The Meridian at Anaheim Hills

Allegation investigated: Resident developed unstageable pressure injury due to staff neglect Facility staff did not notify resident's family about pressure injuries Facility staff locked residents in their bedrooms Facility staff did not adequately supervise residents during showers

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to deliver findings on the allegations listed above. LPA was greeted and granted entry by staff after introducing himself and stating the purpose of the visit. The complaint investigation was initiated by LPA Sean Haddad on July 29, 2025, regarding a complaint filed on July 28, 2025. The complaint was investigated by the Department and consisted of a tour of the physical plant, a review of medical records obtained from hospice providers, interviews with facility staff, and interviews with witnesses like medical professionals, resident family members, and a local ombudsman. Regarding the allegation: Resident developed unstageable pressure injury due to staff neglect During the investigation, 0 of 17 individuals provided any information or evidence that supports the complaint allegations and a majority of the information that was gathered during the investigation through interviews and document review contradicted the complaint allegation. Continued on LIC9099C Unsubstantiated During an interview with Executive Director Ray Pellicer, caregivers are instructed to notify med tech if they observe any skin concerns. Med techs report to the Memory Care Director Ira Lustina, and Ira will contact the doctor and family. When Memory Care Director Lustina was asked about facilities protocol when it comes to pressure injuries, she said, Med techs will report to me… if it’s a stage one hospice will provide a skin barrier cream or ointment. If it’s stage two, hospice will come and treat the wound. If the residents on Home Health, they will come treat it as well. If it’s unstageable, we send them out. We report it to the doctor first then they will order for us to send them to the hospital or skilled nursing. We’re not allowed to treat or stage a pressure wound so we report it to the doctor first. Document review was consistent with the information gathered during interviews. The care team would reposition residents who had pressure wounds, document the time the resident was repositioned and make additional notes regarding status or condition of the resident (what side they are laying on). The documentation was consistent and it was documented the same over an extended period of time. The documentation style was consistent and followed a pattern that was used by all different staff, and used on all different residents, Residents 1 (R1), Resident 2 (R2), and Resident 3 (R3). All three residents were on hospice and were receiving wound care. Regarding the allegation: Facility staff did not notify residents family about pressure injuries During the investigation 0 of 17 individuals provided any information or evidence that supports the complaint allegation. Based on interviews, record review, and due to the lack of information provided when the complaint was filed, much of the information gather contradicts the complaint allegation. During the investigation all five staff members who were asked about the allegation provided a consistent response and it was clear the staff understood their responsibility and know how to respond to pressure injuries appropriately. When the executive director was asked how staff are trained to respond to pressure wounds, executive director stated, the med tecs will report to Memory Care Director, and [The Memory Care Director] will call the doctor, family, and get a treatment order. Continued on LIC9099C pg 2 of 5 The Memory Care Director Lustina was asked the same question about how staff respond when they see a pressure injury and she said, Med techs will report to me… if it’s a stage 1 Hospice will a skin barrier or ointment if it’s stage 2 Hospice will come and treat the wound if they’re on HH they will come treat it as well. If it’s unstageable, we send them out... we report to the doctor first then they will order for us to send the resident to the hospital or skilled nursing. We are not allowed to treat or stage a pressure wound so we report it to the doctor first. According to Staff 3 (S3), if it’s more than stage one, we usually do home health or if they’re on hospice they do the care. We turn the residents every two hours… If the pad comes off, we call hospice to change it because we can’t. If it’s stage one and they prescribe cream, we can apply the cream, but when the wounds opens, we contact the doctor. Document review revealed, facility staff documented consistently and took good notes on each resident. Facility staff would document when residents were repositioned, information about the pressure wounds when necessary, document the time the resident was repositioned, and make additional notes regarding status or condition of the resident during the required check. It was clear the facility uses an effective documenting process and the documentation style was consistent that remains consistent with the different staff, as well as with different residents. A review of resident records for R1, R2, and R3 who were all receiving wound care was all documented the same way over an extended period of time. Facility staff also ensured outside providers like Home Health and Hospice providers were required to fill out outside agency forms with contact information and notes about the residents’ condition and care. Providers fill out forms and document the status of residents’ condition after each visit, consistently. Regarding the allegation: Staff locked residents in their bedroom 0 of 17 individuals provided any information or evidence that supports the complaint allegation. All staff who were asked about residents being locked in their room denied the allegation. According to Executive Director the opposite is happening and Executive Director states, if anything the residents are out of their room too much. Memory Care Director Lustina strongly denied the allegation and said, we don’t lock residents in their room… How can we lock them in if the lock is on the inside. Continued on LIC9099C pg 3 of 4 Staff 3 (S3) said, “No.” when asked the question. S3 was then asked about whether there have been complaints or concerns from family members and S3 denied there had been any complaints or concerns from family members. Staff 5 (S5) said, “No.” We never lock doors. They’re (residents) the ones who lock their door. Like this morning the door was locked for one of the residents. During the investigation, interviews were conducted with six different family members of residents in the memory care unit. All of the family members denied residents are locked in rooms. However, a couple family members did acknowledge they were informed the room doors are locked for a couple days if one of the residents display wandering behaviors and begin to enter rooms that don't belong to them. Another family member stated they were informed they doors are locked if another resident is entering resident rooms. All other family members denied the allegation and said no when asked if residents are locked in their rooms. One family member said their loved one's door is always open. Regarding the allegation: Facility staff did not adequately supervise residents during showers 0 of 17 individual were able to provide any supporting details or information that supports the complaint allegation. All the staff who were interviewed denied the allegation and provided information the opposes the allegation. According to the Memory Care Director, each care staff has their list of residents on who to shower. Residents in memory care always say no. If they refuse, we come back in an hour, if they refuse we try again later. Memory Care Director also confirmed that a staff member is present at all times when residents are being showered. Staff 3 (S3) was asked about the showering process and said, “I don’t do it much because I’m the med tech.” S3 explained, each shower schedule is twice a week. If the resident is on hospice, the hospice provider administers the shower. S3 explained, if they don’t want to shower, we fill out a paper they refused, and we let the boss know they don’t want to shower. Staff 5 did not provide any information that supports the allegation and said, “We usually give them a sponge bath and get them up if they are not on the schedule for showers. Continued on LIC9099C pg 4 of 5 According to staff 4 (S4), residents have showers at least twice a week. S4 explained, ideally, we try to shower them in the morning… if they have a preference, we try to honor that… If they refuse a shower, we attempt to shower them later. If they refuse again, we endorse the PM shift, and they take over and try and get the shower done then. A family member of a memory care resident, was asked if there were any concerns with the supervision at the facility and the family member, strongly denied, and said, No… No. Based on the information gathered through interviews, document review, and observation, the Department is unable to ascertain if the allegations 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, the allegations are deemed unsubstantiated.the state’s words, verbatim · CDSS document, May 13, 2026 · control 22-AS-20250728155238

Allegation investigated: Facility staff did not safeguard resident's personal items

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Administrator (AD) Raymond Pellicer, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that facility staff did not safeguard resident's personal items revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD and residents, and obtained and reviewed copies of the resident roster and staff roster. It was alleged that staff are stealing a resident’s clothing from their room. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed AD who denied that there were any recent reports of lost or stolen items. Per the facility’s resident roster, the resident at issue is not a resident of the facility. LPA interviewed eight residents and did not obtain information corroborating the allegation. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. Unfoundedthe state’s words, verbatim · CDSS document, Nov 19, 2025 · control 22-AS-20251116150017

Allegation investigated: Facility staff is falsifying their medical license.

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an investigation for a complaint received in the Regional Office. LPA was greeted and granted entry and met with Raymond Pellicer, Executive Director (ED). LPA requested the following: Business cards for eight of eight managers, staff and resident rosters. LPA also obtained a marketing folder given to prospective residents and their families. LPA interviewed four of four managers regarding their job duties and asked each manager what the selling points for the community are for prospective clients and their families. LPA confirmed that medical licenses or certifications are not falsely advertised as selling points for the community. (Continued on LIC 9099-C) Substantiated (Continued from LIC 9099) LPA reviewed four of four manager files. LPA reviewed licenses and certifications for four of four staff and observed Staff #2 (S2)'s business card states a different medical license than what is current from the licensing board. LPA conducted a board registry search and found the license stated on the business card could not be found. Staff #2 is certified with a different medical license but it is not the one advertised on the business card. Based on LPA's record review, interview and Registry Board search, the preponderance of evidence standard has been met and a deficiency will be given. The allegation that: Facility staff is falsifying their medical license is Substantiated. An exit interview was conducted with Executive Director (ED) Raymond Pellicer and a copy of this report, LIC 9099-D, LIC 811 and Appeal Rights were provided to the facility.the state’s words, verbatim · CDSS document, Oct 30, 2025 · control 22-AS-20251022163250

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Nov 28, 2025

87207 False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: (continued) LPA record review and interview revealed one of one staff members stating they have a Registered Nurse (RN) license on facility business card. Staff #2 (S2) has a current Licensed Vocational Nurse (LVN) license but there is no RN license associated to S2.the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: Licensee (LE) shall update the business cards for Staff #2 to reflect the current medical license by the Plan of Correction date.

Type of visit: Required - 1 Year

On October 21, 2025, Licensing Program Analysts (LPASs) Eboni Bentley and Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1 Year Annual evaluation. LPAs were greeted and granted entry by Executive Director/Administrator (AD), Ray Pellicer, stated the purpose of the visit and were granted entry. The certificate for Administrator, Ray Pellicer is currently valid expiring on November 7, 2026. The facility has a resident census of seventy three. A sample of eleven resident records and five staff records were reviewed during the visit. Background clearance and association to the facility was verified for staff members on the roster. LPAs toured the physical plant with Resident Services Director Analyn Samson and the following was observed: The facility is three multi-story buildings arranged around a central courtyard. LPAs conducted a tour of the interior and exterior of the physical plant. Eleven resident units in Assisted Living and Memory Care were inspected and found to be clean, sanitary, and in good repair. All units had the required furnishings, bedrooms and bathrooms contained adequate storage space, were clean, and kept free of obstructions. Bathrooms were observed with non-skid mats and grab bars on the inside of the shower. The hot water temperature measured between the ranges of 105.0 and 114.0 degrees Fahrenheit in eleven resident bathrooms and common area bathrooms. All common areas were inspected including the kitchen, dining, activity rooms, and courtyards. LPAs observed sufficient emergency food and water in the kitchen and storage. The outdoor passageway is free of obstruction. CONTINUE TO LIC809-C..... The Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the correct size. Emergency disaster drills was last conducted on July 7, 2025. First aid kit is maintained and contains all the necessary elements. Smoke and carbon monoxide alarms were lasted inspections on May 13, 2025, per the inspection log. The facility has fire extinguishers that were charged throughout the facility, all last serviced on September 3, 2025. Liability Insurance is effective March 1, 2025 through March 1, 2026. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Cleaning supplies and sharp items were inaccessible to residents in care. LPAs reviewed resident medications and found one resident (R1) with medication errors, as four routine medications were not given as prescribed on October 12, 2025. Based on the observations made during today's visit, a Type B deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Executive Director/Administrator, Ray Pellicer. Resident Services Director Analyn Samson, and Memory Care Director Ira Lustina, and a copy of this report, LIC809-D, LIC811, Technical Violation, and appeal rights were provided to Executive Director/Administrator, Ray Pellicer.the state’s words, verbatim · CDSS document, Oct 21, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Oct 29, 2025

87465(C)(2) Once ordered by the physician the medication is given according to the physician's directions. This is evidence by: Based on observations and record reviews, four routine medications were not given as prescribed for R1 on October 12, 2025, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Executive Director stated they will retrain all medication staff and provide proof of training, content, attendees, and date of training to CCLD by POC due date.

Allegation investigated: Staff member sexually abused resident in care.

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA Tirre was greeted and granted entry into the facility by Executive Director Raymond Pellicer and explained the reason for the visit. During the course of the investigation, the Department interviewed staff and residents. During investigation Department reviewed and obtained pertinent documentation including Anaheim Department Police Report, Report of Suspected Abuse, narrative charting notes and shower Records. The investigation conducted revealed the following: On April 30, 2025, the department received a complaint alleging that staff member sexually abused resident (R1) in care. On January 22, 2025, R1 transferred from independent living side to Assisted living side of Meridian at Anaheim hills. CONTINUED ON 9099C Unsubstantiated Based off Resident’s needs and service plan dated April 4, 2025, “resident is independent with most activities of daily living and needs help with PureWick External Female Catheter at night. Female staff assist resident. Resident is alert and able to communicate needs. Resident requires one person total assist with catheter and bathing twice a week”. It was reported that R1 was being showered by Staff member (S1) when they were told to stand up and face the wall while S1 proceeded to wash R1’s back, buttocks and legs with wash cloth. R1 was shocked that S1 would wash them in their private area. It was alleged that after S1 washed backside of R1 they reached around to wash front private area to which R1 felt S1 was being rough. R1 stated that S1 did not say anything while bathing R1 and R1 did not communicate to S1 to stop. Police Department Report dated April 30, 2025, stated that R1 did not report incident until 3 weeks later due to fear of S1 retaliating against them. R1 stated that S1 began cleansing R1’s body and made the statement “We’re going to get nice and clean, we’re going to clean the vagina”. R1 stated the statement made them uncomfortable. R1 stated that S1’s hands were where they shouldn’t belong and stated that S1 began to clean their private area. Police Report also mentioned that R1 stated multiple times “Everything is a blur” and when asked about prosecution for incident, R1 stated that they “wanted behavior corrected, but without incarceration”. Interviews were conducted with seven residents (R2-R8) who also received shower assistance from S1, all stated that they do not have any issues with staff while being assisted with showers and have never been touched inappropriately by staff. Interview with R1 stated that S1 had assisted them twice with showering and first time there was no problems. R1 stated that S1 had assisted with R1’s back, buttocks and legs due to R1 unable to reach area. R1 could not recall if they were sitting in the shower or standing up. R1 stated that S1 had vigorously washed private area and R1 was upset because they did not want staff to wash private area. R1 stated that S1 assisted with the catheter without any incident. R1 stated that they did not want S1 terminated and stated what they believed happened. R1 stated they were satisfied with how facility handled situation by removing staff member from assisting R1 with bathing. CONTINUED ON 9099C Interview with Staff 1 (S1) stated that they only showered R1 twice and stated that before alleged incident, R1 has requested different staff members before to help assist with showers. S1 stated that they have R1 sit on shower chair and helps assist with back, legs and feet. S1 stated that while sitting on shower chair R1 will wash their chest and private areas. S1 stated that they rinse R1 with shower head while R1 uses free hand to rinse off private area without assistance from S1. S1 stated they help assist R1 with the PureWick External Female Catheter which they feel is more invasive due to applying catheter to private extremities. S1 stated that no other residents have complained about them when assisting with care. Interviews with two staff members revealed that S1 was placed on a two day leave while facility conducted internal investigation. Staff stated that S1 was allowed to return to work but was moved to different location to help assist with Activities of Daily living away from R1. Staff interviews revealed that R1’s service plan requires female caregivers to assist with showers. Staff interviews stated that there have been no previous issues with S1. Due to lack of supportive information and inconsistencies of R1’s statements, there is not enough information to support the allegation staff member sexually abused resident while in care. There were no witnesses to incident and R1 is able to communicate how they prefer to be showered. R1 is also able to wash private area without assistance. There is no specific instructions provided on Residents service plan in bathing section other than Resident prefers a female staff member. Therefore, based on interviews conducted and documents reviewed, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted Executive Director Raymond Pellicer and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 22-AS-20250430164904

Allegation investigated: Staff leave the residents unattended for an excessive amount of time Staff are not providing adequate care and supervision

Licensing Program Analyst (LPA) Jenifer Tirre met with Executive Director Raymond Pellicer for the purpose of delivering findings for the above allegations. The complaint consisted of record review, observations and interviews. On July 31, 2024 the department received allegations that staff leave the residents unattended for an excessive amount of time and staff are not providing adequate care and supervision. The investigation was completed by the Department and revealed the following: Based off records review, facility Staff work schedule dated between July 28, 2024 to August 24, 2024 shows that facility has 26 staff members working four shifts throughout the day. Each shift has at least six staff per shift for the exception of PM shift which has only two staff per shift. Facility incident report dated June 4, 2024 regarding an unwitnessed fall for resident 1 (R1) states that during morning rounds a staff member heard R1 yelling for help, CONTINUED ON 9099C Unsubstantiated to which staff member assisted R1 after finding resident on floor by kitchen area. Staff assessed R1’s skin tear on left leg and administered pain meds. Facility staff contacted responsible parties and R1 requested to return to room. R1 later that same morning complained of pain, was reassessed by staff and was sent out to St. Joseph hospital for further evaluation. Facility In Service training log dated from January to July of 2024 documents that facility staff have had on site training's for the following areas of care: fall prevention, colostomy care, fatigue, depression, reporting change of condition, diabetes, and preventing injury using proper body mechanics of lifting & transferring. The Facility Residence and Care Agreement documents the types of care services provided to residents such as Living accommodations, laundry, housekeeping, personal supplies, meals, planned activities, transportation, emergency response and fire protection, consultation, round the clock staffing, incontinence care and dementia services. The Care Agreement also covers additional areas of care such as “change of level of care”, “responsibility with yourself” and “risk of falls”. LPA Tirre contacted Emergency Medical Services (EMS) Coordinator Andrew Tran of Orange County Fire Authority to obtain service calls received from facility for requested assistance to residents. EMS Coordinator stated that Orange County Fire Authority (OCFA) looked into the history of facility and stated that OCFA did not receive any calls for service in over a year. LPA Tirre contacted Anaheim Fire and Rescue regarding service calls from facility requesting for assistance to residents. Anaheim Fire and Rescue Emergency Medical Services (EMS) Nurse Educator Jamie Jantzen stated that their department received 25 calls for fall lift assists for 2024 year. On July 31, 2024 Facility Witness contacted Department and did not corroborate allegations stating they were “just rumors and inaccurate information”. During visit on August 6, 2024 LPA did not observe any health and safety concerns while touring facility. Based off information obtained this agency has investigated the complaint. Although the allegations Staff leave the residents unattended for an excessive amount of time and Staff are not providing adequate care and supervision may have happened or is valid , there is no preponderance of evidence to prove the alleged violation did or did not occur , therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Pellicer and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 22-AS-20240731103344

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Joseph Alejandre and William Vanegas made an unannounced visit to conduct the required annual inspection. LPAs met with the Executive Director Raymond Pellicer and explained the reason for the visit. The facility has a main lobby and 4 separate wings and each wing has multiple floors. There is a fountain outside the main entrance of the facility. The facility has a memory care unit with delayed egress. LPAs observed the main stairway in the lobby did not have an evacuation chair. LPAs observed there are numerous shaded area with tables and chairs outside the facility for residents to sit outside. LPAs and the Executive Director toured the facility. LPAs observed the emergency food and water is stored in a supply closet. LPAs and the Executive Director toured the kitchen and dining room. LPAs observed the dining room is clean and organized. LPAs observed there is a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPAs observed both refrigerators and freezers had temperature logs posted on the doors. LPAs toured 8 resident rooms. LPAs observed all resident bathrooms in the rooms inspected were clean and operational. Hot water measured between 116.6 and 112.2 degrees Fahrenheit in the rooms inspected. LPAs observed all resident rooms had the required furnishings. LPAs observed multiple rooms for activities and social gatherings. The fireplace in the upstairs living room (plaza lounge) is screened. LPAs observed the See Something, Say Something poster posted on the second floor in a hallway. LPAs observed residents having an ice cream social in the upstairs living room. LPAs and the Executive Director toured memory care. LPAs observed residents participating in a sing a long. LPAs observed emergency evacuation chairs in each stairwell. LPAs observed the signal system in the memory care unit is not operational in any of the 19 rooms. The Executive Director verified the signal system in memory care is not operational. LPAs verified the signal system in assisted living is operational. LPAs observed the delayed egress exits in memory care are operational. LPAs observed the medication is kept locked in a medication cart in the medication room. LPAs interviewed staff and residents. LPAs reviewed 5 staff files. All staff interviewed during the visit and staff members who's files were reviewed are background cleared and associated to the facility. LPAs observed that 1 out of 5 staff members (Staff 4) did not have the required 20 hours of annual training. LPAs reviewed 7 resident files and medications. No discrepancies observed. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided.the state’s words, verbatim · CDSS document, Sep 18, 2024

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.