The Lakes

Allegation investigated: Lack of staff supervision resulted in resident sustaining injury. Staff did not seek medical attention for the resident in a timely manner. Staff did not ensure that hazards were inaccessible to resident. Facility call light are in disrepair.

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to deliver findings on the above allegations. LPA met with Executive Director Cristina Ceballos, and discussed the purpose of the visit. Regarding Allegation #1, LPA conducted interviews with five (5) residents. Two (2) residents state there’s enough staff and supervision. Two (2) residents have stated they don’t know if there’s enough staff and supervision while one (1) stated there is not enough staff and supervision. Four (4) of the five (5) residents stated they have not seen any injuries while one (1) resident could not answer LPAs question. LPA conducted interviews with three (3) staff, all whom state they are supervising residents; however Two (2) have stated incidents may happen the second their backs are turned rather than lack of supervision Unsubstantiated Regarding allegation #2, LPA conducted interviews with five (5) residents, three (3) residents have stated medical attention is given timely, one (1) did not know and the other could not answer the question. LPA conducted interviews with three (3) staff all whom state medical attention is absolutely given to residents in a timely manner. LPA also conducted an interview with Executive Director stating that Resident 1 (R1) had just fallen out of their bed, 10 mins later R1 had fallen again. Medication Technicians were assessing R1 before calling 911, while R1 was being assessed Ombudsman walked in. Ombudsman then interrupted staff from attending to R1 and accused them of not assisting R1. 911 was called and Ombudsman continued to intervene while EMT attended to R1. Regarding allegation #3, Interviews with five (5) residents, three (3) residents have stated staff ensure hazards are inaccessible. Two (2) residents could not answer the question LPA also conducted interviews with four(4) staff. All whom state they ensure hazards are inaccessible, one (1) stated that the residents have placed furniture in front of doors; staff constantly place them back where they belong. Another stating the maintenance director does daily walk through's ensuring there are no hazards or passageways being disrupted. Regarding allegation #4, LPA conducted interviews with five (5) residents, one (1) resident states their call button works, three (3) residents have stated they don’t know if their call button works because they have not used it. one (1) resident could not answer the question. LPA tested a call light button in room #201 taking staff two (2) minutes to respond. LPA conducted interviews with three (3) staff, all whom state the call buttons are working properly, with one stating the maintenance director does daily walk throughs ensuring all outlets are in good repair. Based on LPA’s observations, staff and resident interviews, and relevant documentation, the allegations are determined to be Unsubstantiated. An Unsubstantiated finding means that although the allegation may be valid or could have occurred, there is insufficient evidence to support that the alleged violation did or did not happen. An exit interview was conducted with Executive Director Cristina Ceballos, and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 21, 2026 · control 56-AS-20251215090102

Allegation investigated: Facility's generator is not in good repair

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegation. LPA met with Executive Director Cristina Ceballos, and discussed the purpose of the visit. Regarding allegation #1, Facility's generator is not in good repair. During the interview with the Executive Director (ED) and Maintenance Director (MD), both stated that they had an electricity power outage in the area in which the Southern California Edison (SCE) did not give prior notification for the outage on 07/15/26, therefore the reason for the outage was unknown. Both ED and MD informed LPA that the facility immediately handed out emergency flashlights, all managers were on the floor, additional water was purchased, and sandwiches were made for all residents. Although staff were well trained and immediately followed their emergency disaster plan, the facilities generator in both Assisted Living and Memory Care were in disrepair. Substantiated ED and MD contacted the generator company immediately and were scheduled for a troubleshoot appointment. On 7/21/26 the generator company Generac Industrial Power conducted their visit, tests were ran and recommendations were explained on what was needed to maintain the generators working conditions. Based on LPA's observations and interviews, and record review, 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 where this report LIC9099, LIC9099C, LIC9099D, and Appeal Rights were discussed and provided to Executive Director Cristina Ceballos at the conclusion of the visitthe state’s words, verbatim · CDSS document, Jul 21, 2026 · control 56-AS-20260715164427

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 28, 2026

87303 Maintenance and Operation (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. This is not met as evidence by: Based on observation, file review and interview the licensee/executive director did not comply with the section cited above by not ensuring that the facility had an operating generator in the event of emergencies which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 21, 2026

Plan of correction: Executive Director(ED) provided invoices of the generator's company visit, ED will provide proof of the fuel filters that were recommended from the generator company to LPA by POC due date.

Allegation investigated: Staff are financially exploiting residents.

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to deliver findings on a complaint investigation regarding the above allegations. LPA met with Executive Director Cristina Ceballos and discussed the purpose of the visit. Interviews with the Executive Director (ED) reveal the residents coordinate a holiday donation box that is placed in the lobby throughout the year to collect donations, at the end of the year all the money that was collected is distributed to all non salary staff in a form of a gift card. The ED is not aware of anything more, nor have they seen a memo on how the residents request donations. ED also informed LPA that the Residents Counsil have a bank account where all the donations are placed when given. The staff who do not pick up their holiday gift cards at the given deadline, the money is returned back to the resident council bank account. Unsubstantiated LPA also interviewed an additional three (3) staff members whom state staff do not financially abuse residents, two (2) of these staff stated they are aware the residents collect money to distribute to staff, however the committee does the planning on their own. LPA conducted four (4) resident interviews, all four have stated they have not seen, heard, or been victims of financial abuse. Three (3) of these residents have confirmed there is a donation box yearly with one stating “it’s a nice way to recognize and appreciate the staff for all their hard work.” Based on observation, interviews, and pertinent documents the allegation is unsubstantiated. An Unsubstantiated complaint means, that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Executive Director Cristina Ceballos and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 56-AS-20251210164932

Allegation investigated: Staff are not properly supervising residents

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegation. LPA met with Executive Director Cristina Ceballos, and discussed the purpose of the visit. It is alleged staff are not supervising residents. Interviews conducted reveal Resident (R1) has been experiencing agitated behavior. R1 was pushing Resident #2 (R2) in their wheelchair when R1 suddenly became agitated and tipped R2 out of their wheelchair. LPA attempted to interview R2 regarding the incident, however R2 could not remember what happened. R2 with two (2) other residents state there’s enough staff and supervision. LPA also conducted three (3) additional resident interviews, two (2) have stated they don’t know if there’s enough staff and supervision while one (1) stated there is not enough staff and supervision. Unsubstantiated LPA conducted interviews with three (3) staff, all whom state they are supervising residents; however Two (2) have stated incidents may happen the second their backs are turned rather than lack of supervision. Based on observation, interviews, and pertinent documents the allegation is unsubstantiated. An Unsubstantiated complaint means, that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Executive Director Cristina Ceballos and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 56-AS-20260623103626

Allegation investigated: Facility does not have adequate staff to meet the needs of the residents in care.

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to deliver findings on a complaint investigation regarding the above allegations. LPA met with Executive Director Cristina Ceballos and discussed the purpose of the visit. It is alleged that the facility does not have adequate staffing to meet the needs of the residents in care. The LPA conducted interviews with eight (8) staff members. Six (6) of the eight (8) staff reported that, although staffing levels are generally sufficient, additional staff would be beneficial and that shortages do occur when staff call out. The Executive Director informed LPA that additional staff have been hired to address call-offs; however, securing timely coverage can still be challenging. Unsubstantiated The LPA also interviewed eight (8) residents. Four (4) of the eight (8) residents stated that the facility has enough staff, with one noting that staffing is sometimes insufficient. The remaining four (4) residents reported that there are not enough staff to meet resident needs. Based on LPAs observations, record review, and interviews, the above allegation is Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and a copy was provided to Executive Director Cristina Ceballos at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 10, 2026 · control 56-AS-20260205151517

Allegation investigated: Staff did not prevent a resident from sustaining multiple falls while in care. Staff did not report an incident to resident's responsible party.

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to deliver findings on a complaint investigation regarding the above allegations. LPA met with Executive Director Cristina Ceballos and discussed the purpose of the visit. Regarding Allegation #1, it was alleged that staff did not prevent a resident (R1) from sustaining multiple falls while in care. Interviews conducted with eight (8) staff members confirm that staff consistently take measures to prevent resident falls. Four (4) of the eight (8) staff reported that R1 has a tendency to fall frequently; however, they also noted that R1 often does not use their call pendant when needing assistance. One (1) staff member stated they have reminded R1 multiple times to request assistance, but R1 continues to attempt ambulation independently, which has resulted in falls. LPA advised Executive Director that R1 should be reassessed due to the frequency of their falls. Unsubstantiated R1 has a personal caregiver Monday through Friday. Interviews with the caregiver indicate that R1 does not fall under their supervision. The personal caregiver has offered weekend services to R1, but R1 has declined the additional support. LPA conducted interviews with eight (8) residents. R1 informed LPA that staff do take steps to prevent falls. R1 acknowledged experiencing recent falls and stated they become frustrated wanting to stand up on their own. Five (5) of the eight (8) residents reported that staff prevent falls, while three (3) residents stated they either did not know or could not answer whether staff prevent residents from falling. Regarding Allegation #2, it was alleged that staff did not report an incident to the resident’s responsible party. LPA conducted interviews with eight (8) staff members. Based on the interviews, medication technicians are responsible for notifying responsible parties when residents experience falls. LPA reviewed documentation completed by the medication technician, which indicates that R1’s fall was reported to the responsible party as well as all other required parties. Seven (7) of the eight (8) staff reported that responsible parties are notified, with one (1) of those seven stating they have never heard of a situation where a responsible party was not informed. One (1) of the eight (8) staff stated they were unsure whether responsible parties are consistently notified; they indicated they are told that families are notified but do not know if the notification actually occurs. LPA conducted interviews with eight (8) residents. R1 reported that their responsible party is notified when they experience falls, noting that their family typically calls to follow up and verify the incident. However, R1 stated they are unsure whether their family is notified after every fall, as the family does not always initiate a follow-up call. Among the remaining residents, four (4) of the eight (8) stated either that their responsible parties are notified, that they have been informed responsible parties are notified, or that they assume notification occurs. The other four (4) residents reported they did not know or could not answer whether their responsible parties are notified. Based on LPAs observations, record review, and interviews, the above allegations are Unsubstantiated; meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and a copy was provided to Executive Director Cristina Ceballos at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 10, 2026 · control 56-AS-20260211131614

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sarina Ramirez arrived at the facility unannounced to conduct a Case Management Visit for a health and safety. This case management visit is in response to a Special Incident Report (SIR) submitted to the Community Care Licensing Office on 04/02/26. LPA met with Executive Director (ED) Cristina Ceballos and stated purpose of the visit. During today's visit, LPA discussed the incident. The facilities fire panel alarm was activated, indicating there was a fire in the first floor stairwell. ED informed LPA the fire resulted in a malfunctioning light ballast, Facilities maintenance personnel successfully extinguished the fire in 90 seconds. A new fire extinguisher was purchased and replaced prior to the fire department arriving. Upon the fire departments arrival, the facility was inspected, tested, and cleared. No documentation was provided from Engineer's squad 66 and Engine 20 stating it would take a couple weeks. LPA toured the facility, the new light ballast has been replaced, and the facility is in the process of replacing new carpet that was affected by the fire. No deficiencies were observed during this visit. An exit interview was conducted where this report was, reviewed, discussed and then provided to Executive Director Cristina Ceballos.the state’s words, verbatim · CDSS document, Apr 10, 2026

Allegation investigated: Staff did not safeguard resident's personal belongings.

Licensing Program Analysts (LPAs) Sarina Ramirez and Eldin Serrano conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegation. LPAs met with Executive Director Cristina Ceballos, and discussed the purpose of the visit. It has been alleged that staff did not adequately safeguard R1’s personal belongings, specifically a substantial amount of money. Upon review of R1’s personnel file, there is no documentation of this money on the Resident Personal Property and Valuables Form (LIC 621). During an interview with the Executive Director, it was noted that R1 has been observed carrying a small box in and out of the facility on multiple occasions. Staff reported they were unaware that R1 possessed any items of significant value beyond those listed on the LIC 621. LPAs were unable to interview R1 due to no longer living at the facility. Unsubstantiated LPAs interviewed seven (7) staff, all whom stated they have not seen nor taken items from resident’s rooms. Four (4) of the seven (7) staff informed LPAs they do not open cabinets in residents rooms, they only clean counter tops and never touch personal belongings. LPAs interviewed five (5) residents, all whom stated they have not had anything gone missing in their rooms. Based on LPA’s staff and resident interviews, and relevant documentation, the allegation is determined to be Unsubstantiated. An Unsubstantiated finding means that although the allegation may be valid or could have occurred, there is insufficient evidence to support that the alleged violation did or did not happen. An exit interview was conducted with Executive Director Cristina Ceballos, and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 22, 2026 · control 56-AS-20260113133659

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Sarina Ramirez and Eldin Serrano made an unannounced visit to the facility to conduct a required annual inspection. LPAs met Executive Director Cristina Ceballos, and discussed the purpose of the visit. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (276), and a current census of (132). LPAs conducted a general inspection of facility, which included, but was not limited to, the following: Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has a swimming pool that is enclosed and locked inaccessible to residents in care. The facility has sufficient space for resident activities. Seven (7) resident bedrooms were inspected, two (2) in the memory care unit and five (5) in the assisted living unit. Five (5) resident’s bathrooms were inspected, hot water temperatures measured from 105 to 105.7 degrees F. The facility is equipped with operating smoke/carbon monoxide alarms, a total of four (4) resident bedroom alarms were tested. The facility was inspected by Desert Alarm Inc on 1/28/25, the inspection for 2026 is scheduled for the upcoming week. Facility has operating laundry equipment, and telephone service. The facility has posted in a common area, personal rights, facility sketch, the Community Care Licensing complaint poster, Ombudsman poster, menu, activities, and license. Cleaning supplies and sharps were kept inaccessible to residents in care. Food Service: Kitchen and dining areas were maintained cleaned. Non-perishable and perishable food supply is sufficient for number of residents in care. Facility refrigerators and freezers were maintained in operating condition. Continuation on LIC809-C Health Related services: LPAs reviewed (7) resident medications ,no issues found. Resident’s medications are labeled and centrally stored in a locked medication room in both memory care and assisted living units. Record Review: Eight (8) resident files reviewed were observed to be complete. Nine (9) staff files reviewed were observed to be complete. The facility has an emergency and disaster plan on file; last disaster drill was completed on 1/20/26. Based on LPAs observations and records review no deficiencies are being cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report (LIC809), (LIC809C) were discussed to Executive Director Cristina Ceballos. Copies of the reports were provided to the Executive Director at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 22, 2026

Allegation investigated: Staff do not treat resident with respect Staff do not answer residents calls for assistance timely

Licensing Program Analysts (LPAs) Sarina Ramirez and Eldin Serrano conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegations. LPAs met with Executive Director Cristina Ceballos, and discussed the purpose of the visit. Regarding allegation #1, LPAs conducted interviews with five(5) staff, 4 of the 5 staff informed LPA they treat residents with respect, Executive Director has not heared complaints from residents that staff are treating residents disrespectfully. LPAs conducted eleven (11) resident interviews, 8 residents informed LPAs staff treat them with respect and do not make rude comments towards them, 3 residents informed LPAs staff have made rude comments towards them. Unsubstantiated Regarding allegation #2, LPAs conducted interviews with five (5) staff, 4 out of 5 staff informed LPA their goal to respond to call pendants is 10 minutes or less. Executive Director informed LPAs they are in the process of upgrading the communication tracker. LPAs conducted interviews with eleven (11) residents, 3 residents informed LPA they have never used their call pendants; 1 resident does not have a call pendant, 1 resident could not answer LPAs questions, 6 residents informed LPA sometimes staff take a while to respond to their call pendants averaging 20 minutes to an hour, however all residents stated it does not happened often or staff attend in a timely manner. Based on LPA’s observations, staff and resident interviews, and relevant documentation, the allegations are determined to be Unsubstantiated. An Unsubstantiated finding means that although the allegations may be valid or could have occurred, there is insufficient evidence to support that the alleged violations did or did not happen. An exit interview was conducted with Executive Director Cristina Ceballos, and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 56-AS-20251202100018

Allegation investigated: Staff do not provide adequate food service Staff speaks inappropriately to residents

Licensing Program Analysts (LPAs) Sarina Ramirez and Eldin Serrano conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegations. LPAs met with Executive Director Cristina Ceballos, and discussed the purpose of the visit. Regarding allegation #1, it is alleged the facility does not have enough snacks for residents in care. LPAs observed the facilities memory care to have enough snacks stored in their dining room kitchen. LPAs interviewed six (6) staff, all whom agreed facility has enough snacks for residents. Based on interviews if memory care is running low on food or snacks, staff can restock from the Assisted Living kitchen. LPAs interviewed six (6) residents, all whom agreed the facility provides enough snacks, and are never denied a snack upon request. Unsubstantiated Regarding allegation #2, it is alleged staff speak inappropriately to residents. LPAs interviewed six (6) staff, all whom agreed they do not speak to residents inappropriately nor have then witnessed or heard other staff speak to residents inappropriately. LPAs interviewed six (6) residents, all whom stated they are treated and spoken very nicely by staff. Based on LPA’s observations, staff and resident interviews, and relevant documentation, the allegations are determined to be Unsubstantiated. An Unsubstantiated finding means that although the allegation may be valid or could have occurred, there is insufficient evidence to support that the alleged violation did or did not happen. An exit interview was conducted with Executive Director Cristina Ceballos, and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Nov 25, 2025 · control 56-AS-20251124102135

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 3, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. Licensee/Executive Director did not ensure staff are administering medication as prescribed by physician's orders and did not complete medication log book accurately, which poses a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Nov 25, 2025

Plan of correction: Executive Director has agreed to train staff and submit proof of staff traininng on medication by Plan of Correction due date.

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Sarina Ramirez and Eldin Serrano conducted an unannounced visit to the facility to conduct a Health and Safety check. LPAs met with Executive Director Cristina Ceballos, and discussed the purpose of the visit. While LPA Serrano audited residents medication, staff explained to LPA they were not aware they need to report a special incident report when residents refuse medication. Based on observation, record review, and interviews deficiencies were cited per Title 22, Division 6 of The California Code of Regulations. An exit interview was conducted where the Licensing reports were discussed and copies of the reports with Appeal Rights was provided to Executive Director Cristina Ceballos.the state’s words, verbatim · CDSS document, Nov 25, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Dec 3, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(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... This report shall include the resident's name, age, sex and date of admission; date and nature of event... Licensee/Executive Director did not ensure staff are submitting special incident reports to CCLD when residents refused medication which poses a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Nov 25, 2025

Plan of correction: Executive Director has agreed to train staff, review regulation, and provide proof of training/understanding of regulation to LPA by POC due date

Allegation investigated: Staff does not ensure pathways are free of obstruction. Staff does not ensure facility is free of mold.

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegations. LPA met with Executive Director Cristina Ceballos, and discussed the purpose of the visit. Regarding allegation #1: It is alleged that a charging vehicle obstructs the outside passageway. During Licensing Program Analyst’s (LPA’s) visit, no such vehicle was observed. The designated charging area used on Mondays, Wednesdays, and Fridays is located in the driveway and does not interfere with pedestrian access. LPA conducted a thorough tour of both the interior and exterior of the facility and observed no obstructions in any passageways. LPA interviewed three (3) staff members, all of whom confirmed that they routinely ensure all pathways remain clear. Two staff members noted that inside the facility while residents occasionally leave trash outside their doors, staff will promptly remove it and confirmed that such items do not obstruct resident passageways. Unsubstantiated LPA interviewed seven (7) residents, five (5) of the 7 residents stated that the passageways are free of obstruction. Two (2) of the 7 residents stated every once in a while, a car is parked in the charging area which they say obstructs the outside pathway. Regarding allegation #2, LPA interviewed seven (7) residents regarding the allegation. Six residents stated that staff consistently maintain the facility to ensure it remains free of mold. One resident (R1) reported that mold was present inside their toilet tank. During the facility tour, LPA inspected R1’s toilet by removing the tank lid and did not observe any mold. According to R1, the issue was reported to staff, and the toilet tank was subsequently cleaned. Staff member S4 confirmed that the tank was assessed when R1 raised the concern. Upon inspection, S4 identified the substance as slimy buildup rather than mold, which was cleaned the following day by designated staff. LPA also interviewed three (3) staff members, all of whom affirmed that the facility is free of mold and stated they have neither observed nor received reports of mold within the premises. Based on LPA’s observations, staff and resident interviews, and relevant documentation, the allegations are determined to be Unsubstantiated. An Unsubstantiated finding means that although the allegations may be valid or could have occurred, there is insufficient evidence to support that the alleged violation did or did not happen. An exit interview was conducted with Executive Director Cristina Ceballos, and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Nov 13, 2025 · control 56-AS-20251108205259

Allegation investigated: Staff do not timely respond to the residents alerts Staff do not provide adequate food service

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to conduct a complaint investigation and deliver findings on the above allegations. LPA met with Executive Director Cristina Ceballos, and discussed the purpose of the visit. Regarding allegation #1, LPA conducted interviews with four (4) staff, 3 out of 4 staff informed LPA they respond to call pendants within 3-10 minutes minimum, however if they are assisting other residents their response time can vary between 10-20 minutes max. LPA conducted interviews with six (6) residents, all 6 residents informed LPA they hardly use their call pendants; but the times they have staff attend in a timely manner. 4 out of 6 residents stated they have waited 5-20 minutes for staff to respond. Unsubstantiated While interviewing a resident, LPA had the resident test their call pendant. LPA observed two (2) staff respond to the call in 6 minutes and 36 seconds. Regarding allegation #2, LPA conducted interviews with four (4) staff, all four have informed LPA the residents have not complained about the food however, it’s got better. LPA conducted interviews with six (6) residents, 4 out of 6 residents informed LPA the food is good and they do not have complaints, 1 of the 6 residents stated the food is so-so, 1 of the 6 residents informed LPA they are a picky eater; however with the alternatives the food is good. Based on observation, interviews, and pertinent documents the allegations are unsubstantiated. An Unsubstantiated complaint means, that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Executive Director Cristina Ceballos and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 20, 2025 · control 56-AS-20250817234904

Allegation investigated: Staff did not keep facility free of insects

Licensing Program Analyst (LPA) Magda Malcore and Licensing Program Manager (LPM) Karen Clemons conducted an unannounced complaint visit to the facility. LPA and LPM met with Executive Director, Cristina Ceballos, and discussed the purpose of the visit. The investigation consisted of observations and interviews with pertinent parties. Regarding the allegation, staff did not keep facility free of insects, LPA & LPM did not observe flies around dining areas and food. Interviews with four (4) staff and six (6) residents reveals there are no concerns with flies in the dining areas. Based on the Department's investigation, the allegation above is Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Unsubstantiated An exit interview was conducted where this report was discussed and a copy provided to Executive Director Ceballos at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 56-AS-20250819121905

Allegation investigated: Staff did not ensure the facility was free of pests Staff did not ensure the facility bus was not in disrepair

On 8/06/2025 at 10:10 AM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to iniate the investigation and deliver the findings of the above allegations. LPA Serrano met with Executive Director Cristina Ceballos to explain the purpose of the visit. The investigation consisted of file review, interviews with facility staff and residents as well as facility observation. Allegation #1: Staff did not ensure the facility was free of pests – Based on record review, observation/inspection of the facility, The facility has a contract with a pests company and provided invoice to show the services rendered. The facility provided the Department of Health recent inspection and gave the facility an A rating. Based on interviews, they all stated that they have not observed any rodents or any pests activity in the facility. LPA was unable to corroborate the allegation. *** Continuation in LIC9099C *** Unsubstantiated Allegation #2: Staff did not ensure the facility bus was not in disrepair - Based on interviews, record reviews and LPA observation and information received during the investigation, LPA was unable to corroborate the allegation. The vehicle needs the operator/charter permit from Public Utilities Commission and California Highway Patrol clearance to operate the vehicle. LPA observed the bus is in good repair and the facility provided the filed paperwork needed to operate the bus/van. Based on interviews, they all stated that the bus is in good repair. During the investigation, LPA did not find evidence to corroborate the allegations. Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where this report, LIC9099 and LIC9099C were discussed and provided to Executive Director Cristina Ceballos.the state’s words, verbatim · CDSS document, Aug 6, 2025 · control 56-AS-20250729090914

Allegation investigated: Staff did not provide adequate supervision resulting in residents engaging in a physical altercation and resident sustaining an injury.

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegation. LPA met with Executive Director Cristina Ceballos, and discussed the purpose of the visit. Based on interviews with staff and residents, it was determined that Resident 1(R1) sustained an injury due to a fall caused by their sandals. At the time of the incident, Staff 1 (S1) was in the dining room with Resident 2(R2) when R1 entered, shouting, which led to both R1 and R2 becoming agitated. S1 promptly redirected R1 out of the dining room. While walking backward, R1's sandal caught on the floor, causing them to fall and hit their head. S1 immediately responded, providing assistance to R1 and calling 911. Based on observation, interviews, and pertinent documents the allegation is unsubstantiated. An Unsubstantiated complaint means, that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Executive Director Cristina Ceballos and a copy of this report was provided at the conclusion of the visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 20, 2025 · control 56-AS-20250516152555

Allegation investigated: Resident sustained unexplained bruising.

Licensing Program Analysts (LPAs) Sarina Ramirez and Eldin Serrano conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegation. LPA met with Executive Director Cristina Ceballos, and discussed the purpose of the visit. Interviews conducted with staff, residents, and outside parties revealed that around 4/18/25, Resident 1 (R1) sustained unexplained bruising. After an internal investigation, and interviews with staff; staff suspect Resident 2 (R2) attempted to remove R1’s doll and may have caused the unexplained bruising. Due to both residents being in memory care there is not enough evidence to prove how R1 sustained the unexplained bruising. Based on observation, interviews, and pertinent documents the allegation is unsubstantiated. An Unsubstantiated complaint means, that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Executive Director Cristina Ceballos and a copy of this report was provided at the conclusion of the visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 24, 2025 · control 56-AS-20250421152622

Allegation investigated: Staff do not provide adequate food service Staff are not meeting the residents needs while in care Staff do not properly maintain the facility's laundry equipment

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegations. LPA met with Executive Director Cristina Ceballos, and discussed the purpose of the visit. Regarding Allegation #1 LPA conducted interviews with four (4) staff members, all of whom confirmed that the facility provides adequate food service. 2 out of the 4 staff stated they have personally sampled the food and found it to be both edible and nutritious. Additionally, interviews with eight (8) residents revealed that, while some expressed personal preferences regarding the food, such as concerns about it being too salty, all residents agreed the food is nutritious. Regarding Allegation #2 LPA interviewed four (4) staff members, all of whom confirmed that the residents' care needs are being met. Interviews with eight (8) residents indicated that two (2) of them consider themselves independent, while six (6) residents affirmed that their care needs are being met. Unsubstantiated Regarding Allegation #3: Based on observations and interviews conducted by the LPA, staff are properly maintaining the facility's laundry equipment. Based on observation, record review, interviews with facility staff and residents the allegations are unsubstantiated. An Unsubstantiated complaint means, that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Executive Director Cristina Ceballos and a copy of this report was provided to Executive Director at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 16, 2025 · control 56-AS-20250414145149

Allegation investigated: Resident pushed by unknown person.

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegation. LPA met with Business Office Manager Araceli Peters, and discussed the purpose of the visit. Interviews conducted with staff, resident, and outside parties revealed that on 3/12/25, Resident 1 (R1) wandered into another resident’s room attempting to use the restroom. Resident 2 (R2) noticed R1 in their room and became agitated, resulting in pushing R1 to leave from their restroom/room. Staff intervened and R1 was taken to the doctor/hospital and returned to the facility the same day with a head hematoma. R1 was unavailable to be interviewed, due to sleeping. Staff informed LPA, R1 does not like to be woken up too early. Based on observation, interviews with facility staff and resident the allegation is unsubstantiated. An Unsubstantiated complaint means, that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Unsubstantiated An exit interview was conducted with Business Office Manager Araceli Peters and a copy of this report was provided to Business Office Manager at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 56-AS-20250312144905

Allegation investigated: Staff stole multiple residents personal property

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegation. LPA met with Executive Director Cristina Ceballos, and discussed the purpose of the visit. It is alleged that over the past years, multiple residents have reported theft and loss of personal property. An investigation was conducted by Department staff, which included interviews with residents and relevant facility staff to gather information. The interviews revealed that several items were stolen from residents at different times. According to the Administrator, an internal investigation was conducted involving both residents and staff that uncovered several residents personal items were missing. Although no specific individual was identified as responsible for the stolen items, the frequent incidents suggest a need for the licensee to implement measures to better protect residents personal belongings. Substantiated Based on review of records and interviews, 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. An exit interview was conducted. This report, along with the LIC9099D and appeal rights were provided to the Executive Director Cristina Ceballosthe state’s words, verbatim · CDSS document, Feb 6, 2025 · control 56-AS-20250130150819

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Feb 14, 2025

87217 Safeguards for Resident Cash, Personal Property, and Valuables...(b) Every facility shall take appropriate measures to safeguard residents' cash.. personal property and valuables ... entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles... Based on interviews and record review, facility did not follow safeguards for residents personal property regulation due to several residents having their personal belongings being stolen which poses a potential health, safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 6, 2025

Plan of correction: Administrator has agreed to create and send plan of procedures to better safeguard residents belongings to LPA by the POC due date.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Sarina Ramirez conducted an announced visit to the facility for the purpose of a Change of Ownership evaluation. LPA met with Licensee Shlomo Aron. An initial application for change of ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Centralized Applications Bureau (CAB) on 06/26/2024 for a total capacity of two hundred and seventy-six (276) residents. Fire clearance was granted on 08/16/2024. LPA observed the following: Eight (8) bedrooms and Nine (9) bathrooms. There is a gated pool inaccessible to residents in care. The physical plant, in general, was in good repair. Buildings and grounds are free from hazards. Indoor and outdoor passageways were free of obstruction. There is a locked area for medications, cleaning supplies, and sharps. LPA observed a working telephone and basic laundry equipment. Resident bedrooms had the required bedding and furniture. Bedrooms had sufficient lighting. LPA measured the hot water temperature in the resident bathrooms, and it ranged from 105 to 114 degrees F. The facility had a sufficient amount of linen and hygiene items for the residents. The facility had a sufficient amount of nonperishable and perishable food items. The food was kept in a safe and healthful manner. The facility menu was available for review. Dishes, glasses, and utensils were in good condition. The facility had a designated area for staff and client records. Facility sketch, personal rights, CCLD complaint poster, Ombudsman poster, and schedule of activities were posted in a common area. The facility was equipped with a complete first aid kit and manual. There is adequate seating in the common areas. Facility had a supply of activities for the residents. Pre-licensing inspection is complete, and no corrections are needed to be made. Facility appears to be ready for licensure. An exit interview was conducted where this report was discussed and provided to the Licensee Shlomo Aron.the state’s words, verbatim · CDSS document, Dec 6, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 276 Census (if any clients in care): 100 COMP II Participants: Lori Matsushita (A), Steven Aron (C) Interview Method: Telephone interview On November 18, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Activities, Transportation 3. Staffing requirements, Transportation 4. Unusual Incidents/Timeline to report 5. General provisions / pre licensing readinessthe state’s words, verbatim · CDSS document, Nov 18, 2024