The Cottages at Artesia Anaheim

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to conduct a Case Management Deficiencies visit. LPA was greeted and granted entry by staff and met with Administrator (AD) Nora Rodgers and discussed the purpose of the visit. During the investigation of complaint control # 22-AS-20260106122151 LPA reviewed the file of Resident #1 (R1) and did not observe a needs and services plan for R1 in their file at the facility. Based on record review a deficiency is being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with LIC809D and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jul 14, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Aug 11, 2026

(a) ...Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition... This requirement was not met as evidence by: Based on record review the licensee did not comply due to LPA not reviewing an appraisal or needs and services plan for Resident #1 during complaint control # 22-AS-2026010612215. Which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 14, 2026

Plan of correction: Licensee stated they will send a list of residents and when their needs and services plan expires to ensure organization as well as update any plans that have already expired. Licensee will conduct an inservice with office staff and send to LPA by POC due date.

Allegation investigated: Resident developed pressure injuries while in care due to lack of care and supervision. Staff are not adequately assisting resident while in care. Staff did not ensure that resident had access to an emergency call button while in care.

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct an investigation into the above mentioned complaint allegations. LPA was greeted and granted entry by staff. LPA met with Administrator(AD) Nora Rodgers and discussed the purpose of the visit. It was alleged that resident #1 (R1) developed pressure injuries while in care due to lack of care and supervision, Staff are not adequately assisting resident while in care and staff did not ensure that resident had access to an emergency call button while in care. The investigation conducted by the Department revealed the following: LPA reviewed an admission agreement dated July 12, 2024, for R1 signed by facility staff and R1s Responsible Party. LPA observed a physicians report dated August 25, 2025, stating that R1 has a diagnosis of dementia, has motor impairment, requires full assistance with repositioning and has a history of skin breakdown. Continue on 9099C Unsubstantiated R1 also was marked as able to communicate and was marked as non-ambulatory. LPA reviewed daily charting notes for R1 from September 2025 to December 2025 that did not indicate if the resident was turned. Notes reviewed did not indicate staff repositioning R1 or attending to R1s pressure injuries. LPA observed text messages between facility staff and R1s POA regarding R1s pressure injury with updates starting on December 18, 2025, with the last picture update sent on December 23, 2025. Interviews with staff revealed that 3 of 4 staff were aware of the pressure injuries R1 had obtained. 2 of 4 staff informed LPA that they were treating the pressure injures and communicating with R1s family and providing updates. 1 of 4 staff informed LPA that they inform the medtech on duty when they find something on a resident and the medtech informs the family. 1 of 4 staff were not present at the facility when the pressure wounds were found on R1. 3 of 4 staff informed LPA that they do not recall a time when R1 did not have access to their pull chord. LPA interviewed 6 residents in care including R1. 3 of 6 residents interviewed did not confirm or deny the allegations. 2 of 6 residents informed LPA that staff help them whenever they call for assistance. 2 of 6 residents informed LPA that the staff answer the pull chord system whenever they have pulled it, even if it was on accident. 1 of 6 residents stated that staff did not always respond to the pull chord system or assist them in a timely manner. 1 of 6 residents informed LPA that the pull chord often fell where they could not reach it making it to where they could not call staff for assistance. LPA reviewed current staff training on topics such as Resident Care, Skin Care and Elder Abuse. 1 of 4 staff have an active administrators certificate expiring on January 12, 2027. LPA toured the facility and observed the pull chord system to be operational with all pull chords within reach of residents beds. Based on information gathered, interviews and tour of the physical plant, the Department is unable to ascertain if the above 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 violations occurred; therefore, the allegations are deemed UNSUBSTANTIATED and no citation was issued. An exit interview was conducted and a copy of this report was left at the facility. LPA observed emails between AD and R1s POA dated January 9, 2025. AD sent the required Community Care Licensing documentation to R1s POA, but did not have shower or rotation logs for R1 during the time requested. AD informed LPA that they provided R1s POA with all documentation requested that they had found on file and informed R1s POA that they did not have shower or rotation logs for R1 during the time frame that was being requested. Per Title 22 regulations, shower and rotation logs are not a required to be maintained unless it is stated in the residents care plan. LPA did not review such notations in R1s file. Upon interviews with R1s POA it was revealed to LPA that they were informed verbally of a pressure injury the day after the pressure injury was found after returning from a doctors appointment. Per Title 22 regulations, facilities have seven days from the occurrence to report to the person responsible for the resident in care. Based on the evidence gathered, the Department finds that the allegations are 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 left at the facility.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 22-AS-20260106122151

Type of visit: Required - 1 Year

On today's date Licensing Program Analyst (PA) William Vanegas made an unannounced inspection for the purposes of conducting an annual inspection. Upon arrival LPA was greeted and granted entry to the facility by care giving staff. Administrator was available to assist with the annual inspection. LPA explained the purposes of the visit and began to conduct a tour of the facility, and observed the following. Administrator (AD) Nora Rodgers has a valid administrator certificate valid from February 25, 2025 through January 12, 2027. The facility consists of one large two storied building that is equipped with nineteen resident bedrooms that are all shared. Resident bedrooms are equipped with jack and jill restrooms, and shared restrooms. The second floor of the building is occupied the facility owner and their family. Additionally the facility is equipped with a laundry room, staff office, dinning room, kitchen, medication room, storage rooms, and a shaded courtyard to participate in outdoor activities upon resident request. At the time of the inspection the facility presented to be clean and sanitary. No debris or mildew were noted in resident restrooms, kitchen area, or dining room area. Medications, hazards, and sharps were all locked away and inaccessible to residents in care. LPA observed resident bedrooms to be free of any hazards, mildew and debris. Bedrooms were observed to be large enough to walk about freely, and accommodate all required furnishings. Bedrooms were observed to be equipped with required furnishings including: A bed, clean linens in good repair; meaning no strains or tears, a reading lamp, a chair, a chest of drawers, and enough storage space to store personal belongings. CONTINUED ON LIC809-C LPA observed resident restrooms to be clean and sanitary. Water faucets and toilets tested operational, and restrooms had all required furnishings such as: A shower chair, slip resistant floor matts, and grab bars. Hot water temperature tested between 105.8 and 106.1 degrees Fahrenheit. LPA reviewed smoke detector and carbon monoxide detector test log. Test conducted on November 25, 2025 by Sphinx Alarm & Communications Systems. Test log indicates that test conducted on this date passed and smoke detectors and carbon monoxide detectors tested operational. LPA observed all fire extinguishers to be fully charged and have an updated service tag on them. LPA observed the facility to have a two day supply of perishable food and seven day supply of non-perishable food on hand; along with a sufficient amount of emergency water. LPA reviewed first aid kit and observed for it to have all required items such as: Adhesive tape, scissors, tweezers, bandages, thermometer, and a first aid manual. LPA conducted a tour of the exterior of the facility and observed the following: Exterior of the facility presented to be clean and free of any obstructions a long exit routes. Exterior is equipped with an outdoor shaded sitting area, and side doors were observed to be self latching and unlocked. LPA reviewed four staff files and four resident files. All files (Staff and Resident) Had all required documents. Staff training was up to date and documented correctly. LPA reviewed medications with AD. Per LPA review medications reviewed are being documented correctly and being administered per physicians orders. Based on observations made during today's inspection no deficiencies will be issued per title 22 chapter 6 division 8 of the California Code of Regulations. An exit interview was conducted with AD Nora Rodgers, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 30, 2026

Allegation investigated: Staff hit resident in care Staff spoke inappropriately to resident in care Staff did not follow reporting requirements

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct an investigation into the above mentioned complaint allegations. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Nora Rogers and discussed the purpose of the visit. The investigation into the facility allegation of staff hit resident in care and staff spoke inappropriately to resident in care revealed the following: It was alleged that Staff #1(S1) was speaking roughly to Resident #1 (R1) and pummeling R1s back and shoulders. LPA reviewed a Physicians Report for R1 dated August 21, 2025, stating that R1 had no cognitive conditions and is able to communicate their needs. This report was signed and dated by a medical professional on August 27, 2025. Witness #1 (W1) informed LPA via email that S1 may have meant absolutely no harm, but suspected that R1 was intimidated by S1 before W1 looked over at the pair and saw what appeared to be a disturbed look on R1s face. Continue on LIC9099C Unsubstantiated W1 provided their email account to AD that stated that something drew their attention to S1 and got the impression that S1 spoke to R1 roughly. W1 informed AD via email that they observed S1 pummeling R1s back and shoulders as though playfully, good natured, or mock aggression once S1 saw W1 look over. Witness #2 (W2) informed LPA that W1 informed them that they did not actually see an incident occur between S1 and R1, but saw S1 pummeling/massaging R1s back and found it disturbing. Witness #3 (W3) informed LPA that they had no concerns of R1s care and was at the facility every day to check on R1. W3 informed LPA that they do not believe the incident occurred as reported and had no complaints regarding R1s care. W3 informed LPA that they spoke to facility staff and confirmed that the AD informed them of the alleged incident verbally. LPA interviewed staff and 5 of 5 staff denied the allegations. LPA interviewed 6 residents in care and 2 of 6 residents informed LPA that they have never been harmed or yelled at by facility staff. 4 of 6 residents did not confirm or deny the above mentioned allegations. LPA was unable to view video footage at the facility due to it already being recorded over. LPA was unable to interview R1 due to no longer residing at the facility. LPA reviewed staff training for S1 and observed personal rights training was last conducted on August 18, 2025. The investigation into the facility allegation of staff did not follow reporting requirements revealed the following: It was alleged that staff did not cross report an alleged incident that occurred. The SOC341 was submitted to LPAs email inbox on January 30th 2026, stating that on January 23rd, 2026, they were informed of an incident where S1 was handling R1 in a rough manner. LPA interviewed AD and informed LPA that they sent an SOC341 to licensing and the Ombudsman and notified R1s family. AD was unable to verify when they sent the form to the ombudsman. LPA interviewed Witness #4 (W4) and informed LPA that they did not receive an SOC341 from the facility regarding the incident that occurred. Continue on LIC9099C Based on information gathered and interviews conducted, the Department is unable to ascertain if the above 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 allegations are deemed UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 16, 2026 · control 22-AS-20260204143815

Allegation investigated: Staff did not safeguard resident's personal belongings Staff was verbally abusive towards resident

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to investigate the above mentioned complaint allegations. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Nora Rodgers and discussed the purpose of the visit. The investigation into the allegations of Staff did not safeguard resident’s personal belongings and Staff was verbally abusive towards residents revealed the following: It was alleged that facility staff was given hearing aids and a watch for Resident #1(R1) by Witness#1 (W1) and upon moving out of the facility they did not receive them back. LPA observed R1 moved into the facility on November 25, 2025. LPA observed a physician’s report for R1 signed and dated by a physician on November 24, 2025, stating that R1 does not have auditory impairment and has a diagnosis of dementia. LPA observed a preplacement appraisal dated November 24, 2025, for R1 that was done by facility staff that states that R1 wears hearing aids. Continue on LIC9099C Unsubstantiated LPA observed a LIC621 for R1 that does not state they have hearing aids as their personal property at the facility that was signed and dated by facility staff on November 25, 2025. LPA observed a theft and loss policy stating that the Responsible Party of the resident shall fill out an LIC621 on the day of move in and all items will be discharged at the time of move out. The policy also states that if an item goes missing, the resident or responsible party can fill out a LIC9060 theft and loss record form. LPA did not observe an LIC9060 for R1. LPA observed a notice of transfer/discharge for R1 from Downey Post Acute stating that on November 25, 2025, R1 will be transferred to the facility. This form has an itemized list of R1s belongings and upon discharge R1 had 2 hearing aids that were noted on the form. This document was signed and dated by W1 and nursing staff on November 25, 2025. Upon interviews with two of three staff it was revealed that R1 arrived at the facility with the clothes they were wearing and their cell phone, and no hearing aids. One of three staff informed LPA that they arrived via non emergency ambulance without family or their responsible party. Two of three staff informed LPA that they did not recall R1 having hearing aids during their short time at the facility. One of three staff informed LPA that R1 did not have hearings aids or a watch and was not informed if staff had received such items. Upon interviews with W1 it was revealed that they handed staff R1s hearing aids, but could not recall the staffs name. W1 informed LPA that they did not fill out a valuables and property form for R1. W1 informed LPA that they are not sure about a watch. Regarding the allegation of Staff was verbally abusive towards resident revealed the following: It was alleged that staff would yell at R1 and call them derogatory names. Upon interviews with three of three staff it was revealed that they never have verbally abused R1 and had not observed other staff in the facility verbally abuse residents. Upon interviews with four of four residents it was revealed that two of four residents were unable to confirm or deny if they had heard staff verbally abuse residents. Two of four residents informed LPA that they have never been verbally abused and had not heard staff verbally abuse other residents in care. Based on interviews, the Department is unable to ascertain if the above 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 allegations are deemed UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 22-AS-20260107125840

Allegation investigated: Unqualified staff are assisting with adminstering medication

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to investigate the above mentioned complaint allegation. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Nora Rodgers and discussed the purpose of the visit. The investigation into the allegation of unqualified staff are assisting with administering medications revealed the following: It was alleged that staff #1(S1) and staff #2 (S2) are dispensing medications to residents without the proper training. LPA reviewed S1s file and observed a medication management training certificate from a DK Homecare Pharmacist that was conducted on August 8, 2025. LPA observed staff training for S2 dated March 16, 2022, stating that they have completed medication management training with ExcelCare Pharmacy. LPA did not observe update medication training for S2. LPA observed annual training for S1 expired on October 1, 2025 and annual training for S2 expired on January 4, 2026. Continue on LIC9099C Substantiated Four of five staff informed LPA that S1 has passed medications. Three of five staff informed LPA that S2 has passed medications including S2. Two of five staff informed LPA that they have never passed medications to residents at the facility. One of five staff informed LPA that S2 had expired training that has not been renewed. Based on interviews conducted, record review and information gathered during the investigation, 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 are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report, LIC9099-D, LIC811 and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 22-AS-20260114094647

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: Feb 20, 2026

1569.625(b)(2) Staff Training Training requirements shall also include an additional 20 hours annually... This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement was not met as evidence by: Upon interviews and records reviewed, it was revealed that S1 and S2 were passing medications to residents with expired trainings. This poses a potential health safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: Licensee stated they will train staff and send proof to LPA by POC due date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct a health and safety case management visit. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Nora Rodgers and discussed the purpose of the visit. LPA introduced herself to the facilities new AD and answered any questions they had as a new AD of the community. LPA printed requested documentation during the visit such as a blank physicians report and needs and services plan. LPA toured the facility and observed the medication room to be locked and made inaccessible to residents in care. LPA observed residents relaxing in their rooms and watching tv in the dining room. LPA toured the outdoor patio area and it was clean and free of debris and obstructions. Based on today's observations no deficiencies are being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 16, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Hanna Gough conducted an unannounced health and safety visit to the facility. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Aldo Apostol and discussed the purpose of the visit. The facility appears clean and sanitary. LPA was introduced to the new AD and discussed any questions that they had. LPA and AD toured the facility and observed a staff meeting taking place in the dining room. LPA observed residents napping in their rooms and on the outdoor patio visiting with family. Residents appeared to be clean and well taken care of. LPA observed resident medication with AD and a medtech on duty. Based on today’s observations no deficiencies are being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted an a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 7, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility for the purpose of conducting a case management health and safety check. LPA was greeted and granted entry by staff and met with Administrator (AD) Rose Martellotti and discussed the purpose of the visit. LPA toured the facility and observed residents in care relaxing in their bedrooms and watching tv in the dining room. Facility appeared clean, safe and sanitary. No health and safety concerns noted during the visit. AD requested LPA print a POC letter for complaint number 22-AS-20240426093629. Based on today’s observation no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AD Rose Martellotti and a copy of this report and POC letter clearance was given at the time of the visit.the state’s words, verbatim · CDSS document, Jul 21, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conducted an unannounced case management deficiency inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Rose Martelloti and explained the reason for the visit. The regional office received an unusual incident report on July 8th, 2025 regarding an incident that occurred on July 5, 2025. The report stated that Resident 1 (R1) eloped from the facility and was found by a neighboring resident to the facility. Facility staff picked R1 up from the neighboring resident’s home and brought R1 back to the facility. LPA toured the facility, gathered necessary documentation, and conducted interviews. LPA attempted to interview R1 but they could not recall leaving the facility. Upon interview with AD it was revealed that the resident was last seen in the dining room around 1:30pm and was received back at the facility around 4pm, making R1s whereabouts unknown for approximately two and a half hours. AD informed LPA that the facility staff was not aware of R1 leaving the facility until they received a phone call from the police. AD informed LPA that R1 did not have family consent at the time of the incident to leave the facility. AD received the resident back to the facility and conducted a body check for R1, no injuries were noted. AD notified hospice of the incident and had a meeting with R1s family on July 8, 2025. Upon file review LPA observed an in service training that was held on July 5, 2025 regarding an elopement training. LPA reviewed R1 physician’s report dated February 25, 2025, which states that the resident is able to leave the facility unassisted with family consent. Based on today’s inspection a deficiency along with a $500 immediate civil penalty is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Rose Martelloti and a copy of this report, LIC 809D, LIC421IM and appeal rights were given at the time of inspection.the state’s words, verbatim · CDSS document, Jul 8, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(e)(5) · Plan of correction due date: Jul 9, 2025

Care Of Persons With Dementia 87705(e)(5) Facility staff shall ensure the continued safety of residents if they wander away from the facility... This requirement is not met as evidence by: Licensee did not ensure supervision of resident with continued safety when wandering from the facility. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: Administrator provided LPA with an in service elopment training dated July 5, 2025 at the time of inspection. Administrator stated they will send LPA resident behavior monitoring log on August 1st for all residents in care.

Allegation investigated: Resident sustained injury while in care Facility did not seek medical attention in a timely manner

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility for the purpose of investigating the above mentioned allegations. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Rose Martellotti and discussed the purpose of the visit. The investigation into the allegations of resident sustained injury while in care and facility did not seek medical attention in a timely manner revealed the following: During the course of the investigation interviews with resident #1 (R1) responsible party revealed that in the morning of July 11, 2024, they notified staff that R1 had an injury and questioned staff of its origins. Staff informed responsible party that R1 did not have injuries the night before and that they will have someone come and look at R1’s reported injuries. It was revealed that 2 of 4 staff observed an injury on R1s arm. On the same day, the person responsible arrived at the facility on or about 3:30pm and observed that R1 had not been addressed and decided to take R1 to the hospital for evaluation. The interview with the previous facility Administrator stated that R1 was sent out to the hospital, but they did not have any injuries. Continue on LIC9099-C Substantiated During file review an incident report submitted to the Department stated that on July 11, 2025, staff noticed R1 had redness on their left arm around 8:00am. Medical records from the VA hospital with an admission date of July 11, 2024 revealed that R1 was admitted at 3:41pm due to left arm weakness, pain and left hand swelling. The medical records also stated that R1 had a rash to their inner arm and a possible fall. Based on observation, interviews, record review and information gathered during the investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 are being cited on the attached LIC 9099D. An exit interview was conducted with AD Rose Martellotti and a copy of this report, LIC9099-D and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jul 3, 2025 · control 22-AS-20240711133659

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 24, 2025

Basic Services 87464(f)(1) Care and supervision This requirement was not met as evidence by: Based on interviews and record review the licensee did not ensure R1 had care and supervision resulting in a hospital visit due to pain, weakness and redness on their arm even though 2 of 4 staff stated they observed the injured arm.the state’s words, verbatim · CDSS document, Jul 3, 2025

Plan of correction: Administrator stated they will do an in-service training with staff about providing care and supervision and reporting when residents are denying care or being combative to staff. Administrator will send proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jul 24, 2025

Incidental medical and dental care 87465(a)(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidence by: Based on interviews and record review the licensee did not assist in appropriate medical arrangements for R1 even though staff observed the injured arm at 8:00am resulting in R1 being taken to the hospital by their responsible party with an admission time of 3:41pm.the state’s words, verbatim · CDSS document, Jul 3, 2025

Plan of correction: Administrator stated they will do an in-service with staff on arranging and assisting procedures for residents and send proof to LPA by POC due date.

Allegation investigated: Staff neglect led to resident sustaining pressure injury Staff did not meet resident's medical needs Reporting Requirements

Licensing Program Analyst (LPA) Hanna Gough and Licensing Program Manager (LPM) Alisa Ortiz made an unannounced inspection for the purpose of investigating the above mention complaint allegations. LPA and LPM met with Administrator (AD) Rose Martellotti and discussed the purpose of the inspection. The investigation into the allegations staff neglect led to resident sustaining pressure injury, staff did not meet resident's medical needs and reporting requirements revealed the following: During the course of the inspection the Department interviewed AD Olais at the facility, Four staff members, and the responsible party (RP) of Resident 1(R1). During interviews it was revealed that AD Olais was aware of a blister on R1's foot and that an unknown caregiver had put a patch on it. LPA interviewed four staff members. Of the staff members interviewed two of four staff reported having knowledge of R1's wound but assumed someone else was managing it. The remaining two staff members denied having knoweldge of R1's wound with one of those staff members reporting they did not notice the wound due to R1 not taking their socks off. Continue on 9099-C Substantiated R1's Responsible Party informed the department that they did not know of the wound until it was discovered by R1's doctor during a visit on April 23, 2024. R1's responsible party was not informed by the facility of R1's wound prior, despite two of four staff members being aware of the wound. During file review it was revealed that the resident’s physician report dated August 17, 2023 stated that the resident does not have the capacity to bathe, dress or groom themselves and is bedridden. The LIC 603A Appraisal dated August 04, 2020 completed by facility staff documents that R1 requires assistance with dressing. An after visit medical summary dated April 23, 2024, was reviewed that stated the resident had a stage 2 pressure ulcer of the right foot. Following the doctor’s visit a home health agency came to the facility to provide wound care to the resident. Based on observation, interviews, and information gathered during the investigation and review of all documents obtained. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 are being cited on the attached LIC 9099D. An exit interview was conducted with Administrator Rose Martellotti and a copy of this report, LIC 9099-D, LIC811 and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jun 3, 2025 · control 22-AS-20240426093629

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 24, 2025

Basic Services 87464(f)(1) Basic services shall at a minimum include: Care and supervision This requirement is not met as evidence by: The licensee did not ensure staff were changing R1's socks resulting in R1 developing a stage 2 ulcer that was not observed or treated timely. Based on interview and R1 physicians report, R1 required assistance with dressing. This poses a potential risk to resident's health and safety in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: Licensee stated they will do daily skin integrity checks on all residents and document it and send proof of documentation for two weeks to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Jun 24, 2025

Personal Rights of Residents in All Facilities 87468.1(a)(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. The requirement is not met as evidence by: Based on interview and record review the licensee did not comply with the section cited above due to the responsible party not being informed of the resident's medical needs. This poses a potential risk to resident's health and safety in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: Upon record review the licensee conducted an in service training on May 2, 2024 covering reporting with facility staff. Corrected during time of visit.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by staff. LPA informed Administrator (AD) Rose Martellotti the purpose of the inspection. The facility currently has thirty-two residents in care. The facility is a one story building with nineteen resident bedrooms, bathrooms, dining room, kitchen, medication room, staff office, laundry room, storage rooms, and a courtyard. The facility appears clean, safe and sanitary. LPA observed the required departmental postings at the entrance of the facility. LPA observed the resident bedrooms to have all the required components and furnishings. LPA observed resident bathrooms to have toilet paper, paper towels, and non-slip mats. LPA tested the water in the resident bathrooms to be between 105.2 degrees Fahrenheit and 110.6 degrees Fahrenheit. LPA observed the kitchen to be free of debris and vermin. LPA observed the kitchen to be locked and made inaccessible to residents in care. LPA observed the two day perishable and seven day non-perishable food supply on hand. LPA observed the refrigerator temperature to be tested at forty-eight degrees Fahrenheit. LPA observed the centrally stored medication locked in the medication room in a locked medication cart and made inaccessible to residents in care. LPA observed the fire extinguishers throughout the facility to be charged and with a service date of November 6, 2024. LPA observed the emergency food and water supply to be in a supply closet next to the medication room. LPA observed a shaded seating area for resident use in the outside courtyard. LPA observed all exits that lead outside of the facility to have an operational alarm. LPA observed toxins and chemicals to be stored in a supply closet in the courtyard and made inaccessible to residents in care. Continue on 809-C LPA reviewed staff files and no discrepancies were observed. LPA reviewed resident files and no discrepancies were observed. LPA reviewed resident medication and no discrepancies were observed. LPA observed that the last fire drill conducted was on April 22, 2025. LPA reviewed that the carbon monoxide and smoke detectors are tested yearly and were found operational when tested on November 7, 2024. Based on today’s inspection one citation is being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Rose Martellotti and a copy of this report and 809-D and appeal rights were given at the time of the inspection.the state’s words, verbatim · CDSS document, May 16, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conducted an unannounced case management deficiency inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Rose Martellotti and explained the reason for the inspection. The regional office received an unusual incident report on February 27th, 2025 regarding an incident that occurred on February 25, 2025. The report stated that Staff #1 (S1) administered the wrong medication to Resident #1 (R1) on this date. S1 informed Staff #2 (S2) of the incident right away and S2 called R1s doctor and responsible party. S1 monitored R1 to ensure that no side effects took place every 3 hours for 12 hours. A medication training was taken place with S1 in attendance. LPA toured the facility, gathered necessary documentation, and conducted interviews with S1, S2 and R1. During interviews S1 and S2 stated that S1 administered the wrong medication and that R1 was monitored per doctors order. R1 stated that they were okay and did not feel any side effects from the medication given. Upon file review LPA observed the daily log that showed R1 being monitored with their vitals being taken every 3 hours for 12 hours. S2 held a three hour in service training and LPA observed that S1 attended the training via the training log sign in sheet on February 26, 2025. Based on today’s inspection a type A deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Rose Martellotti and a copy of this report, LIC 809D and appeal rights were given at the time of inspection.the state’s words, verbatim · CDSS document, Mar 25, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Mar 26, 2025

87465(c) Incidental Medical and Dental Care (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by: Based on interview and file review administrator did not ensure that S1 gave R1 the correct medication. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 25, 2025

Plan of correction: During the inspection administrator provided LPA with proof of medication trainings that S1 attended.

Allegation investigated: Staff inappropriately touched resident. Staff threw food at resident.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Administrator (AD) Aurelia Olais and explained the reason for today’s inspection. The investigation into the allegations that staff inappropriately touched resident and staff threw food at resident revealed the following: During the course of the investigation, Department staff inspected the facility, interviewed AD, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, the Facility’s Video Footage regarding Resident #1 (R1), the Facility’s Investigation Summary dated November 8, 2023, the Facility’s Staff Statement dated October 28, 2023, R1’s Physician’s Report dated November 25, 2022, and Staff #1’s (S1) Staff File. CONTINUED Unsubstantiated Regarding the allegation that staff inappropriately touched resident: it was alleged that on October 27, 2023, R1 was observed crying loudly and reported that S1 inappropriately touched their chest. One staff interviewed stated that on October 27, 2023, R1 told them that the staff who cleans the rooms “grabbed them” but did not provide a name or description of the staff, but the staff also reported that when R1 does not get what they want they engage in behavioral outbursts. Department staff reviewed the Facility’s Video Footage regarding R1 showing the outside of R1’s room, but obtained no information corroborating the allegation. When interviewed, AD stated that they conducted an investigation into the allegation and found no information corroborating that S1 acted inappropriately with residents. Per the Facility’s Investigation Summary dated November 8, 2023, AD interviewed R1, S1, and four other staff and did not obtain information corroborating the allegation. Per the Facility’s Staff Statement dated October 28, 2023, four staff stated that R1 has a history of behavioral outbursts while S1 “is not capable of hitting anyone.” Department staff interviewed R1 who showed some confusion, did not present with any signs of injury or abuse, denied any inappropriate incidents, stated they feel safe living at the facility and have no concerns at the facility, and denied knowing who S1 was. Per R1’s Physician’s Report dated November 25, 2022, R1 has dementia and is noted to have confusion. Per AD, R1 has a history of making false statements and also engages in self-harming behavior and blames the resulting injuries on staff. LPA reviewed the Facility’s Video Footage regarding R1 which shows R1 hitting themselves on the chin with an object and, per AD, R1 accused staff of causing a bruise on their chin after engaging in this behavior. LPA interviewed S1 who denied the allegation. LPA reviewed S1’s Staff File, interviewed five additional residents, and interviewed three additional staff and did not obtain information corroborating the allegation. The information obtained did not corroborate the allegation. Regarding the allegation that staff threw food at resident: it was alleged that on October 27, 2023, S1 was observed throwing cookies at R1. Department staff reviewed the Facility’s Video Footage regarding R1 showing the outside of R1’s room, but obtained no information corroborating the allegation. When interviewed, AD stated that they conducted an investigation into the allegation and found no information corroborating that S1 acted inappropriately with residents. Per the Facility’s Investigation Summary dated November 8, 2023, AD interviewed R1, S1, and four other staff and did not obtain information corroborating the allegation. Per the Facility’s Staff Statement dated October 28, 2023, four staff stated that R1 has a history of behavioral outbursts while S1 “is not capable of hitting anyone.” Department staff interviewed R1 who showed some confusion, did not present with any signs of injury or abuse, denied any inappropriate incidents, stated they feel safe living at the facility and have no concerns at the facility, and denied knowing who S1 was. Per R1’s Physician’s Report dated November 25, 2022, R1 has dementia and is noted to have confusion. LPA interviewed S1 who denied the allegation. LPA reviewed S1’s Staff File, interviewed five additional residents, and interviewed three additional staff and did not obtain information corroborating the allegation. The information obtained did not corroborate the allegation. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegations that staff inappropriately touched resident and staff threw food at resident occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 26, 2024 · control 22-AS-20231113104340

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with Complaint #22-AS-20240711133659. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the complaint investigation, LPA toured the facility and reviewed medications as well as reviewed file for Resident 1 (R1). Audit of three of R1's medications showed that medications on hand do not match start date of medication bottles and Medication Administration Record is missing multiple staff initials for May, June and July 2024. Information obtained during complaint investigation indicated R1 had a half bed rail during the time of complaint incident. Facility does not have an order for half bed rails in resident file. Based on the visit conducted, deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jul 16, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 17, 2024

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not being met as evidenced by: Based on record review, Licensee failed to ensure care was being provided to R1. Medication audit revealed medications are not being administered per physician order. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: Licensee to provide medication retraining to staff and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(3) · Plan of correction due date: Jul 30, 2024

Based on the individual's preadmission appraisal.. Postural supports may be used under the following condition: A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This req is not being met as evidenced by: Based on record review, Licensee failed to ensure there is a written physician order for half rails for R1. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: Licensee to provide a statement of understanding of the regulation and forward proof to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Dwayne Mason Jr. made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Business Office Manager (BOM) Pam Bracamonte. LPA met with BOM and Administrator (AD) Aurelia Olais. The facility is a one-story building with nineteen resident bedrooms with access to shared bathrooms, dining room, kitchen, medication room, staff office, laundry room and courtyard. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. The courtyard has shaded seating areas. Water temperature measured between 105 and 120 F degrees in resident bathrooms. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted throughout the facility. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke alarm and sprinkler system was serviced in November of 2023. LPA initially observed the signal system console to be unplugged. A deficiency is being issued. LPA instructed staff to plug it back in. While inspecting the kitchen, LPA observed a tray of desserts in the refrigerator uncovered. A deficiency is being issued. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication was observed to be locked. LPA reviewed four resident medications, four resident files and four staff files. LPA conducted resident and staff interviews. Based on the observations made during today’s inspection, two 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 was provided.the state’s words, verbatim · CDSS document, Jun 18, 2024

Type of visit: POC

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the plan of corrections for one type B deficiency cited during the investigation of complaint #22-AS-20240213154220.. LPA was greeted and granted entry by facility staff after explaining the reason of the visit. Administrator Aurelia Olais was present and assisted with the visit. On February 27, 2024, LPA issued a type B citation for failure to meet the requirements of the California Code of Regulations Section CCR 87303(i)(1)(A) regarding Maintenance and Operations on the operation and accessibility of the facility's call system. During today's visit, LPA verified that the pull cords for the call system were within reach of the residents and that the missing pull cords had been replaced. A proof of an in-service training conducted on February 28, 2024 was provided to LPA by facility administrator via email. During the visit, at least three residents were observed to be provided with an inaccessible pull cord, including one resident for whom the pull cord was positioned at the foot of the bed with no ability to adequately alert facility staff. As a result, a civil penalty is assessed for failure to correct the earlier violation of the California Code of Regulations for the seven-day period from March 28, 2024 until April 3, 2024. An exit interview was provided and a copy of this report along with appeal rights and civil penalty assessmenr were provided to a facility representative.the state’s words, verbatim · CDSS document, Apr 3, 2024

Allegation investigated: Staff do not ensure resident call buttons is accessible to the resident while in bed

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegations listed above and delivering findings to the licensee. LPA was greeted and granted entry by facility staff. Administrator Aurelia Olais arrived later to assist with the visit. An initial complaint investigation visit tool place on February 22, 2024. LPA requested and obtained the current facility census, facility roster and staff schedule for the months of January and February 2024. Three staff interviews and three resident interviews were conducted. Resident records were requested for three residents, provided and reviewed during the visit. LPA accompanied with administrator toured the physical plant and tested the operation of the call system. During the present follow-up, LPA accompanied by staff toured the facility and conducted an additional resident interview. The current census was also requested and obtained. CONTINUED ON FORM LIC9099-C Substantiated CONTINUED FROM FORM LIC9099-A Regarding the allegation that Licensee does not ensure facility is adequately staffed to meet residents’ needs, the following has been concluded: Based on interviews and records reviewed, there is a constant of one med tech and three caregivers present during the AM shift, one med tech and two caregivers during the PM shift and two caregivers during the overnight shift which appears to meet the staffing requirements present in Title 22 of the California Code of Regulations. Interviews with residents were inconclusive as to whether failures to meet the need of care and supervision for individual residents occurred as a result of insufficient staffing. Regarding the allegation that Staff do not assist resident with transfers in a timely manner, the following has been concluded: Based on records reviewed and interviews conducted, measures such as a task schedule focused on the needs of a specific resident to be transferred in and out of bed were stated to have been implemented during the month of February 2024. Additionally, LPA accompanied by administrator tested the response from staff to an activation of the call system which appeared satisfactory. However, interviews provided accounts of multiple instances during which staff is alleged to have refused to assist or delayed assistance in transferring a resident. As a result, both 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 that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM LIC9099 Regarding the allegation that Staff do not ensure resident call buttons is accessible to the resident while in bed, the following has been concluded: During two separate visits to the facility, LPA observed that pull cords activating the call system to alert staff were missing in at least three distinct units occupied by six residents. In a total of four other units observed, the bedside pull cords were observed to be positioned out of reach from residents, either at the foot of the bed, or behind the bed's head beyond the full rails observed in use as postural support. As a result, the call system is found to be either inaccessible or non-operational for at least 8 of the 33 residents currently admitted. The allegation is therefore found to be Substantiated, meaning that the preponderance of evidence standard has been met. A corresponding violation is being cited per California Code of Regulations Title 22, Division 6 on the attached form LIC9099-D. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.the state’s words, verbatim · CDSS document, Feb 27, 2024 · control 22-AS-20240213154220

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(A) · Plan of correction due date: Mar 27, 2024

Per CCR 87303(i)(1)(A) regarding Maintenance and Operations: "Facilities shall have signal systems which shall meet the following criteria: (A) Operate from each resident's living unit." This requirement is not met as evidenced by: Based on interviews and observation conducted, the signal system was found to be either inaccessible or non-operational due to the absence of a pull cord in multiple units, constituting a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Feb 27, 2024

Plan of correction: Licensee will ensure all pull cords are present and operational. Additionally, an in-service training will be provided to all staff in order to ensure the pull cords are positioned to be accessible to the residents in care.

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of documenting a deficiency observed during an initial complaint investigation visit for complaint reference #22-AS-20240213154220. During a tour of the facility's physical plant, LPA observed the presence of two pairs of scissors in the drawer used to store a resident's colostomy supplies. Facility staff proceeded to remove the scissors during the visit and indicated a lock would be installed on the drawer in question. Type A citation issued and cleared during the visit. Based on the visit conducted, one deficiency is being cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Feb 22, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: Feb 23, 2024

Per CCR Section 87705(f)(1) on the Care of Persons with Dementia: "The following shall be stored inaccessible to residents with dementia: (1) Knives, (...), tools and other items that could constitute a danger to the resident(s)". This requirement is not met as evidenced by: Based on observations made during the visit, two pairs of scissors are observed to be freely accessible in an unlocked drawer. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Facility staff removed the scissors during the visit. Licensee indicates that they will install a lock on the drawer if scissors are to remain stored at that location.

Type of visit: Case Management - Other

On today's date, Licensing Program Analyst (LPA)LPA Quiroz conducted a Case Management-Other inspection visit while conducting ten day inspection visit regarding complaint control #22-AS-20231113104340. LPA Quiroz met with Administrator (AD) Aurelia Olais and Office Manager (OM) Pamela Bracamonte and discussed purpose of today's Case Management-Other visit. During today’s visit, LPA Quiroz along with (OM) Bracamonte conducted a facility tour inspection of facility premises. On or about 10:47am, while inspecting dining-room area, LPA Quiroz observed Resident 1 (R1) attempting to fill his water bottle from water system placed in dining-room area. LPA Quiroz observed water system to not be functional and operational as evidenced by (R1) not able to fill their water bottle and requesting water from kitchen staff. (OM) Bracamonte indicated "We had to turn it off because it was leaking." (AD) Olais indicated "I didn't know it was leaking but I will order one today." LPA Quiroz provided consultation on the following California Code of Regulations: Maintenance and Operation: 87303(a) (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (AD) Olais provided receipt invoice of water system purchase during today's visit. An Advisory Note Technical Violation (LIC 9102 TV) was conducted during today's visit addressing CCR 87303(a). An exit interview was conducted with (AD) Aurelia Olais. A copy of this report along with Confidential Names- LIC 811 and LIC 9102 TV were provided at exit.the state’s words, verbatim · CDSS document, Nov 15, 2023