The Burlington

Allegation investigated: Staff do not ensure the facility is free of bed bugs Staff do not allow resident to leave the facility Staff do not ensure resident's finances are safeguarded

On 05/14/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint investigation and deliver complaint findings. LPA met with Administrator Carlene Reinke. During the course of the investigation, the department received copies of records, conducted interviews, and toured the facility. The facility was observed free of bed bugs. R1 confirmed staff allows the resident to leave the facility unassisted and manage own finances. R1 confirms the resident have not borrow any money to staff or to any other residents. Therefore, based on interviews conducted, the preponderance of evidence standard has not been met, the above allegations are found to be UNSUBTANTIATED. Exit interview was conducted. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 14, 2026 · control 24-AS-20260507113909

Allegation investigated: Staff disposed of resident's personal belongings. Staff does not allow a resident to use a physician of their choice. Staff does not allow a resident to store food in the refrigerator.

On 02/25/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint investigation. LPA introduced self, stated the purpose of the visit, and met with Administrator Carlene Reinke. The department conducted interview, toured the facility, received copies of records, and copies of R1 files. R1 resided and relocated with all R1's belongings. Residents at the facility are able to choose their own physician. A refrigerator is available for residents to store their food in the dining area. Based on interviews conducted and observation, the preponderance of evidence standard has not been met, therefore, the above allegations are found to be UNSUBTANTIATED. Exit interview conducted. A copy of this report was provided to Administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 25, 2026 · control 24-AS-20260224090611

Type of visit: Required - 1 Year

On 10/16/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA introduce self, stated the purpose of the visit, and met with Administrator (A1) Ashley Bell. All 20 residents were present during inspection. LPA toured facility with A1. The facility was observed to be at a comfortable temperature. The facility was observed clean, and no passageway obstructions or fire hazards were observed inside or outside. Outside of facility toured and observed to be free of debris. Adequate outside seating was observed available for residents. Last fire drill completed on 06/20/25. Fire extinguisher was observed throughout the facility with a service date of 05/05/25. An adequate supply of perishable and non-perishable food was observed. Walk in refrigerator temperature maintained at 32 degrees F. Freezer temperature maintained at -29 degrees F. Cleaning chemicals observed stored and locked under kitchen counter and in staff bathroom. PPE supplies such as gloves and masks were observed in medication room. Medications observed kept locked in medication cart in the medication room. Medications were checked and MARs were reviewed. Washer and dryer was located in detached garage. Paper supplies observed in detached garage. All bedrooms were observed to have required furnishings with adequate lighting and at comfortable temperature. Carbon monoxide and smoke detectors were tested and observed in each bedroom. Bathrooms observed with grabbed bars and non-skid mat. Bathrooms observed with adequate paper supplies. Toilet observed good repair and operational. Bathroom hot water temperature was tested at 117.6 degrees F in bathroom 1, 120 degrees F in bathroom 2, and 119.7 degrees F in bathroom 3. Continue to Lic 808C. A sample of resident and staff files were reviewed to have all the required documents. A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6. Exit interview was conducted. The following documents are requested and submitted to Fresno CCL by: 10/22/25. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, and current liability. A copy of this report and appeal rights was provided to Administrator.the state’s words, verbatim · CDSS document, Oct 16, 2025

Allegation investigated: Staff unlawfully evicted a resident

On 05/28/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint visit and deliver complaint findings. LPA introduced self, stated the purpose of the visit, and met with Administrator Ashley Bell. Regional Director Steven Cruz later during visit. Licensee Anthony Barbato was called via telephone. During the course of the investigation, the Department conducted interviews, records were reviewed and toured the facility. R1 was admitted to the facility on 05/19/25 and was observed at the facility. Based on interviews conducted and observation, the above allegation is UNFOUNDED, meaning they were false, could not have happened, and/or are without reasonable basis. We have therefore dismissed the complaint. Exit interview conducted. A copy of this report was provided to Administrator. Unfoundedthe state’s words, verbatim · CDSS document, May 28, 2025 · control 24-AS-20250522110556

Type of visit: Case Management - Other

On 05/28/25, Licensing Program Analyst (LPA) M. Yang arrived for unannounced visit discussed case management visit. LPA introduced self, stated the purpose of the visit, and met with Administrator Ashley Bell. Regional Director Steven Cruz later during visit. Licensee Anthony Barbato was called via telephone. The department conducted interviews and reviewed records. LPA discussed with Administrator, Licensee, and Regional Director on completing a completed and proper pre-appraisal and needs and services plan for residents. Re-appraisal and new needs and services is to be completed upon resident’s change of condition. Additional discussion included skilled nursing records and assessment cannot be substituted as facility’s pre-appraisal or as needs and services plan for any residents. An exit interview was conducted. A copy of this report was provided to Administrator whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, May 28, 2025

Type of visit: Case Management - Deficiencies

On 05/28/25, Licensing Program Analyst (LPA) M. Yang arrived for unannounced visit discussed case management visit. LPA introduced self, stated the purpose of the visit, and met with Administrator Ashley Bell. Regional Director Steven Cruz later during visit. Licensee Anthony Barbato was called via telephone. During visit, the department toured the facility and observed R1 lying in full rail bed. Based on records reviewed and interviews, R1 is not on hospice care and has no doctor's order on file for rail bed. A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D. Exit Interview conducted. A copy of this report and appeal rights was provided to Administrator, whose signature confirms received of this report.the state’s words, verbatim · CDSS document, May 28, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: May 30, 2025

87608(a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on interviews conducted, observation and records reviewed, R1 is not on hospice care was observed lying bed using a hospital bed with full rail with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Full bed rails are prohibited. Full rail will be removed by POC due date. If the resident needs a half rail, resident will be assessed and Licensee shall obtain doctor orders for R1 that specific the need for half bed rails and submitted to the Fresno CCL by POC due date 05/30/25.

Allegation investigated: Staff made inappropriate comments towards resident

On 05/14/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint investigation. LPA introduced self, stated the purpose of the visit, and met with Administrator Ashley Bell. LPA discussed the purpose of the visit and delivered complaint findings. During the course of the investigation, the Department conducted interviews, records were reviewed and toured the facility. A verbal altercation had occurred between S1 and R1. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Under California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report and appeal rights was provided to the Administrator whose signature confirms received of this report. Substantiatedthe state’s words, verbatim · CDSS document, May 14, 2025 · control 24-AS-20250509163615

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: May 15, 2025

87468.2 (a)(8) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on interviews conducted, S1 and R1 had a verbal altercation after R1 continuously squirt S1 with a water gun which poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, May 14, 2025

Plan of correction: S1 will be retrained in in-service training on Personal rights and copies of training will be submitted to Fresno CCL by POC due date 05/15/25.

Allegation investigated: Staff do not ensure residents’ incontinence needs are being met. Staff are not repositioning resident as needed. Licensee does not ensure that staff are receiving required training.

On 01/09/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to delivered complaint findings on the above allegations. LPA introduced self, stated the purpose of the visit and met with Administrator Ashley Bell. During the course of the investigation, records were received, interviews were conducted, and facility was toured. Interviews were conducted with residents that confirms resident do not need repositioning. It was confirmed by R1 and R2 that staff assists and check on residents more often than resident wants staff to. LPA observed R1 sleeping in bedroom. Records were reviewed and recorded facility staff have trainings up to date.Based on observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore, the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was provided to the Administrator, whose signature on this form confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 9, 2025 · control 24-AS-20241014084136

Type of visit: Case Management - Other

On 11/13/24, Licensing Program Analysts (LPA) M. Yang arrived unannounced for a case management - other inspection regarding immediate exclusion of Staff 1 (S1). LPA was greeted by staff Dolores Garcia and met with Facility Manager Stacey Smith. LPA introduce self, stated the purpose of the visit and requested to meet with Administrator. Administrator Ashley Bell and Licensee Anthony Barbato was called. Administrator authorized staff to sign report. LPA discuss S1 with Administrator and Licensee via telephone. LPA was informed by Licensee and Administrator that excluded Staff member has been disassociated from the facility and have not been employed for over a year. No deficiency was observed. Exit Interview was conducted. A copy of this report was provided via email to Administrator's report.the state’s words, verbatim · CDSS document, Nov 13, 2024

Type of visit: Required - 1 Year

On 10/17/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA introduce self, stated the purpose of the visit, and met with Designee Stacey Smith. Licensee (L1) arrived during inspection. All 13 residents were present during inspection. LPA toured facility with L1. The facility was observed to be at a comfortable temperature. The facility was observed clean, and no passageway obstructions or fire hazards were observed inside or outside. Outside of facility toured and observed to be free of debris. Adequate outside seatings were observed available for residents. A sample of resident and staff files were reviewed to have all the required documents. An adequate supply of perishable and non-perishable food was observed. Walk in refrigerator temperature maintained at 32 degrees F. Cleaning chemicals observed stored and locked under kitchen counter. Washer and dryer was located in detached building. LPA observed washer and dryer operational during inspection. Medications observed kept locked in medication cart in the medication room. Fire extinguisher was observed throughout the facility with a service date of 05/06/24. All bedrooms were observed to have required furnishings with adequate lighting and at comfortable temperature. Carbon monoxide and smoke detectors were tested and observed in each bedroom. Bathrooms observed with grabbed bars and non-skid mat. Toilet observed good repair and operational. Bathroom hot water temperature was tested at 112.6 degrees F in bathroom 1, 110.4 degrees F in bathroom 2, and 116.2 degrees F in bathroom 3. At approximately 1:35PM, LPA and L1 observed a shovel outside room 6 patio unlock. At approximately 1:48PM, LPA and L1 observed a tool set and automatic screwdriver stored in between the kitchen counter unlock. LPA and L1 observed a hole in the wall under kitchen sink. A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6. Exit interview was conducted. The following documents are requested and submitted to Fresno CCL by: 10/23/24. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current liability, and control of property. A copy of this report and appeal rights was provided to Licensee, .the state’s words, verbatim · CDSS document, Oct 17, 2024

Type of visit: Case Management - Licensee Initiated

On 09/24/24, Licensing Program Analyst (LPA) M. Yang arrived announced to conduct a pre-licensing inspection for the change of status/increase in capacity inspection. LPA was greeted by Licensee Anthony Barbato. LPA introduced self and stated the purpose of the visit. LPA toured the facility inside and outside with Licensee. LPA received the fire clearance which was granted by Kern County Fire Department. Fire clearance was granted for an additional 1 non-ambulatory resident to occupy the dwelling for a total of 22 capacity. Adequate nonperishable and perishable food were observed. Adequately outdoor seatings observed for the residents. The department has found room 8 which is 12 feet by 10.6 feet is ready for increase for 1 resident to be occupant at the facility for a total of 22 capacity. An exit interview was conducted. The department will send Licensee new license via mail. A copy of this report was provided to Licensee, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Sep 24, 2024

Allegation investigated: Staff forced resident to get a payee

On 08/15/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings onthe above allegation. LPA introduce self, stated the purpose of the visit, and met with Facility Manager Ashley Bell. Staff and LPA attempted to reach Licensee Anthony Barbato. Administrator Kala Gibson was called via telephone. LPA delivered findings to Administrator via telephone and Facility Manager. During the course of the investigation, LPA conducted interviews and records were reviewed. Interviews conducted the residents were not forced to get a payee. Residents were asked and provided information on having a payee. Based on the interviews conducted, the preponderance of evidence standard has not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. An exit interview was conducted with Administrator via telephone and Facility Manager. A copy of this report was provided to the Facility manager, whose signature on this report confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 15, 2024 · control 24-AS-20240502113950

Allegation investigated: Staff did not comply with basic service requirements

On 08/15/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegation. LPA introduce self, stated the purpose of the visit, and met with Facility Manager Ashley Bell. Staff and LPA attempted to reach Licensee Anthony Barbato. Administrator Kala Gibson was called via telephone. LPA delivered findings to Administrator via telephone and Facility Manager. During the course of the investigation, LPA conducted interviews. A food bank organization was contacted and provided information to the residents at the facility. No resident had signed up and received any food assistances form the program. Therefore, based on the interviews conducted, the preponderance of evidence standard has not been met, the above allegation is found to be UNSUBSTANTIATED. An exit interview was conducted via telephone with Administrator and Facility Manager. A copy of this report was provided to the Facility Manager, whose signature on this report confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 15, 2024 · control 24-AS-20240503104314

Allegation investigated: Staff member emotionally abuses residents in care.

On 07/17/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint inspection. LPA introduce self, stated the purpose of the visit, and met with Administrator Assistant (AA) Ashley Bell. Administrator Kala Gibson was called and stated unable to attend meeting. LPA delivered findings to AA. During the course of the investigation, the department conduct interviews with residents. Interviews conducted confirmed, S1 called R1 inappropriate name and S1 spoke to residents with attitude. Based on interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report and appeal rights was provided to the Administrator Assistant, whose signature confirms received of this report. Substantiatedthe state’s words, verbatim · CDSS document, Jul 17, 2024 · control 24-AS-20240710163035

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468(a)(1) · Plan of correction due date: Jul 18, 2024

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met: Based on interviews conducted, it was confirmed, S1 called R1 inappropriate names and did not speak to residents at the facility in an appropriate manner when approaching residents which poses an immediately health and safety and personal rights risk to the person in care.the state’s words, verbatim · CDSS document, Jul 17, 2024

Plan of correction: S1 shall have in-service training on personal rights. Training materials and proof of staff attendance shall be submitted to the department by POC due date 07/18/24.

Type of visit: Case Management - Health Checks

On 04/04/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct case management visit for the purpose of checking on the health and safety of the residents in care. LPA introduced self, stated the purpose of the visit, and met with Administrator Kala Gibson. During today's inspection, LPA conducted a tour of the facility. All passageways were clear from obstructions. Residents were observed in hallway, outside porch, and in bedrooms. No deficiencies cited during today's inspection. Exit interview conducted. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of these report.the state’s words, verbatim · CDSS document, Apr 4, 2024

Allegation investigated: Facility did not safeguard residents cash Facility did not provide assistance with residents medical care needs

On 03/08/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegations. LPA stated the purpose of the visit and met with Administrator Kala Gibson. During the course of the investigation, LPA toured the facility, reviewed records, and conducted interviews. R1 and Administrator confirms R1 does not have cash store at the facility. Based on iinterview which were conducted, staff provides first aid and assists upon request by resident. Therefore, the preponderance of evidence standard has not been met, the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was provided to the Administrator, whose signature on this report confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 8, 2024 · control 24-AS-20240208091113

Allegation investigated: Resident was inappropriately touched while in care. Staff did not provide adequate food service to a resident. Staff do not prevent the residents from being mistreated while in care.

On 02/12/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a subsequent complaint visit and deliver complaint findings on the above allegations. LPA introduced self, stated the purpose of the visit and met with Facility Manager Ashley Bell. Administrator Kala Gibson was called and unable to attend meeting. During the course of the investigation, interviews were conducted, records were reviewed, and facility was toured. Adequate perishable foods were observed in the facility walk in refrigerator and large freezer. Adequate nonperishable foods were observed in facility walk-in pantry. The facility menu consists of a variety of food choices. Allegations resident was inappropriately touched while in care and staff do not prevent the residents from being mistreated while in care, although these allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur. Therefore, based on the interviews conducted, observation, and records reviewed, the above allegations are found to be UNSUBSTANTIATED. Exit interview was conducted. A copy of this report was provided via email to Administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 12, 2024 · control 24-AS-20240111123635

Type of visit: Case Management - Incident

On 01/12/24, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct a case management visit based on record review of incident report submitted to the department. LPA introduced itself, announced the purpose of the visit and met with Administrator Kala Gibson and Regional Director Steven Cruz. The purpose of today's visit is to follow up on an incident that was reported to the Fresno CCL office on 01/09/24. It was reported that on 01/05/24 at approximately 05:30PM, Resident 1 (R1) was sent out to hospital due to drinking hand sanitizer. During today’s visit, LPA conducted interviews, toured the facility, and reviewed records. LPA obtained copies of R1’s record. The information provided will be reviewed; a follow up case management will be conducted if necessary. An exit interview was conducted. A copy of this report was provided to Administrator, whose signature confirm receipt of this report.the state’s words, verbatim · CDSS document, Jan 12, 2024

Type of visit: Prelicensing

On 11/27/23, Licensing Program Analyst (LPA) M. Yang conducted an announced Pre-licensing and Component III inspection. LPA introduced self, stated the purpose of the visit, and met with Licensee (L1) Anthony Barbato, Administrator (A1) Kala Gibson, and Facility Manager (F1) Rufino Beltran. The facility has 12 resident rooms. Fire clearance was granted for 14 Non-Ambulatory and 7 bedridden for total of 21 capacity. LPA toured the facility with L1, A1, and F1. Residents were observed in the dining area and in the bedroom. Facility temperature is set to 73 degrees F. Common areas were furnished and had adequate seating and lighting available. Fire extinguisher was observed throughout the facility with a service date of 04/13/23. Kitchen was toured and observed to have dishes, plates, and utensils. Refrigerator temperature maintained at 38 degrees F. LPA observed a 2-day supply of perishable foods and a 7 day supply of non-perishable foods. Medications observed locked and inaccessible to residents in the medication room. Cleaning supplies and chemicals were observed locked in a cabinet in the staff bathroom and in the staff room. LPA observed an extra supply of bed linens. All bedrooms were toured and observed to have required furnishings. Smoke detectors and carbon monoxide detectors were observed. All bathrooms were toured and observed with securely fastened grab bars and non-skid mat. Hot water measured at 108.1 degrees F in bathroom 1, 111.3 in bathroom 2, 114.4 degrees F in the bathroom 3, and 112.2 in bathroom 4. First aid kit was observed to contain all required items. Outside of facility toured and observed free of debris. Outdoor seatings were observed available for residents. Resident records were reviewed. LPA observed resident Admission Agreements, Physician Reports, and Pre-Appraisal. All staff records were reviewed and observed to have criminal record clearances. Component III was conducted during today's pre-licensing visit. I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.the state’s words, verbatim · CDSS document, Nov 27, 2023

Type of visit: Office

COMP II by CAB successfully completed Facility Type: RCFE Application Type: CHOW Capacity: 21 Census (if any clients in care): 20 Method: Telephone call with CAB COMP II Participants: Kala Gibson, Administrator; Anthony Barbato, Owner; Shannon Betker, analyst. Applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Nov 17, 2023