a representative of the Office of the Medical Examiner (OME) of County of Santa Clara who stated "[R1]'s death was ruled as natural". Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. The Department has completed the investigation of the above incident. Based on a review of pertinent documents and interviews, there is no indication that the death was due to staff neglect or failure to seek timely medical care. The Department has found that the allegation of neglect or failure to seek timely medical, as UNFOUNDED, meaning that the allegation were false, could not have happened and/or are without a reasonable basis. No deficiencies were cited at this time as per California Code of Regulations, Title 22. This report was reviewed with Administrator Sam Apostol and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 13, 2026

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

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Legal/Non-compliance visit and met with Administrator (ADM) Samuel Apostol. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on February 8, 2024. During visit, LPA Marrufo toured the facility hallways, common areas, resident bedrooms, bathrooms, and outdoor areas. One bedroom was undergoing renovations during visit. ADM stated that the facility has received a grant and is renovating each room one at a time. All fire exit routes were free and clear of obstruction. LPA observed signs posted next to the resident bedroom doors for the residents who are a fall risk. Fly traps were observed next to exit doors, inside the resident bedrooms, smoking areas, common areas, and hallways. The facility protocol for contacting 911 and signs instructing staff what to do if a resident has a fall were posted throughout the facility. LPA randomly reviewed 3 resident files, which included but were not limited to: physicians report, needs and services plan, and admission agreement. 3 staff files were randomly reviewed and the staff training files were up-to-date. LPA observed facility maintenance log. LPA observed the fall risk log is completed daily and every 2 hours, which contains the list of residents who are a fall risk and incontinent. No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed with Administrator Samuel Apostol and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 15, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with House Manager (HM) Ivonne Chavez. LPA reviewed 5 resident files and 4 staff files. LPA observed licensee, Administrator Certificate, and personal rights posters at the facility. LPA toured the facility with HM inside and out. LPA inspected living room, dinning room, kitchen offices, 1 staff restroom, 2 shower rooms, TV room, and 23 resident rooms in the facility. Each resident room has its own restroom. Two days perishable foods and seven day nonperishable foods were observed sufficient. Room temperature was observed at 69 degree F, hot water temperature was observed at 105 degree F. The temperature of the freezer was observed at 0 degree F and the temperature of the refrigerator was observed at 37 degree F. Medication room, laundry room, kitchen were observed locked. The facility was equipped with fire alarm, smoke and carbon monoxide detectors. Carbon monoxide detector was tested, and was working. Fire extinguisher was serviced on 5/20/2025. The fire alarm system test report dated 12/15/2025 was observed. First aid box was observed in the facility. The facility has emergency lighting system. The last time the facility conducted the fire drill was on 12/15/2025. Front yard and backyard were inspected. There was no obstruction to block the walkways. One storage room with food and refrigerator was observed at backyard. No citation noted for today's visit. Exit interview was conducted with HM. This report was provided to HM for signature. A copy of this report was provided to HM.the state’s words, verbatim · CDSS document, Dec 18, 2025

Type of visit: Case Management - Incident

On November 19, 2025 at 8:45am, Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management - Incident visit in regards to an Incident Report the Department received on 11/18/2025. LPA met with Administrator Sam Apostol and stated the purpose of the visit. On 11/18/2025, the Department received an LIC 624 Incident Report stating on 11/17/2025 resident R1 was found unconscious and staff called 911 in response and R1 was transported to the hospital. Administrator Sam Apostol was informed R1 passed away at the hospital the same day. During today's visit, LPA Rai received information from Administrator, Sam Apostol and two staff members. LPA Rai obtained a copy of R1's ID and Emergency Information and LPA Rai received copies of R1's Appraisal/Needs and Services Plan and R1's Physician's Report. At this time, LPA Rai determined this case management needs further investigation. Administrator Sam Apostol will provide a copy of R1's Death Report when it becomes available. This report was reviewed with Administrator Sam Apostol and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 19, 2025

Allegation investigated: Facility staff dispensing medication is under the age of 18 years old

This is a continuation of the LIC 9099 report On 10/3/2025, LPA Mita Partoza, reviewed the record and observed that the staff was given training for medication administration. Based on interview of staff 1 (S1), S1 stated that staff 2 (s2) was given medication administration training. S1 stated that S2 is not alone during the time of medication pass. Based on review of document, S2 is under the age of 18 and is a staff. S1 stated that S2 comes to the facility after school and arrives at around 4:00 and 4:30 p.m. to help out at the facility. S1 stated and S4 stated that S2 does not dispense medication by himself/herself. S1 stated that S2 accompanies S4 and S5, who are the regular medication technicians at the facility during medication pass, but does not dispense medication. Page 3 of 4 Unsubstantiated Based on document review and interviews although the allegation that facility staff dispensing medication is under the age of 18 years old could have happened the preponderance of evidence have not been met and therefore the allegation is unsubstantiated. No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with Licensee/Administrator Samuel Apostol and a copy of the report was provided. End of Report page 4 of 4the state’s words, verbatim · CDSS document, Nov 10, 2025 · control 26-AS-20250930142518

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provide adequate supervision resulting in resident sexually abusing another resident.

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced visit to deliver the finding of the complaint investigation that was received by the Department on 10/02/25. On 10/03/25, the Department conducted a 10-day visit at the facility and gathered information. On 10/20/25, the Department continued the investigation and interviewed resident (R1) other residents and staff. Based on interview R1 could not provide the current date and time. When questioned about the details of the sexual abuse by another resident at the facility and beaten by an adult female R1 could not provide details or information on the incidents. When asked if the person was R1s roommate, R1 is not able to provide any identifying information. R1 stated that a person who sexually assaulted him/her was from a year ago while at the hospital. R1 could not give any information of who assaulted him/her at the hospital. page 1 of 2 Unfounded Based on the document review, R1 does not take his/her medication at home resulting to a severe schizoaffective disorder, bipolar and catatonia. R1 has history of mental illness, R1 is able to ambulate and is able to leave the facility unassisted as stated on his/her physician's report (LIC 602). R1 has mild cognitive disorder. R1 was admitted to the hospital from 02/06/25 and was discharged on 07/17/25. R1 was admitted due to history of odd behaviors and changing cognition. R1 moved to the facility after discharged from the hospital. Based on observation. LPA observed at the time of the visit on on 10/03/25, that R1 called a family member and alleges that he/she was being maltreated. Family called the facility and ADM assured R1s family member that R1 is unharmed. At the same time R1 called his/her case manager from Telecare and stated that there is an emergency happening at the facility. R1s CM called the facility to confirm, ADM assured CM that R1 is unharmed and no emergency or EMT personnel is at the facility. R1 approached LPA and stated to LPA that he/she was beaten on his/her arms, shoulder, body. LPA did not observed any bruising on R1s arms or legs. R1 followed LPA while LPA was conducting inspection of the facility on 10/03/25. LPA did not observed R1 to be in pain. Based on interview, observation and document review, the department has investigated the complaint alleging that, staff did not provide adequate supervision resulting in resident sexually abusing another resident. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies were cited during today's visit based on the California Code of Regulation (CCR) Title 22. An exit interview was conducted with LIC/ADM Samuel Apostol and a copy of the report was provided. Page 2 of 2 end of reportthe state’s words, verbatim · CDSS document, Nov 10, 2025 · control 26-AS-20251002125338

Type of visit: Case Management - Deficiencies

On 10/03/2025, Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an complaint investigation regarding an underage staff at the facility dispensing medication. On 11/10/2025, LPA conducted a case management for deficiency that is not related to the complaint that was filed on 09/30/2025. Based on document review, the facility hired S2 who is under the age of 18. Based on the the California Code of Regulation (CCR), under the 87411 Personnel Requirements - General (b) All persons who supervise employees or who supervise or care for residents shall be at least eighteen (18) years of age. Based on document review, the facility hired S2 on 10/08/2024 and have not turned 18 years of age at the time of hire. Based on document review S2 has a CA identification/driver's license that states his/her true age and completed medication administration training on 2/27/2025. S1 stated that S2 comes to the facility after school around 4:00 to 4:30 p.m. and works part-time at the facility. Deficiencies were cited based on California Code of Regulations (CCR) Title 22 (See LIC 809-D). An exit interview was conducted Licensee/Administrator Samuel Apostol and a copy of the report and appeals rights were provided. End of reportthe state’s words, verbatim · CDSS document, Nov 10, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(b) · Plan of correction due date: Nov 11, 2025

87411 General Personnel Requirement (b)All persons who supervise employees or who supervise or care for residents shall be at least eighteen (18) years of age. This requirment is not met as evidenced by: Based on record review, LIC/ADM did not ensure that S2 was at least 18 years of age at time of hire S2 on 10/08/2024. S2s CA ID/DL confirms S2 is under age18. S2 works partime at the facility, which pose/poses an immediate health, safety & personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Nov 10, 2025

Plan of correction: LIC/ADM stated that he/she will submit a written plan of correction by the POC due date of 11/11/2025 stating the he/she will ensure that prior to hiring he/she will conduct a age check and will be verified based on his/her provided identification. ADM stated he she will submit to LPA by 11/10/25.

Allegation investigated: Facility staff did not take appropriate measures to safeguard resident’s belongings resulting in resident missing multiple items Facility staff does not accord resident with privacy during showers

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the finding for the above allegations. LPA met with Administrator, Sam Apostol and Office Manager, Ivonne Chavez. On 09/30/2025, the Department received the complaint alleging the above allegations. On 10/03/2025, the initial complaint investigation was conducted. Documents were obtained to include resident roster, physician's report and appraisal needs and services plan & pre-appraisal assessment. It was alleged that the facility staff did not take appropriate measures to safeguard resident (R1)’s clothing items, leg brace that was prescribed by the doctor, cell phone, and a cell phone charger. It was also alleged that the R1's clothing items were locked inside the washing machine and the staff are unable to take them out. Page 1 of 3. Unfounded Resident (R1) was interviewed who stated that he/she only came to the facility with a suitcase, clothes, and a cane. R1 states he/she did not come to the facility with any other item to include a leg brace. R1 states that he/she only came with a few clothes but his/her family member and facility staff bought extra clothes for him/her. R1 states that he/she has 2 cell phones and a phone charger. R1 stated that his/her family member bought clothes for him/her but all the clothes are locked in the washing machine. 2 staff members were interview. Based on staff interviews, R1 did not come to the facility with a leg brace. It was stated that R1's previous facility did not send all his/her personal items and R1 only came with the clothes he/she was wearing, a guitar and a cane. Based on observation of R1's bedroom, LPA Kabariti observed R1's closet has at least 5 pairs of pants, at least 6 shirts, socks and briefs. LPA Kabariti observed additional clothing items on the floor next to R1's bed, 2 cell phones, a charger which R1 states he/she uses for his/her cell phone, and a walker. The review of records shows that R1 was admitted to the facility in July 2024. When R1 moved into the facility items that were safeguarded included a cell phone and clothing items but the leg brace and cell phone charger was not listed as part of safeguard items. LPA Kabariti entered into the laundry room with staff and observed the washer and dryers were in good repair. LPA observed the washers and dryers were in use. It was stated that all resident clothing items are labeled with the resident's name, which LPA observed. The office manager and Administrator states that the resident's clothing items are washed daily and as needed. LPA observed the laundry room is locked and only accessible to staff. It was also alleged that the facility staff does not accord resident with privacy during showers. Based on the reporting party (RP), it was stated that R1 has a health condition where he/she has difficulty walking and cannot stand for a long period of time. It was stated that R1 did not like that staff were sitting in the shower with him/her. Page 2 of 3. Based on interview with R1, it was stated that he/she has to ask permission to use the shower because the shower rooms are locked. R1 stated that before, there used to be a staff who sat in the shower room while R1 was showering and R1 did not like that. R1 states that now, the staff waits outside for him/her to finishing showering. R1 states they wait outside for him/her in case R1 has a fall. Based on record review, R1 does have the capacity for self-care to include bathing, dressing and grooming, but has a condition that affects his/her movement and coordination. 2 staff members interviewed stated that because they are an assisted living facility the staff supervise the residents during shower for their safety, such as a fall. It was stated that the staff assist R1 in the shower because they are afraid that R1 will fall due to his/her health condition. S1 and S2 stated that if a resident does not feel comfortable with the staff assisting them in the shower and they are able, the staff would do a body check of the resident to ensure there are no changes in condition, and then step outside and wait for the resident to finish showering. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unfounded, meaning the allegations are false, could not have happened, and/or is without reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Sam Apostol and Office Manager, Ivonne Chavez and a copy of the report was provided. Page 3 of 3.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 26-AS-20250930133622

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

Licensing Program Analysts (LPA) Christine Kabariti arrived unannounced to conduct a case management - legal/non-compliance visit. LPA met with Lead MedTech Julianna "Julie" Garcia, Administrator Sam Apostol and Office Manager Ivonne Chavez. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on February 8, 2024. During visit, LPA toured the facility with staff to include all the resident bedrooms, hallways, common areas, storage and exterior. It was observed the facility is currently undergoing renovations. Staff stated that the renovations are starting in the resident bedrooms but only one bedroom is being renovated at a time to minimize the impact to the residents. All fire exit routes were free and clear of obstruction. LPA observed signs posted next to the resident bedroom doors for the residents who are a fall risk. Fly traps observed next to exit doors, inside the resident bedrooms, smoking areas, common areas and hallways. Facility protocol for contacting 911 and what to do if a resident has a fall signs posted throughout the facility. LPA observed the facility was well maintained. Page 1 of 2. LPA randomly reviewed 3 resident files, which included but not limited to; physicians report, needs and services plan, and admission agreement. 3 staff files were randomly reviewed and the staff training files were up-to-date. LPA observed facility maintenance log. LPA observed the fall risk log are completed daily and every 2 hours, which contains the list of resident who are a fall risk and incontinent. During visit, LPA obtained the facility's request letter to increase capacity, LIC200, and the facility sketch. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Samuel Apostol and Office Manager Ivonne Chavez a copy of the report was provided. Page 2 of 2.the state’s words, verbatim · CDSS document, Oct 7, 2025

Allegation investigated: Facility Administrator did not address resident’s sleep concerns affecting his/her health.

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the complaint investigation finding. LPA met with Administrator(ADM) Samuel Apostol and Office Manager (OM) Ivonne Chavez. On 04/25/2025, the Department received the complaint. On 04/30/2025, the initial complaint investigation was conducted. The following documents were obtained to include 2 residents physician's report, appraisal/needs and services plan, identification and emergency contact information, progress notes, and admission agreement. It was alleged that the facility Administrator did not address resident (R1)’s sleep concerns as R1’s roommate (R2) snores at night, which is causing sleep deprivation and affecting R1’s health. 2 staff members and Administrator were interviewed. Based on interview with the Administrator, it was stated that the facility has changed out R1’s roommate about 3 times due to different conflicts R1 had with his/her roommates. Page 1 of 2. Unfounded The Administrator stated that R1 does not like to have a roommate, however, is unable to pay for the cost of a private bedroom. Administrator stated that R1 was aware that his/her bedroom would be a shared bedroom and consented to it. It was stated that due to conflicts with R1’s previous roommate, they thought R2 would be a good fit to be R1’s roommate Administrator stated to address R1’s sleep concerns they have provided R1 was ear plugs and reached out to R1’s case manager. It was stated that R1 also had headphone that he/she uses during the night. It was stated that due to the constant roommate switches, the facility has challenges in finding another roommate who would be compatible with R1’s needs. It was stated that it was also unfair to move residents around who are already settled and comfortable in their rooms. Administrator denied R1 reaching out to request for a specific roommate. Based on interview with R1, it was stated that R1 had a preference for which roommate he/she preferred. R1 stated that he/she did not talk to the Administrator and staff regarding his/her roommate request. R1 stated that he/she found ear plugs inside his/her room on 04/30/2025 but R1 didn’t need that as R1 was already using noise canceling headphones. R1 states that even with the use of noise canceling headphone, R2’s snoring was too loud that he/she can hear it through the headphones resulting in sleep deprivation. R1 did not want to inform the Administrator of his/her request and consented for LPA Kabariti to inform the Administrator regarding his/her roommate request. On 05/01/2025, the Administrator switched R1’s roommate to the preferred roommate R1 requested. Based on record review, it was stated that R1 and R3 both agreed to share a room. The Department has investigated the above allegation. Based on interview and record review, the above allegation is unfounded meaning the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator(ADM) Samuel Apostol and Office Manager (OM) Ivonne Chavez and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 9, 2025 · control 26-AS-20250425092020

Allegation investigated: Facility staff not meeting resident's incontinence care needs

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the finding for the above allegation. LPA met with Administrator(ADM) Samuel Apostol and Office Manager (OM) Ivonne Chavez. On 04/04/2025, the Department receive a complaint regarding the above allegation. On 04/11/2025, the initial complaint investigation was conducted. The following documents were obtained to include the resident roster, resident tracking log, list of fall risk/incontinent residents, 3 resident's physician's report, appraisal/needs and services plan, admission agreement and progress notes. It was alleged that the facility staff are not meeting resident (R1’s) incontinent care needs as the resident was often observed wearing a diaper full of urine resulting in R1’s bedroom smelling of urine. Page 1 of 3. Unsubstantiated R1 was admitted to the facility on 03/03/2025. 3 residents were interviewed. Based on interview, 1 out of 3 resident stated to have helped R1 clean his/her bed with a witness (W1) because R1 and R1’s bed was soiled. This resident stated to have voluntarily cleaned R1’s bed because the staff was taking too long to come to the room. This resident denied staff checking on the residents regularly and in the morning. 2 out of 3 residents interviewed stated that the staff check in on the residents daily in the morning and throughout the day, and denied observing other residents left in soiled adult briefs. Based on interview with witness (W1), W1 observed R1 laying in bed soaked full of urine about 3 times since he/she has visited the facility. W1 was unable to recall the dates of observation. W1 stated that he/she visits the facility daily at 10:00am and around 2:00pm. It was stated that he/she has observed R1 left laying in his/her urine around 10:00am and when he/she returned to the facility at 2:00pm. W1 states that when he/she observed R1 laying in bed soaked in urine, W1 did not tell the staff. W1 states that there was always staff in the hallways and assumed they’d check in on R1. W1 denied observing staff help R1. The review of R1’s pre-placement appraisal notes that R1 is incontinent and did not need help with toileting but needs help with bathing and personal hygiene. 6 staff members were interviewed. Based on staff interview, it was stated that R1 came from an independent living home. The facility was informed that R1 was able to change his/her own adult briefs. It was stated that when R1 first moved in, R1 refused staff assistance to change his/her adult brief and any assistance in the bathroom. Staff stated that in beginning R1 needed to be constantly reminded to use the bathroom and change his/her adult briefs. Staff members stated that they ensure R1 is checked and asked every 2 hours to go to the bathroom and to change his/her adult brief. Page 2 of 3. The review of facility records shows that the facility noted on 03/12/2025 that R1 woke up with a wet bed and heavy adult brief but did not want to change his/her adult brief. Staff asked R1 to return to his/her room and change his/her adult brief. On 03/16/2025, a staff communication was noted to make sure R1 changed his/her adult brief every 2 hours and to shower if necessary. Based on observation on 04/11/2025, R1 was not observed soiled around 10:00am and 11:00am. R1’s bedroom did not have an odor of urine and feces. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator(ADM) Samuel Apostol and Office Manager (OM) Ivonne Chavez and a copy of the report was provided. Page 3 of 3.the state’s words, verbatim · CDSS document, Jul 9, 2025 · control 26-AS-20250404111503

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

Licensing Program Analysts (LPA) Christine Kabariti arrived unannounced to conduct a case management - legal/non-compliance visit. LPA met with Administrator(ADM) Samuel Apostol and Office Manager (OM) Ivonne Chavez. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on February 8, 2024. During visit, LPA toured the facility with OM to include all the resident bedrooms, hallways, common areas, storage and exterior. All fire exit routes were free and clear of obstruction. LPA observed signs posted next to the resident bedroom doors for the residents who are a fall risk. Fly traps observed next to exit doors, inside the resident bedrooms, smoking areas, common areas and hallways. Facility protocol for contacting 911 and what to do if a resident has a fall signs posted throughout the facility. LPA observed the facility was well-maintained. LPA randomly reviewed 3 resident files, which included but not limited to; physicians report, needs and services plan, and admission agreement. 3 staff files were randomly reviewed and the staff training files were up-to-date. LPA observed facility maintenance log. LPA observed the fall risk log are completed daily and every 2 hours, which contains the list of resident who are a fall risk and incontinent. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Samuel Apostol and Office Manager Ivonne Chavez a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 9, 2025

Allegation investigated: Facility staff violated resident's personal rights

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to open the initial complaint investigation. LPA met with Administrator Samuel Apostol and Office Manager Ivonne Chavez. On 04/22/2025, the Department received the complaint. On 04/30/2025, the initial complaint investigation was conducted. Documents were obtained to include the staff schedule, resident roster, and resident (R1)’s physician’s report, appraisal/needs and services plan, identification and emergency contact information, progress notes, and county contract. Page 1 of 3. Unfounded It was alleged that when resident (R1) returned from the hospital, R1’s room looked different than how he/she left it. It was alleged that staff went through resident (R1)’s bedroom, threw R1’s shoes over the fence outside of R1’s bedroom, and threw away R1’s dry foods inside his/her bedroom. It was also alleged that staff had taken R1’s jacket and new shoes. A witness (W1) was interviewed. Based on interview, it was stated that R1 had only reported that his/her items were missing to W1, but denied observing staff remove these items from R1’s bedroom. W1 was unable to provide proof that the items were taken from the staff. 3 staff members were interviewed. Based on staff interview, it was stated that on 04/10/2025 staff needed to remove items from R1’s bedroom as staff observed expired and molded food inside R1’s personal refrigerator that was purchased by the Administrator. It was stated that R1 also had items that are not allowed to be stored in the resident rooms to include cleaning supplies, scissors, and tools. For the resident’s safety, staff talked to R1 about the items that needs to be removed in which R1 began to get verbally aggressive towards the staff. Due to R1’s aggression, law enforcement was called and R1 was transported to the hospital to be evaluated. Staff stated that the only items that was removed was the dry foods, expired food inside R1’s personal refrigerator, chemicals and sharp objects. 3 out of 3 staff interviewed denied removing any clothing items from R1’s bedroom to include R1’s shoes and jackets. 5 residents were interviewed. Based on interview, 5 out of 5 residents could not prove that staff removed items from their bedroom without any good reason. Page 2 of 3. Based on interview with R1’s former roommate, R2 observed shoes outside their bedroom but was unsure how the shoes got there. R2 later found out it was R1’s shoes. R2 was unsure how the shoes got outside but states that R1 was upset and stated that staff put them there. R2 denied observing staff throw R1’s shoes outside and denied observing staff throw R1’s clothing items away. When staff questioned R1 about the shoes that was observed over the fence, it was stated that R1 admitted to throwing his/her shoes over the fence and later apologized to staff. Based on record review, R1 only safeguarded 1 shoe, 2 shirts, 2 shorts, 2 socks, 1 book, and 3 pairs of underwear. No additional items were safeguarded on the form to include a jacket and additional pairs of shoes. R1’s records note that on 04/10/2025, staff observed expired and molded food inside R1’s personal refrigerator. Staff talked to R1 who started to get aggressive towards the staff for not letting staff clean and throw away items. 911 was called due to R1’s aggressive behavior towards the staff. There was no indication that R1's clothing items were removed to include shoes and a jacket. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded meaning the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Samuel Apostol and Office Manager, Ivonne Chavez and a copy of the report was provided. Page 3 of 3.the state’s words, verbatim · CDSS document, Apr 30, 2025 · control 26-AS-20250422165928

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

Licensing Program Analysts (LPAs) Christine Kabariti and Manuel Monter arrived unannounced to conduct a case management - legal/non-compliance visit. LPAs met with Administrator(ADM) Samuel Apostol. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on February 8, 2024. During visit, LPAs toured the facility with ADM and staff to include all the resident bedrooms, shower room, hallways, common areas, beauty room, and exterior. All fire exit routes were free and clear of obstruction. LPAs observed signs for the residents who are a fall risk. LPAs observed fly traps in the backyard smoking area and hallways. During the tour, LPAs observed facility protocol for contacting 911 and what to do if a resident has a fall throughout the facility. LPAs observed staff members cleaning the facility. LPA randomly reviewed 3 resident files, which included but not limited to; physicians report, needs and services plan, and admission agreement. LPAs also reviewed staff training files were up-to-date. LPAs observed facility maintenance log and the 2 hourly check log. LPAs observed the fall risk log, which contains the list of resident who are a fall risk. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Samuel Apostol and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 11, 2025

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

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced Case Management to conduct a Non-Compliance Plan Visit. LPA met with Administrator(ADM) Samuel Apostol and stated the purpose of today's visit. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on February 8, 2024. During visit, LPA toured the facility with ADM, inside and out, including the beauty room. All fire exit routes were free and clear of obstruction. LPA observed signs for the residents who are a fall risk. LPA observed fly traps in the backyard smoking area. During the tour, LPA observed facility protocol for contacting 911 and what to do if a resident has a fall throughout the facility. LPA observed a staff member doing the status check rounds. LPA randomly reviewed 3 resident files, which included but not limited to; physicians report, needs and services plan, and admission agreement. LPA also reviewed staff training files and facility file. LPA observed facility maintenance log and the 2 hourly check log. LPA observed the fall risk log, which contains the list of resident who are a fall risk. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Samuel Apostol and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 9, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Samuel Apostol. During the visit, ADM stated the home has 43 residents LPA explained the purpose of the visit. LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, restrooms and residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured to range from 112-116 degrees F in resident bathrooms. Fire extinguisher was serviced in April 29, 2024. The facility was equipped with smoke and carbon monoxide detectors. The fire alarm system was last inspected in October 2024. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on December 1, 2024. LPA conducted interviews with 2 staff and 3 residents. LPA reviewed facility records for 4 staff and 5 residents. LPA reviewed 5 resident medications and centrally stored medication records (CMR). 5 Out of 5 CMR's reviewed did not have the start date written on the log for all residents reviewed. While reviewing R2's CMR, LPA observed 2 medications were not listed on the centrally stored medication log. A Deficiency is being cited & a technical assistance was provided during today's visit. This report was reviewed with ADM Samuel Apostol and a copy of the signed report and Appeal; rights were provided.the state’s words, verbatim · CDSS document, Dec 18, 2024

Allegation investigated: Facility staff withholding prescribed medication causing resident to be hospitalized Facility staff selling resident's medication for financial gain

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint investigation to deliver the findings on the above allegations. LPA met with Administrator Samuel Apostol. On August 26, 2024, the Department received a complaint alleging Facility staff withholding prescribed medication causing resident to be hospitalized. It has been alleged that that facility staff withheld R1’s medication. On September 5, 2024, Licensing Program Analyst Manuel Monter interviewed 5 residents. (R2-R6). 5 Out of 5 Residents interviewed stated they get their medication everyday & staff does not withhold residents’ medications. Page 1 Out of 4. Unfounded LPA Monter interviewed Staff S1-S5. 5 Out of 5 staff interviewed stated staff do not withhold residents’ medications. 5 Out of 5 staff interviewed stated residents’ medications are being administered daily. LPA interviewed ADM. ADM stated facility staff does not withhold residents’ medications. ADM stated residents’ medications are being administered. On November 12, 2024, LPA Monter interviewed R1. R1 stated the facility did not administer his/her medication, such as his/her antibiotic medication, because he/she knew about staff S1’s Infidelity. R1 stated he/she does not know the name of the medications he/she wasn’t given. R1 stated he/she doesn’t remember when the medication was not administered either. On November 15, 2024, LPA Monter interviewed residents R7-R12. 5 Out of 6 residents interviewed (R7-R11) stated they get their medication daily and staff does not withhold their medications. 1 Out of 6 residents interviewed (R12), stated he/she does not want to answer LPA's questions and declined to be interviewed. Based on a review of R1’s Physicians Report, dated September 22, 2014, and Needs and services plan, dated February 5, 2023, states R1 experiences auditory and visual hallucinations. The Physicians Report also states R1 is paranoid that something is trying to get him/her. Based on a review of R1’s Medication Administration Log, the form shows R1’s medications were administered. Further review of R1’s medication administration record showed R1’s antibiotics were administered as well. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 2 Out of 4. Facility staff selling resident's medication for financial gain On August 26, 2024, the Department received a complaint alleging staff selling resident's medication for financial gain. It has been alleged that R1’s medications were sold for financial gain. On September 5, 2024, Licensing Program Analyst Manuel Monter interviewed Staff S1-S5. 5 Out of 5 staff interviewed stated staff do not sell residents medications. LPA Monter interviewed residents R2-R6. 5 Out of 5 Residents interviewed stated they get their medication everyday and staff do not withhold their medication. On November 12, 2024, LPA Monter interviewed R1. R1 stated the facility did not administer his/her medication, such as his/her antibiotic medication, because he/she knew about staff S1’s Infidelity. R1 stated he/she does not know the name of the medications he/she wasn’t given. R1 stated he/she doesn’t remember when the medication was not administered either. R1 stated he/she overheard S1 talking to a family member on the phone discussing selling R1’s medications. R1 stated he/she does not remember when this phone call took place. On November 15, 2024, LPA Monter interviewed residents R7-R12. 5 Out of 6 residents interviewed (R7-R11) stated they get their medication daily and staff does not withhold their medications. 1 Out of 6 residents interviewed (R12), stated he/she does not want to answer LPA's questions and declined to be interviewed. Based on a review of R1’s Physicians Report, dated September 22, 2014, and Needs and services plan, dated February 5, 2023, states R1 experiences auditory and visual hallucinations. The Physicians Report also states R1 is paranoid that something is trying to get him/her. Page 3 Out of 4. Based on a review of R1’s Medication Administration Log, the form states R1’s medications were administered. Further review of R1’s medication administration record showed R1’s antibiotics were administered as well. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 4 Out of 4. END OF REPORT.the state’s words, verbatim · CDSS document, Nov 15, 2024 · control 26-AS-20240826154515

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

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced Case Management to conduct a Non-Compliance Plan Visit. LPA met with Administrator(ADM) Samuel Apostol and stated the purpose of today's visit. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on February 8, 2024. During visit, LPA toured the facility with ADM, inside and out. All fire exit routes were free and clear of obstruction. LPA observed signs for the residents who are a fall risk. LPA observed fly traps in the backyard smoking area. During the tour, LPA observed facility protocol for contacting 911 and what to do if a resident has a fall throughout the facility. While touring the facility, LPA observed a shed in the backyard. ADM stated the shed does have electricity and they contacted an electrician to set up the electrical. LPA requested a copy of the work order. While touring the front yard of the home, LPA observed a new gazebo in the garden area. LPA reviewed 2 resident files, which included but not limited to; physicians report, needs and services plan, and admission agreement. LPA also reviewed staff training files and facility file. LPA observed facility maintenance log and the 2 hourly check log. LPA observed the fall risk log, which contains the list of resident who are a fall risk. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Samuel Apostol and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 25, 2024

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

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced Case Management to conduct a Non-Compliance Plan Visit. LPA met with Administrator(ADM) Samuel Apostol and stated the purpose of today's visit. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on 02/08/2024. During visit, LPA toured the facility with ADM, inside and out. All fire exit routes were free and clear of obstruction. LPA observed signs for the residents who are a fall risk. LPA observed fly traps in the backyard smoking area. During the tour, LPA observed facility protocol for contacting 911 and what to do if a resident has a fall throughout the facility. LPA reviewed 2 resident files, which included but not limited to; physicians report, needs and services plan, and admission agreement. LPA also reviewed staff training files and facility file. LPA observed facility maintenance log and the 2 hourly check log. LPA observed the fall risk log, which contains the list of resident who are a fall risk. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Samuel Apostol and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 23, 2024

Allegation investigated: Facility staff did not prevent physical altercation between residents

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegation listed above. LPA met with facility Administrator (ADM) Samuel Apostol. On May 9, 2024, the Department received a complaint alleging Facility staff did not prevent physical altercation between residents. It has been alleged that resident R2 pushed R1. On May 16, 2024, LPA Monter interviewed residents R1-R13. 1 Out of 13 residents interviewed (R1) stated R2 had pushed R1. 4 Out of 13 residents interviewed (R2, R4, R5, R12) stated R2 did not push R1 and R1 had bumped into R2, causing R1 to fall. 8 Out of 13 residents (R3, R6-R11, R13) stated they did not see the alleged altercation between R2 and R1. Page 1 Out of 3. Unfounded Resident R1 stated R2 came running and hit R1. R1 stated R2 had pushed him/her and hit him/her on the head, shoulder, and spine. Resident R2 stated he/she started walking towards the home to go inside. R2 stated R1 then got in front of R1 and they bumped into each other. R2 stated when R1 bumped into R2, R1 fell down. R2 denies pushing R1. On May 16, 2024 and June 5, 2024, LPA interviewed 3 staff (S1-S3) and facility ADM. 3 Out of 3 staff and facility ADM stated they did not witness the R2 pushing R1. ADM stated the alleged altercation occurred during dinner time, while he was in his office. Staff S1 stated he/she was in the medication room prepare medications for the 5pm pass out. Staff S2 stated he/she was in the kitchen preparing the food for the second seating and was keeping an eye on dinning residents. S3 stated he/she was in the laundry room. All staff interviewed stated they did not hear residents R1 or R2 yelling, arguing or screaming prior to the alleged incident. ADM stated he was informed by R1 that he/she was pushed by R2. ADM stated he assessed the resident and called 911, following his fall protocol. ADM stated R1 had returned from the hospital the same day with no new orders. Based on record review, there is no history of physical altercations between resident R1 and R2. Although R1 falling is a fact, based on interviews conducted, this incident was caused by R1 and R2 bumping into each other, was an accident. As this incident happened in a split moment, with no prior audio ques, facility staff could not feasibly prevent resident R2 from accidentally bumping into R1. Facility staff also responded immediately once they became aware of the alleged incident and sought timely medical attention for R1, per facility policies. Page 2 Out of 3. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited, an exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided. END OF REPORT. Page 3 Out of 3.the state’s words, verbatim · CDSS document, Jun 7, 2024 · control 26-AS-20240509125227

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to conduct a case management to amend a complaint investigation LIC9099 and LIC9099-C issued on April 26, 2024 (26-AS-20240419161735) due to additional information. LPA met with Administrator Samuel Apostol. No deficiencies cited. A copy of the report was provided to Administrator Samuel Apostol.the state’s words, verbatim · CDSS document, May 2, 2024

Allegation investigated: Staff forced resident to sign documents Staff did not allow resident to have a private visitation

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegation listed above. LPA met with facility Administrator (ADM) Samuel Apostol. This Report is beng amended and the findings are being changed from Unfounded to Unsubstantiated due to new information. On April 19, 2024 the Department received a complaint alleging Staff did not allow resident to have a private visitation. On April 26, 2024, LPA's interviewed residents R1-R10. 8 Out of 10 residents inteviewed (R2-R3, R5-R10) stated the facility provides them with privacy, when having visitors. R1 & R4 stated they did not know if they had privacy. On April 26 & May 2,2024 LPA interview facility ADM. ADM stated the staff are instructed to give the residents and their case managers space if they are requesting privacy. ADM stated if the case manager asks staff member for privacy, then staff will give the resident and their case manager privacy. ADM confirmed if residents are talking in the gazebo area with their Case manager, then staff will give them privacy. Unsubstantiated On May 2, 2024, LPA interviewed 6 staff, (S1-S6). All staff interviewed stated they give residents privacy when they are meeting with their case managers. S1 & S2 stated the front yard gazebo is sometimes used by staff to eat their lunch, but if a case manager is already there, the staff will give them privacy. S6 stated he/she and S4 were already eating lunch when R1 arrived with his/her case manager. Staff Forced Resident to Sign Documents On April 19, 2024 the department received a complaint alleging Staff forced resident to sign documents On April 26, 2024, LPA's interviewed residents R1-R10. 8 Out of 10 (R2-R3, R5-R10) residents interviewed stated the facility did not force them to sign documents. R4 stated he/she did not know if he/she was forced to sign documents. R1 stated he/she was forced to sign documents, but doesn't know what he/she was forced to sign or when he/she was forced to sign the documents. On April 26 & May 2, 2024, 2024, LPA interviewed facility ADM. ADM stated the facility does not force residents to sign documents. ADM stated if a resident does not want to sign, then they will write, "refused to sign." ADM stated he will then inform their case manager that the resident is refusing to sign. ADM confirmed that R1's social worker was present when R1 was admitted. ADM stated R1's social worker was explaining to R1 what was being signed. On May 2, 2024, LPA interviewed R1. LPA showed R1 his/her resident file. LPA showed R1 the signed documents and R1 confirmed those were the documents he/she signed, this included R1's Identification and emergency information form, Personal Rights, Admission Agreement, Photo release, House rules, Personal Property form, Consent for Emergency Medical Treatment & Release of Client medical information form. R1 stated he/she does not like to sign forms because he/she stated once she signs, she's responsible. R1 confirmed that he/she was not forced or coerced but the staff. R1 stated she likes living at the facility and likes her roommate, R1 confirmed his/her social worker was with him/her when he/she signed. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No deficiencies cited, an exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided. END OF REPORT.the state’s words, verbatim · CDSS document, Apr 26, 2024 · control 26-AS-20240419161735

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

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced Case Management to conduct a Non-Compliance Plan Visit. LPA met with Administrator(ADM) Samuel Apostol and stated the purpose of today's visit. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on 02/08/2024. During visit, LPA toured the facility with ADM, inside and out. All fire exit routes were free and clear of obstruction. LPA observed signs for the residents who are a fall risk. During the tour, LPA observed facility protocol for contacting 911 and what to do if a resident has a fall throughout the facility. LPA reviewed 2 resident files, which included but not limited to; physicians report, needs and services plan, and admission agreement. LPA also reviewed staff training files and facility file. LPA observed facility maintenance log and the 2 hourly check log. LPA observed the fall risk log, which contains the list of resident who are a fall risk. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Samuel Apostol and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 26, 2024

Type of visit: Case Management - Incident

On February 21, 2024, Licensing Program Analyst, Manuel Monter conducted an unannounced case management visit. The purpose of this case management is regarding an incident that occurred on July 2, 2023, where R1 grabbed a fork and stabbed R2 on the forehead. On July 28, 2023, the Department received an incident report regarding resident R1 assaulting resident R2 around 12pm. R2 was taken to the hospital and has returned to the facility. As a result, R1 was arrested. On August 01, 2023, the Department conducted a preliminary case management visit to get residents R1 and R2’s documents. LPA also requested facility staff schedule and progress notes. On August 28,2023 the Department interviewed resident R2, Staff S1-S3, and Administrator (ADM) regarding the altercation that occurred on July 2, 2023. Based on the Department’s investigation, while staff S1 was about to serve food to the residents, S1 noticed that resident R1 and R2 were arguing at the dining area during a mealtime. S1 saw that R1 got a fork and stabbed R2 on the forehead. S1 stated that ADM was close by and grabbed R1 by the hand that was holding the fork to prevent the assault from continuing. S1 was also grabbing R1’s other hand at the same time. S1 stated staff S2 and S3 assisted as well once they heard the commotion. R2 confirmed that either S1 or S3 were present in the area and staff members pulled R1 off of him/her. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the Department has found that the allegation of neglect/lack of supervision were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited during today’s visit. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Feb 21, 2024

Type of visit: Office

A Noncompliance meeting was conducted on February 8, 2024 at CCLD San Jose office. Present at the meeting were San Bruno Adult and Senior Care Regional Manager Vivien Helbling, Licensing Program Manager Romeo Manzano, Licensing Program Analysts Simi Rai and Manuel Monter, Licensee/Administrator Samuel C Apostol. The purpose of the noncompliance meeting was to discussed a substantiated complaint allegations for the following date: 08/25/2022, 2/10/2022, 03/15/2018. As a result, the allegation is Substantiated. Deficiencies were cited for violations of Title 22 California Code of Regulations. Noncompliance Conference Summary LIC 9111 and compliance plans were established during the meeting. The facility will begin a 2 year monitoring plan by licensing which includes more frequent licensing inspections. Additional civil penalties are being reviewed. Report was reviewed with facility Licensee. A copy of this report, LIC 9111 was provided to licensee during today's office visit.the state’s words, verbatim · CDSS document, Feb 8, 2024

Allegation investigated: Resident had to be hospitalized while in care

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegation listed above. LPAs met with facility Administrator (ADM) Samuel Apostol. On 08/25/2022 the department received a complaint alleging that a resident fell and sustained an injury. It has also been alleged that staff did not seek timely medical attention for a resident. The investigation revealed either 08/20/2022 or 08/21/2022 during the night shift, a resident living at the facility (R1) was searching for cigarette buds in the facility’s backyard and had an unwitnessed fall around 0600 hours. A staff member (S1) brought R1 inside of the facility and placed him/her in a wheelchair. S1 assessed R1 for pain wherein R1 stated he/she was fine. S1 stated R1 was able to lift his/her left leg while the right leg hurts. S1 informed staff S2 that R1 fell outside. Page 1 out of 3 Substantiated The Department obtained a copy of the facility staff ‘pass-down notes.’ Based on review that on August 21, 2022, or August 22, 2022, at around 6am, a resident R2 informed staff S1 that R1 had fallen. S1 went to check and found R1 on the ground. S1 observed a bowel movement next to R1. S1 asked R1 “did you have an accident out here?” R1 responded, “no, I don’t know.” S1 asked R1 if he/she was in pain, R1 responded that he/she was okay. S1 told R1 to get up after cleaning him/her and R1 requested help. S1 stated R1 has fallen before and rarely asks for help. R1 requested help from S1. When R1 got up and tried to walk R1 said he/she felt pain on his/her upper right leg. On August 22, 2022, S1 asked R1 if he/she was in pain. R1 told S1 that he/she “still had pain.” On August 23, 2022, R1 told staff (S3) that he/she was in a lot of pain and that he/she “hurt so bad”. S3 contacted 911 services. On February 28, 2023, ADM was interviewed. ADM stated he/she reads the staffs notebook of "pass down notes" "mostly every day." ADM stated that on August 21, 2022, was a Sunday and ADM does not read the staff's notebook on the weekends. ADM stated, "no one reported anything to her/him on Sunday." ADM explained the staff are all "trained to call 911 and he/she does not know why the staff did not call 911 this time." On November 18, 2022, R1’s Case Manager (CM) was interviewed. CM stated, “the facility called him/her after R1 had been transported to the hospital…R1 was complaining of pain… had been in a wheelchair for two days”. CM stated he/she did not know that R1 fell at the facility two days before being taken to the hospital. A review of facility documentation did not show any documented evidence that the facility informed R1’s case manager about the fall incident before R1’s hospitalization on August 23, 2022. A review of medical records indicated that R1 was transported and admitted to the hospital on August 23, 2022. While at the hospital, R1 was diagnosed with a right hip fracture. On August 28, 2023, R1 passed away in the hospital due to complications with the surgery required to treat his/her hip fracture. R1's cause of death was due to heart failure complicated by a right hip fracture from an witnessed fall. Page 2 out of 3 A review of R1’s medical discharge records from the hospital from August 23 to 28, 2022 stated the R1 was admitted due to an unwitnessed fall associated with a right leg pain. R1’s right leg shortens and externally rotated. R1’s findings were of right closed displaced intertrochanteric hip fracture. Furthermore, R1 was found to have an acute comminuted intertrochanteric fracture of the right proximal femur. According to Clevelanclinic.org, “a closed intertrochanteric fracture of the hip, right [happens when the upper part of the thighbone breaks, usually from a fall or a car accident].” On February 28, 2023 & March 1, 2023, the Department conducted interviews with facility staff (S1 to S4) and ADM. S1, S4 & ADM stated R1 had fall incidents while in the facility. S4 stated R1 was hospitalized for a broken hip in 2019. (Before the August 23, 2022, hospitalization). During a review of R1’s Appraisal Needs and Services Plan (ANS) and interview with ADM, the facility did not develop and implemented interventions to mitigate R1’s safety. ADM did not update R1’s ANS before and after R1 sustained injury. The Department has investigated the above allegation. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Administrator Samuel Apostol and a signed copy of this report was provided along with appeal rights. An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in serious injury to a resident in care. An additional Civil Penalty in the amount of $9,500.00 for violation resulting in serious bodily injury is pending review. Page 3 out of 3the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 26-AS-20220825122345

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 20, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, and services that meet their individual needs and are delivered by staff ... to meet their needs. This requirement was not met as evidenced by Based on investigation, R1 did not receive immediate medical assistance after R1 fell and subsequently verbalized having pain. Staff did not adhere to facility’s protocol on medical emergency by calling 9-1-1the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Licensee stated he will send plan of action on how the facility will meet the residents needs after a resident has fallen. Licensee stated he will send POC by 10/20/2023 to LPA.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(1) · Plan of correction due date: Oct 20, 2023

87405 Administrator - Qualifications and Duties (d)(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement was not met as evidenced by: Based on investigation, ADM was not aware of R1’s fall because according to ADM he/she does not read staff notes on the weekend. ADM also did not inform R1’s CM of R1’s fall and R1 being a fall risk was not addressed in 2019 when he/she had his/her initial fall at the facility.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Licensee stated he will send letter of understanding regaring the regulation and his role and responbilities as ADM and how he will provide care and supervison to the residents. Licensee stated he will send POC by 10/20/2023 to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Oct 26, 2023

87463 Reappraisals (a) The pre admission appraisal shall be updated, in writing as frequently as necessary to note significant changes ...document changes in the resident's physical, medical, mental, and social condition. This requirement was not met as evidenced by: Based on investigation, R1 was a fall risk with an associated fall history. R1 had a fall in 2019. A review of R1’s LIC624 Appraisal Needs and Services Plan (ANS) dated Feburary 2, 2019, the facility did not update R1’s ANS to address fall prevention.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Licensee stated he will send Plan of action on how the facilty will updates residents needs and services plans when residents have changes in conditioin. Licensee stated he will send POC by 10/26/2023 to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Oct 26, 2023

87468.1 Personal Rights of Residents in All Facilities (a)(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evicenced by; Based on investigation, R1’s responsible party and/or Case Manager was not immediately informed when R1 had a fall and current health condition before he/she was admitted to the hospital.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Licensee stated he will send plan of action on how the facilty will regulary inform residents representatives about their care, ongoing evaluations. Licensee stated he will send by POC date, 10/26/2023 to LPA.

Allegation investigated: Resident fell and sustained an injury Staff did not seek timely medical attention for resident

Licensing Program Analyst (LPAs) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegation listed above. LPA met with facility Administrator (ADM) Samuel Apostol. On October 24, 2022 the department received a complaint alleging that a resident fell and sustained an injury. It has also been alleged that staff did not seek timely medical attention for resident. The investigation revealed either 08/20/2022 or 08/21/2022 during the night shift, a resident living at the facility (R1) was searching for cigarette buds in the facility’s backyard and had an unwitnessed fall around 0600 hours. A staff member (S1) brought R1 inside of the facility and placed him/her in a wheelchair. S1 assessed R1 for pain wherein R1 stated he/she was fine. S1 stated R1 was able to lift his/her left leg while the right leg hurts. S1 informed staff S2 that R1 fell outside. Page 1 out of 3 Substantiated The Department obtained a copy of the facility staff ‘pass-down notes.’ Based on review that on August 21, 2022, or August 22, 2022, at around 6am, a resident R2 informed staff S1 that R1 had fallen. S1 went to check and found R1 on the ground. S1 observed a bowel movement next to R1. S1 asked R1 “did you have an accident out here?” R1 responded, “no, I don’t know.” S1 asked R1 if he/she was in pain, R1 responded that he/she was okay. S1 told R1 to get up after cleaning him/her and R1 requested help. S1 stated R1 has fallen before and rarely asks for help. R1 requested help from S1. When R1 got up and tried to walk R1 said he/she felt pain on his/her upper right leg. On August 22, 2022, S1 asked R1 if he/she was in pain. R1 told S1 that he/she “still had pain.” On August 23, 2022, R1 told staff (S3) that he/she was in a lot of pain and that he/she “hurt so bad”. S3 contacted 911 services. On February 28, 2023, ADM was interviewed. ADM stated he/she reads the staffs notebook of "pass down notes" "mostly every day." ADM stated that on August 21, 2022, was a Sunday and ADM does not read the staff's notebook on the weekends. ADM stated, "no one reported anything to her/him on Sunday." ADM explained the staff are all "trained to call 911 and he/she does not know why the staff did not call 911 this time." On November 18, 2022, R1’s Case Manager (CM) was interviewed. CM stated, “the facility called him/her after R1 had been transported to the hospital…R1 was complaining of pain… had been in a wheelchair for two days”. CM stated he/she did not know that R1 fell at the facility two days before being taken to the hospital. A review of facility documentation did not show any documented evidence that the facility informed R1’s case manager about the fall incident before R1’s hospitalization on August 23, 2022. A review of medical records indicated that R1 was transported and admitted to the hospital on August 23, 2022. While at the hospital, R1 was diagnosed with a right hip fracture. On August 28, 2023, R1 passed away in the hospital due to complications with the surgery required to treat his/her hip fracture. R1's cause of death was due to heart failure complicated by a right hip fracture from an unwitnessed fall. Page 2 out of 3. A review of R1’s medical discharge records from the hospital from August 23 to 28, 2022 stated the R1 was admitted due to an unwitnessed fall associated with a right leg pain. R1’s right leg shortens and externally rotated. R1’s findings were of right closed displaced intertrochanteric hip fracture. Furthermore, R1 was found to have an acute comminuted intertrochanteric fracture of the right proximal femur. According to Clevelanclinic.org, “a closed intertrochanteric fracture of the hip, right [happens when the upper part of the thighbone breaks, usually from a fall or a car accident].” On February 28, 2023 & March 1, 2023, the Department conducted interviews with facility staff (S1 to S4) and ADM. S1, S4 & ADM stated R1 had fall incidents while in the facility. S4 stated R1 was hospitalized for a broken hip in 2019. (Before the August 23, 2022, hospitalization). During a review of R1’s Appraisal Needs and Services Plan (ANS) and interview with ADM, the facility did not develop and implemented interventions to mitigate R1’s safety. ADM did not update R1’s ANS before and after R1 sustained injury. The Department has investigated the above allegation. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided. Page 3 out of 3the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 26-AS-20221024102823

Allegation investigated: Mental/verbal abuse to resident.

Licensing Program Analyst (LPA) Manuel Monter & Mita Partoza conducted an unannounced visit to deliver findings regarding the allegation listed above. LPAs met with facility Administrator (ADM) Samuel Apostol. On 10/02/2023 the department received a complaint alleging that a resident sustained mental/verbal abuse from staff and residents. On 10/10/2023, LPA's interviewed R1. R1 stated the staff are not teasing, taunting, or saying mean things to him/her. R1 stated the female residents are teasing him/her regarding his/her girlfriend. R1 stated this is due to jealously. LPA asked R1 who was teasing him/her, R1 stated he/she did not know. Page 1 out of 2 Unfounded LPA's interviewed 10 residents. 8 out of 10 residents denied the allegation that staff were teasing, taunting or saying mean things to residents. 7 out of 10 residents denied the allegation that residents were taunting, teasing, or saying mean things to other residents. LPA's interviewed 3 staff members, S1-S3. 3 out of 3 staff members denied the allegation that staff were teasing, taunting or saying mean things to residents. 3 out of 3 staff members denied the allegation that residents were taunting, teasing or saying mean things to other residents. LPA's interviewed ADM regarding the allegations. ADM stated the staff do not tease/taunt/say mean things to residents. ADM stated the residents will sometimes tease/taunt/ say mean things to one another. ADM stated the facility staff will intervene and de-escalate the situation. ADM stated the staff will try to re-direct the residents and encourage to cooperate as they live in the same home. ADM stated R1 accuses ADM of speaking with his/her wife. ADM stated R1 accuses others of talking with his/her wife. A review of R1's Appraisal/Needs and Services Plan states; R1 struggles from paranoid thoughts and behaviors(past characterized by a generalized over concern of others). The form states R1 has delusional thoughts such as thinking his/her "girlfriend" is imprisoned. The form also states R1 is fixated on his/her "fiance" and paranoid of people talking to her or saying bad things. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited, an exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 26-AS-20231002152059

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Manuel Monter and Mita Partoza conducted an unannounced annual inspection visit, and met with Administrator(ADM) Sam Apostol. LPA toured the facility inside out with ADM which included; the Living room, kitchen, dinning room, facility restrooms and 10 residents bedrooms. During LPA's tour of the resident bedrooms, LPA's observed residents bed sheet were observed to be recently changed. The medication room of the facility was also inspected. Front yard and backyard were inspected. LPA observed fly traps were observed and ADM stated the facility changes the fly traps once a week. There was no obstruction to block the walkways. LPA observed the front yard free of debris and in good condition. Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degree F, and hot water temperature was measured in 3 facility bathrooms. The water temperature ranges from 105 to 110 degrees F. Fire extinguisher was serviced in March 2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. The fire alarm system was last inspected on 07/06/2023. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on October 2023. LPA reviewed facility records for 3 staff and 4 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 4 staff (S1 to S4) and 4 residents (R1-R4). No deficiencies cited during today's visit. This report was reviewed with ADM Sam Apostol and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Oct 10, 2023