The Gate of Beautiful II

Allegation investigated: Licensee did not comply with reporting requirements

On 06/22/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to deliver complaint findings for the allegation above. LPA Pascua was greeted by Staff Member (SM),Melvina Waters and explained the purpose of the visit. LPA Pascua met with Facility Designated Representative (FDR), Stephanie Cason. Current census was 4. A brief interview with FDA Ell was conducted. It was alleged that the Licensee did not comply with reporting requirements. Based on interviews conducted, it was learned that the facility was notified of potential verbal abuse from a staff member and conducted an internal investigation in which was found to have validity to the claims. It was further reported that the facility did not submit a Special Incident Report along with notification to the outside agencies. LPA Pascua reviewed facility records which confirmed that the facility did not notify the department upon notification of alleged verbal abuse from staff to resident. Based on the information gathered, the licensee did not comply with reporting requirements. Substantiated As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.the state’s words, verbatim · CDSS document, Jun 22, 2026 · control 27-AS-20260613172233

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jun 23, 2026

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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 specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This not met as evidenced by: Based on interview and record review, the licensee did not report suspected verbal abuse regarding a resident within 7 days of occurence. This poses an immediate health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jun 22, 2026

Plan of correction: Licensee shall provide a statement of correction by POC date.

Type of visit: Required - 1 Year

On 04/30/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA Pascua was greeted by Staff Member (SM), Janet Murphy and Jessica Galvan and explained the purpose of the visit. LPA Pascua was able to speak with Facility Designated Administrator (FDA), Nicole Ell and explained the purpose of the visit. LPA Pascua was informed that FDA Ell was on her way to the facility. Shortly after, LPA Pascua met with FDA Ell and explained the purpose of the visit. Current census was 4. Upon arrival at the facility LPA Pascua witnessed 3 residents board on a bus to go to Central Valley PACE. 1 resident was at the facility at the time of LPA Pascua's visit. This facility is licensed to served 6 residents, all of whom may be non-ambulatory. This facility also has a dementia plan on file and has a current hospice waiver for 6. This facility is also vendorized by Valley Mountain Regional Center to serve and retain Level 6 elderly residents at this time. LPA Pascua reviewed 4 resident files and 4 staff files. The facility administrator has a current certificate #700583740 and expires 08/16/2026. All resident and staff files were complete and up to date. A tour of the facility was conducted. The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annual inspected by Assured Fire Company and is valid until 03/13/2027. The kitchen area was toured. LPA observed a sufficient supply of 7 day non-perishable and 2-day perishable food supply in the pantry and refrigerator. LPA observed a locked centralized stored medication cabinet located in the laundry room. Along with the FDR, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components. Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time A tour of the bathroom was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time. A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time. Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time. A tour of the garage was conducted. Additional perishable food supplies were identified. The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair. LPA Pascua also provided Technical Assistance to this facility towards the end of this visit. The following forms and documents were obtained during the course of this visit. -LIC 308 -LIC 400 -LIC 500 -LIC 610 Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies are being cited today. Exit interview held with Administrator and a copy of report given at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 30, 2026

Allegation investigated: Licensee does not ensure that the required food supply is maintained at facility

On 10/31/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met was met by Facility House Manager, Stephanie Cason and explained the purpose of the visit. The purpose of this visit was to inform the facility and its representative that a complaint has been filed against it at this time. Current census was 4. 2 out of 4 residents were out on outings, and 2 out of 4 residents were at their respective day program at this time. A brief telephone interview with Facility Designated Administrator (FDA), Nicole Ell was conducted. It was alleged that this facility does not ensure that the required food supply is maintained at the facility. it was observed that the facility food supply was sufficient to meet the 2-day perishable and 7-day non perishable food supply requirements at this time. A review of the food items was conducted for the interior food storage units, as well as, the exterior food storage units. There were no expired food items observed for the perishable foods nor the non perishable food supply. It was observed that meals were prepared, and offered, for breakfast, lunch and dinner throughout the day. Unsubstantiated LPA also observed a facility menu at the facility and compared it to food supply available. This was sufficient to meet residents needs. Due to the above noted information, 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, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 31, 2025 · control 27-AS-20251023103942

Allegation investigated: Staff do not provide activities for residents in care. Staff do not allow residents to access P&I funds in a timely manner.

On 10/31/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met was met by Facility House Manager, Stephanie Cason and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current census was 4. 2 out of 4 residents were out on outings, and 2 out of 4 residents were at their respective day program at this time. A brief telephone interview with Facility Designated Administrator (FDA), Nicole Ell was conducted. Allegation: Staff do not provide activities for residents in care. It was alleged that staff do not provide activities for residents in care. During the course of this investigation, the department conducted interviews and reviewed facility records. Based on interviews conducted, it was denied that facility staff do not provide activities for the residents in care. It was learned that each resident able to go on activities on a weekly basis. In addition, an interview with 4 residents were conducted. 4 out 4 deny that they are unable to have activities. Futhermore, the facility hires a third party service to conduct additional activities for residents in care. Unsubstantiated Allegation: Staff do not allow residents to access P&I funds in a timely manner. During the course of this investigation, the department conducted interviews and reviewed facility records. Based on interviews conducted, it was denied that facility staff that do not allow residents access to P&I funds in timely manner. LPA Pascua reviewed P&I cash and receipts with no issues and indication with issues noted. Interviews revealed that the administrator and house manager provide access to the facility key and provide director to the staff on where the P&I key can be accessed. Based on observations, interview and document review the preponderance of evidence standards have not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violathe state’s words, verbatim · CDSS document, Oct 31, 2025 · control 27-AS-20250917111443

Type of visit: Required - 1 Year

On 06/03/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with House Manager (HM), Ricki Cantu and explained the purpose of the visit. The purpose of this visit was conduct an annual visit. Shortly after, LPA met with Facility Designated Administrator (FDA), Nicole Ell. There was one other staff member present, Jessica Galvan. This facility is licensed to served 6 residents, all of whom may be non-ambulatory. This facility also has a dementia plan on file and has a current hospice waiver for 6. This facility is also vendorized by Valley Mountain Regional Center to serve and retain Level 4I elderly residents at this time. Current census was 4. Upon arrival, LPA Pascua observed 3 residents leave to their perspective day program. There was 1 resident present during the course of this visit. LPA reviewed 4 residents files and 3 staff files. All files were complete and up to date. The Facility Designated Administrator has a current and up to date administrator certificate #7005838740 and expires on 08/16/2026. A tour of the facility was conducted. The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annual inspected by Jorgenson Fire Co and is valid until 03/18/2025. The kitchen area was toured. LPA observed a sufficient supply of 7 day non-perishable and 2-day perishable food supply in the pantry and refrigerator. LPA observed a locked centralized stored medication cabinet located in the laundry room. Along with the FDR, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components. Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time A tour of the bathroom was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time. A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time. Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time. A tour of the garage was conducted. Additional perishable food supplies were identified. The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair. The following forms and documents were obtained during the course of this visit. -LIC 308 -LIC 400 -LIC 500 -LIC 610 Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies are being cited today. Exit interview held with Administrator and a copy of report given at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jun 3, 2025

Allegation investigated: Staff do not ensure residents are administered prescribed medications. Staff are not properly trained to care and supervise residents. Staff do not ensure facility has adequate food supply. Staff do not ensure facility is cleaned.

On 03/19/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Nicole Ell. and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current census was 3. A brief interview with FDA Ell was conducted. Allegation: Staff do not ensure residents medications are administered prescribed medications. It was alleged that staff do not ensure residents medications are administered as prescribed. During the course of this investigation, interviews were conducted and a review of facility records were conducted. Based on interviews conducted 3 out 3 staff members deny that medications are not being provided as prescribed. It was stated by most residents obtain medication through a bubble pack system and are changed according to the doctor’s orders. An interview with 2 residents were attempted however, due to medication conditions, 2 out 2 residents did not know what medications were taken throughout the day. A review of the Medication Administrator Record and compared to current mendication. There was nothing to indicate that staff was not providing medication as prescribed. Based on the information gathered, it is unclear if the staff did not ensure residents are administered prescribed medications. Unsubstantiated A review of the Medication Administrator Record and compared to current medication. There was nothing to indicate that staff was not providing medication as prescribed. Based on the information gathered, it is unclear if the staff did not ensure residents are administered prescribed medications. Allegation: Staff are not properly trained to care and supervise residents. It was alleged that staff are not properly trained to care and supervise residents. During the course of this investigation, interviews were conducted and a review of facility records were conducted. Based on interviews conducted, 3 out 3 staff members state that they went through a series of training during orientation as well as shadowing another caregiver prior to being on their own. In addition, 3 out 3 staff members state that they are provided additional training throughout the year. A review of the facilities training records were conducted which confirmed that staff were provided orientation training required through Title 22 regulations as well as annual training. Based on the information gathered, it is unclear if staff are not properly trained to care and supervise residents. Allegation: Staff do not ensure facility has adequate food supply It was alleged that staff do not ensure facility has adequate food supply. During the course of this investigation, interviews were conducted and a review of facility records were conducted. Based on interviews conducted, 3 out 3 staff members deny that they do not have food supply. 3 out 3 staff members state that food is bought on a weekly basis or as needed. 2 out 2 residents state that they enjoy the food that they eat and have options when picking what to eat for the day. In addition, a review of the facilities credit card statements show that the facility conducted shopping trips every 1-2 weeks in the amounts between $360-$500. Based on the information gathered, it is unclear if the staff do not ensure facility has adequate food supply. Allegation: Staff do not ensure facility is clean. It was alleged that staff do not ensure facility is clean. During the course of this investigation, interviews were conducted and a tour of the facility was conducted. Based on interviews conducted, 3 out 3 staff members deny that the facility is not cleaned. 3 out 3 staff members state that cleaning is primarily done at night time however, cleaning should be done on a continuous basis. 2 out 2 residents state that they have no issues with the facility being dirty and witness staff cleaning throughout the day. A tour of the facility was conducted on 12/20/2024 and there were no observations made that indicate that the facility was not kept clean Based on the information gathered, it is unclear if the staff do not ensure that the facility is clean. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 27-AS-20241213101754

Allegation investigated: Staff did not communicate with residents’ authorized representative about medication changes.

On 03/19/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Nicole Ell and explained the purpose of the visit. The purpose of the visit was to inform the facility and its representative that a complaint has been filed against it at this time. Current census was 3. 3 out 3 residents were out of the facility. A brief interview with FDA Ell was conducted. It was alleged that staff did not communicate with residents' authorized representative about medication changes. Based on interviews conducted, it was learned that R1 had a change in anxiety medication on 1/07/2025, however was still prescribed a seperate medication for anxiety. This medication change was reviewed by the doctor as well as the resident's authorized representative. On 01/08/2025, the facility called the doctors office to clarify the resident's medication. However, it was denied that there was were no medication changes where the resident's representative was not notified through the doctors office. Unsubstantiated An addition, an interview conducted disclosed that there were no reports that the facility called for an increase with medication. However, it was reported that the doctors office does not approve any medications with notification to the responsible party. A review of the facility records do not indicate any record that the facility attempted to increase the resident's medication without the responsible parties knowledge. Based on the information gathered, it is unclear if the facility did not notify the responsible party of any medication changes. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 27-AS-20250311153725

Type of visit: Case Management - Deficiencies

On 12/19/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA was greeted by Facility Staff, Sherri Morenobinda and explained the purpose of this visit. Shortly after, LPA Pascua met with Administrator, Nicole Ell and explained the purpose of the visit. The purpose of this visit was in response to a complaint visit conducted on 12/19/2024. During the course of this visit it was learned that S1 did not have a criminal background clearance and was currently in progress in obtaining one. It was stated by S1 that they have worked at the facility since 11/01/2024. LPA reviewed the facility documents that show that the facility submitted S1's live scan on 12/12/2024. In addition, this LPA reviewed the Guardian facility roster and confirmed that S1's criminal record clearance was currently in progress as of 12/12/2024. An immediate civil penalty of $500 was for violation of 87355(e) for criminal record clearance. Based on the observations made during today's visit, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. An exit interview was conducted, and a copy of the report was given end the of this visit.the state’s words, verbatim · CDSS document, Dec 19, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e) · Plan of correction due date: Dec 20, 2024

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Based on record review and observation, the licensee did not comply with the section cited above by not ensuring that S1 had a current criminal background clearance. This poses an immediate health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Dec 19, 2024

Plan of correction: Licensee escorted facility staff out of the facility at the time of this visit.

Type of visit: Required - 1 Year

On 05/16/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with Facility Designated Representative (FDR), Sarena Arias and explained the purpose of the visit. This facility is licensed to served 6 residents, all of whom may be non-ambulatory. This facility also has a dementia plan on file and has a current hospice waiver for 6. Current census was 4. 3 out 4 residents were out at of the facility at this time. A brief interview with FDR Arias was conducted. LPA reviewed 4 resident files.LPA reviewed 3 staff files. 3 out of 3 staff files were complete and up to date. Facility Designated Administrator currently holds an active and current administrator certificate #6019506740 and expires on 08/16/2024. A tour of the facility was conducted. The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annual inspected by Jorgenson Fire Co and is valid until 09/19/2024. The kitchen area was toured. LPA observed a sufficient supply of 7 day non-perishable and 2-day perishable food supply in the pantry and refrigerator. LPA observed a locked centralized stored medication cabinet located in the laundry room. Along with the FDR, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components. Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time A tour of the bathroom was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time. A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time. Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time. A tour of the garage was conducted. Additional perishable food supplies were identified. The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair. The following forms and documents were requested to be updated and submitted into CCL -LIC 308 -LIC 400 -LIC 500 -LIC 610 -Liability Insurance -Surety Bond A technical violation is being provided today for 87458(a). LPA discussed that physicians report must be conducted on a yearly basis. Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies are being cited today. Exit interview held with Administrator and a copy of report given at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 16, 2024