Sunnycrest Senior Living

Allegation investigated: Staff does not ensure facility plumbing is in good repair resulting in ceiling collapsing. Staff does not ensure facility is free of mold. Facility did not provide services as agreed upon. Staff does not ensure facility is free of roaches.

Licensing Program Analyst (LPA) Garlli Tat made an unannounced visit to the facility to deliver the findings on the above allegations. LPA met with the Assistant Executive Director (ED) Monica Aguirre and explained the purpose of the visit. An initial complaint investigation visit took place on July 3, 2026. During the visit, the Department accompanied by staff conducted a tour of the facility's physical plant. The Department requested and obtained the resident and staff roster, resident records, transportation scheduling appointment, and maintenance records. Five staff and six resident interviews were conducted during the visit. The investigation revealed the following: Regarding the allegation staff does not ensure facility plumbing is in good repair resulting in ceiling collapsing, it was reported that Resident 1’s (R1) room was flooded, causing damage to the room and furnishings. Continued on LIC9099-C. Unsubstantiated R1 felt rushed and stated they couldn’t get ready that fast. It was stated that the offer remained, but R1 refused. One out of five staff stated R1’s family member gave R1 a ride to their appointment for the same day. Record review revealed R1’s family member signed out R1 on June 16, 2026. R1’s admission agreement states “We will make available to residents, or otherwise assure the provision of, scheduled transportation to the nearest appropriate health facilities…” Regarding the allegation staff does not ensure facility is free from roaches, it was reported that there are cockroaches under R1’s sink. The Department did not observe any insect under R1’s bathroom sink. However, the Department observed insects in three out of six additional rooms inspected. Two out of six staff interviewed stated an extermination company comes out every three months. Three out of six residents interviewed stated they have seen insects, but have not reported the issue. Two out of five staff interviewed stated they have seen insects from time to time. One out of five staff interviewed stated they are addressing the issue. The remaining three staff interviewed did not add anything relevant to the allegation. Record review shows that an extermination company comes over every three months or more often if needed. The facility keeps a log of vermin observed and reported to the facility including the scheduling of exterminator visits. In addition, the facility provided records of work orders for instances when vermin are reported. Based on the evidence gathered during the investigation, the allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the present report was provided to the Assistant Executive Director. Appeal Rights were reviewed. The Department toured the bedrooms on the first and second floors. LPAs observed two rooms under construction being repaired do to water leak. Two out of five staff interviews stated that the construction is due to a clogged toilet on the second floor, seeping water into the first floor. Affected residents were immediately moved into other rooms. The facility made immediate repairs. The remaining staff did not add anything relevant to this allegation. Two out six residents interviewed stated they were moved to different rooms due to a flood. Four of the remaining residents did not add anything relevant to this allegation. One of the two residents interviewed stated that their room was completely flooded but wasn’t in the room when it happened. The other resident interviewed stated that there were repairs being made to their room and they were placed in another room for the time being. Both residents interviewed denied any health or safety concerns due to the hazard. Although there was water damage to the room, it did not affect the health and safety of R1 as the facility immediately moved the resident to a new room while the repairs were being conducted. Regarding the allegation staff does not ensure facility is free from mold, it was reported that R1’s family purchased and used a mold test kit to test for mold near the sink, entryway, bathroom, and the bed. R1’s family stated the test confirmed mold was present in the room. The Department toured seven bedrooms in the lower and upper levels of the facility. The Department didn’t observe any mold at the facility at the time. Five out of five staff interviewed stated they have not observed any mold at the facility. Six out of six residents interviewed stated they have not observed any mold in their bedrooms. Regarding the allegation staff did not provide services as agreed upon, it was reported that R1 had a scheduled medical appointment on June 16, 2026 at 8:40am and the facility did not assist R1 with the transportation. Per record review, R1 had an appointment scheduled on the respective time and date. This was documented on an appointment slip and the appointment book provided by the facility. One out of five residents interviewed stated they have used transportation services at the facility and did not indicate any issues with scheduling. Two out of six residents interviewed stated they do not use transportation services provided by the facility but know it’s available for them. Two out of the remaining residents interviewed did not add anything relevant to the allegation. Two out of five staff interviewed stated there are no concerns with transportation services scheduled and reminders are provided 15 minutes prior. One of the two staff interviewed stated on June 16, 2026, they had reminded R1 of the appointment. Continued on LIC9099-C.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 22-AS-20260624081858

Allegation investigated: Staff hits residents

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to deliver findings for a complaint received in the Regional Office. LPA was greeted and granted entry by the receptionist. LPA met with Monica Aguirre, Assistant Executive Director, and explained the purpose of the visit. LPA reviewed three of three staff files and reviewed Personnel Records, signed paperwork regarding Residents' Rights, mandated reporting, annual performance reviews and staff training documentation. LPA also reviewed resident files related to the complaint, which include: the Medical Assessments to obtain medical history for the residents. LPA interviewed seven of seven staff members, seven of nine residents and one witness. The witness could not confirm, nor deny the allegations. (Continued on LIC 9099-C) Unfounded (Continued from LIC 9099) It was alleged that staff hit residents. Seven of seven staff interviewed denied the allegation and have not witnessed other staff members hitting residents. Seven of nine residents interviewed also denied this allegation and have not experienced this behavior from the staff. Two of nine residents were not able to confirm, nor deny the allegation. LPA observed staff files had signed documentation for Personal Rights and Mandated Reporting. Staff have ongoing training regarding Resident Rights. Annual Performance reviews on file did not report staff hitting residents and there were no Corrective Action paperwork observed. Based on LPA's observations, interviews and file review the allegation that Staff hits residents is Unfounded. That allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Assistant Executive Director, Monica Aguirre, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 22, 2026 · control 22-AS-20260617082820

Allegation investigated: Staff do not ensure that residents' incontinence needs are met Staff inappropriately speaks to residents Staff do not safeguard resident's personal belongings Staff do not answer residents' call buttons in a timely manner

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to deliver findings for a complaint received in the Regional Office. LPA was greeted and granted entry by receptionist and met with Monica Aguirre, Assistant Executive Director, and explained the purpose of the visit. LPA reviewed three of three staff files and reviewed Personnel Records, signed paperwork regarding Residents' Rights, mandated reporting, annual performance reviews and staff training documentation. LPA obtained the pendant call log, resident and staff roster during the initial visit on June 23, 2026. LPA also reviewed two of two resident files related to the complaint,which include the Medical Assessments to obtain medical history for the residents. LPA interviewed seven of seven staff members, seven of nine residents and one witness. The witness could not confirm, nor deny the allegations. The investigation revealed the following. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) LPA investigated the allegation that Staff do not ensure that residents' incontinence needs are met. LPA reviewed two of two resident files and both residents were non-ambulatory. Resident #5 (R5) receives hospice services and the Preplacement Appraisal states the resident needs full assistance with bathroom functions. The Medical Assessment dated April 13, 2026 report resident has bowel and bladder impairment, requires continuous bed care and is unable to care for own toileting needs. LPA attempted to interview R5 but was unable to interview. LPA interviewed seven of nine residents. One resident confirmed the allegation that incontinence needs are not being met. Five residents interviewed denied the allegation and had not heard or witnessed residents sitting in soiled diapers. One resident could not confirm nor deny the allegation. LPA interviewed seven of seven staff members who denied the allegation. It was alleged that Staff inappropriately speaks to residents. One of nine residents confirmed this allegation regarding an incident that occurred in the middle of the night. Six of nine residents denied having this experience with staff. Two of nine residents could not confirm, nor deny the allegations. LPA reviewed three of three staff records who work at night and there were no documents regarding corrective action. Three of three staff members had signed personal rights and mandated reporter documents. LPA observed staff training regarding Resident Rights and are provided ongoing training. LPA interviewed seven of seven staff members. Three of the seven staff members interviewed work at night and stated there have been no complaints or issues from residents regarding their work or behavior and that they were unaware of the incident reported in the complaint. Seven of seven staff members denied the allegation. The Department investigated the allegation that: Staff do not safeguard resident's personal belongings. Two of nine residents reported they have had issues with missing personal belongings. One of the residents stated they report missing items to staff but staff are unable to locate the items. The second resident stated they were missing an item in their apartment but that the staff was able to assist the resident in finding it. (Continued on LIC 9099-C1) (Continued from LIC 9099-C) Five of nine residents interviewed reported they have not had any items missing and denied the allegation that staff do not safeguard resident's personal belongings. Two of the nine residents interviewed could not confirm, nor deny the allegation. LPA interviewed seven of seven staff members. Seven of seven staff members stated they have not observed staff members taking residents' personal belongings. Two of the seven staff interviewed stated that a resident regularly reports staff take personal belongings but when staff follow-up with the complaint, the missing items were thrown out by the resident or misplaced. Law enforcement has been called to the community on multiple occasions and they are also unable to confirm allegations made by the resident. LPA also investigated the allegation that Staff do not answer residents' call buttons in a timely manner. One of nine residents confirmed this allegation. Five of the nine residents interviewed denied this allegation; stating that call lights are answered timely and that staff are responsive. Three of three residents could not confirm, nor deny the allegation. Five of seven staff members interviewed stated call lights are answered timely. Two of the staff interviewed do not answer pendant calls and could not confirm, nor deny if the call lights were timely and have not heard any complaints from the residents. LPA reviewed the pendant call log from June 23, 2026 and observed fifty one of fifty four calls were answered under fifteen minutes. Two of the fifty four calls were answered under thirty minutes as staff had to locate the residents. Based on LPA's interviews, document review and observations, the allegations that: Staff do not ensure that residents' incontinence needs are met, Staff inappropriately speaks to residents, Staff do not safeguard resident's personal belongings and Staff do not answer residents' call buttons in a timely manner are Unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove the alleged violations occurred. An exit interview was conducted with Assistant Executive Director, Monica Aguirre and a copy of this report and LIC 811 was provided to the facility.the state’s words, verbatim · CDSS document, Jul 22, 2026 · control 22-AS-20260617082820

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced Case Management visit and was greeted and granted entry by the receptionist at 8am. LPA met with Assistant Executive Director (AED) Monica Aguirre and explained the purpose of the visit. The purpose of this visit was to amend a licensing report on June 23, 2026. An exit interview was conducted with Assistant Executive Director, Monica Aguirre and a copy of the amended report from June 23, 2026 and this report were provided to the facility.the state’s words, verbatim · CDSS document, Jul 22, 2026

Allegation investigated: Staff do not ensure that resident is accorded dignity in their relationship with staff or other persons

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in the Regional Office. LPA was greeted and granted entry by the Receptionist. LPA met with Assistant Executive Director Monica Aguirre and explained the purpose of the visit. LPA obtained the current resident and staff rosters and the following documents for Resident #1 (R1): Medical Assessment dated 12/01/2025, Physician Communications dated 6/1/2026, 01/03/2026, 12/14/2025 and 11/1/2025, Medication Administration Records from January - June 2026 and an After Visit Summary from 4/21/2026. LPA interviewed seven of seven residents. One resident could not confirm, nor deny the allegation and one resident confirmed the allegation. Five of seven residents denied witnessing or hearing staff violating resident's rights or hearing of any incident that involved R1's rights being violated. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) LPA interviewed seven of seven staff members. One staff member could not confirm, nor deny the allegation. Six of seven staff members denied the allegation; stating they have not observed that Resident #1 (R1) is not accorded dignity in their relationship with staff or other persons. R1 communicates with staff regarding any issues, and staff will investigate the matter and respond to R1 in a timely manner. Staff stated they are not able to confirm the issues. LPA reviewed staff training records and staff have received personal rights training. Staff continue to receive ongoing training regarding personal rights and treating residents with dignity and respect. LPA interviewed one of one witness who confirmed the allegation. The witness addressed one observed incident with management and the issue was resolved. Witness has not observed any additional incidents where staff do not ensure that resident is accorded dignity in their relationship with staff or other persons. Local law enforcement has been called to the community multiple times by R1 but police are not able to confirm the allegations. Based on LPA's record review, interviews and observations, the allegation that Staff do not ensure that resident is accorded dignity in their relationship with staff or other persons is Unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Assistant Executive Director, Monica Aguirre and a copy of this report was provided to the facility. ***This is an amended report.***the state’s words, verbatim · CDSS document, Jun 23, 2026 · control 22-AS-20260615093533

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by the receptionist at 8am. LPA met with Executive Director (ED) Melanie Washington and explained the purpose of the visit. The facility is a two story building with a capacity of 210 non-ambulatory residents with an approved hospice waiver for 15 residents. LPA obtained staff and resident rosters. Currently there are 103 residents in care with nine residents on hospice. During today's visit, LPA toured the facility and inspected the physical plant. There are two elevators and three stairwells with evacuation chairs. Fire extinguishers were charged and inspected on September 15, 2025. Carbon monoxide detectors were tested and operational. LPA requested copies of current liability and vendor testing of smoke alarms/sprinklers. The Fire system was inspected on April 14, 2025 and passed. The facility is awaiting approval for 2026 fire inspection. The facility's last fire drill was conducted on May 25, 2026. The facility temperature was seventy-five degrees. The liability insurance is current through 12/23/2026. LPA tested the hot water temperature in five of five resident apartments. The temperatures measured between 107.1 to 113.6 degrees Fahrenheit. Resident apartments were clean, and had the required linens and furnishings. LPA did not observe medications in resident apartments. Resident bathrooms had grab bars and non-skid flooring. LPA observed the facility common areas were clean with no odors detected. LPA observed residents in the activity room engaged in activities and a resident outing to Trader Joe's. Residents came to the dining room for breakfast and lunch. (Continued on LIC 809-C) (Continued from LIC 809) Upon entering the kitchen LPA observed staff cleaning up after the lunch service. Temperature logs were observed for the walk-in refrigerator/freezer as well as an additional refrigerator. The facility retained a minimum of two days of perishable items and the pantry had more than seven days of non-perishable food on hand. Emergency supplies are stored in the basement with water tanks. While touring the exterior LPA noted there were shaded seating areas and smoking areas in breezeways and in the courtyard. LPA entered the medication room and audited medications. Controlled substances were secured and all medications were centrally stored. Per review medications are being given as prescribed. A First Aid Kit was mounted on the wall but there is also a designated cart for wound care and first aid. A First Aid book is stored in the medication room. LPA reviewed six of six staff training and fingerprint records and ten of ten resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed the administrator has a current administrator certificate which expires on September 5, 2027. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Melanie Washington, Executive Director and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Jun 12, 2026

Allegation investigated: Staff pushed resident. Staff does not ensure that resident receives meals.

On May 15, 2026, Licensing Program Analyst (LPA) Eboni Bentley made an unannounced visit for the purpose of conducting a subsequent complaint investigation and delivering findings for the above allegations. LPA met with Executive Director Melanie Washington and explained the reason for the visit. During the course of the investigation, LPA interviewed ten residents, six staff, and obtained the following documentation: Resident/Staff Roster, Staff Contacts, Caregiver, Med Tech, and Dining Staff Schedules, Meal Roll Call Forms, Menus, Resident Identification and Emergency Information, Physician’s Report, Residence & Care Agreement, Service Plan, and Personal Rights. CONTINUE TO LIC-9099-C........ Unsubstantiated The investigation revealed the following: Regarding the allegation, Staff pushed resident, it is alleged that staff told a resident to “shut up” and pushed the resident while walking past them in a common area hallway. Interviews were conducted with residents and staff. Nine out of ten residents denied the allegation, stating Staff #1 (S1) is always nice, courteous, and professional. A resident who has lived at the facility for almost two years and stated, S1 “would never do anything like that. He’s too much of a gentleman.” Six out of six staff interviewed denied the allegation, stating they have never witnessed S1 yelling, pushing, or being inappropriate with residents in any way. There were no witnesses present during the alleged incident. Regarding the allegation, Staff does not ensure that resident receives meals, it is alleged that staff do not bring meals to a resident when they are unable to walk to the dining room/hall and the resident cannot access food. Based on the interviews conducted, nine out of ten residents and six out of six staff denied the allegation, stating that residents are served meals three times a day, staff checks on residents when they are not present in the dining room, and meals are delivered upon request or automatically when residents are sick. One resident stated that meal trays are always delivered to them when they are not present in the dining room and staff never forget to give them food. Six out of six staff stated Meal Roll Call forms are completed by staff during each meal, to record which residents are present and absent from the dining room, there is a fee of $10 charged to residents’ room for each meal tray delivered and that charge is applied to their monthly billing statement, however residents who are sick are not charged for meal tray service. A review of the Residence & Care Agreement dated December 31, 2020 indicates there is a charge of $5 per meal for Meal Tray Delivery Services. Therefore, based on the observations made, interviews which were conducted, and the records that were reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the following allegations: Staff pushed resident and Staff does not ensure that resident receives meals, are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Melanie Washington, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, May 15, 2026 · control 22-AS-20260112103415

Allegation investigated: Resident developed pressure injuries due to lack of care and supervision. Resident did not receive medical attention timely. Facility did not notify family regarding pressure injuries.

On May 15, 2026, Licensing Program Analyst (LPA) Eboni Bentley made an unannounced visit for the purpose of delivering the investigation findings into the above allegations. LPA met with Executive Director Melanie Washington and explained the reason for the visit. On August 19, 2025, the Department received a complaint alleging neglect/lack of care and supervision of Resident #1 (R1) and the investigation was initiated on August 21, 2025. During the course of the investigation, the Department interviewed twenty-nine staff and witnesses and obtained the following documentation: Resident/Staff Roster, Staff Contacts, Caregiver Duty Statement, Facility Progress Notes, Facility Shower Sheets, Caregiver and Med Tech Schedules, Physician Communications, R1’s Identification and Emergency Information, Physician’s Report, Preplacement Appraisal Information, Residence & Care Agreement, Service Plan, Unusual Incident Reports, Home Health Records, Kaiser Medical Records, and Photos Taken. CONTINUE TO LIC9099-C........ Substantiated ...... CONTINUE from LIC9099 The investigation revealed the following: Regarding the allegation, Resident developed pressure injuries due to lack of care and supervision, the investigation is as follows: On August 18, 2025, R1 was found to have a stage 3 pressure injury on the coccyx, measuring 3cm x 4 cm x 0.3 cm; a linear ulceration on the left posterior thigh (probably friction and moisture related), measuring 0.5cm x 7cm x 0.2cm, and an unstageable pressure injury on his right heel, measuring 3cm x 4cm x unknown depth. The facility first noted an open wound on R1’s right heel and a pressure injury on his coccyx on August 11, 2025. During interviews, facility caregivers admitted that they were not repositioning R1 in his wheelchair and that the wounds were likely the result of continuous sitting on the wheelchair with his heel pressed against the footrest or floor. On August 13, 2025, R1’s coccyx pressure injury was documented at stage 2, measuring 5.2cm x 1.3cm, but measurements for the heel wound were not documented. The facility only arranged for R1’s hospitalization for assessment after his daughter/Power Of Attorney (POA) requested it, but by this time, the wounds had progressed to greater than stage 2. On August 18, 2025, R1 was admitted to Kaiser Anaheim Hospital due to multiple newly discovered pressure injuries that were not reported to his POA. Based on staff admissions, following the discovery of these wounds, R1 continued being placed in his wheelchair, at his request, but was not being repositioned in it. The allegation that R1 sustained stage 3 and unstageable pressure injuries because of facility neglect is therefore Substantiated. Regarding the allegation, facility did not seek medical attention in a timely manner, the facility was aware at least one full week before R1’s hospitalization, that resident had developed pressure injuries. Based on records obtained, Staff 1 (S1) was the first caregiver to document a “blister” on R1’s right heel, which was observed while providing R1 a bed bath on August 11, 2025. Per progress notes, Staff 2 (S2) documented on the progress notes that S1 reported having observed an “open wound” on R1’s right heel while providing a bed bath. CONTINUE TO LIC9099-C........ S2 observed fluid leakage from R1’s legs and increased swelling to both feet, with the skin of both feet “very dry and cracking.” S2 elevated R1’s legs to reduce the swelling and planned to continue monitoring the resident’s skin condition and reporting changes. S2 notified home health of the open wound via fax and called the office of his Primary Care Physician (PCP) about the “open blister.” Records reviewed indicate the facility faxed PCP’s office to report that R1’s legs are more swollen than usual and leaving fluid and faxed Excell Home Care (Home Health) to report an “open wound on R1’s right heel, about a quarter size.” R1 complained of pain and discomfort when applying pressure. The facility requested for the Home Health to send a nurse to check the wound as soon as possible. On August 12, 2025, Staff 3 (S3) noted that Excell Home Care would visit R1 on August 13, 2025. Staff 4 (S4) documented on August 13, 2025 that she spoke with POA to request softer/looser shorts to prevent friction and tightness in R1’s buttocks due to “skin peeling.” S4 also called the PCP’s office to request assessment of this skin peeling. Later that day, S3 noted their belief that Home Health had not visited R1 as arranged, and requested that a follow up be done. On August 14, 2025, while providing a sponge bath, Staff 6 (S6) documented on Shower Sheets redness and “peeling skin” to R1’s buttocks area and an “open blister” on the right heel. On August 15, 2025, R1 was placed on alert charting for 72 hours due to complaints of leg pain. Later that day, Staff 6 (S6) called R1’s PCP’s office to request Home Health wound care “for bedsores on the buttocks and pressure bedsore on the left heel.” S5 applied Calmoseptine on R1’s buttocks, put him in bed after lunch, and elevated his legs. On August 16, 2025, S6 again applied Calmoseptine to R1’s “private area” and placed a patch on his heel. The facility was aware on August 11, 2025, one full week before R1’s hospitalization, that he had developed pressure injuries. Although the facility notified Excell Home Care (Home Health) of the change in condition in a timely manner, it failed to ensure R1 received treatment. The facility did not inquire with Home Health about the progression of the wounds, had no documentation of treatment as required by 22 CCR § 87631, was not aware appointments were being cancelled due to R1’s purported refusals and failure to respond to agency calls, and did not even know whether home health was providing treatment. Home Health did not visit R1 between July 26, 2025 and August 12, 2025; and while the Home Health did treat the coccyx wound on August 13, 2025, this was the last time treatment was provided, and it never treated the right heel wound. The facility only arranged for R1’s hospitalization for assessment after his POA requested it, but by this time, the wounds had progressed to greater than stage 2. The allegation that the facility failed to ensure R1 received timely medical attention for his pressure injuries is therefore Substantiated. CONTINUE TO LIC9099-C........ Regarding the allegation, Facility did not notify family regarding pressure injuries. On August 18, 2025, around 3:00pm, S2 called Daughter/Power Of Attorney (POA) and informed them that the facility was trying to get a hold of R1’s doctor to get medicine for pressure injuries, explaining that the wounds were on R1’s foot, buttocks, and inner thigh. After reviewing pictures received by staff, the POA asked the facility to send R1 to Kaiser Anaheim Hospital. A Kaiser physician called POA to report that the pressure injuries were at stage 3. On August 19, 2025 Witness 1 (W1) submitted a SOC341 to The Department to report that R1 was admitted to Kaiser Anaheim Hospital on August 18, 2025 due to multiple newly discovered pressure injuries that were not reported to his daughter/POA. It was reported that during visits with family, R1 wore “diabetic shoes,” and the POA never saw the resident’s exposed feet, but the facility bathed R1 at least twice a week and also changed his clothes daily. Although the facility first became aware of the pressure injuries on August 11, 2025, the POA was not aware until August 18, 2025, prior to requesting R1 be sent to the hospital. Therefore, the allegation that the facility did not notify family regarding pressure injuries is deemed Substantiated. Therefore, based on interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations: Resident developed pressure injuries due to lack of care and supervision, facility did not seek medical attention in a timely manner, and Facility did not notify family regarding pressure injuries are deemed SUBSTANTIATED. Deficiencies are being cited on the attached LIC 9099Ds, as per Title 22, Division 6, Chapter 8 of the California Code of Regulations. An exit interview was conducted with Executive Director Melanie Washington, and a copy of this report, LIC 9099-Ds, LIC 811, and appeal rights were provided at exit.the state’s words, verbatim · CDSS document, May 15, 2026 · control 22-AS-20250819142857

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: May 16, 2026

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on interviews and record review, licensee did not find a solution necessary to prevent and address R1’s pressure injuries, R1 continued being placed in his wheelchair, and was not being repositioned in it, which posed an immediate Health, Safety, and Personal Rights risk to persons in care. Due to lack of care and supervision, R1 sustained stage 3 and unstageable pressure injuries.the state’s words, verbatim · CDSS document, May 15, 2026

Plan of correction: Executive Director (ED), Melanie Washington stated that residents with pressure injuries will be repositioned according to their doctor’s orders and care plan, the licensee will ensure all staff are trained to meet the resident’s needs, and ED will submit an Acknowledgement of Understanding of the said deficiency. The above statement and proof of training will be submitted to LPA via email by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: May 16, 2026

87465(g) Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, ... medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by: Based on interviews and record review, R1 was observed with pressure injuries one week before hospitalization and the facility did not seek immediate medical attention, which posed an immediate Health, Safety, and Personal Rights risk to persons in care. The facility only arranged for R1’s hospitalization for assessment after his POA requested it.the state’s words, verbatim · CDSS document, May 15, 2026

Plan of correction: Executive Director (ED), Melanie Washington stated that all care staff will be trained on when to seek medical attention to ensure resident’s needs are met, and ED will submit an Acknowledgement of Understanding of the said deficiency. The above statement and proof of training will be submitted to LPA via email by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 22, 2026

87211(a)(1) Reporting Requirements (a) Each licensee shall … (1) A written report ... to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) .. of the case. This requirement was not met as evidenced by: Based on interviews and record review, the facility first became aware of the pressure injuries on August 11, 2025, the POA was not aware until August 18, 2025, prior to requesting R1 be sent to the hospital, which posed a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, May 15, 2026

Plan of correction: Executive Director (ED), Melanie Washington stated that all care staff will be trained on Reporting Requirements Section 87211 of the California Code of Regulations, and ED will submit an Acknowledgement of Understanding of the said deficiency. The above statement and proof of training will be submitted to LPA via email by POC due date.

Allegation investigated: Residents are not being provided adequate food service. Residents are being left in soiled diapers for an extended amount of time.

On February 19, 2026, Licensing Program Analyst (LPA) made an unannounced subsequent visit for the purpose of continuing the investigation into the above allegations. LPA was greeted by Medication Technician Rebecca Ramos and explained the reason for the visit. LPA met with Assistant Executive Director (AED) Monica Aguirre approximately 10am. During the course of the investigation, LPA interviewed eight staff and nine residents, however LPA was unable to obtain a statement for one resident. LPA obtained the following documentation for review: Resident/Personnel Rosters, Face sheets, Physician's Reports, Care Plans, and dining menu. The investigation is as follows: Regarding the allegation, Residents are not being provided adequate food service, it is alleged that residents have not been fed or not fed in a timely manner having residents to wait for hours. LPA observed one meal service in the dining room on February 19, 2026 approximately 7:40am. Residents were served on time with a wait time of approximately 5-10 minutes after residents were seated. Substantiated LPA observed residents were served based on the dining menu which was chorizo scrambled eggs with toast or hot or cold cereal. Based on the interviews, four out of eight residents and four out of eight staff confirmed the delay in meal service. Three out of the four residents who confirmed the allegation were interviewed in October 2022. The three residents indicated that the wait time in the dining room in 2022 was approximately 1-2 hours due to staff shortages which was also confirmed by Executive Director Melanie Washington. Regarding the allegation, Residents are being left in soiled diapers for an extended amount of time, it is alleged that the residents are left in soiled diapers for hours. Based on the interviews, six of eight residents and three of eight staff confirmed the delay. Six residents reported waiting to get changed 30-45 minutes after the pendant was pressed with one of the six residents reported waiting 3 hours. The investigation revealed that the staff turnover caused delays in serving food on or approximately October 2022 and the wait time for diaper changes would range between 30-45 minutes. Therefore, based on LPA's observations, interviews which were conducted, and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations, Residents are not being provided adequate food service and Residents are being left soiled in diapers for an extended amount of time are deemed SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D. An exit interview was conducted with Assistant Executive Director Monica Aguirre, and a copy of this report including the appeal rights were provided at exit.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 22-AS-20221021140107

From the deficiency page — Deficiency type: Type B · Section cited: CCR 8755(b)(18) · Plan of correction due date: Mar 6, 2026

9877 General Food Service Requirements (b) The following food service requirements shall apply: (18) Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. This requirement was not met as evidenced by: Based on interviews, ED confirmed the delay in food service due to staff turnover also corroborated by four out of eight residents/staff which poses a potential Health, Safety, and/or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: AED will forward poof of server schedule and will submit a plan addressing server call-outs to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(2) · Plan of correction due date: Mar 6, 2026

87464 Basic Services (f) Basic services shall at a minimum include: (2) Safe and healthful living accommodations and services... This requirement was not met as evidenced by: Based on interviews, six of eight residents and three of eight staff confirmed the delay in diapers changes which poses a potential Health, Safety, and/or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: AED will forward a plan to mitigate diaper change delays which will also include a diaper change schedule log to track completion times to LPA by POC due date.

Allegation investigated: Staff do not ensure residents laundry service is provided in a timely manner.

On February 9, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced to conduct the subsequent complaint investigation visit into the above allegations. LPA introduced self and stated the purpose of the visit to Executive Director (ED) Melanie Washington. During the initial visit on September 26, 2025, LPA obtained copies of pertinent facility records for review: Resident/staff rosters, laundry and housekeeping schedules, and documents for ten residents which includes face sheets, physician’s reports, service plans, and admissions agreements. LPA toured the facility and interviewed residents and staff. CONTINUE TO LICE9099-C...... Unfounded The following was revealed during the course of the investigation: Regarding the allegation that Staff do not ensure residents laundry service is provided in a timely manner, the investigation revealed the following: LPA observed nine out of ten laundry bags in resident rooms that were empty and eight out of ten residents interviewed reported laundry service is provided in a timely manner. Residents interviewed, stated they had no issues with the frequency of when laundry is done nor the cleanliness of the laundered clothing. The facility provided a laundry schedule for residents and LPA observed a functioning laundry room during the visit. Therefore, this agency has investigated the complaint allegation and based observations made and interviews conducted, the above allegation is deemed UNFOUNDED. 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. We have therefore dismissed this portion of the complaint. An exit interview was conducted with Executive Director Melanie Washington, and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Feb 9, 2026 · control 22-AS-20250917152500

Type of visit: Case Management - Deficiencies

On February 9, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for a case management visit to follow up on complaint control no 22-AS-20251222102645. LPA introduced self and stated the purpose of the visit to Executive Director Melanie Washington. During today's visit, LPA amended second deficiency for allegation Staff gave medication to the wrong resident, SUBSTANTIATED during complaint investigation visit on December 29, 2025. See LIC9099-D for details. An exit interview was conducted with Executive Director Melanie Washington, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Feb 9, 2026

Type of visit: Case Management - Deficiencies

On January 26, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for a case management visit to follow up on complaint control no 22-AS-20251222102645. LPA introduced self and stated the purpose of the visit to Assistant Executive Director (AED) Monica Aguirre. During today's visit, LPA issued second deficiency for allegation Staff gave medication to the wrong resident, SUBSTANTIATED during complaint investigation visit on December 29, 2025. See LIC9099-D for details. An exit interview was conducted with Assistant Executive Director Monica Aguirre, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Jan 26, 2026

Allegation investigated: Staff lost resident's diapers

On January 13, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Melanie Washington was present and assisted on today's visit. During the course of the investigation, the Department reviewed facility records, and conducted resident and staff interviews. Regarding the allegation, staff lost resident's diapers, the following has been concluded: It was alleged that Resident #1 (R1) diapers were lost by a staff. The Department was unable to conduct an interview with R1 due to R1 no longer residing at the facility. The Department conducted an interview with R1's hospice agency who confirmed that a supply of R1's diapers were delivered to the facility on September 1, 2022. The hospice agency stated that R1's diaper supply was accepted by Staff #1 (S1). The Department conducted an interview with S1 who admitted that they lost R1's diaper order and were no longer able to locate them. CONTINUED ON LIC9099-C Substantiated Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegation that, staff lost resident's diapers. The preponderance of evidence standards has been met; therefore, the above allegation is SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D. An exit interview was conducted with Exective Director Melanie Washington. A copy of the report and Appeal Rights were provided. The Department conducted four staff interviews. Four out of the four staff interviewed denied the allegation and stated that they have not heard of a resident being left in a soiled diaper. Regarding the allegation, staff are not following physicians orders for oxygen, the following has been concluded: It was alleged that staff were not following R1's physician orders for oxygen. The Department was unable to conduct an interview with R1 for this complaint due to R1 no longer residing at the facility. The Department conducted eight resident interviews. However, only two out of the eight residents interviewed reported using oxygen while at the facility. Both of those residents denied the allegation and stated that they have not had any issues with their oxygen while at the facility. The Department conducted four staff interviews. Four out of the four staff interviewed also denied the allegation. Regarding the allegation, staff do not make the food accessible to resident, the following has been concluded: It was alleged that staff did not make food accessible to R1. The Department was unable to conduct an interview with R1 for this complaint due to R1 no longer residing at the facility. The Department conducted eight resident interviews. Eight out of the eight residents interviewed denied the allegation and denied having any issues with accessing food. The Department conducted four staff interviews. Four out of the four staff interviewed also denied the allegation. Regarding the allegation, residents sheets are not being changed timely, the following has been concluded: It was alleged that R1's sheets were not being changed timely. The Department was unable to conduct an interview with R1 for this complaint due to R1 no longer residing at the facility. The Department conducted eight resident interviews. Eight out of the eight residents interviewed denied the allegation and reported no issues with their sheets not being changed timely. The Department conducted four staff interviews. Four out of the four staff interviewed denied the allegation and reported not hearing any issues with residents sheets not being changed timely. Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the four allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Melanie Washington and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 13, 2026 · control 22-AS-20220907120801

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Feb 6, 2026

87217 Safeguards for Resident Cash, Personal Property, and Valuables: (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property.... This was not evidenced by: Based on interviews conducted, the Licensee did not ensure that R1's diapers were appropirately safeguarded. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 13, 2026

Plan of correction: The Executive Director stated that they will complete a statement of understading for this regulation. The Executive Director agreed to provide LPA the statement via email or fax by POC date.

Allegation investigated: Residents are not provided care in a timely manner due to facility being understaffed. Facility is not promptly and appropriately responding to residents' concerns. Facility equipments are in disrepair.

On January 13, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Melanie Washington was present and assisted on today's visit. During the course of the investigation, the Department reviewed facility records, and conducted resident and staff interviews. Regarding the allegation, residents are not provided care in a timely manner due to facility being understaffed, the following has been concluded: The Department was unable to obtain any staffing records from the facility for the time period that this complaint was received. The Department conducted six resident interviews. Four out of the seven residents interviewed denied the allegation and stated that they believe there has been adequate staffing at the facility and that they have been provided care in a timely manner. CONTINUED ON LIC9099-C Unsubstantiated However, two of the six residents interviewed corroborated the allegation and stated that there were previous issues with staffing at the facility. The two residents also stated that residents were not being provided care in a timely manner due to the staffing issues. The Department conducted four staff interviews. Two out of the four staff interviewed denied the allegation. However, two out of the four staff interviewed also corroborated the allegation and stated that previously, residents were not provided care in a timely manner due to staffing issues at the facility. Regarding the allegation that, facility is not promptly and appropriately responding to residents' concerns, the following has been concluded: The Department conducted six resident interviews. Five out of the six residents interviewed denied the allegation and stated that their concerns have been addressed appropriately by the facility. However, one out of the six residents interviewed corroborated the allegation and stated that her concerns were not addressed appropriately by the facility. The Department conducted four staff interviews. Four of the four staff interviewed denied the allegation and stated that residents concerns have been addressed appropriately. Regarding the allegation that, facility equipment's are in disrepair, the following has been concluded: The Department conducted six resident interviews. Four of the six residents interviewed denied the allegation and stated that they have not had any issues with the facility's equipment's. However, two out of the six residents interviewed corroborated the allegation and confirmed they have had previous issues with the facility's equipment's. The Department conducted four staff interviews. Four out of the four staff interviewed denied the allegation and denied ever hearing of any issues with the facility's equipment's. Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the three allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Melanie Washington and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 13, 2026 · control 22-AS-20220815094602

Allegation investigated: Facility does not have adequate record keeping. Resident's hygiene needs are not being met. Resident was left out of bed for an extended period of time. Facility does not have adequate staffing. Facility does not have PPE.

On January 13, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Melanie Washington was present and assisted on today's visit. During the course of the investigation, the Department reviewed facility records, and conducted resident and staff interviews. Regarding the allegation that, facility does not have adequate record keeping, the following was discussed: The Department conducted seven staff interviews. Four of the seven staff interviewed denied the allegation and denied any issues with the facility's record keping. However, three out of the seven staff interviewed corroborated the allegation and stated that there were previous issues with the facility's record keeping. CONTINUED ON LIC9099-C Unsubstantiated Regarding the allegation, resident's hygiene needs are not being met, the following has been concluded: The Department conducted seven resident interviews. Six out of the seven residents interviewed denied the allegation and stated that all of their hygiene needs have been met by the facility. However, one of the seven residents interviewed stated that their hygiene needs were not being met due to staffing issues at the facility. The Department conducted seven staff interviews. Six out of the seven staff interviewed denied the allegation and stated hat resident hygiene needs have been met by the facility. However, one out of the seven staff interviewed corroborated the allegation. Regarding the allegation, resident was left out of bed for an extended period of time, the following has been concluded: The Department conducted seven resident interviews. Seven out of seven residents interviewed denied the allegation and stated that they have not heard of any resident being left out of bed for an extended period of time. The Department conducted seven staff interviews. Seven out of the seven staff interviewed denied the allegation and stated that they have not heard of any resident being left out of bed for an extended period of time. Regarding the allegation, facility does not have adequate staffing, the following has been concluded: The Department was unable to obtain any staffing records from the facility for the time period that this complaint was received. The Department conducted seven resident interviews. Six out of the seven residents interviewed denied the allegation and stated that they believe there has been adequate staffing at the facility. However, one of the seven residents interviewed corroborated the allegation and stated that there were previous issues with staffing at the facility. Regarding the allegation that, facility does not have PPE, the following has been concluded: The Department conducted seven resident interviews. Seven out of the seven residents interviewed denied the allegation and stated there has been sufficient supply of PPE at the facility. The Department conducted seven staff interviews. Seven out of the seven staff interviewed also denied the allegation and confirmed there has always been a sufficient supply of PPE at the facility. Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the five allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Melanie Washington and a copy of the report was provided. Based on the evidence gathered during this investigation, the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis. An exit interview was conducted with Executive Director Melanie Washington and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 13, 2026 · control 22-AS-20220721101300

Allegation investigated: Staff do not adhere to COVID-19 protocol Staff did not observe resident for change in condition Facility does not meet resident's dietary needs Resident's bathroom faucet does not deliver hot water Resident's personal alarm system is inoperable

On January 13, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Melanie Washington was present and assisted on today's visit. During the course of the investigation, the Department reviewed facility records, and conducted resident and staff interviews. Regaring the allegation that, staff do not adhere to COVID-19 protocol, the following has been concluded: The Department reviewed the facility COVID-19 Workplace Infection Plan and observed that staff were required to use Personal Protective Equipment (PPE) such as masks. Staff were also required to use gloves and gowns when necessary. The Department conducted six resident interviews. Five out of the six residents interviewed denied the allegation and stated that they observed staff wearing PPE while at the facility. However, one resident interviewed corroborated the allegation and stated that he observed times where staff would not wear their PPE as required. CONTINUED ON LIC9099-C Unsubstantiated The Department conducted five staff interviews. Five out of the five staff interviewed denied the allegation and stated that staff followed the facility's COVID-19 protocols. Regarding the allegation that, staff did not observe resident for change in condition, the following has been concluded: It was alleged that the facility did not observe a change of condition for Resident #1 (R1). The Department was unable to conduct an interview with R1 for this complaint due to R1 no longer residing at the facility. The Department conducted six resident interviews. Six out of the six residents interviewed denied the allegation and stated that staff provide them appropriate supervision. The Department conducted five staff interviews. Five out of the five staff interviewed denied the allegation and stated that residents are provided with adequate supervision to determine when they have a change of condition. Regarding the allegation that, facility does not meet resident's dietary needs, the following has been concluded: It was alleged that R1's dietary needs were not met. The Department was unable to conduct an interview with R1 for this complaint due to R1 no longer residing at the facility. The Department conducted six resident interviews. Six out of the six residents interviewed denied the allegation and stated that their dietary needs are being met by the facility. The Department conducted five staff interviews. Five out of the five staff interviewed also denied the allegation. Regarding the allegation that, resident's bathroom faucet does not deliver hot water, the following has been concluded: The Department conducted six resident interviews. Four out of the six residents interviewed denied the allegation and stated that they have not had any issues with the hot water in their bathrooms. However, two out of the six residents interviewed corroborated the allegation and stated that they have had previous issues with the hot water in their bathrooms. The Department conducted five staff interviews. Three out of the five staff interviewed denied the allegation. However, two out of the five staff interviewed corroborated the allegation and stated that there were previous issues with the hot water in certain resident bathrooms. The Department tested the hot water in each of the six resident's bathrooms. The hot water in each of the resident bathrooms measured within regulatory requirements. Regarding the allegation that, resident's personal alarm system is inoperable, the following has been concluded: The Department conducted six resident interviews. Six out of the six residents interviewed denied the allegation and stated that they have not had any issues with their personal alarm system. CONTINUED ON LIC9099-C The Department conducted five staff interviews. Five out of the five staff interviewed denied the allegation. Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the five allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Melanie Washington and a copy of the report was provided. Based on the evidence gathered during this investigation, the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis. An exit interview was conducted with Executive Director Melanie Washington and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 13, 2026 · control 22-AS-20220607083355

Type of visit: Case Management - Other

On January 9, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced to deliver amended complaint investigation findings for Complaint Control No 22-AS-20251222102645 for visit date December 29, 2025 from 8am-3pm. LPA was greeted and granted entry after stating the purpose of the visit to Executive Director Melanie Washington. An exit interview was conducted with Executive Director Melanie Washington, and a copy of this report including the amended complaint investigation report were provided at the end of the visit.the state’s words, verbatim · CDSS document, Jan 9, 2026

Allegation investigated: Staff gave medication to the wrong resident. Staff did not follow reporting requirements.

THIS REPORT HAS BEEN AMENDED TO INCLUDE A SECOND DEFICIENCY ON LIC809-D PAGE. On December 29, 2025, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced to initiate the complaint investigation into the above allegations. LPA was greeted and granted entry after stating the purpose of the visit to Executive Director (ED) Melanie Washington. During the visit, LPA toured the facility, conducted health and safety checks, and interviewed staff and residents. The following facility documents were obtained: Resident Roster, Staff Roster and contact information, Staff Schedule, Medication Policy, and In-Service documentation regarding medication administration practices. LPA also obtained the following resident records for Resident #1 (R1) and Resident #2 (R2): Identification and Emergency Information, Care Plans, Physicians Reports, Medication Administration Records (MARs), and Hospice records. CONTINUE TO LIC9099-C.... Substantiated THIS REPORT HAS BEEN AMENDED TO INCLUDE A SECOND DEFICIENCY ON LIC809-D PAGE. Regarding the allegation, Staff gave medication to the wrong resident, it is alleged that on November 3, 2025, Staff #1 (S1) administered R2’s medication of Oxycodone to R1 instead of Tramadol prescribed by R1’s doctor. Based on record review, R1’s MAR dated November 3, 2025, indicates 50mg of Tramadol was administered to R1 at 8am. However, the Morning Controlled Drug Administration Record (MCDAR), an internal record used by facility to count medication during shift change, has an entry for November 3, 2025, that was crossed out with the word “error”. There are no additional entries for the morning dose which indicates the resident was not administered Tramadol for the morning pass on November 3, 2025. This conflicts with the MAR mentioned above. A record review of R2’s MAR dated November 3, 2025 indicates 10-325mg of Oxycodone-Acetaminophen was administered to R2 six times throughout the day, however, the Controlled Medication Record (CMR), a record used by facility to count medication during shift change, has seven staff entries for November 3, 2025 with one crossed out and the words “error got wet” noted beside the date. During the investigation, interviews were conducted and three out of six staff confirmed that on November 3, 2025, Staff #1 (S1) administered R2’s medication of Oxycodone to R1 instead of Tramadol and R2 received the usual dose of Oxycodone as well. One staff interviewed stated the medication count for R1 had an extra dose of Tramadol, causing the count to be “off”. A second staff stated R2 was missing a dose of Oxycodone, which was causing that resident’s count to be “off”. A third staff member stated they were aware that R1 was given R2’s medication on November 3, 2025, as staff counted medication and discovered the wrong medication was given to R1 instead of R2 on that date. S4 stated they do not recall the errors occurring on that date and could not confirm or deny if a medication error did or did not happen. S4 reviewed the records and stated that a Medication Destruction Record is used by facility when any medication is damaged or disposed of but could not provide any record of disposal for R1 and R2 on November 3, 2025. Interviews were attempted with residents and LPA was unable to qualify Resident #1 due to diagnosis and Resident #2 was out of the facility at the time of the visit. Regarding the allegation, Staff did not follow reporting requirements, it is alleged that staff did not report the medication error for R1 to resident's family, physician, and the Department. Interviews were conducted and three out of six staff confirmed the allegation. One staff stated R1's family was not informed about the medication being administered incorrectly. A second staff stated R1's physician was not informed about the medication error. A third staff stated they were specifically told not to document the medication error of R2’s medication of Oxycodone being administered to R1 instead of Tramadol prescribed by R1’s doctor. A record review revealed that as of December 29, 2025, no incident reports were submitted to the Department regarding R1’s medication error. Executive Director was interviewed and denied knowledge of the medication error that occurred on November 3, 2025. Based on LPA's observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the allegations Staff gave medication to the wrong resident and Staff did not follow reporting requirements are deemed SUBSTANTIATED. Deficiencies are being cited per Title 22 Division 6 Chapter 8 of the California Code of Regulations. An exit interview was conducted with Executive Director Melanie Washington, and a copy of this report, LIC 9099-D, and appeal rights were provided at exit.the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 22-AS-20251222102645

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Feb 16, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events... This requirement was not met as evidenced by: Based on LPA's observation, interviews, and record review, the facility did not report R1's medication error to R1's family and physician and did not submit an report to the Department within 7 days of the event, which poses a potential Personal, Health, and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 29, 2025

Plan of correction: Administrator stated that they will submit the incident report regarding R1's medication error to the Department today. THIS IS AN AMENDED REPORT

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Mar 5, 2026

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident ... provided all ... requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on observation, interviews, and record review, the facility did not administer medication to R1 as prescribed, which poses a potential Health, Safety, and Personal Rights risk to persons in care. Interviews conducted corroborated that R1 was administered R2's medication on 11/3/2025.the state’s words, verbatim · CDSS document, Dec 29, 2025

Plan of correction: The facility will retrain all staff on the section cited above and submit proof of attendees to CCLD via email by POC due date. THIS IS AN AMENDED REPORT

Type of visit: Case Management - Other

On December 5, 2025, Licensing Program Analyst (LPA) Eboni Bentley and Licensing Program Manager (LPM) Lourdes Montoya arrived unannounced for a case management visit to follow up on an incident report received by Orange County Regional Office on November 6, 2025 for Resident 1 (R1). LPA and LPM introduced selves and stated the purpose of the visit to Assistant Executive Director (AED) Monica Aguirre. During today's visit, LPA and LPM were provided full access to R1’s paper and electronic records. A copy of the Coroner's Report and Death Certificate were also requested and the facility stated they would provide copies at a later date. No deficiencies were cited during this visit. An exit interview was conducted with Assistant Executive Director Monica Aguirre, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Dec 5, 2025

Type of visit: Case Management - Other

On November 12, 2025, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced to deliver an amended report for a case management visit on November 7, 2025, which was a follow-up visit for an incident report received by Orange County Regional Office on November 6, 2025. LPA also conducted a Case Management – Other visit for the purpose of attempting to inspect and audit all resident records for Resident 1(R1), that were not available during the previous visit. LPA introduced self and stated the purpose of the visit to Executive Director (ED) Melanie Washington. During today's visit, at 3:15m, LPA requested full access to R1’s resident paper and electronic records. At 3:40pm, ED stated her Licensee will not permit full access to electronic resident records. ED offered to sit with LPA to review all electronic resident records. ED stated any documents requested could be printed. LPA explained that LPA needed to be able to access and review records independently to determine which documents needed to be inspected and reviewed for R1 and all residents. LPA requested to review the electronic system with staff while ED continued to request LPA electronic access from Licensee. During review, the following records were received: Evaluations dated July 19, 2024, August 15, 2024, February 13, 2024, and July 31, 2025, Fall Evaluation/Fall Investigation dated February 28, 2025, and Incident Report dated November 5, 2025. These documents were not received during the previous visit and are not available in the paper file and chart. At 4:15pm, LPA was informed that the electronic resident records would not be provided and LPA did not receive full access to any electronic records. A deficiency is being cited as per Title 22 of the California Code of Regulations. An exit interview was conducted with Executive Director Melanie Washington, and a copy of this report, LIC809-D, and appeal rights were provided at exit.the state’s words, verbatim · CDSS document, Nov 12, 2025

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Nov 13, 2025

87506 (d)(1)Licensing representatives shall not remove the following current records for current residents unless the same information is otherwise readily available in another document or format/ This requirement was not met as evidenced by: The Licensee did not grant licensing agency full access to inspect, audit, and copy/print all electronic resident records upon demand. Electronic resident records were not readily available on 11/7/25 and by 5pm on today's date, which poses potential risk to resident’s health and safety.the state’s words, verbatim · CDSS document, Nov 12, 2025

Type of visit: Case Management - Health Checks

THIS IS AN AMENDED REPORT On November 7, 2025, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced case management visit to the facility to follow up on an incident report received by Orange County Regional Office on November 6, 2025. LPA was greeted by Executive Director Melanie Washington, explained the reason for the visit, and was granted entry into the facility. During the visit, LPA toured the facility and observed no imminent health and safety issues. LPA obtained copies of Resident/Staff Roster, Staff Schedule, Activity Calendar, Attendance and Resident Sign in/Out sheets for November 4-5, 2025, and the following records for R1: Emergency Contact Sheet, Physician’s Report, Admissions Agreement, Service Plans dated July 19, 2024, August 15, 2024, February 13, 2025, and July 31, 2025, and Progress Notes from July 2024 -Nov 2025. No deficiencies were cited during this visit. An exit interview was conducted with Executive Director Melanie Washington, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Nov 7, 2025

Allegation investigated: Staff do not ensure floors in residents rooms are kept clean.

On this date, Licensing Program Analysts (LPAs) Eboni Bentley and Jessica Cho arrived unannounced to conduct the 10-day complaint investigation visit into the above allegation. LPAs announced self and stated the purpose of the visit to Executive Director (ED) Melanie Washington. During today’s visit, LPAs conducted a tour of ten apartment units and obtained copies of pertinent facility records for review: resident/staff rosters, housekeeping schedules, and documents for ten residents which includes face sheets, physician’s reports, and admissions agreements. The following was revealed during the course of the investigation: Regarding the allegation, staff do not ensure floors in residents’ rooms are kept clean, it is alleged that the staff do not clean the floors in any of the residents’ rooms. CONTINUE TO LIC9099-C.... Unfounded Based on observation of ten apartment units, LPAs observed the floors were clean and sanitary. Therefore, this agency has investigated the complaint allegation and based observations made, the above allegation is deemed UNFOUNDED. 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. We have therefore dismissed this portion of the complaint. An exit interview was conducted with Executive Director Melanie Washington, and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Sep 26, 2025 · control 22-AS-20250917152500

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On August 6, 2025 at 8:00am, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced for the purpose of conducting compliance checks following the Noncompliance Conference on May 14, 2025. LPA explained the purpose of the visit and was granted entry by Receptionist Jasmine Aguirre. Assistant Executive Director (AED) Monica Aguirre and Executive Director (ED) Melanie Washington arrived a short time later and the following pertinent documents were obtained: Staff and Resident Rosters, LIC500 Personnel Record, staff schedules, weekly water logs, Dietary Services Consultant Report, and daily and weekly audits. There are currently 118 residents on census. At 9:00 am, ED Melanie Washington accompanied LPA Bentley on a tour of the facility. During the inspection, LPA conducted health and safety checks on residents and observed hot water temperatures measured between 98.2 and 104.5 degrees F in four out of five separate bathrooms used by residents in care. A deficiency is being cited. Per record review of medication training, a new medication technician was hired and trained in accordance with the compliance plan. AED Aguirre stated the facility has not begun the ten hours annual refresher training required for facility staff. Medication quality assurance checks are being done daily and weekly. The dining service director performs weekly food quality assurance audits and met with a dietician on June 5, 2025. Water temperatures are checked weekly and logs are maintained. The facility has also hired a medication manager and care manager to provide oversight of resident needs and staff. CONTINUE TO LIC809-C PAGE... LPA provided a gentle reminded to licensee to provide Quality Assurance checklist due to the department via email by August 31, 2025. Based on the observations made during today's visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report with appeal rights was provided to Administrator/Executive Director Melanie Washington.the state’s words, verbatim · CDSS document, Aug 6, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Aug 6, 2025

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for....shall be maintained to automatically regulate ..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 on LPA observation, the licensee did not comply with the section cited above in 4 out of 5 resident bathrooms, which poses an immediate health and safety risk to residents in care. LPA observed Rm#126 measure at 98.2, Rm#136 at 98.6, Rm# 276 at 103.1 and 263 measure at 104.5 degrees F.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Licensee stated they will submit water temperature logs for hot water temperatures checked in all four rooms, and measured every two hours for the next 24 hours, to CCLD by 5pm on POC due date. Licensee will send proof to LPA via email.

Allegation investigated: Staff do not provide quality meals to residents Facility has foul odor Staff are not providing a reasonable level of personal privacy Staff are not maintaining facility floors clean

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced inspection visit to deliver findings for complaint investigation LPA explained the reason for the visit with Assistant Executive Director Monica Aguirre. During the course of the investigation LPA toured facility, reviewed records, conducted staff and resident interviews, made visual observations and requested pertinent documentation such copies of menus, food invoices, housekeeping schedules, Admission Agreement, Resident face sheets, resident care plan, and emergency plan training. Regarding allegation “Staff do not provide quality meals to residents”, during visit LPA Tirre toured facility and observed that facility has adequate supply of perishable and non perishable foods. While touring kitchen pantry and freezer LPA observed foods to be sealed in containers with labels of when items were opened and expiration dates. LPA did not observe expired foods. Per Food invoices facility gets shipment of foods twice a week from two separate vendors. Invoices show facility gets a variety of produce, dairy, frozen, dry goods and meats. Per facility interviews ten out of eleven residents enjoy the food and state that food is of good quality. Interviews with staff stated that Five of Seven Staff enjoy facility food while other two staff prefer to bring their own meals. CONTINUED ON 9099C Unsubstantiated Regarding allegation “Facility has foul odor”, during investigation LPA Tirre toured facility and observed the following areas: lobby, restrooms, bistro, dining, laundry, salon, activities room, hallways and resident rooms on both first and second floors. LPA observed that facility lobby has a air purifier and rotating fans to help circulate air flow. LPA did not observe any foul odors in any of the mentioned areas. LPA toured hallway where Resident 1’s apartment is located. LPA observed that facility has a designated smoking area for residents located on second floor balcony area located outside above first floor courtyard. Designated smoking area is located on opposite side of building in relation to R1’s room. Per facility interviews, eleven out of eleven residents stated they have never witnessed foul odors in any areas of building. Interviews with staff revealed that seven of seven staff have not experienced lingering foul odors. Regarding allegation “Staff are not providing a reasonable level of personal privacy”, LPA observed during tour staff knocking on resident bedrooms before entering. Investigation interviews with residents revealed that eleven of eleven residents stated that staff value residents privacy while at facility. Interviews with staff stated that seven of seven staff members give residents privacy while in bedrooms. Staff interviews stated that if residents have to use bathroom or showers, staff members will exit during these times. Record review revealed that on 6/3/2025, a incident occurred where R1 had been taking a shower with bathroom door open causing steam to set off smoke detector inside facility apartment. Staff came to resident room to check on resident and see if situation was an emergency situation. Per record review Emergency drill reports state that staff “Need to calm residents and provide basic needs for evacuation and working with authorities” in the event of an emergency. Regarding allegation “Staff are not maintaining facility floors clean”, LPA toured facility and observed the floors and carpets in the lobby, resident hallways on both first & second floors to be clean, vacuumed and free of debris. LPA observed that hard wood floors located in dining and activities area are mopped after each meal and activity. LPA did not observe any floors that were uncleanly. Interviews with eleven of eleven residents and seven of seven staff all indicate that floors are well cleaned. All interviews conducted with staff and residents revealed that facility staff clean bedrooms once to twice a week, deep cleaning done once a month and common areas such as lobby, restrooms and kitchen are done daily. Based on observations, record reviews and interviews LPA Tirre is unable to corroborate allegations made that Staff do not provide quality meals to residents, facility has foul odor, staff are not providing a reasonable level of personal privacy and staff are not maintaining facility floors clean does not meet the preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Assistant Executive Director Monica Aguirre and Executive Director Melanie Washington. A copy of this report was provided during this visit.the state’s words, verbatim · CDSS document, Jun 11, 2025 · control 22-AS-20250604144107

Type of visit: Required - 1 Year

On May 27, 2025 at 8:00am, Licensing Program Analysts (LPASs) Eboni Bentley and Jenifer Tirre made an unannounced visit to the facility for the purpose of conducting an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPAs were greeted and granted entry by Dining Services Manager, Sergio Mendoza and stating the purpose of the visit. Administrator/Executive Director (AD), Melanie Washington was notified and assisted with the visit. LPAs reviewed the facility's resident census, staff roster, Emergency and Disaster Plan, Infection Control Plan, staff schedules. A sample of ten staff records and ten resident records were reviewed during the visit. Background clearance and association to the facility was verified for staff members on the roster. Emergency safety drills was last conducted on March 10, 2025 and are conducted quarterly. First aid kit is maintained and contains all the necessary elements. Smoke and carbon monoxide alarms were inspections were reviewed and observed operational. The facility has several fire extinguishers that were charged throughout the facility, all last serviced on or around August 7, 2024. Liability Insurance is effective December 23, 2024 through December 23, 2025. The facility is a two-story building arranged around a central courtyard. LPAs conducted a tour of the interior and exterior of the physical plant. Rooms reviewed were provided with furniture in good repair, clean linens, adequate storage space, and kept free of obstructions. Bathrooms were observed to be in good repair, with non-skid strips and grab bars on the inside of the shower. Hot water was measured between 125.4 and 130.2 F in three out of ten separate bathrooms throughout the physical plant. CONTINUE TO LIC809-C PAGE Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Cleaning supplies and sharp items were inaccessible to residents in care. LPAs reviewed the five resident medications records and found one resident, Resident #1 (R1) missing a medication that staff could not locate and an addition medication for R1 found in resident’s room. Based on the observations made during today's visit, two Type A deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report with appeal rights was provided to Administrator/Executive Director Melanie Washington.the state’s words, verbatim · CDSS document, May 27, 2025

Allegation investigated: Facility staff are not abiding by the terms and conditions of the Admission Agreement.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Assistant Executive Director (AED) Monica Aguirre and explained the reason for the visit. The investigation revealed the following. It was alleged the facility is not abiding by the admission agreement because on page 2 it states under Section A Living Accommodations, " 2. Utilities. Your apartment will be furnished with basic cable television hook-up, water, electricity, garbage removal, heat and air conditioning.". Staff reported that the TV channel guide is provided at the time of move in to all residents. The guide lists 52 channels. LPA and AED toured the facility. LPA observed the TV in the activity room receives 51 channels, channel 39 only showed the Direct TV logo and according to the channel list it should show, TVLand. LPA and the AED observed that in Resident 1's (R1) room that the TV did not have any sound on channel 15 but had sound on all the other channels. Substantiated LPA observed 5 channels out of the 51 received had a poor quality picture with static interference. LPA and the AED observed the TV in Resident 2's room (R2) that 5 channels received had a poor quality picture with static interference. LPA interviewed the maintenance director and the activities director who reported the problem has been ongoing since around January 2025. 3 out of 3 residents interviewed verified this report. The Executive Director stated that the cable provider has been out at least 3 times in the last 30 days but the problem is ongoing. Based on the evidence gathered the preponderance of evidence standard has been met therefore the allegation is substantiated. Deficiencies are being cited per Title 22 Division 6 of California Code of Regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided.the state’s words, verbatim · CDSS document, Mar 25, 2025 · control 22-AS-20250319163927

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Apr 25, 2025

The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not being met as evidenced by... LPA observed that the admission agreeement states basic cable television hook-up will be provided but channel 39 is not being provided, 5 out of the 51 channels have poor picture quality with static and channel 15 does not have sound for R1, this poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 25, 2025

Plan of correction: License agrees to have the cable TV in the facility fixed so all residents can view channels with sound and good picture quality without any static or distortion.

Allegation investigated: Staff did not ensure that resident was provided a comfortable environment while in care.

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to conduct the initial visit to begin the investigation into the allegations listed above. LPA met with Melanie Washinton, Executive Director and explained the nature of the visit. Based on the information obtained during this investigation the department has concluded the investigation into the above mentioned allegation. Findings are based upon this investigation which included interviews conducted, tour of the physical plant of the facility and copies of pertinent documents obtained. It is alleged facility staff did not ensure that resident was provided a comfortable environment while in care. Interviews with 6 of 6 residents indicated that they were always made aware of the remodel that the facility was doing. They indicated that there was a large notification in the lobby with illustrations of what Continued on LIC9099 Unsubstantiated was being done. They indicated that there were various ways that the facility would notify the residents of the remodel whether it was by a paper notice, meeting, postings, and notices posted throughout the facility. They indicated that the remodel did not affect the comfort, care or supervision for them. Interview with staff (S1) indicated that when there is a possible move in, they notify them of the situation. S1 indicated that there was no construction being done but rather a refresh of painting the interior/exterior, flooring, and furnisher in common spaces. S1 indicated that the refresh did not create a disruption to the environment that would create an obstacle for the care and supervisor of the residents. S1 indicated that when they were made aware that there was to be painting by residents’ room, they asked the painters to stop work in that area until further notice. Interviews with residents verified the state from S1. Interview with witness (W1) revealed that they did not observe the room to have a tarp in the sliding door of the balcony and that on one occasion they observed painters getting ready to work however it stopped shortly after and workers moved to another area of the facility. Furthermore, they stated that the facility staff did a great job of providing the care needed for the resident in the sensitive time that they were presented with.Evidence presented to LPA did not present any observations of a tarp in the room or of construction being done. LPA toured the physical plan of the facility and toured the resident’s room in question. LPA did not observed any construction being done at the facility. LPA observed that there was a working AC unit giving out cool air in resident room in question. LPA took measurements of the temperature on multiple areas of the room including the areas where the sun was entering room directly and the measurements were between 78.2-79.9 Fahrenheit degrees. Per regulation section 87303(b)(2) Maintenance and Operation: A comfortable temperature for residents shall be maintained at all times. The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with the Executive Director and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Jul 15, 2024 · control 22-AS-20240708163527

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by front desk staff after introducing himself and stating the purpose of the visit. Executive Director Melanie Washington was notified and assisted with the visit. LPA reviewed the facility's resident census, staff roster, Emergency and Disaster Plan, Infection Control Plan, staff schedules. A sample of ten staff records and ten resident records were reviewed during the visit. Background clearance and association to the facility was verified for all 39 staff members on the roster. Sufficient staffing levels were observed throughout the facility as well as in the kitchen. The facility is a two-story building arranged around a central courtyard which is currently undergoing renovations. LPA conducted a tour of the interior and exterior of the physical plant. Rooms reviewed were provided with furniture in good repair, clean linens, adequate storage space, and kept free of obstructions. Smoke, carbon monoxide, and facility call system were operational. Bathrooms were observed to be in good repair, with non-skid strips. However some bathrooms observed had no grab bars on the inside of the shower itself. Hot water was measured within acceptable range in four separate bathrooms throughout the physical plant. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to residents in care. LPA reviewed the facility's two medication carts during the medication round in the dining room. Fire extinguishers were mounted and charged. For the exterior portion, facility has several patio furniture sets with umbrellas for shade and the grounds and routes of egress were free of tripping hazards. Based on the observations made during today's visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Two Technical Violation Advisory Notes were provided. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jun 19, 2024

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Due to neglect resident sustained multiple falls resulting in injuries

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the allegations listed above. LPA was greeted and granted entry by staff after stating the purpose of the visit. Administrator Melanie Washington was present at the facility and assisted with the visit. An initial complaint investigation visit was on January 4 after a complaint was filed on January 11, 2024. The complaint was investigated by the Department and consisted of a tour of the physical plant conducted with the facility’s administrator, a review of resident and hospice records, a Health and Safety check conducted with no immediate health and safety issues observed with the residents, as well as additional interview with facility residents, witnesses, and facility staff. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 Resident R1 is an 95-year-old resident who was admitted at the facility on March 3, 2022. Upon admission, R1 was stated to be ambulatory, requiring limited assistance with activities of daily living and administering her own medications. Following an increase in fall risk and fall incidents, R1 was reevaluated by their primary care provider and admitted on hospice care in October 2023. Additional preventative measures were implemented or offered by facility staff to address the resident’s fall risk, such as providing a commode toilet, removal of some furniture in order to make R1’s room more accessible and education on the use of the pendant and call system to request staff assistance. Postural supports were discussed but ruled out by R1 and their responsible party. R1’s medical assessment dated October 5, 2023 indicates a primary diagnosis of Coronary Arterial Disease with quadruple Cornonary Arterial Bypass as well as an indication of Mild Cognitive Impairment. Regarding the allegation that Due to neglect resident sustained multiple falls resulting in injuries, the following has been concluded: On January 1, 2024, R1 sustained a fall incident around 12:30pm and were found by facility caregiving staff on the floor of their unit’s bathrooms, as corroborated by interviews and staff notes reviewed. Resident was assessed after the fall and reported to pain or injury when assisted back up. No potential head injury was suspected. At approximately 1:30pm, R1 complained of pain and was provided with PRN pain medication. Later the same day, R1 received visits from their responsible party as well as from the hospice nurse. During the hospice assessment on that day, R1 “stood up very confidently on her own and seamed steady on her feet during [the] assessment. [R1] said she had mild pain and said she hurt a little bit. [Hospice nurse] said he assessed R1 from head to toe and said she was oriented; her pupils were alert and there were no visible injuries or bruising”. After the visits, at approximately 6:20pm, a loud noise was heard from the R1’s room. R1 was found unconscious and laying on the floor, with visible facial lacerations. A call to the paramedics was confirmed to have been initiated immediately and R1 was transported to UCI Hospital. R1 was admitted to the hospital with a diagnosis of subdural hematoma, blunt head trauma, subarachnoid hemorrhage, closed fracture of left side of maxilla and closed fracture of orbit. R1 is stated to have been unconscious upon admission. R1 was later discharged to a Vitas Hospice facility on January 3, 2024. R1 later passed away at the same facility on January 6, 2024. The death certificate was requested and obtained by the Department and indicated the primary cause of death as “coronary artery disease with contributing factors of chronic obstructive pulmonary disease”. CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C R1 had an established history of fall risk. Facility followed the fall prevention plan and there were only two fall incidents requiring medical assistance verified to have been addressed by a call to paramedics and incident reports submitted to the Department. Based on the evidence gathered and interviews conducted during the investigation, there is insufficient evidence to corroborate the occurrence of neglect and/or lack of supervision on the part of the facility’s staff. The allegation listed above is therefore found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, May 6, 2024 · control 22-AS-20240109121350

Type of visit: Case Management - Deficiencies

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced case management visit for the purpose of issuing a civil penalty concluded during investigation of complaint control #22-AS-20230817163330 completed by the department. LPA Quiroz was greeted and granted entry into the facility by front desk receptionist and met with Melanie Washington, Executive Director and explained the reason for the visit. Civil penalty assessed on today's date. (SEE LIC 421IM) An exit interview was conducted with (ED) Melanie Washington and was provided with copy of report, Appeal rights and Civil penalty assessment- LIC 421IM.the state’s words, verbatim · CDSS document, Feb 27, 2024

Allegation investigated: -Staff did not make medication inaccessible to resident, resulting in hospitalization.

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA Quiroz was greeted and granted entry into the facility by Front desk receptionist and met with Melanie Washington, Executive Director and explained the reason for the visit. During the course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation including Physician Report. The purpose of today’s visit is to deliver the findings regarding the above allegation. The investigation conducted revealed the following: Resident 1 (R1) was admitted to the facility on April 1, 2023, and has a diagnosis of history of Transient Ischemic Attack (TIA) per Physician report dated June 8, 2023. Per Physician report resident is not able to administer or store their own medication. On August 12, 2023, Staff 1 (S1) reported being busy finishing tasks before the end of their shift and passed off medication duty to another MedTech, Staff 2(S2), to finish distributing. CONTINUED... Substantiated CONTINUED...S1 reported placing R1’s medication and a second resident, Resident 2 (R2)’s medication into white cups with their room numbers written on it. S1 signed off on both R1 and R2 taking their medications based on verbal information received from S2. S1 and S2 did not physically see residents take their medications. On the morning of August 13, 2023, R1 saw a white cup with medications on the nightstand and assumed they were for them and ingested them. When S1 came in to do R1’s morning medication disbursement, S1 found out S2 had left medications for R2 on R1’s dresser and didn’t distribute them like they had said they did the night before. Shortly after taking the wrong Medications, R1 became lethargic and unresponsive and was transported to St.Jude Hospital and returned to the facility later that night. On August 15, 2023, approximately two days after being hospitalized for ingesting the wrong medications, R1 was getting showered by a caregiver and once again became lethargic and unresponsive and was transferred to St. Jude Hospital. St. Jude Hospital medical records state R1 suffered from a stroke and was diagnosed with a cerebral blood clot causing R1 to undergo surgery. Medication Administration Records (MARs) for R1 show R1 had a prescription for Eliquis to be taken 1 tablet by mouth twice daily. Interviews conducted with Administrator Melanie Washington confirmed R1 missed their evening dose of medication on 8/13/23 due to returning back to the facility late after being hospitalized. The morning of 8/15/23, facility staff were prepared to administer R1’s medications but did not due to R1’s medical emergency causing them to be re-hospitalized. Due to R1 being hospitalized two times as a result to taking the wrong medication, R1 missed their Eliquis medication doses. Per Medical Expertise received by the Department, R1’s missed Eliquis medication was a contributing factor to R1 having a blood clot/stroke. Upon finding out R1 ingested another resident’s medication, Facility Administrator Melanie Washington conducted an internal investigation and determined that facility protocol had not been followed. Both S1 and S2 were terminated. Therefore, based on interviews conducted and records reviewed, the preponderance of evidence has been met. The allegation that staff did not make medication inaccessible to resident, resulting in hospitalization has been Substantiated. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f). An exit interview was conducted, and a copy of this report, 9099-D Page, and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Feb 15, 2024 · control 22-AS-20230817163330

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Feb 16, 2024

87465(c)(2) Incidental Medical and Dental Care- …Once ordered by the physician the medication is given according to the physician's directions… This requirement was not met as evidence by: Licensee failed to ensure R1 received prescribed Eliquis medication twice CONTINUED... CONT... daily resulting in at least one missed dosage on the dates 8/13/23 and 8/15/23. As a result, R1 suffered a stroke and was diagnosed with a cerebral blood clot requiring surgery. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 15, 2024

Plan of correction: Facility hired a medication room Manager who is an addition to MT Staff to ensure proper medication administration and agreed to conduct inservice training to all personnel administering medication and submit proof of medication training by POC due date of 2/20/2024.

Type of visit: Case Management - Deficiencies

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA Quiroz was greeted and granted entry into the facility by front desk receptionist and met with Melanie Washington, Executive Director and explained the reason for the visit. During the course of the investigation, the following deficiencies were observed and are being cited via this case management deficiency. Resident 1 (R1) was admitted to the facility on April 1, 2023. Per R1’s Physician report dated June 8, 2023 resident is not able to administer or store their own medication. On August 12, 2023, Staff 1 (S1) reported being busy finishing tasks before the end of their shift and passed off medication duty to another MedTech, Staff 2(S2), to finish distributing. S1 reported placing R1’s medication with Resident 2 (R2)’s, medication into white cups with their room numbers written on it. S1 signed off on both R1 and R2 taking their medications based off word of mouth from S2. S1 and S2 did not physically see residents take their medications. On the morning of August 13, 2023, R1 saw a white cup with medications on the nightstand and assumed they were for them and ingested them. When S1 came in to do R1’s morning medication disbursement, S1 found out S2 had left medications for R2 on R1’s dresser and didn’t distribute them like they had said they did the night before. Shortly after taking the wrong medications, R1 became lethargic and unresponsive and was transported to St. Jude Hospital and returned to the facility later that night. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report, 809-D Page, and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Feb 15, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Feb 20, 2024

87465(h)(2) Incidental Medical and Dental Care- Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. CONT BELOW... This requirement was not met as evidence by: Licensee failed to ensure medications were locked inaccessible to R1 resulting in R1 ingesting another resident’s medication. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 15, 2024

Plan of correction: Facility hired a medication room manager in addition to MT's to ensure proper medication administration. AD agreed to provide inservice training to all staff identied on LIC 500 on CCR 87465 by POC due date of 2/20/2024.

Allegation investigated: Resident's room is in disrepair Facility is not adhering to the admission agreement

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of initiating the investigation into the allegations listed above. LPA was greeted and granted entry by Executive Director Melanie Washington after stating the purpose of the visit and listing the allegations. LPA accompanied with administrator conducted a survey of the room resident R1 is admitted to. Water temperature along with operation for the two wall heater units in the room were verified. A resident interview with R1 was conducted along with a staff interview with the facility's executive director and business services manager. The current admission agreement for R1 was requested and reviewed. Regarding the allegation that Resident's room is in disrepair, the following has been concluded: During the tour of the physical plant conducted, LPA verified the operation for the thermostatic faucet in the shower. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM LIC9099-C The water from the shower was measured at a maximum temperature of 117F. The temperature adjustment was observed to be functional, ranging from cold water on the left to the hottest setting on the right, with accurate stops in each direction. During R1's interview, it was stated that the water could change from cold to scalding without the temperature setting being modified, however LPA was unable to replicate this after monitoring the temperature for approximately five minutes. The two HVAC units observed in the dining room and the bedroom were both verified to be functional. Both units turn on, can be placed in Hot/Cold/Energy Saving/Fan only modes, blow hot and cold depending on the settings used and the target temperature set onto the unit. R1 stated that the living room unit had been replaced recently, as evidenced by the presence of plastic wrapping alongside the wall outlet. Based on these observations, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred. Regarding the allegation that Facility is not adhering to the admission agreement, the following has been concluded: LPA reviewed the agreement to include the following statement "You will receive a monthly statement that itemizes any fees or charges that you have incurred". LPA requested documentation of the statements sent to R1's responsible party. Monthly statements were historically emailed to the resident's responsible party with the exception of the most recent month during which staff stated that it should have been mailed out. Email records dated prior to December 18, 2023 are no longer accessible due to a change of management. Upon review it was determined that the address on file used in late December 2023 may have been outdated. The facility does not keep any logs of outgoing mail, and could therefore not provide evidence. Facility staff is currently working on the upcoming billing cycle for February and will return to emailed invoices. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jan 29, 2024 · control 22-AS-20240122111856

Allegation investigated: Staff are not assisting resident with bathing needs. Resident was billed for services not rendered.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit to the facility for the purpose of following up on the investigation of the allegations listed above. LPA was greeted and granted entry by front desk staff after explaining the purpose of the visit. Executive Director Melanie Washington was present to assist with LPA's requests throughout the visit. An initial complaint investigation visit took place on December 19, 2023. LPA requested and obtained records maintained at the facility for three current residents along with the December billing records for the full census and individual billing records for resident R1. One staff interview and one resident interview were conducted during the visit. During the present visit, LPA requested the full census and reviewed four more resident records. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099-A Regarding the allegation that Staff did not provide resident with a copy of an admissions agreement, the following has been concluded: Based on an interview conducted with resident R1 during the initial complaint investigation visit, the request for a copy of the admission agreement effective September 12, 2023 was granted and a copy was provided to the resident which allowed a clarification regarding toileting care to take place. The allegation is therefore found to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff are not assisting resident with bathing needs, the following has been concluded: Based on a review of resident R1's pre-admission assessment, physician report and admission agreement, R1 is determined to require occasional assistance from facility staff with toileting care which is confirmed by the Care Level assessment of a Level 1 appearing in the current admission agreement signed by the resident and a facility representative prior to admission. Additionally, R1 does not have any documented cognitive impairment. LPA conducted an interview with R1 during the initial complaint investigation visit during which R1 stated she had not received toileting assistance from facility staff during the first weeks of her admission. However an interview with facility staff appears to indicate R1 requested a discount after declining one of her weekly showers two weeks in a row. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. Regarding the allegation that Resident was billed for services not rendered, the following has been concluded: Based on a review of R1s billing records provided by the facility, an additional $500 for Assisted Living - Care Level 1 was assessed monthly in addition to the residence fees. R1 was stated and/or documented as having declined to be assisted for one of her weekly showers on September 28, 2023 and October 1, 2023 and requesting a discount of the care fees as a result. However, the care fees are not assessed per services rendered, and pro-rating of the fee to reflect declined showers could not be accommodated per the terms of the admission agreement. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of this report along were provided to a facility representative.the state’s words, verbatim · CDSS document, Jan 22, 2024 · control 22-AS-20231213110026

Allegation investigated: Facility is not abiding by the admission agreement Facility admission agreement does not have description of services Facility did not specify additional fees owed

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit to the facility for the purpose of following up on the investigation of the allegations listed above. LPA was greeted and granted entry by front desk staff after explaining the purpose of the visit. Executive Director Melanie Washington was present to assist with LPA's requests throughout the visit. An initial complaint investigation visit took place on January 16, 2024. LPA requested and obtained records maintained at the facility for resident R1 along with copies of a prospective admission agreement drafted in anticipation of a facility-wide update of the admission packets following a change of ownership. One staff interview was conducted during the visit. During the present visit, LPA requested the full census and reviewed four more resident records. A total of six resident interviews were either conducted or attempted in addition to one staff interview. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099-A Regarding the allegation that Facility did not obtain a proper medical evaluation for resident prior to admission, the following has been concluded: After prospective admission packets were provided to facility residents and/or their responsible parties, multiple parties interviewed stated that they had been confused by the inclusion of a blank assessment form in the packet that had been provided to them and thought that it did apply to each individually. During both visits conducted, LPA reviewed a random selection of six resident records, all of which were observed to include the required medical assessment. As a result, the allegation is found to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC9099 Regarding the allegation that Facility is not abiding by the admission agreement, the following has been concluded: Based on interviews and records reviewed, the facility changed ownership on December 18, 2023. On or around that time, the new management made an announcement and provided new admission agreements for review to residents and/or their responsible parties with an initial instruction to return these signed within 5 days. The instruction was later rescinded. At the time of the initial investigation, the updated packets are stated to not be in effect yet. A review of six randomly selected resident records showed that the initial agreements were still valid and in effect, both for recently admitted residents as well as residents with a longer admission period at the facility. At this time, the admission agreements on file are still in place and valid. The allegation is therefore found to be Unsubstantiated, meaning that there is not a preponderance of evidence to prove or refute the alleged violation occurred. Regarding the allegations that Facility did not specify additional fees owed and Facility admission agreement does not have description of services, the following has been concluded: Both the initial admission agreements on file and the prospective documents provided for review include a list of the basic services provided as well as a list of the additional services available as well as the fee schedule for these. Assisted Living Care Levels are also described and the cost associated is described in both instances. Some of the residents and/or responsible parties interviewed described being confused by the fact that copies of the prospective admission packet indicated increased fees starting December 18, 2023 and expressed concerns that these amounts could be binding despite assurances to the contrary made by the facility's Executive Director. These concerns were compounded by the presence of an inaccurate balance amount on the invoices provided for January 2024 due to the inclusion of fees already paid prior to the change of ownership to the total balance owed. It was however determined that none of the fee structure had been modified at this time. As a result, the allegations are found to be Unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred. One Technical Assistance Advisory Notes is attached to the present report. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jan 22, 2024 · control 22-AS-20240116104221

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting a Case Management visit. LPA explained the nature of the visit to Executive Director Melanie Washington. On December 20, 2023, LPA obtained knowledge of the following during the investigation in connection to Complaint Control Number: 22-AS-20230911142552. The facility did not submit a written report within seven days of the occurrence pertaining to the skin tear Resident #1 (R1) sustained from the fall by the rose bush on June 1, 2022. Per Progress Notes, resident had a change of condition after a fall and sustained an injury on September 23, 2023. Facility did not have an updated Physician’s Report or a doctor’s order prescribing the wheelchair. As a result of today’s Case Management visit, Technical Violation Advisory notes will be issued. An exit interview was conducted with Executive Director Melanie Washington, and a copy of this report along with Technical Violation Advisory Notes form LIC9102s and the LIC811 were provided at the end of the visit.the state’s words, verbatim · CDSS document, Dec 22, 2023

Allegation investigated: Staff did not seek medical attention for resident in a timely manner. Staff mismanaged resident's medication. Staff did not provide a safe and comfortable environment for resident.

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced and met with Executive Director Melanie Washington for the purpose of delivering the findings into the above allegations. LPA explained the reason for the visit and reviewed the allegations. On September 21, 2023, LPA initiated the 10-day complaint investigation for the complaint received on September 11, 2023. During the course of the investigation, LPA interviewed residents/staff and obtained pertinent documentation. The investigation revealed the following: It is alleged that the staff did not seek medical attention for the resident in a timely manner. Per review of the Progress Notes dated February 3, 2021 to September 23, 2023, there was no incident documenting a skin tear to the left arm that Resident #1 (R1) allegedly sustained from their dog on or before August 28, 2023. Three out of the four staff were not aware of the incident while one out of the four staff confirmed treating the resident however was unable to recall the details. Unsubstantiated Two out of the three residents indicated that the facility staff responds to their request in a timely manner, therefore LPA lacks sufficient information to corroborate the allegation. It is alleged that the staff mismanaged the resident’s medication. R1 joined the medication management program effective May 31, 2023, as noted on the Progress Notes. Per interviews conducted, four out of the four staff did not corroborate with the allegation. One out of the three residents that were interviewed indicated that the Medication Technicians (MTs) stand and watch to ensure that the medication is taken while two out of the three residents indicated that they are not participants in the medication management which was verified on the Physician’s Reports. It is alleged that the staff did not provide a safe and comfortable environment for the resident. Two out of the two staff indicated that Staff #1 (S1) maintains an open-door policy and welcomes residents and families to communicate their concerns. Only one out of the three residents interviewed was able to identify the position of S1 while two out of the three residents expressed that they did not have an interaction with S1. Based on the interviews which were conducted and the records that were reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the following allegations: Staff did not seek medical attention for resident in a timely manner, Staff mismanaged resident’s medication, and Staff did not provide a safe and comfortable environment for resident are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Melanie Washington, and a copy of this report including the LIC9099-C and LIC811s were provided at the end of the visit. Therefore, based on LPA's observations and interview, the preponderance of evidence standard has been met, therefore the following allegation: Facility is in disrepair is deemed SUBSTANTIATED. The California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with Executive Director Melanie Washington, and a copy of this report including the LIC9099-C, LIC9099-D, LIC811, and the appeal rights were provided at the end of visit.the state’s words, verbatim · CDSS document, Dec 20, 2023 · control 22-AS-20230911142552

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(4) · Plan of correction due date: Dec 27, 2023

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement was not met as evidenced by: Based on the observations and interview, the backyard patio ground is uneven/unstable and may potentially be a safety risk to R1, who has a motor impairment. This poses a potential Health, Safety, or Personal Rights risk to the person in care.the state’s words, verbatim · CDSS document, Dec 20, 2023

Plan of correction: The Executive Director stated that a handrail and/or the patio grounds would be leveled and the POC will be submitted to LPA via email by the due date.