The Residences at Royal Bellingham

Allegation investigated: Staff did not prevent resident from verbally abusing another resident in care

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegation. The LPA arrived at 2:33PM and met with Executive Director (ED) Lito Vitug. Entrance interview conducted. On 07/30/2026, the LPA conducted an initial visit. Between 10:47AM and 1:30PM, the LPA conducted a physical plant tour, interviewed four (4) residents, five (5) staff, and the ED, and reviewed and obtained pertinent documents. During today’s visit, the LPA and ED conducted a physical plant tour at 2:39PM, and no immediate concerns were observed. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegation: “Staff did not prevent resident from verbally abusing another resident in care” It was reported that staff did not prevent Resident #1 (R1) from verbally and emotionally abusing their roommate, Resident #2 (R2). Interview with R1 revealed that they do not often speak to each other, do not have arguments, and consider themselves friends. R1 stated that R2 frequently watches TV and uses the restroom, which can be disruptive at times. R2 denied being verbally abused by R1 and reported that, at most, R1 will tell them to pass gas elsewhere. Interview with staff reflected inconsistent knowledge regarding any conflicts between R1 and R2. Staff reported that R1 previously had a roommate who was relocated due to complaints; however, staff were not familiar with the details of the situation. Staff indicated that R1 and R2 are generally calm and have not previously reported issues regarding their shared room. Staff #1 (S1) reported that R2 confided in them that R1 believes R2 is too loud when using the restroom or watching TV. S1 offered to speak with the Administrators to help resolve any concerns, but R2 declined. The Facility Manager stated that approximately one (1) week prior to the allegation, R2 approached them requesting a room change due to R1’s complaints about noise. R2 did not report any verbal abuse during this interaction. R2 was informed that the facility would accommodate the room change once a room became available. The Facility Manager further clarified that R1’s previous roommate was relocated due to concerns about incontinence needs, not due to interpersonal conflicts. Review of R1’s Appraisal/Needs and Services plan dated 01/14/2026 and R2’s plan dated 12/01/2025 documented no history of aggressive behavior for either resident. Based on interviews and record review, the facility was not made aware of any alleged verbal abuse. Once notified of R2’s concerns, the facility took steps to accommodate R2’s request. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur; therefore, the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Aug 26, 2026 · control 29-AS-20260726105225

Allegation investigated: Staff do not ensure call signal alerts are answered in a timely manner Staff does not ensure residents food is kept free of contaminants Staff do not ensure resident’s room is clean, safe and sanitary

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegations. The LPA arrived at 2:33PM and met with Executive Director (ED) Lito Vitug. Entrance interview conducted. On 07/30/2026, the LPA conducted an initial visit. Between 10:47AM and 1:30PM, the LPA conducted a physical plant tour, interviewed four (4) residents, five (5) staff, and the ED, and reviewed and obtained pertinent documents. During today’s visit, the LPA and ED conducted a physical plant tour at 2:39PM, and no immediate concerns were observed. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegations: “Staff do not ensure call signal alerts are answered in a timely manner,” “Staff does not ensure residents food is kept free of contaminants,” and “Staff do not ensure resident’s room is clean, safe and sanitary” It was reported that staff do not respond when Resident #1 (R1) uses their call light, that meals delivered to R1’s room contain pests, and that R1’s room is cluttered, uncomfortable in temperature, and malodorous. Interview with R1 revealed that staff do not respond when they attempt to use their call light. During the interview, R1 tested the call light, and it was determined that R1 was not pulling the cord with significant force to activate the system. R1 stated that they stop pulling the cord after the initial clock and do not continue pulling until the alert triggers. R1 denied that cockroaches were present on meals at the time food is delivered. R1 reported that meals arrive covered in plastic wrap and that pests appear only if food is left uncovered in the room for an extended period. R1 also noted that the facility has been conducting pest control treatment in their room due to the presence of pests. Regarding room conditions, R1 stated they do not have concerns about the room being too hot and are able to adjust the in-unit air conditioning as needed. R1 expressed more concern about the room being too cold at times, but that staff provide them with extra blankets. R1 denied any clutter that would create a hazard or prevent them from safely entering or exiting the room with their wheelchair. During the visit, the LPA observed R1’s room to be clean and sanitary. A mild odor was present due to R1’s indwelling catheter. Interviews with staff disputed all allegations. Staff reported that R1 does not typically use their call light and instead goes to the front desk when needing assistance. Staff stated they have not observed pests in R1’s room and explained that routine pest control services are performed as a preventative measure. Staff also reported that R1 frequently empties their own catheter bag, which sometimes results in spillage and associated odor. Staff stated they assist when permitted and ensure the room is cleaned and organized. Staff added that R1 often removes clothing items from storage and places them on the floor shortly after the room is cleaned. Report Continued on LIC 9099-C Staff reported that R1’s room is not typically hot and that they offer to adjust the temperature when needed; R1 occasionally declines such assistance. Staff further noted that R1 frequently leaves their window open despite high outdoor temperatures. On 07/27/2026, the Department received an incident report indicating that on 07/26/2026 an individual notified the facility of concerns regarding the condition of R1’s room. The facility conducted an internal investigation and addressed each concern. The facility also contacted R1’s family who reported no concern and stated they observed no conditions consistent with the allegations during prior visits. Based on interviews and record review, although the allegations may have happened or are valid, there is insufficient evidence to prove the alleged violations did or did not occur; therefore, the allegations are deemed UNSUBSTANTIATED at this time. Allegations: “Staff handled resident in a rough manner,” “Staff does not ensure resident receives adequate incontinence care due to neglect,” and “Staff do not ensure resident is accorded personal privacy in their room” It was reported that staff twisted Resident #1’s (R1) arms behind their back while performing catheter care, failed to provide adequate incontinence care, and that R1’s door remained open, resulting in other residents entering their room. Interview with R1 revealed disorganized thoughts and a primary recollection of their recent hospital stay. R1 stated that while at the hospital, staff were not attentive to their needs, and several hospital patients entered their room and used their restroom. R1 reported that the hospital staff apologized and stated that the hospital did not have enough restrooms. R1 did not provide clear details regarding whether hospital staff handled them roughly but indicated that they had been treated in a rough manner. R1 described the hospital as “like a prison.” In contrast, R1 reported that the facility staff are respectful and do “everything they need to.” R1 stated they can empty their own catheter bag and that staff also assist appropriately when needed. R1 also stated that their door remains open and confirmed that they prefer it to be cracked open. Interview with facility staff revealed no concerns, mistreatment, or neglect. Staff confirmed that R1 preferred to keep their door open and noted that they offer to close it when exiting the room, but R1 declines. Staff reported that when they assist with emptying R1’s catheter bag, the procedure does not require staff to place their hands on R1’s body. Based on the information obtained, the allegations are deemed UNFOUNDED at this time. A finding of unfounded means that the allegations are either false, could not have happened, and/or are without a reasonable basis. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Aug 26, 2026 · control 29-AS-20260729083754

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management Legal/Non-Compliance visit at 11:44AM. The purpose of today’s visit is to ensure the facility is maintaining substantial compliance as discussed in a Non-Compliance Conference on 12/15/2025. The LPA met with Executive Director (ED) Lito Vitug. Entrance interview conducted. During today’s visit, the LPA and ED conducted a physical plant tour beginning at 12PM to ensure there were no health and safety hazards. LPA Huynh observed a total of six (6) resident rooms, each with a private restroom, on the first and second floor and interviewed four (4) residents and one (1) family member. Interviews with residents did not reveal any immediate concerns. Resident rooms obtained all required furniture and had sufficient lighting. Restrooms were observed to have non-slip mats and grab bars. The dining room was observed to be in compliance, with residents visibly enjoying their lunch. Medication review began at 12:42PM. Two (2) resident medications were reviewed and observed to be in compliance. The LPA observed accurate centrally stored records and refusal communication logs. Five (5) resident records were reviewed at 1PM. Records were reviewed for but not limited to care plans, admission agreements, and consent forms. All records were in order, however the LPA reminded the ED to ensure dates and signatures are documented on all care plans. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Jun 30, 2026

Type of visit: Case Management - Other

Licensing Program Analyst, Erica Mosley arrived on June 16, 2026 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. The LPA met with Angelito "Lito" Vitug, Executive Director and Rizaandrea Vitug, Assistant Administrator. On October 28, 2025, the Department concluded a complaint investigation regarding the following allegation: Sexual Abuse. The licensee was cited for California Code of Regulations (CCR) 87468.2(a)(8) Additional Personal Rights of Residents in Privately Operated Facilities. At the time of the complaint visit on October 28, 2025, the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for physical abuse. The Welfare and Institutions Code Section 15610.63 for physical abuse means any of the following: (b) Battery, as defined in Section 242 of the Penal Code. This is evidenced by a staff (S1) having a sexual relationship with a resident (R1) when R1 was unable to give consent. Today, June 16, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as physical abuse in the amount of $10,000. Exit interview conducted. A copy of the report issued. Appeal rights provided. Angelito "Lito" Vitug, Executive Director and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Jun 16, 2026

Allegation investigated: Staff did not seek timely medical care for resident resulting in hospitalization on multiple occasions Staff neglect resulted in resident sustaining a fracture due to multiple unwitnessed falls Staff did not ensure a functioning signal system was accessible to resident Staff did not assist resident with personal care needs in a timely manner Staff did not ensure resident’s room was maintained in clean condition Staff did not provide adequate laundry services to resident Staff did not provide resident with adequate personal care supplies

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegations. The LPA arrived at 10AM and met with Assistant Administrator (AA) Rizaandrea Vitug. The Executive Director (ED) Angelito “Lito” Vitug arrived at 11:10AM. Entrance interview conducted. On 01/12/2026 LPA Huynh conducted an initial visit. Between 9:15AM and 2PM, the LPA conducted a physical plant tour, reviewed and obtained pertinent documents, and interviewed six (6) staff, one (1) family, the AA, and the ED. Between 01/14/2026 and 03/25/2026 the Department interviewed facility staff, residents, family, and obtained and reviewed medical records. Report Continued on LIC 9099-C Unsubstantiated During today’s visit, the LPA and AA conducted a physical plant tour at 10:16AM, and no immediate concerns were observed. The following was then determined: Allegations: “Staff did not seek timely medical care for resident resulting in hospitalization on multiple occasions,” “Staff neglect resulted in resident sustaining a fracture due to multiple unwitnessed falls,” “Staff did not assist resident with personal care needs in a timely manner,” “Staff did not ensure a functioning signal system was accessible to resident,” “Staff did not ensure resident’s room was maintained in clean condition,” “Staff did not provide adequate laundry services to resident,” and “Staff did not provide resident with adequate personal care supplies” It was reported that Resident #1 (R1) was hospitalized due to sepsis, pneumonia, and a collapsed lung and that R1 sustained multiple falls resulting in a shoulder fracture due to staff neglect. It was further reported that staff did not provide timely assistance with personal care needs in addition to providing services such as housekeeping, laundry, and personal care supplies. It was also alleged that the facility did not ensure R1’s call signal system was functioning and accessible. Staff reported that upon admission to the facility, R1 did not require assistance; however, approximately two (2) to six (6) months prior to the allegations, R1 began needing help with showering and toileting/incontinence care. Staff stated that R1 routinely refused assistance and attempted to complete these tasks independently despite needing support. Staff reported making daily attempts to provide care, but R1 was often verbally aggressive and would not allow staff to enter their room for housekeeping, personal care, or routine checks. R1 also did not make requests for staff assistance. Staff reported that they were occasionally successful in assisting R1, but it was infrequent due to R1’s refusals. Staff did not recall the fall that resulted in a fracture and denied observing R1 with a cough or being aware of any hospitalization for sepsis, pneumonia, or a collapsed lung. Interview with the ED supported staff’s statements regarding R1’s noncompliance. They reported that on 05/07/2024, R1 fell while showering and transported to the hospital for right shoulder and upper arm pain, where they were diagnosed with a right humerus fracture. Report Continued on LIC 9099-C The ED stated that R1 did not want to wait for assistance and showered independently. The ED further explained that in October 2025, R1’s family requested the facility administer cough medicine; however, no physician’s order was obtained, and the facility informed the family of the requirement. The ED stated they did not observe R1 with a cough at that time. The family later transported R1 to the hospital for diarrhea. The ED additionally reported that R1 had not been hospitalized due to sepsis, pneumonia, or a collapsed lung while under the facility’s care. Interview with R1’s Power of Attorney (POA) revealed no overall concerns with the facility or the level of care provided. They confirmed that R1 frequently refused staff assistance despite staff’s continued efforts and that the facility maintained an open line of communication regarding R1’s care. The POA visited the facility approximately every other day and stated that staff did their best to accommodate R1. They reported that R1 developed pneumonia approximately six (6) to eight (8) months prior and that the facility could not have prevented it due to R1’s medication refusals. R1 reported that they had been living with their family for one (1) year and described facility staff as “bossy.” R1 stated that staff did not assist them and were attentive but slow. R1 was unable to recall their fall resulting in a fracture or if they had sepsis, pneumonia, and a collapsed lung. R1’s Physician Report dated 03/04/2025 documented diagnoses of hypertension, hyperlipidemia, and dementia. R1 was ambulatory with assistance, incontinent, confused/disoriented, and required assistance with medication management, bathing, grooming, feeding, and toileting/incontinence care. Individual Service Plan (ISP) dated 11/11/2025 documented that R1 had difficulty remembering and using information, frequently impaired judgement, disruptive or aggressive behaviors, and difficulty understanding their own personal care needs. The Medication Administration Record (MAR) indicated R1 accepted medications for thirteen (13) days in October 2025, seven (7) days in November 2025, and two (2) days in December 2025. Report Continued on LIC 9099-C Hospital records dated 05/07/2024 indicated R1 was assessed for a non-displaced fracture of the neck of the right radius. R1 reported to hospital staff that they chose not to wait for assistance and showered independently, slipped, and fell on their arm. R1 presented with pain and a deformity of their arm and was diagnosed with an oblique right humeral fracture and discharged on 05/08/2024. Hospital records dated 10/17/2025 indicated R1 presented with a cough and chest pain. A pulmonary exam was positive for a cough, a cardiovascular exam was positive for chest pain, and a gastrointestinal exam was positive for diarrhea and melena. A chest x-ray showed clear lungs with no new or urgent problems but noted some bibasilar atelectasis, indicating partial or full collapse of lung lobes due to blocked air sacs. R1 tested positive for a clostridium difficile (C-diff) antigen (indicating the bacterium was present) negative for the toxin test (indicating no detectable toxin). Lab results showed elevated white blood cells, and R1 was prescribed antibiotics for possible pneumonia. R1 was discharged on 10/20/2025 with diagnoses of “severe sepsis due to C-diff, community acquired pneumonia ruled out, diarrhea, melena, coronary artery disease, dementia, and hypertension.” During the initial complaint visit on 01/12/2026, LPA Huynh observed R1’s room. The room was clean, and the carpet had been recently washed. The LPA observed R1’s pull cord was not near the bed; however, the cord was functional, accessible, and extended comfortably to the bed. The ED stated that R1 refused to utilize the pull cord and did not request staff assistance. In the closet, the LPA observed clean clothes stored in bags on the floor. The ED stated that staff placed clothes on hangers, but R1 preferred to keep them in bags. In the bathroom, the LPA observed personal hygiene supplies which included hand soap, mouth wash, multiple toothbrushes and toothpaste, body wash, shampoo/conditioner, and a hairbrush. Based on interviews, observations, and record review, although the allegations may have happened or are valid, there is insufficient evidence to prove the alleged violations did or did not occur therefore the allegations are deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, May 18, 2026 · control 29-AS-20260108161808

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 10:00AM for a required one-year visit. The LPA met with Assistant Administrator (AA) Riza Vitug and Executive Director (ED) Lito Vitug arrived at 11:10AM. Entrance interview conducted. At 10:16AM, the LPA and AA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: RESIDENT ROOMS: The LPA observed ten (10) randomly selected rooms with private restrooms on the first and second floor and no immediate health or safety hazards were observed. Restrooms were clean, with properly installed grab-bars and non-skid mats in showers. Resident rooms were furnished with all required furniture within regulation. Water temperature was tested throughout the units and measured between 116.8 degrees F and 121.5 degrees F. The water temperature was lowered during the visit. COMMON AREAS: The facility is a two-story building with a total of eighty-eight (88) units. On the first floor, there are the kitchen facilities, dining room, laundry room, lobby, outdoor lobby/smoking area, medication room, staff offices, common restrooms, and outdoor courtyard. On the second floor, there are common restrooms, library, and common/activity space. Report Continued on LIC 809-C The LPA observed common areas to be clean and contain furniture in good condition. There were no obstructions and/or tripping hazards throughout the facility. There were cameras in the common areas, outdoor courtyard, and exterior perimeter. Required postings were found in the hallways on the first floor. LPA observed electric stair lifts in the staircases in the event of an emergency. There were no bodies of water observed during today’s visit. KITCHEN: Facility dining room and commercial kitchen were inspected and in compliance with Title 22 regulations. There was a sufficient supply of perishable and non-perishable food. The refrigerator and freezer were maintained with the required temperatures. Food appeared to be of good quality and labeled appropriately. MEDICATION: Medication review began at 11:05AM. The LPA reviewed medications for three (3) residents. Medications are maintained locked inaccessible to residents in an attached room behind the concierge desk located on the first floor. Resident medications reviewed were documented and stored in compliance with regulation at this time. The LPA reviewed records and reporting requirements regarding medication refusals. It was observed that the facility did not have an adequate system of documenting notifications of medication refusals of residents’ physicians and responsible parties. RECORDS: Resident records were reviewed at 12:40PM. The LPA reviewed five (5) resident records for, but not limited to admissions agreements, consent forms, medical assessments, and appraisals. Records were in order at this time. Five (5) personnel records were reviewed for, but not limited to job application, health assessments, TB results, criminal record statements and clearances, first aid/CPR certification, and staff trainings. Records reviewed were in order. Report Continued on LIC 809-C EMERGENCY DISASTER/INFECTION CONTROL: The LPA reviewed the facility's Emergency Disaster Plan and Infection Control Plan and is in compliance with regulation. Emergency food and water were observed in a secured closet on the first floor. The facility conducts emergency disaster drills as required with the last drill documented on 02/26/2026. Fire alarm systems were last inspected on 11/05/2025 by Advance Building Protection. Fire extinguishers were observed throughout the facility and last serviced on 03/26/2026. Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (Refer to LIC 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, May 18, 2026

Allegation investigated: Due to staff neglect resident developed multiple pressure injuries while in care Facility did not seek timely medical attention for resident with pressure injuries

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegations. The LPA arrived at 10:05AM and met with Assistant Administrator (AA) Riza Vitug. The Executive Director (ED) Lito Vitug arrived at 11:13AM Entrance interview conducted. On 01/12/2026, LPA Huynh conducted an initial visit. Beginning at 9:52AM the LPA conducted a physical plant tour and reviewed and obtained pertinent documents. Between 01/14/2026 and 02/27/2026, the Department interviewed residents and staff and obtained and reviewed medical records. During today’s visit, the LPA and AA conducted a physical plant tour at 10:07AM and no immediate concerns were observed. The following was then determined: Report Continued on LIC 9099-C Substantiated Allegations: “Due to staff neglect resident developed multiple pressure injuries while in care” and “Facility did not seek timely medical attention for resident with pressure injuries” It was alleged that Resident #1 (R1) developed two (2) Stage II pressure injuries due to staff neglect and that facility staff failed to seek timely medical attention. Physician’s Report dated 05/22/2025 documented that R1 had coronary artery disease and was receiving hospice services at that time. R1 also had mild cognitive impairment but was able to follow instructions and communicate their needs. R1 had a history of skin breakdown, including an open skin impairment on the “butt and sacrum.” Resident Appraisal dated 11/24/2025 indicated R1 was non-ambulatory with a wheelchair and required assistance with transferring, repositioning, and incontinence care. Interviews with staff and the ED revealed no documented reports or observations of pressure injuries, and staff denied the allegations. Staff stated they provided incontinence care and repositioned R1 every two (2) hours; however, their statements were inconsistent regarding R1’s repositioning schedule and whether R1 was bedbound. Approximately three (3) months prior to the allegations, R1 was discharged from hospice services. While on hospice, R1 received wound care for a wound staff reported had “healed.” Staff further reported that R1 experienced recurring redness and a dry, scabbing blister on the right buttock. Staff stated they applied “cream” and “ointment” to the area during incontinence care. Staff #1 (S1) reported observing an intermittent “small wound” approximately the size of a quarter prior to the allegations but could not recall whether this was reported to Administrators or Med-Techs. Staff #2 (S2) also confirmed that a pressure injury appeared to be developing but stated that lotion was applied and it “went away.” According to the ED, staff are trained to report skin changes to Management, who then assesses the issue, notifies the resident’s physician and responsible party, and document the occurrence in the resident’s file. S1 stated they did not receive training on identifying pressure injuries. Staff #3 (S3) confirmed being notified of R1’s dry blister but could not recall the location of the blister or timing of the report. S3 stated that no follow up occurred because the blister was “dry.” S3 also reported that skin changes are not documented and that staff notifications are verbal only. Report Continued on LIC 9099-C R1 reported that staff do not respond promptly to requests for assistance and that they often wait a long time for help. R1 stated they remain in bed for “too long” and rely on staff for repositioning and transfers, which is sometimes delayed or does not occur. R1 reported being treated well overall and receiving frequent brief changes but could not provide specifics. R1 acknowledged having pressure injuries and stated that staff apply cream “most of the time.” A review of R1’s Service Log between 11/01/2025 to 01/06/2026 showed that “Incontinent Care” was provided between one (1) to four (4) times a day, with some days showing gaps of more than ten (10) hours between services. Mobility assistance was documented approximately once per day. On 01/06/2026, R1 was admitted to the hospital at 6:44PM with left-sided facial droop. R1 was transferred to a second hospital on 01/07/2026 at 12:44AM, where pressure ulcers were observed during the admission assessment. A wound consult completed on 01/08/2026 confirmed two (2) Stage II pressure injuries on the left and right buttocks. Based on interview and record review, R1 experienced skin changes that were not addressed in a timely manner, resulting in the development of Stage II pressure injuries. The preponderance of evidence standard has been met; therefore, the allegations are deemed SUBSTANTIATED at this time. An immediate civil penalty in the amount of $500 was assessed today (Refer to LIC 421M). The ED was informed that additional civil penalties may be assessed based on Health and Safety Code Section 1569.49. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited (Refer to 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 29-AS-20260107170806

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 16, 2026

(f) basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c) This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section in R1 developed 2 Stage II pressure injuries which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: The Licensee will provide staff training regarding documentation, reporting, and pressure injuries and will provide proof to CCLD by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87631(a)(3) · Plan of correction due date: Apr 16, 2026

(a)Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances: (3) Residents with a stage one or two pressure injury must have the condition diagnosed by a physician or an appropriately skilled professional. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section in R1 developed 2 Stage II pressure injuries that were not treated which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: The Licensee will provide staff training on identifying pressure injuries and reporting to facility management and will provide proof to CCLD by POC due date

Allegation investigated: Staff did not safeguard resident’s belongings Staff did not ensure resident door lock was functioning properly

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced initial complaint visit for the above allegations. The LPA arrived at 9:48AM and met with Assistant Administrator (AA) Riza Vitug. The Executive Director (ED) Lito Vitug arrived at 11:08AM. Entrance interview conducted. During today’s visit, the LPA conducted a physical plant tour, interviewed one (1) resident and seven (7) staff, and reviewed and obtained pertinent documents between 10:02AM and 1:49PM. The following was then determined: Allegation: “Staff did not safeguard resident’s belongings” and “Staff did not ensure resident door lock was functioning properly” Report Continued on LIC 9099-C Unsubstantiated It was reported that Resident #1’s (R1) door lock was not functioning properly resulting in individuals entering their room and stealing $450 in cash. Interview with R1 revealed that the locking mechanism on their door has been an ongoing issue since they moved into the facility and have addressed it with Maintenance staff several times. R1 stated that it was replaced and the locking mechanism continued to break. R1 further reported that their cash had been stolen out of their wallet, however no time or date was provided. R1 then inquired about transferring their bank institution from out of state to a local institution with the ED. Staff reported only providing R1 assistance with dressing and obtaining ice from the kitchen when requested in addition to routine check-ins. They stated that R1 had not notified them of any stolen cash or about their door lock not functioning. The ED, Staff #1 (S1), and Facility Manager confirmed that R1’s door lock is an ongoing issue that has been replaced previously, however continues to jam due to the way R1 inserts their key. S1 has explained to R1 the proper way of inserting the key, but R1 explains that they are “old” and “does not have time for that.” The facility is currently considering replacing R1’s door lock with an alternative lock that does not require a physical key. The ED and Facility Manager further revealed that due to R1’s bank institution being out of state, R1 is unable to withdraw money or have access to cash resources. The facility has assisted R1 with purchasing medications, co-pays, and miscellaneous items R1 has requested. R1 then repays the facility through checks or would include it with their rent checks. The facility is in the process of assisting R1 with their request for a bank institution transfer. R1’s Individual Service Plan dated 08/28/2025 documented R1 to be at risk for mismanaging finances and lack of funds for incidentals. Additionally, R1 experiences episodes of forgetfulness and episodes of “not being able to recall events.” Based on interviews and record review, although the allegations may have happened or are valid, there is insufficient evidence to prove the alleged violations did or did not occur therefore the allegations are deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 29-AS-20260317112342

Allegation investigated: Due to staff neglect, resident sustained pressure injuries Staff retained a resident with a prohibited health condition

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced subsequent visit to deliver findings for the above allegations. The LPA arrived at 9:48AM and met with Assistant Administrator (AA) Riza Vitug. The Executive Director (ED) Lito Vitug arrived at 11:08AM Entrance interview conducted. On 11/05/2025, the LPA conducted an initial visit. Between 9:41AM and 10:38AM, the LPA conducted a physical plant tour and reviewed and obtained pertinent documents. Between 11/10/2025 and 02/13/2026, the Department conducted interviews with facility Administrators, staff, residents, and related facility. The Department also obtained and reviewed hospital records. Report Continued on LIC 9099-C Unsubstantiated During today’s visit, the LPA conducted a physical plant tour at 10:02AM and no immediate concerns were observed. The following was then determined: Allegations: “Due to staff neglect, resident sustained pressure injuries” and “Staff retained a resident with a prohibited health condition” It was reported that Resident #1 (R1) sustained pressure injuries while under the care of the facility in addition to the facility admitting R1 with an existing unstageable pressure injury. On 10/25/2025, R1 was transported unannounced to The Residences At Royal Bellingham from a previous licensed facility. Upon admission, R1 was assessed and noted a sacral area that was reportedly only red in discoloration at that time. On 10/29/2025, R1 was transferred to the hospital for recurrent nosebleeds and returned to the facility later that evening. The following day, 10/30/2025, staff observed R1’s sacral area had opened and arranged transportation to the hospital for further evaluation and treatment. Staff #1 (S1) reported that prior to the hospital visits, they had provided R1 with two (2) showers and did not observe any open wounds. The Facility Manager stated that staff provided care as required, including repositioning R1 every two (2) hours. Interview with R1 revealed no concerns regarding their care and stated that staff met their needs. When asked about their pressure injuries, R1 reported that they had existed for a long time. Physician’s Report dated 07/22/2025 documented that R1 was bedridden with diagnoses including hemiplegia and hemiparesis following infarction affecting the left non-dominant side, as well as protein-calorie malnutrition. Hospital records dated 10/31/2025 documented right lower extremity cellulitis and three (3) exposed subcutaneous chronic non-pressure ulcers located on the right hallux, right plantar forefoot, and the right heel. R1 subsequently received wound care consultations addressing only the lower extremity wounds; no documentation confirmed the presence of an unstageable sacral wound. Based on interviews and record review, R1 had pre-existing chronic non-pressure ulcers and hospital documentation did not confirm the presence of an unstageable sacral wound. The facility additionally took appropriate action by seeking a higher level of care when R1’s sacral area showed signs of deterioration. Although the allegations may have happened or are valid, there is insufficient evidence to prove that staff neglect contributed to R1’s condition, therefore the allegations are deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 29-AS-20251104153855

Allegation investigated: Staff leave resident in soiled diapers for extended periods of time. Resident developed a bed sore while in care due to staff neglect.

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegations. The LPA arrived at 9:48AM and met with Assistant Administrator (AA) Riza Vitug. The Executive Director (ED) Lito Vitug arrived at 11:08AM. Entrance interview conducted. On 06/03/2025, LPA Emily Peraldi conducted an initial complaint visit and conducted a physical plant tour and interviewed the ED, five (5) staff, and ten (10) residents. LPA Peraldi also reviewed and obtained pertinent documents. On 07/08/2025, LPA Huynh conducted a subsequent visit and conducted a physical plant tour, attempted to interview one (1) resident, and obtained contact information. Report Continued on LIC 9099-C Unsubstantiated During today’s visit, the LPA and AA conducted a physical plant tour at 10:02AM and no immediate concerns were observed. The following was then determined: Allegations: “Staff leave resident in soiled diapers for extended periods of time.” and “Resident developed a bed sore while in care due to staff neglect.” It was alleged that Resident #1 (R1) was left in their soiled diapers for extended periods, resulting in the development of a bed sore. R1’s Physician Report dated 10/15/2024 documented diagnoses including end stage renal disease, heart failure, and hypertension. Additionally, R1 was receiving hemodialysis four (4) times a week. R1 was noted to be non-ambulatory with a history of skin conditions or skin breakdown and required assistance with bathing, dressing, toileting, and transfers. Interviews with staff indicated that resident diapers are checked and changed every one (1) to two (2) hours. Staff stated that residents also request additional assistance by using their pull cord or calling out. Staff reported that any observed wounds or skin changes are communicated to the med-tech, who assesses the resident and notifies home health or hospice agencies and the resident’s primary care physician. The ED and staff reported conducting a head to toe skin assessment and no skin or wound concerns were observed. The ED further stated that R1 can be uncooperative during care and often refuses assistance. R1 reported that on occasion they have been left in their soiled briefs during the evenings, however it does not occur often. Although R1 expressed conflicts with the evening staff, they reported no overall concerns with the care provided and that staff response times to the pull cords vary. R1 denied having any bed sores during this period and reported only minor diaper-related rashes. Additional resident interviews revealed no concerns regarding incontinent care or wound development. Report Continued on LIC 9099-C Record review further showed that R1 visited the hospital on three (3) occasions: 05/16/2025, 05/19/2025, and 06/02/2025. After Visit and Discharge summaries from these encounters did not document any wounds. However, R1’s Discharge Summary dated 05/17/2025 included a scheduled Wound Care procedure on 06/11/2025, though no additional details were provided. Staff and R1 continued to deny the presence of bed sores. Facility Service Logs between 05/27/2025 and 06/02/2025 documented twenty-eight (28) services provided to R1 including incontinent care, mobility checks, and incidentals. Based on interviews and record review, although the allegations may have happened or are valid, there is insufficient evidence to prove the alleged violations did or did not occur therefore the allegations are deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 29-AS-20250530152112

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management Legal/Non-Compliance visit at 9:48AM. The purpose of today’s visit is to ensure the facility is maintaining substantial compliance as discussed in a Non-Compliance Conference on 12/15/2025. The LPA met with Assistant Administrator (AA) Riza Vitug and Executive Director (ED) Lito Vitug arrived at 11:08AM. Entrance interview conducted. During today’s visit, the LPA and AA conducted a physical plant tour at 10:02AM to ensure there were no health and safety hazards. The following was observed: LPA Huynh observed a total of sixteen (16) randomly selected resident rooms, each with a private restroom, on the first and second floor and interviewed nine (9) residents. Interviews with residents did not reveal any immediate concerns and they were all generally happy and appreciative of the care provided by the facility. Resident rooms obtained all required furniture and had sufficient lighting. Restrooms were observed to have non-slip mats and grab bars. Hot water temperature was measured and six (6) out of eleven (11) restroom sinks measured above 120 degrees F, which is not within the required range. The ED explained that the facility installed a new boiler a few months ago with follow up inspections, which may have been the cause of the temperature spiking. The Maintenance staff stated that the boiler’s temperature was set to 120 degrees F and that they would lower it. Report Continued on LIC 809-C The facility’s kitchen was observed to be in compliance with food of good quality and knowledge of residents’ dietary restrictions. Emergency food and water were maintained in a secured hallway storage closet. The facility’s immediate exterior perimeter did not pose a risk or contain any safety hazards to residents in care. There was also a courtyard that contained furniture in good condition and shade for resident and visitor use. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Mar 24, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Mar 25, 2026

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents... Hot water temperature controls shall be maintained to... a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in 6 resident restroom sinks measured above the required range which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 24, 2026

Plan of correction: The Licensee will lower the boiler and re-test the 6 resident restroom sinks and provide proof to CCLD by POC due date.

Allegation investigated: Staff did not provide resident with assistance in a timely manner Staff did not treat resident with respect

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced subsequent complaint visit to deliver findings for the above allegations. The LPA arrived at 12:50PM and met with Facility Manager Joey Vitug and Administrator Lori McKay. Entrance interview conducted. On 02/03/2026, the LPA conducted an initial complaint visit. Between 10:03AM and 4PM, the LPA conducted a physical plant tour, reviewed and obtained pertinent documents, and interviewed four (4) residents and four (4) staff. During today’s visit, the LPA and Administrator conducted a physical plant tour at 12:58PM and no immediate concerns were observed. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegations: “Staff did not provide resident with assistance in a timely manner” and “Staff did not treat resident with respect” It was reported that Resident #1 (R1) was left unassisted on the evening of 01/21/2026 which resulted in R1 spending the night in their wheelchair. It was also alleged that on 12/18/2025, overnight staff mocked R1 and did not provide them with assistance. Interview with R1 revealed that at approximately 6:25PM on 01/21/2026, they had dinner and asked who would be assisting them with preparing for bed. They were informed that Staff #1 (S1) would assist; however, S1 never arrived. At approximately 9:25PM, R1 called the facility phone and S1 told them they would be assisted shortly. Assistance did not occur, and when R1 called again, there was no answer. R1 remained in their wheelchair throughout the night and was afraid to fall asleep until Staff #2 (S2) found them the following morning. R1 stated they did not use their call button that night. R1 also reported that they enjoy living at the facility, that the Administrators address concerns promptly, and that staff generally treat them well. R1 denied experiencing disrespect or mocking from staff and expressed a preference for certain caregivers. S1 reported that R1 typically returns from Dialysis between 6PM and 6:30PM, waits about an hour before requesting dinner due to post-treatment weakness, and then receives assistance with bedtime preparation around 8:30PM. On 01/21/2026, S1 stated that R1 refused assistance and requested a specific caregiver who was not scheduled. S1 reported offering assistance multiple times, but R1 allegedly became angry and yelled at S1 to leave. When S2 arrived for their shift, S1 informed them of R1’s refusals. S2 attempted to assist but was also unsuccessful. S2 reported checking on R1 every two (2) hours and leaving R1’s door slightly ajar to maintain visual monitoring due to R1’s agitation and yelling. S2 observed R1 to sleep and watch TV in their wheelchair throughout the night. S2 stated that R1 used their call button once and also called the facility phone between 4AM and 5AM requesting restroom assistance. Additional staff interviews indicated that R1 frequently refuses assistance and requests specific caregivers who may not be available, though staff attempt to accommodate these preferences. Staff denied witnessing or engaging in disrespectful behavior toward residents. Report Continued on LIC 9099-C A review of the facility’s internal incident reports revealed four (4) additional occurrences involving R1’s refusals and aggressive behavior toward staff. R1 had also made a secondary claim of not receiving assistance overnight; however, the facility’s investigation determined that staff had provided care. Facility service logs for 01/21/2026 to 01/22/2026 documented that R1 received “Aid Incidentals” at 6:41PM, Quality Check at 7:41PM, Meal Service at 7:45PM, Quality Check at 12:38AM, and Incontinent Care at 9:02AM. Staff reported they were unable to scan the QR code in R1’s room to confirm additional Quality Checks due to R1’s refusals. Although S2’s assistance between 4AM and 5AM was not logged, an Unusual Incident Report documented that R1 used their call button at 4:30AM requesting assistance. R1’s Physician’s Report dated 02/20/2025 documented a diagnosis of end stage renal disease requiring Dialysis treatment. At that time, R1 was not noted to be disoriented, aggressive, or depressed and was able to follow instructions and communicate their needs. Individual Service Place (ISP) dated 08/01/2025 later documented R1 additional diagnoses of depression and an unspecified mental disorder. The ISP noted that R1 has difficulty remembering and using information, experiences some difficulty in new situations, and sometimes demonstrates impaired judgment. R1 also exhibited agitation, disruptive or aggressive behavior, and emotional states that created frequent difficulties with others. The ISP emphasized that maintaining open communication with R1 is essential to establishing trust, safety, comfort, and social engagement. Based on interviews and record review, although the allegations may have happened or are valid, there is insufficient evidence to prove the alleged violations did or did not occur therefore the allegations are deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 29-AS-20260127152355

Allegation investigated: Staff abandoned resident at hospital

Licensing Program Analyst (LPA) Quoc Huynh conducted an initial complaint visit for the above allegation. The LPA arrived at 12:50PM and met with Facility Manager Joey Vitug and Administrator Lori McKay. Entrance interview conducted. Between 12:58PM and 2:06PM, the LPA conducted a physical plant tour and interviewed, the Facility Manager and Administrator, and reviewed and obtained pertinent documents. The following was then determined: Allegation: “Staff abandoned resident at hospital” It was reported that the facility refused to accept Resident #1 (R1) back from the hospital. On 02/27/2026, R1 was transferred to the hospital due to constipation. Upon R1’s discharge, the facility informed the hospital that R1 required a higher level of care and could not be re-admitted. Report Continued on LIC 9099-C Substantiated Interview with the Facility Manager revealed that the facility believed R1 required a higher level of care due to a diagnosis of incomplete quadriplegia and frequent hospital visits for disimpaction. The Facility Manager stated that R1 required extensive care and acknowledged that a re-appraisal had not been completed. The Facility Manager also reported that prior to the 02/27/2026 hospital transfer, R1 had expressed interest in relocating to a Skilled Nursing Facility (SNF), and that R1’s provider and the Long-Term Care Ombudsman (LTCO) agreed that a higher level of care was appropriate. The Facility Manager further stated that R1’s provider informed the hospital that R1’s safety would be at risk if discharged back to the facility. R1 was later transferred to a second hospital, which also contacted the facility to arrange R1’s return; the facility again refused readmission. Interview with the Administrator revealed that the facility believed R1’s disruptive behaviors, need for a two (2) person assist, and assistance with smoking were beyond what the facility could provide. The Facility Manager and Administrator stated that the facility attempted to relocate R1 to other licensed facilities and SNFs but was unsuccessful. Record review confirmed that the facility did not document a change of condition, did not complete a re-appraisal, and did not provide evidence that R1’s needs exceeded the facility’s licensed capacity. Information provided by the hospital indicated that R1 was medically cleared for discharge back to the facility and that R1 was in agreement with returning. Based on interviews and record review, the facility initiated the refusal of readmission despite the hospitals’ attempts to discharge R1 and R1’s expressed desire to return. The preponderance of evidence standard has been met; therefore, the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 9099-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 29-AS-20260309155141

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(20) · Plan of correction due date: Mar 11, 2026

(a) In addition to the rights listed in Section 87468.1... residents... shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions... This requirement was not met as evidenced by: Based on interview and record review the Licensee did not comply with the section cited above in the facility refused R1's readmission upon hospital discharge which poses/posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 10, 2026

Plan of correction: The Licensee will re-admit R1 to the facility from the hospital and send proof to CCLD by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced Case Management – Other visit at 10:55 a.m., LPA was greeted by front door receptionist and explained the reason for the visit. LPA met with Rizaandrea Vitug, Assistant Administrator (AA) and Angelito "Lito" Vitug, Executive Director and the reason for the visit was explained. Entrance interview conducted. The purpose of the visit is to conduct staff interviews pertaining to a prior investigation. During today’s visit, LPA and AA conducted a physical plant tour to ensure there are no immediate health and safety concerns, conducted five (5) in-person staff interviews, one (1) telephonic staff interview along with obtained copies of pertinent documents. No immediate health and safety concerns were observed during today's visit. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Feb 19, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management visit in conjunction with Complaint #29-AS-20251215145511. The LPA arrived at 10:20AM and met with Assistant Administrator (AA) Rizaandrea Vitug and Executive Director (ED) Angelito Vitug arrived shortly thereafter. Entrance interview conducted. Beginning at 10:25AM the LPA and AA conducted a physical plant tour, and no immediate concerns were observed. Resident #1 (R1) was admitted to the facility on 09/03/2025 and was diagnosed with incomplete quadriplegia and documented to be bedridden. Individual Service Plan dated 04/17/2025 documented R1’s physical environment to be accessible and safe, with adaptive equipment to aid in their daily activities. This included conducting regular safety assessments, removing potential hazards, and providing necessary mobility aids. It was additionally recommended that the facility coordinate with occupational and physical therapists to assess and implement additional aids that would enhance R1’s comfort and safety. Report Continued on LIC 809-C During the complaint investigation, it was revealed that the facility did not follow R1’s care plan in coordinating with occupational and physical therapists or other third-party consultants to implement necessary mobility aids. On 01/13/2026 after an initial finding was delivered, the facility then consulted with a physical therapist for an assessment and confirmed that R1 had some strength for movement. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Jan 22, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Jan 13, 2026

(d) …if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident’s needs as identified in the pre-admission appraisal… and providing the other basic services specified below, either directly or through outside resources. This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not comply with the above cited section as the facility did not follow R1's care plan which poses/posed a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 22, 2026

Plan of correction: The Licensee consulted with a physical therapist on 01/13/2026 and provided CCLD clinical notes. POC Cleared.

Allegation investigated: Licensee did not ensure facility was free from pests

Licensing Program Analyst (LPA) Quoc Huynh conducted an initial complaint visit for the above allegation. The LPA arrived at 9:47AM and met with Assistant Administrator (AA) Rizaandrea Vitug. The Executive Director (ED) Angelito “Lito” Vitug arrived at 10:50AM. Entrance interview conducted. During today’s visit, the LPA and AA conducted a physical plant tour at 9:52AM. Between 10:38AM and 2PM, the LPA reviewed and obtained pertinent documents and interviewed six (6) staff, one (1) family member, the AA, and the ED. The following was then determined: Report Continued on LIC 9099-C Substantiated Allegation: “Licensee did not ensure facility was free from pests” It was reported that Resident #1 (R1) previously had cockroaches observed in their bathroom and currently had cockroaches in their bedside dresser. During a tour of R1’s room, the AA opened the bedside dresser that was utilized as a nightstand, and multiple cockroaches were observed to scatter. The LPA observed cockroach droppings in the drawer in addition to cockroaches crawling on the walls. The AA stated that it was reported approximately one (1) week ago, and that the facility had attempted to remove the dresser, but R1 refused. The ED stated that a pest control treatment was scheduled for 01/06/2026 when R1 was at a doctor’s appointment; however, R1 did not make the appointment. A follow up appointment was scheduled for 01/12/2026. During the visit, the LPA spoke with R1’s family member who expressed concerns and agreed to have the dresser removed. Interview with staff revealed that one (1) staff confirmed observing cockroaches in R1’s room and three (3) other staff confirmed observing cockroaches in the hallways in addition to receiving resident reports of cockroaches in their rooms. Staff showed knowledge of reporting pest concerns to maintenance who in turn respond by treating the resident rooms with a spray that does not put residents at risk. Based on interviews and observation, the preponderance of evidence standard has been met, therefore the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to 9099-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Jan 12, 2026 · control 29-AS-20260108161808

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jan 26, 2026

(a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidence by: Based on interview and observation, the Licensee did not comply with the above cited section in R1 had cockroaches in their room which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 12, 2026

Plan of correction: The facility removed the dresser during the visit and will send proof of complete pest control treatment by POC due date.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff are not providing reasonable accommodations to resident in care

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to amend findings for the above allegation. The LPA arrived at 10:20AM and met with Assistant Administrator (AA) Rizaandrea Vitug. Executive Director (ED) Angelito “Lito” Vitug arrived shortly thereafter. Entrance interview conducted. On 12/23/2025, LPA Huynh conducted an initial visit at 9:26AM. Between 9:45AM and 3:44PM, the LPA conducted a physical plant tour, reviewed and obtained pertinent documents, and interviewed five (5) staff and one (1) resident. Long-Term Care Ombudsman Regional Director (LTCORD) Ginger Perini joined the visit at 1:16PM. Report Continued on LIC 9099-C Unsubstantiated On 01/12/2026, the LPA conducted a subsequent visit and delivered substantiated findings for the above allegation at 9:47AM. At 9:52AM, a physical plant tour was conducted, and no immediate concerns were observed. During today’s visit, the LPA and AA conducted a physical plant tour at 10:25AM, and no immediate concerns were observed. The following was then amended: Allegation: “Staff are not providing reasonable accommodations to resident in care” It was reported that staff did not assist Resident #1 (R1) with obtaining cigarettes or smoking outside and did not accommodate R1’s condition with a reasonable alternative for their call button/pull cord. R1 was diagnosed with incomplete quadriplegia and documented to be bedridden. Individual Service Plan dated 04/17/2025 documented R1’s physical environment to be accessible and safe, with adaptive equipment to aid in their daily activities. This included conducting regular safety assessments, removing potential hazards, and providing necessary mobility aids. It was additionally recommended that the facility coordinate with occupational and physical therapists to assess and implement additional aids that would enhance R1’s comfort and safety. Staff interview revealed that staff assistance with smoking cigarettes is based upon staff discretion and their openness to exposing themselves to the elements. Two (2) caregivers have reportedly been observed to assist R1 in the late afternoon and evenings with smoking which includes holding the cigarette and bringing it to their mouth. Staff reported that R1’s pull cord was wrapped around their arm due to their condition and that R1 did not express any complaints. Staff stated that R1 would often request for staff to wrap the cord around their arm. They further indicated that there were no other alternatives that did not require R1 to be tethered to the pull cord and if there was, it was not their decision to make. Staff also reported that R1 often changed their minds when they made decisions or when they agreed to allow staff assistance, and that R1 was very demanding about their care. Report Continued on LIC 9099-C Interview with R1 confirmed that the facility obtained cigarettes after R1 had provided the facility with money. They also confirmed that staff assisted them once to twice a day in the evenings by going outside and smoking. R1 reported that they only request to go outside for a smoke about twice a day. R1 stated that utilizing the pull cord around their arm is sufficient in the meantime due to the facility not providing other accommodations. R1 raised concerns about the pull cord being accessible only when they are in bed and when their wheelchair is positioned close to the call button system. However, if they were further away, they would not be able to utilize the system and request for staff assistance. Interview with the ED revealed attempts to provide alternatives for R1’s pull cord which included attaching a lanyard to R1’s arm and obtaining a push button pendant. Due to R1’s condition, R1 stated they would not be capable of utilizing a pendant and it was reported that R1 also refused the lanyard alternative. The ED stated that R1 often refused assistance and redirection from staff and frequently changed their mind when they made requests. The ED expressed difficulty with finding accommodations for R1’s pull cord system, but that they were actively working on solving the issue. On 01/13/2026, the facility consulted with a Physical Therapist (PT) to assess R1’s mobility and alternatives to the call system. The PT noted that R1 has some strength for movement in their elbow, hand, and fingers to utilize the pull cord. Furthermore, R1 was confirmed to adequately pull the cord in addition to pushing the button on a pendant to trigger the call system. Based on interview and record review, R1 confirmed assistance with smoking and was provided alternatives to the call system; however, they refused those alternatives and requested for staff to attach the pull cord around their arm. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Jan 12, 2026 · control 29-AS-20251215145511

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jan 13, 2026

Deficiency rescinded - intentionally left blank.the state’s words, verbatim · CDSS document, Jan 12, 2026

Plan of correction: Deficiency rescinded - intentionally left blank.

Allegation investigated: Staff did not complete a personal property inventory for a resident in care

Licensing Program Analyst (LPA) Quoc Huynh conducted an initial complaint visit for the above allegation. The LPA arrived at 9:26AM and met with Assistant Administrator (AA) Rizaandrea “Riza” Vitug. The Executive Director (ED) Angelito “Lito” Vitug arrived at 10:43AM. Long-Term Care Ombudsman Regional Director (LTCORD) Ginger Perini joined the visit at 1:16PM. Entrance interview conducted. During today’s visit, the LPA and AA conducted a physical plant tour at 9:45AM and no immediate concerns were observed. Between 10AM and 3:44PM, the LPA reviewed and obtained pertinent documents and interviewed five (5) staff, one (1) resident, and the ED. The following was then determined: Report Continued on LIC 9099-C Substantiated Allegation: “Staff did not complete a personal property inventory for a resident in care” It was reported that the facility did not conduct a personal property inventory for Resident #1 (R1). Interview and record review confirmed an inventory was not completed upon R1’s admission to the facility. The facility has since completed an inventory on 11/25/2025 of R1’s current belongings. Based on interview and record review, the preponderance of evidence standard has been met, therefore the allegation is deemed SUBSTANTIATED at this time with no deficiency as the facility was cited for this violation on 12/04/2025 and has met their Plan of Correction (POC). No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided. Allegation: “Staff did not safeguard resident's personal possessions” It was reported that Resident #1 (R1) had a bag of missing clothes that the facility did not appropriately safeguard. Interview with staff revealed that R1 arrived to the facility with minimal belongings. R1 had reported a bag of clothes missing, however, staff observed their clothes to be stored away in R1’s dresser and closet. Interview with R1 insisted they had two (2) bags of clothing and that one (1) was missing. R1 was unable to specify which clothing items were missing. Prior to admission to the facility, R1 was at a Skilled Nursing Facility (SNF). Record review of R1’s Inventory of Personal Effects at their SNF and review of current clothing items in their possession were accounted for. Clothing items included eight (8) shirts, five (5) pants, four (4) pairs of socks, and one (1) beanie. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Dec 23, 2025 · control 29-AS-20251215145511

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff confines resident to their bedroom

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegation. The LPA arrived at 9:26AM and met with Assistant Administrator (AA) Rizaandrea “Riza” Vitug and Executive Director (ED) Angelito “Lito” Vitug who arrived at 10:43AM and explained the reason for the visit. Entrance interview conducted. On 11/13/2025, LPA Huynh conducted an initial complaint visit. Between 12:40PM and 5:05PM, the LPA reviewed and obtained pertinent documents, conducted a physical plant tour, interviewed four (4) residents and four (4) staff, and attempted one (1) resident interview. Report Continued on LIC 9099-C Substantiated On 12/04/2025, LPA Huynh conducted a subsequent visit. Between 10:17AM and 1:35PM, the LPA conducted a physical plant tour and interviewed five (5) residents and four (4) staff. During today’s visit, the LPA and AA conducted a physical plant tour at 9:45AM, and no immediate concerns were observed. The following was then determined: Allegation: “Staff confines resident to their bedroom” It was reported that Resident #1 (R1) was confined to their bedroom and staff did not provide assistance with transfers to enable R1’s participation in community activities. Staff interviews revealed that R1 had limited mobility, was unable to sit independently, and required assistance with transfers. R1’s family specifically requested staff to assist with transfers so R1 could have social exposure, fresh air, and meals in the dining room. The family reportedly visited the facility daily and often completed transfers themselves, which limited opportunities for staff to assist. Despite this, staff acknowledged awareness of the family’s requests over previous months, but confirmed they were not accommodated due to R1’s need for full supervision when in a wheelchair. Staff further reported they were instructed not to assist R1 into the dining room for meals, without explanation. Staff noted R1 was only transferred out of bed two (2) to three (3) times per week for scheduled showers. Although R1 had a wheelchair restraint available to aid with sitting, staff declined to utilize it. Staff later stated that following the LPA’s initial visit conducted on 11/13/2025, facility staff began assisting R1 outside of their bedroom and into the community. The Department of Health Care Services Individual Service Plan (ISP) updated on 08/28/2025 documented that R1 should be supported to avoid social isolation. Staff were directed to encourage and assist R1 with escorting and reminders for activities to promote participation. The ISP also required staff to encourage R1 to engage in safe, independent activity whenever possible. Due to R1’s bed-bound status, unsteady gait and need for safe transfers, staff were expected to provide necessary support to ensure safety. Report Continued on LIC 9099-C Staff were also expected to assist with activities of daily living (ADLs) to promote movement and independence, and to facilitate interaction with other residents to foster social connection. Through these efforts, R1 was expected to maintain or improve their level of mobility. R1’s Physician Report dated 04/02/2025 confirmed R1 was non-ambulatory with motor impairment, utilized a wheelchair, and required assistance with transfers. Based on interview and record review, the facility did not assist or encourage R1 with mobility and social engagement. The preponderance of evidence standard has been met, therefore the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 9099-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided. On 12/04/2025, LPA Huynh conducted a subsequent visit. Between 10:17AM and 1:35PM, the LPA conducted a physical plant tour and interviewed five (5) residents and four (4) staff. During today’s visit, the LPA and AA conducted a physical plant tour at 9:45AM, and no immediate concerns were observed. The following was then determined: Allegation: “Staff did not respond to a resident’s call button in a timely manner” It was reported that facility staff failed to respond to a resident’s call button in a timely manner, with a response time of one (1) hour. Interviews with five (5) out of nine (9) residents indicated that while most do not frequently utilize their call button, staff response time generally ranged from immediate assistance to approximately twenty (20) minutes. In contrast, four (4) residents reported experiencing delays of up to one (1) hour, which they attributed to low staffing levels. Staff interviews revealed that response times vary depending on current tasks and simultaneous call button use, with an average response time between ten (10) minutes to twenty (20) minutes. Staff stated they prioritize requests based on urgency, ensuring completion of ongoing assistance before responding to other residents. Typical call button requests include showers, incontinence care, transfers, and obtaining items such as ice. One (1) staff reported the longest wait time was approximately forty-five (45) minutes when a resident requested a transfer. The ED explained that they will first check in with residents to determine the nature of their request before prioritizing assistance. The ED also noted that call button activity is typically low due to routine care being provided throughout the day. Additionally, Staff are required to verbally acknowledge call button activations via facility radios. LPA Huynh tested five (5) randomly selected resident rooms on the first and second floors. Call buttons were located at residents’ bedsides and in each restroom. All tested call buttons successfully triggered the call lights located in the med-tech room and activated the corresponding auditory alarm. Report Continued on LIC 9099-C During the investigation, the LPA observed staff acknowledging call buttons and responding to residents’ requests for assistance. Based on interviews and observation, there is insufficient evidence to determine whether staff failed to respond to resident call buttons in a timely manner. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. Allegation: “Staff did not safeguard a resident’s personal item” It was reported that the facility did not safeguard R1’s hairbrush and was unable to locate it. Interview with staff revealed that the facility does not frequently receive reports of missing or stolen items. In most cases, residents reported items as missing that are later found within the bedrooms. Staff noted that residents with cognitive impairments often report missing items they did not possess. Staff further stated that they have generally been successful in locating and returning residents’ belongings when such reports are made. Facility practices for safeguarding personal property include ensuring resident doors are closed and locked, maintaining staff presence and supervision in hallways, and monitoring cameras positioned throughout the facility. When items are reported missing, staff assist in searching the facility, notifying administrators, and maintaining communication with the residents regarding the status of the search. Interview with the AA revealed that R1’s hairbrush went missing shortly after their admission to the facility. R1’s family mentioned the issue and the facility offered to provide a locked drawer for safe keeping of personal items as well as offered to replace the hairbrush. R1’s family declined the offer and stated they would replace it themselves and provided the AA photo documentation. During this time, it was reported that R1 received several visitors daily which included physical therapists and home health or hospice nurses who may have misplaced the item. R1’s family reportedly agreed. Report Continued on LIC 9099-C Interviews with six (6) residents revealed that they had not experienced missing or stolen personal items. One (1) resident reported towels missing after laundry service, which were later found and returned. Another resident reported missing items and stated that staff “did what they could” to assist in locating the items. Based on interviews and review of facility procedures, there is insufficient evidence to determine whether staff failed to safeguard R1’s personal item. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited related to the above allegations. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Dec 23, 2025 · control 29-AS-20251107125915

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(a) · Plan of correction due date: Jan 6, 2026

(a) The services provided by the facility shall be conducted… to continue and promote, to the extent possible, independence and self-direction.... Such persons shall be encouraged to participate… as their conditions permit in daily living activities both in the facility and in the community. This requirement was not met as evidence by: Based on interview and record review, the Licensee did not comply with the above cited section as R1 was not assisted with daily living activities in the community which poses/posed a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 23, 2025

Plan of correction: The Licensee hired a Resident Care Coordinator to oversee residents' needs and has since assisted R1 into the community. The Licensee will provide CCLD proof of the Care Coordinator's employment by POC due date.

Allegation investigated: Staff did not report an incident to licensing Staff did not complete a personal property inventory for a resident in care

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegations. The LPA arrived at 9:56AM and met with Assistant Administrator Rizaandrea “Riza” Vitug, Executive Director (ED) Angelito “Lito” Vitug who arrived at 11:14AM and explained the reason for the visit. Entrance interview conducted. On 11/13/2025, LPA Huynh conducted an initial complaint visit. Between 12:40PM and 5:05PM, the LPA reviewed and obtained pertinent documents, conducted a physical plant tour, interviewed four (4) residents and four (4) staff, and attempted one (1) resident interview. Report Continued on LIC 9099-C Substantiated During today’s visit between 10:17AM and 1:35PM, the LPA conducted a physical plant tour and interviewed five (5) residents and four (4) staff. No immediate concerns were observed. The following was then determined: Allegation: “Staff did not report an incident to licensing.” It was reported that the facility did not notify Community Care Licensing (CCL) of an unwitnessed fall. On 07/26/2025, Resident #1 (R1) sustained an unwitnessed fall in their unit and was found on the floor by their bedside. The facility notified R1’s family and R1 was subsequently transferred to the hospital via Emergency Services. Interview with five (5) out of seven (7) staff revealed that they were unaware about the CCL reporting requirements, or if facility incidents were reported to CCL. Staff responsibilities include logging incidents in the facility’s electronic system and facility Administrators are responsible for the remaining steps. Interview with the ED noted that they “assumed Licensing received the report” of R1’s fall. When the LPA inquired about the details of the fall, the ED requested to review the copy the LPA obtained and provided information off the Incident Report. On 11/05/2025, the LPA conducted an unrelated complaint visit and addressed facility Incident Reports with the Office Manager Joey Vitug. The Office Manager is responsible for completing Incident Reports and sending them to CCL. They stated they utilize an App called Genius Scan that scans the Incident Reports which processes and automatically emails CCL the reports. During the visit on 11/13/2025, the LPA reviewed CCL’s record of Incident Reports received from 2024 to present with the ED, the incident on 07/26/2025 not included as it was not received. The ED expressed and confirmed that the record did not reflect the accurate number of incidents the facility has experienced. The LPA addressed the Genius Scan App and suggested that the facility email all reports to the Woodland Hills North Regional Office directly to ensure receipt and compliance. The ED agreed. Report Continued on LIC 9099-C Based on interviews and record review, the preponderance of evidence standard has been met, therefore the allegation is deemed SUBSTANTIATED at this time. Allegation: “Staff did not complete a personal property inventory for a resident in care.” It was reported that the facility did not complete a personal property inventory upon admission. Four (4) out of seven (7) staff reported the facility does not complete a personal property inventory upon resident admission and are unsure of the procedure. The ED confirmed that resident personal property inventory is only completed if the property is entrusted to the facility. The LPA reviewed Health and Safety Code Section 1569.153 Theft and Loss Program and CA Code of Regulations Section 87217 Safeguards for Resident Cash, Personal Property, and Valuables with the ED. Record review of five (5) resident records revealed that LIC 621 Client/Resident Personal Property and Valuables form and Theft and Loss Policy were included in the resident Admission Agreement on pages “RB RF-31” to “RB RF-34.” The LIC 621 on page RB RF-31 did not list the residents’ names and included typed notes stating “I have no property/valuables entrusted to Royal Bellingham at this time” and “NOTE: The Residences at Royal Bellingham will only inventory and provide the resident or responsible party with a copy of the resident’s personal properties/valuables as inventoried items if said items are entrusted to the facility and are stored in a secured area controlled by the facility. Any and all other personal properties or valuables are solely the responsibility of the resident and/or their responsible party.” Health and Safety Code Sections 1569.152, 1569.153, and 1569.154 on page RB RF-32 did not contain signatures of receipt. The facility’s Theft and Loss Policy on page RB RF-33 noted “The Administrator will be responsible for maintaining a record of each Resident’s personal property/valuables. Resident’s Personal Property and Valuables (Form 621) will be completed upon admission with the assistance of the Resident or Responsible Party” and “An inventory of personal property will be maintained by The Royal Bellingham.” Six (6) out of nine (9) residents confirmed a personal property/valuables inventory was not completed upon admission. Report Continued on LIC 9099-C Based on interviews and record review, the preponderance of evidence standard has been met, therefore the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (Refer to LIC9099-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided. During today’s visit between 10:17AM and 1:35PM, the LPA conducted a physical plant tour and interviewed five (5) residents and four (4) staff. No immediate concerns were observed. The following was then determined: Allegation: “Staff did not prevent a resident from being locked outside for a long period of time” It was reported that on 11/02/2025 around 8:30PM, Resident #1 (R1) returned to the facility and was locked outside for approximately twenty-five (25) minutes. Interview with nine (9) residents revealed that they have not experienced, or observed other residents locked outside. Eight (8) staff reported residents waiting a maximum of ten (10) minutes and noted that response time is typically very quick when visitors and residents return to the facility late at night. The facility locks the exterior doors in the late evening, and visitors can utilize the doorbell/buzzer and call the facility phone number to gain entrance. Staff reported the doorbell to be heard easily in the night due to most residents resting and the facility being quiet. Additionally, staff carry a wireless phone which receives all phone calls made to the facility. Doorbell footage of the rear entrance on 11/02/2025 revealed that R1 approached the door at 8:42PM. R1’s family rang the doorbell at 8:43PM and was observed to subsequently ring the doorbell several times before attempting to call the facility phone number. At 8:47PM, Staff opened the rear door while R1 and their family entered the facility. R1 was at the rear entrance for approximately five (5) minutes before gaining entry. Although the allegation may have happened or are valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of today’s report was reviewed and provided.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 29-AS-20251107125915

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Dec 18, 2025

(a) Each licensee shall furnish to the licensing agency such reports…including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency… within seven days of the occurrence of any of the events specified in (A) through (D) … This requirement was not met as evidenced by: Based on interview and record review the Licensee did not comply with the above cited section as CCL did not receive a report/notification of an unwitnessed fall which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: The Licensee plans to continue utilizing Genuis App in addition to emailing CCL incident reports. An in-service staff training will also be conducted on CCL reporting requirements and will be provided to CCLD by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.153(d) · Plan of correction due date: Dec 18, 2025

(d) A written resident personal property inventory is established upon admission and retained during the resident's stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident's representative, and dated. … This requirement was not met as evidenced by: Based on interview and record review the Licensee did not comply with above cited section in the facility did not complete a personal property inventory written in ink upon admission which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: The Licensee removed the disclaimer from LIC 621 and will inventory resident belongings upon admission. An in-service staff training will also be conducted on admisison precedures and will be provided to CCLD by the POC due date.

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: Sexual Abuse

Licensing Program Analyst (LPA) Erica Mosley conducted a subsequent complaint visit to investigate the above listed allegation. The purpose of this visit is to deliver findings for the above listed allegation. LPA met with Rizaandrea Vitug, Assistant Administrator and Angelito "Lito" Vitug, Executive Deirector and explained the reason for the visit. On 04/14/2025, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint regarding the allegation of sexual abuse which was revealed during an unrelated investigation. On 04/15/2025 a referral was made to the Community Care Licensing Division's (CCLD) Investigation Branch (IB). Investigator (Inv.) Veronica Padilla was assigned to the investigation. On 04/15/2025 LPA Mosley conducted the initial 10-day complaint visit. Starting at 9:55 a.m., LPA along with Assistant Administrator, Rizaandrea Vitug conducted a physical plant tour to ensure there were no immediate health and safety concerns, along with requested copies of pertinent documents relevant to the investigation. Report continued on LIC 9099C.... Substantiated (Page 2) Report continued from LIC9099... On the allegation Sexual Abuse, it is the concern of the reporting party (RP) that Staff #1 (S1) sexually assaulted Resident #1 (R1) and engaged in sexual relations with Resident #2 (R2). To investigate this complaint on 04/09/2025, Inv. Padilla conducted a visit to the facility and reviewed and requested copies of R1, R2, and S1 files, as well as S1’s work schedule from 03/01/2025 to 04/30/2025. On 03/20/2025 at approximately 2:50 p.m., a telephonic interview was conducted with Staff #2 (S2). On 03/28/2025 at approximately 11:40 a.m., an in-person interview was conducted with R1; at 1:00 p.m., an in-person interview was conducted with Staff #3 (S3). On 04/02/2025 at approximately 9:10 a.m. and 12:40 p.m., electronic correspondence via email was exchanged with an LAPD Detective. On 04/07/2025 at approximately 3:26 p.m., an additional interview was conducted with S2. On 04/08/2025 at approximately 8:20 a.m., a telephonic interview was conducted with R1. On 04/08/2025, Investigator Padilla conducted a visit to the facility; at approximately 10:40 a.m., an in-person interview was conducted with R2; at approximately 11:40 a.m., video footage was reviewed and obtained. On 04/09/2025 at approximately 8:45 a.m., electronic correspondence via email was exchanged with LAPD Detective. On 04/16/2025 at approximately 2:10 p.m., a telephonic interview was conducted with an Ombudsman from the Wise and Healthy Aging Ombudsman Office. On 04/23/2025 at approximately 3:55 p.m., electronic email correspondence was received from the facility containing S1’s timesheet from 03/26/2025 to 04/10/2025. On 04/25/2025 at approximately 2:50 p.m., a telephonic interview was conducted with LAPD Detective. On 04/28/2025 at approximately 1:50 p.m., a telephonic interview was conducted with the Ombudsman Supervisor from the Wise and Healthy Aging Ombudsman Office. On 05/16/2025 at approximately 9:30 a.m., Home Health records for R2 were subpoenaed; on 05/19/2025 at approximately 2:10 p.m., the records were received. On 06/02/2025 at approximately 11:15 a.m., a telephonic phone call was received from the facility’s Executive Director (ED) Angelito Vitug. On 06/12/2025 at approximately 1:41 p.m., a telephonic phone call was received from LAPD Detective. On 07/08/2025 at approximately 10:05 a.m., a telephonic interview was conducted with LAPD Detective. On 07/14/2025 at approximately 11:50 a.m., a telephonic interview was conducted with the Power of Attorney (POA) for R2. On 08/12/2025 at approximately 1:30 p.m., an in-person interview was conducted with R1. On 08/22/2025 at approximately 1:40 p.m., a telephonic call was received from the ED. On 08/26/2025 at approximately 1:30 p.m., a visit to the facility was conducted to review files and collect pertinent documents relevant to the investigation; at approximately 2:30 p.m., a telephonic interview was conducted with the facility Pharmacist/Supervisor. On 08/29/2025 at approximately 9:30 a.m., a telephonic interview was conducted with Staff #4 (S4). Report continued on LIC 9099-C PAGE 3... (Page 3) Report continued from LIC9099 PAGE 2... On 09/03/2025 at approximately 12:30 p.m., a telephonic interview was conducted with the Primary Care Physician (PCP) for R2. On 09/04/2025 at approximately 11:20 a.m., a visit to the facility was conducted and an interview was held with the ED. On 09/04/2025, a subsequent interview was conducted with the ED and an interview was conducted with Facility Manager Joselito “Joey” Vitug. On 09/11/2025 at approximately 9:05 a.m., a phone call was received from LAPD Detective. Several attempts were made during the investigation to interview S1. Although S1 was unavailable to be reached for interview. According to R1’s Physician Report, dated 02/16/2022 R1’s primary diagnosis is listed as Gait D/O, Neuropathy, and Hypokalemia, Requires medication management. R1 uses alcohol, motor impaired/paralyzed, and uses an electric wheelchair, and has a history of skin condition or breakdowns – skin tears. R1 can follow instructions, communicate needs, and leave the facility unassisted. R1 is unable to bathe, dress, groom, or manage toileting independently. R1 unable to independently transfer to and from bed. According to R2’s Physician Report, dated 03/05/2021 R2’s primary diagnosis is listed as Paranoid Schizophrenia, COPD, and Mood Disorder. R2 unable to manage treatment/medication/equipment. R2’s Secondary Diagnosis is listed as Major Depression, Seizures, Insomnia, and encephalopathy, R2 unable to manage treatment, medication, and equipment. R2 is on a Special Diet. R2 presents episodes of confusion but remains capable of following instructions and effectively communicating personal needs. R2 is diagnosed with depression and requires support with Activities of Daily Living (ADLs). Additionally, R2 is unable to independently manage medications and relies on staff assistance for proper administration and oversight. According to R2’s Physician Report, dated 03/17/2023 R2’s primary diagnosis is listed as Bipolar, COPD, Mood Disorder, and Depression, R2 is unable to manage treatment, medication, and equipment. R2’s Secondary Diagnosis is listed as Seizures and Insomnia. R2 is on a Special Diet. R2 exhibits episodes of confusion but remains capable of following instructions and effectively communicating personal needs. R2 has been diagnosed with depression and requires support with Activities of Daily Living (ADLs). Additionally, R2 is unable to independently manage medications and relies on staff assistance for proper administration and oversight. According to R2’s Physician Report, dated 05/09/2025 R2’s primary diagnosis is listed as Bipolar, COPD, Mood Disorder, and Depression B and C. R1 needs assistance managing their treatment and medication. Report continued on LIC 9099-C PAGE 4... (Page 4) Report continued from LIC9099 PAGE 3... R2 experiences episodes of confusion but can follow instructions and communicate personal needs. R2 is diagnosed with depression and requires assistance with Activities of Daily Living (ADLs). R2 is unable to leave the facility without supervision. R2 is capable of administering injections independently. R2 requires assistance with medication administration, including PRN (as-needed) medications, and support with proper medication storage. According to R2’s Department of Health Care Services (DHCS), Individual Service Plan (ISP) dated 04/21/2025 - 10/21/2025 is diagnosed with Paranoid schizophrenia, unspecified encephalopathy. COPD, seizures, extrapyramidal & movement disorder, mood affective disorder, anxiety disorder, major depressive disorder, insomnia, and generalized weakness. Due to R2’s diagnosis, R2 has difficulty understanding their own personal care needs. With the assistance of staff, they are able to manage many of these needs with little issues. It was noted that R2 is Alert and Oriented to Person and Place with periods of confusion and forgetfulness. R2 does not require assistance with making decisions and being aware of their needs. R2’s POA is the one who assists with making decisions. Interview with R2’s PCP revealed that they are the PCP for several residents including R2, staff, and the owner of Residences at Royal Bellingham. They visit the facility once a month, or more frequently if necessary. PCP knows R2 very well because they live in the facility as they have significant psychiatric conditions and are currently prescribed psychotropic medications as part of their treatment plan, however they are currently managing well with it. The review of facility records including but not limited to S1 work schedule from 03/01/2025 to 04/30/2025 indicated that S1 was scheduled off on 03/06/2025, 03/13/2025, 03/18/2025, 03/23/2025, 03/30/2025, 04/03/2025, 04/08/2025, 04/24/2025. S1 employee file and trainings including Relias, one (1) hour training on Abuse, Neglect, and Exploitation in the Elder Care Setting dated 12/29/2024, Relias, twenty-five-minute (.25) training on Care of Bedridden Residents dated 12/23/2024. It was noted that all documents that require an address are blank in the address section. However, S1’s CA ID lists the facility address. Video footage obtained on 04/08/2025 at 11:40 a.m. revealed that on 03/30/2025, at 7:58 p.m. S1 was wearing a black t-shirt and shorts, walked towards R2’s room. S1 had the door keys in hand, opened the door, and entered the room. On 03/30/2025 at 8:18 p.m., the door of R2’s room opens, and S1 exits the room. Report continued on LIC 9099-C PAGE 5... (Page 5) Report continued from LIC9099 PAGE 4... Interviews with R1 revealed that they no longer reside at the facility, having moved out approximately two (2) years ago. R1 lived at the facility for about four (4) months. While R1 generally liked living at the facility, they expressed dissatisfaction with the caregivers’ response time. R1 stated that some male staff appeared to be inappropriate, describing instances where they made suggestive comments during diaper changes and were occasionally rough. R1 recalled experiencing inappropriate remarks from a male caregiver during one (1) or two (2) diaper changes but chose to "brush it off." R1 reported that during a diaper change, a male staff member, name unknown, inserted a finger into their vagina multiple times to remove feces, while making flirtatious remarks. Additionally, R1 stated that they did not witness any inappropriate physical contact by any caregivers. During an attempted second interview on 04/08/2025, R1 claimed to be unaware of any alleged incidents and did not wish to be interviewed. Interviews with R2 revealed that they have lived at the facility for approximately three and a half (3.5) years and have had an overall positive experience. R2 requires assistance with medication management, transportation, and visits to their PCP, who is based at the facility. During the day, R2 is typically assisted by female caregivers, while male caregivers are assigned during the night. R2 stated that during room checks, caregivers knock and use a key to open the door, although R2 usually opens the door themselves. R2 reported that they have never been touched inappropriately, nor have they witnessed any other resident being touched inappropriately. R2 disclosed that they are secretly in a relationship with S1, though they do not publicly display affection. The relationship began as a friendship. R2 initially denied that S1 spent time in their room or that any sexual contact occurred. However, R2 later stated that they had been dating S1 for approximately two (2) years. S1 hugs, kisses, and checks in on R2 to ensure they are okay. R2 later acknowledged that they are intimate with S1, although it is infrequent and occurs approximately once every two (2) months. Intimacy typically begins with text messages of a romantic nature. Sexual activity takes place in R2’s room at the facility, usually during nighttime hours between 8:00 p.m. and 9:00 p.m. S1 would remain in the room for approximately 30 minutes to an hour before leaving. R2 stated that S1 was aware of the potential consequences if they were caught and expressed that they do not want S1 to get into trouble. S1 had informed R2 that they were aware of the camera placement, including one positioned at R2’s door. The last reported instance of sexual activity between S1 and R2 occurred on 03/30/2025 at approximately 8:00 p.m. and lasted about 15–20 minutes. S1 did not stay long due to concerns about the cameras. Report continued on LIC 9099-C PAGE 6... (Page 6) Report continued from LIC9099 PAGE 5... Interviews with POA of R2 revealed that they were aware of the relationship between R2 and S1. The POA stated they learned of the relationship approximately two (2) years ago but were unaware that it was ongoing. Upon being informed of the relationship, the POA contacted the facility’s Executive Director (ED) to verify its validity. The POA reported that the ED denied the allegation. The POA noted that both they and the ED work at licensed facilities and are required to comply with Title 22 regulations, or risk facing consequences. The ED stated that they were “just friends.” The POA acknowledged that R2 can sometimes fabricate stories, and since the ED denied the claims, they chose not to pursue the matter further. The POA emphasized that based on R2’s diagnosis of Schizophrenia and their most recent evaluation, R2 lacks the capacity to consent to a relationship or engage in sexual activity; hence, the POA was established. The POA believes R2 does not possess the ability to understand or make informed decisions, making it difficult to be in a relationship or consent to sexual activity. Although R2 occasionally presents well and appears alert when making decisions about daily activities, such as choosing clothing or deciding where to go, they continue to experience delusions. The POA expressed disbelief that the facility would permit such a relationship to occur. They added that R2 is a patient and S1 is a caregiver. Additionally, the POA stated that both the facility’s ED and Manager were aware of the relationship, as they had inquired about it. Furthermore, the POA asserted that regardless of S1’s intentions, the situation constitutes abuse. R2 is a patient at the facility, and regardless of how the situation is framed, the relationship should not have occurred. The POA concluded that management staff should never have allowed the situation to happen. Interviews with former staff revealed that multiple serious concerns had been reported at the facility, including harassment, inappropriate conduct, and sexual behavior by S1. Allegations of both past and ongoing sexual abuse were also raised. Staff described S1’s behavior as involving romantic entanglements, verbal abuse, and suspected manipulation of vulnerable residents. S2 reported that S1 disclosed to them on two (2) separate occasions that they had inserted their finger into R1’s vagina during a diaper change, stating it was due to the presence of feces. S2 expressed uncertainty about S1’s comment and did not understand why S1 told S2 this on two different occasions and suggested it might be an attempt to appear “macho” or impress S2. Additional concerns included claims that management either ignored or protected problematic behavior. Report continued on LIC 9099-C PAGE 7... (Page 7) Report continued from LIC9099 PAGE 6... Interviews with the Facility Manager (FM) Joselito “Joey” Vitig revealed that they were aware of rumors regarding S1 and R2 but had no direct knowledge or formal reports confirming a relationship. The FM considered their friendship acceptable but acknowledged that a sexual relationship would be inappropriate. The FM confirmed viewing video footage of S1 entering R2’s room and noted that the interaction appeared to be expected by both parties. The FM denied receiving any reports of inappropriate touching by male staff and emphasized that staff-resident relationships are strictly prohibited. Additionally, the FM stated that the facility has since implemented improvements, including enhanced staff training and the hiring of additional female employees. Interviews with the ED revealed that the facility did not have a formal policy regarding staff-resident relationships or off-duty visits, although such relationships are prohibited under Title 22. R2’s POA had spoken with the ED about a possible romantic relationship between R2 and S1; however, a romantic relationship was never confirmed. The ED stated that if such a relationship had been verified, S1 would have been terminated. The ED denied receiving any reports of inappropriate touching or misconduct involving S1 and asserted that any such behavior would have resulted in immediate termination. Furthermore, the ED confirmed that S1 served as the lead caregiver responsible for managing staff schedules and duties. The ED was unaware that S1 had listed the facility’s address on their identification card. The ED stated that S1 is no longer employed or associated with the facility, citing complaints regarding S1’s demeanor. Additionally, the ED noted that improvements are being implemented, including the hiring of more female staff, and reaffirmed their commitment to protecting both residents and staff from misconduct and false accusations. Based on the Department’s investigation, there is sufficient evidence to support the allegation of Sexual abuse. Therefore, the allegation is deemed Substantiated at this time. The following deficiency was observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. A $250 civil penalty is assessed for the citation related to CCR 87468.2(a)(8) for a repeat violation. Assistant Administrator and Executive Director were made aware that failure to correct the deficiencies may result in civil penalties. Assistant Administrator and Executive Director were also informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 28, 2025 · control 29-AS-20250414153609

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Oct 28, 2025

Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition ...(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on interviews, facility video footage, and records review, the licensee did not comply with the section cited above. S1 sexually abused R1 and R2, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: S1 no longer works at the facility has been removed from roster as of 10/13/2025. The Licensee will send LPA a statement of understanding by POC of the cited regulation, Conduct abuse prevention training for all employees, with a specific focus on sexual abuse. The Licensee must submit proof to LPA of the completed training, including materials provided to staff. All staff shall sign an acknowledgment form confirming participation, and the signed forms must be maintained in each staff member's file by 11/11/2025.

Allegation investigated: Staff sexually assaulted resident

Licensing Program Analyst (LPA) Erica Mosley conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Rizaandrea Vitug, Assistant Administrator and explained the reason for the visit. On 01/08/2025, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a self-reported Unusual Incident/Injury Report (UIR) from the facility pertaining to an incident that allegedly occurred on 12/29/2024 regarding Resident #1 (R1) and Staff #1 (S1). R1 alleged that S1 entered R1’s room on 12/29/2024, around 11:30pm stating they were there to check R1’s laundry but then proceeded to jump on R1’s bed and kiss R1. R1 stated they pushed S1 off R1 causing S1 to fall. R1 then asked S1 since they were there, if they could hand R1 their cough drops and S1 then proceeded to leave. On 01/09/2025, the case was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Veronica Padilla to interview R1 to determine if a full investigation was warranted for sexual abuse. Report continued on LIC 9099C.... Substantiated (PAGE 2) Report continued from LIC 9099... On 01/28/2025, the assignment was upgraded to a full investigation. Subsequently, on 02/20/2025, the RO received a complaint pertaining to the same allegation. On 01/09/2025, from 12:02pm to 3:00pm, Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced Case Management visit regarding the self-reported Unusual Incident/Injury Report (UIR) incident report received on 01/08/2025. The UIR pertained to an incident that allegedly occurred between R1 and S1. LPA Byrne met with Executive Director (Administrator) Lito Vitug at 12:02pm and explained the reason for the visit. During the visit, the LPA conducted an interview with the Administrator, conducted a brief physical plant tour, and obtained copies of pertinent information. The LPA informed the Administrator that a referral was submitted to CCL’s Investigations Branch and assigned to Investigator Veronica Padilla. The LPA determined further investigation was needed prior to issuing findings. On 02/26/2025, from 9:30am to 3:20pm, Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced initial complaint visit to the facility. At 9:35am, LPA Mosley met with Rizaandrea Vitug, Assistant Administrator, and explained the reason for the visit. The Executive Director (Administrator) Lito Vitug arrived during the visit. On 02/20/2025 the Department received a complaint alleging staff do not ensure that resident is treated with dignity and respect and a personal rights violation. The personal rights violation is in relation to the self-reported Unusual Incident/Injury Report (UIR) received on 01/08/2025 regarding R1 and S1. The initial visit was conducted on 01/09/2025 by LPA Trevor Byrne. A referral was submitted to Community Care Licensing Division's (CCLD) Investigation Branch (IB) and Investigator Veronica Padilla was assigned to investigate the personal rights violation. At 9:40am, LPA Mosley, along with the Assistant Administrator conducted a physical plant tour to ensure there were no immediate health and safety concerns. From 10:30am to 2:30pm, the LPA conducted interviews with ten (10) residents and six (6) staff including the Administrator and obtained copies of pertinent documents relevant to the investigation. The LPA determined further investigation was needed prior to issuing findings. On 01/28/2025, from approximately 10:30am to 12:50pm, Investigator Padilla conducted interviews with Resident #1 (R1), residents, and Administrator; on 01/30/2025, at approximately 11:00am, with Los Angeles Police Department (LAPD) Detective; on 02/20/2025, at approximately 9:30am, with Administrator; on 03/11/2025, from approximately 9:00am to 2:51pm, with LAPD Detective, and former facility med tech; Report continued on LIC 9099C PAGE 3.... (PAGE 3) Report continued from LIC 9099-C PAGE 2... On 03/12/2025, from approximately 9:23am to 2:10pm, with former caregiver, residents and staff; on 03/20/2025, at approximately 2:50pm, with former med tech; on 03/21/2025, at approximately 1:30pm, with Long-Term Care Ombudsman (LTCO); on 03/28/2025, from approximately 11:40am to 2:00pm, with former residents and former caregiver; on 04/08/2025, from approximately 8:20am to 12:51pm, with former resident, residents, caregivers, facility manager, and Staff #1 (S1); on 04/16/2024, at approximately 2:10pm, with LTCO; on 04/23/2025, at approximately 11:05am, with Administrator; and on 04/24/2025, at approximately 11:20am, with Staff #2 (S2). In addition, the investigator reviewed LAPD Report #25-003466, facility Ring video footage, and facility file documents pertaining to the investigation. According to R1’s Physician Report, dated 10/02/2024, R1’s primary diagnosis is listed as debility and neuropathic pain; the second diagnosis is listed as chronic hypokalemia, depression, hypothyroidism, leukemia, migraine, osteo arthritis, peripheral neuropathy, scoliosis s/p lumbar; R1 can manage own treatment, medication and equipment; mental condition is listed as R1 can follow instructions, communicate needs, and leave the facility unassisted. R1 is ambulatory. The review of the facility staff schedule, laundry schedule and service log revealed the following: According to the facility staff schedule, S1 works the AM shift (7:00am to 3:30pm) and S2 works the NOC shift (11:30pm to 8:00am). The laundry schedule noted that R1’s laundry service was scheduled on Saturdays during the PM shift (3:00pm to 11:30pm). The service log report does not show any service log entries (including laundry service for R1) for 12/29/2024. The review of the facility Ring video revealed that on 12/29/2024 at 11:09pm – S2 stepped out of the stairwell door and walked toward R1’s room, standing in front of the door as S2 retrieved the key from S2’s right pocket. At 11:12pm, it appears that S2 is closing and locking the door to R1’s room, walking down the hallway, and entering another room without knocking. The facility manager confirmed that the person in the video entering R1’s room was S2. It was discovered that S1 did not enter R1’s room during the night of 12/29/2024. R1 likely confused their names due to their similar appearances. On March 11, 2025, Investigator Padilla reviewed LAPD Report #25-003466. On the allegation “Staff #1 (S1) sexually assaulted Resident #1 (R1)” During the Department’s investigation, Investigator Padilla determined that S1 was not the suspect, despite R1 labeling S1 as such due to S1’s similar appearance as S2. Report continued on LIC 9099C PAGE 3.... (PAGE 4) Report continued from LIC 9099-C PAGE 3... Based on the time and date given by R1, along with the facility video footage, Investigator Padilla identified S2 as the person who entered R1’s room during the assault on 12/29/2024 at 11:09pm. Resident #2 (R2) stated on the night of the incident, R1 came to R2’s room at approximately 11:30pm crying and stating that someone had come into their room and jumped on top of R1, kissing and licking R1. On 02/07/2025, the LAPD detective created a photographic lineup that placed S2 in the number three position, and R1 selected S2 from that position. The Administrator Angelito (Lito) Vitug and facility manager Joselito (Joey) Vitug acknowledged that R1 did not call for help on the night of the incident. The service log report does not show any service log entries (including laundry service for R1) for 12/29/2024. The Administrator admitted that completing a laundry task should have taken less than a minute, but if the resident declined laundry services, the caregiver should leave the room, which only takes seconds. On the afternoon of 12/30/2024, the Administrator reviewed the facility Ring video footage and discovered that S2 had entered R1's room the night before. The facility supervisor, admitted that they and the Administrator and facility manager, were aware that S2, not S1, entered R1’s room that night. However, the Administrator chose not to disclose this information to CCL and the police. The Administrator instead wrote an unusual incident report (UIR) under S1’s name, withholding details about S2. The licensee will be cited for reporting requirements under a separate report. On 12/29/2024, S2 was scheduled to start work at 11:30pm. However, S2 entered R1’s room at 11:09pm and was there for approximately three minutes before S2’s shift. S2 stated that S2 started work early to get R1’s laundry. When Investigator Padilla informed S2 that it was not R1’s scheduled laundry day; S2 said, “It was a mistake on my part.” S2 denied the allegation. The facility suspended S2 and S2 is no longer associated to the facility. Based on the Department’s investigation, there was sufficient evidence to support that R1 was sexually assaulted by S2. Therefore, the allegation is deemed Substantiated at this time. The following deficiency was observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Assistant Administrator was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided. (PAGE 2) Report continued from LIC 9099... On the allegation Staff do not ensure that residents are treated with dignity and respect it is the concern of the reporting party (RP) that Staff #5 (S5) and Staff # 6 (S6) retaliated against R1 and told male clients not to go near R1 because they will file a complaint. To investigate this complaint on 02/26/2025 starting at 10:30 a.m. LPA conducted interviews with ten (10) residents including R1, six (6) staff including S5, obtained copies of pertinent documents relevant to the investigation, and on 04/07/2025 at 2:45 p.m. conducted a telephonic interview with a resident. Interview with R1 revealed that they noticed a shift in the staff and resident’s interactions starting in January 2025. R1 stated that Resident #2 (R2) was unresponsive and believes its due to S5 and S6. Interviews with residents revealed that they have positive remarks and experiences with S5 and S6. Residents state that the staff have never discouraged or instructed them not to interact with anyone at the facility including R1. Male residents state they never been discouraged or instructed by staff to not interact with anyone at the facility including R1. Furthermore, R2 stated that they decided on their own to distance themselves from R1, expressing that they did not want to be involved in any conflict or drama. Interviews with staff revealed that R1 tends to behave in a rude and disrespectful manner. Despite occasional behavioral challenges, staff continue to treat R1 with dignity, respect, and professionalism. Staff state that S5 and S6 maintain a professional demeanor and positive interactions with residents including R1. Interview with S5 revealed that there has been no retaliation against R1 by staff or administration. At no point were male residents instructed to avoid interacting with R1 out of concern that they might file a complaint. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff do not ensure that residents are treated with dignity and respect is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 29-AS-20250220154549

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Jul 2, 2025

Additional Personal Rights of Residents in Privately Operated Facilities (a) (a) In addition ...(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on interviews, facility video footage, and records review, the licensee did not comply with the section cited above. S2 sexually assaulted R1, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2025

Plan of correction: The Licensee has suspended S2 and removed them from the facility roster as of 06/05/2025. The Licensee will conduct abuse prevention training for all employees, with a specific focus on sexual abuse.The Licensee must submit proof to LPA ... of the completed training, including materials provided to staff. All staff shall sign an acknowledgment form confirming participation, and the signed forms must be maintained in each staff member's file by POC date 07/16/2025

Allegation investigated: Staff member sexually abused resident in care.

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit. The purpose of this visit is to deliver findings for the above allegation. Upon arrival at 10 a.m., LPA Mosley was greeted by front desk staff and Assistant Administrator. LPA Mosley met with Assistant Administrator Rizaandrea Vitug and explained the reason for the visit. On 10/17/2024 the Department received a complaint regarding the following allegation Staff member sexually abused resident in care. On 10/18/2024 a referral was made to the Community Care Licensing Division's (CCLD) Investigation Branch (IB). Investigator Olivia Spindola was assigned to the investigation. On 10/18/2024 LPA Mosley conducted the initial 10-day complaint visit. Strating at 9:50 a.m., LPA along with Assistant Administrator, Rizaandrea Vitug conducted a physical plant tour to ensure there were no immediate health and safety concerns, starting at 10:30 a.m., LPA requested copies of pertinent documents relevant to the investigation, starting at 11:05 a.m. LPA conducted a file review. Report continued on LIC 9099C.... Unsubstantiated (PAGE 2) Report continued from LIC 9099... On 11/12/2024 starting at 10:30 a.m., Investigator Olivia Spindola conducted an interview with Resident #1 (R1). On 12/18/2025 LPA Mosley conducted an unannounced subsequent complaint visit. Starting at 10:15 AM., the LPA, along with Assistant Administrator Rizaandrea Vitug conducted a physical plant tour to ensure there were no immediate health and safety concerns. From 11:30 a.m., - 3:20 p.m., LPA conducted interviews with eight (8) residents and four (4) staff including the Executive Director and the Assistant Administrator and obtained copies of pertinent documents relevant to the investigation. During today’s visit, starting at 10 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations. On the allegation Staff member sexually abused resident in care it is the concern of the reporting party (RP) that a staff member came into R1’s room and inappropriately touched R1. To investigate this complaint, on 10/18/2024 a referral was made to the Community Care Licensing Division's (CCLD) Investigation Branch (IB) and Investigator Olivia Spindola was assigned to the investigation. On 10/18/2024 starting at 10:30 a.m., LPA requested copies of pertinent documents relevant to the investigation, starting at 11:05 a.m. LPA conducted a file review. On 11/12/2024 starting at 10:30 a.m., Investigator Olivia Spindola conducted an interview with R1. On 11/21/2024 Investigator Olivia Spindola identified that the complaint did not warrant upgrading and was returned to the Woodland Hills North Regional Office. On 12/18/2025 starting at 11:30 a.m., LPA Mosley conducted interviews with eight (8) residents including R1, four (4) staff including the Executive Director (ED), the Assistant Administrator and obtained copies of pertinent documents relevant to the investigation. Interviews with R1 revealed that in August sometime the exact date is unknown around 2:30 a.m., a shadow of a man, possible staff member entered their unlocked room. The room was dark however there was a dimmed light on. Report continued on LIC 9099C PAGE 3.... (PAGE 3) Report continued from LIC 9099... R1 began grunting, seemingly startled by the person who entered, prompting them to turn around and exit. R1 stated that after this no one returned to their room. R1 was not inappropriately touched or assaulted. Interview with ED revealed that R1 had made the facility aware they believed someone entered their room however was unable to specify who and when. In response, the ED reviewed the security footage but found no evidence of anyone entering R1s room during the approx. day and time. R1 did not disclose any sexual abuse to the ED. Interviews with staff revealed that facility staff do not enter resident rooms without knocking adhering to the facilities privacy policy. The staff have never heard or witnessed inappropriate behavior from colleagues, including any incidents of sexual misconduct. Resident interviews revealed that they have never experienced staff coming into their room without permission and have no concerns with the staff. The resident has never experienced inappropriate or sexual contact from staff and has never heard of such incidents occurring between staff and residents. Furthermore, the residents feel safe at the facility and their needs are being met. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff member sexually abused resident in care is deemed unsubstantiated at this time. No deficiencies were observed or cited. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 29-AS-20241017162102

Type of visit: Case Management - Deficiencies

This report has been amended to reflect revised wording. A telephonic review was conducted on August 29, 2025, at 1:43 p.m. with Rizaandrea Vitug - Assistant Administrator to confirm the changes. LPA emailed the amended report for signature, and it will remain on file. Licensing Program Analyst (LPA) Erica Mosley conducted a Case Management - Deficiencies visit. During the Department’s investigation of complaint # 29-AS-20250220154549, the following deficiencies were observed. On 12/30/2024, Resident #1 (R1) reported to the Administrator that R1 was sexual assaulted by Staff #1 (S1) during the evening of 12/29/2024. However, the Administrator did not submit the Unusual Incident/Injury Report (UIR) to Community Care Licensing (CCL) until 01/08/2025. Due to the nature of the allegation, the suspected abuse should have been reported within 24 hours to CCL, Long Term Care Ombudsman (LTCO), and the local police. In addition, the information in the UIR was incorrect. The Administrator reviewed the facility Ring video footage on 12/30/2024 and discovered that S2 had entered R1's room the night before. Both the facility Supervisor and the Administrator were aware S2 entered R1’s room on the night of the incident and not S1. However, the incident report only reflected what R1 reported to the Administrator. The facility manager stated that staff were sleeping in the basement room which also serves as a lounge for employees and did not see anything wrong with the employees living in the basement room. The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Assistant Administrator was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 2, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(c) · Plan of correction due date: Jul 2, 2025

87211 Reporting Requirements (c) Any suspected physical abuse... shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours ... This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above. Administrator submitted the incident report late and with incorrect information, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2025

Plan of correction: Administrator agrees to review 87211 Reporting Requirements. Submit memo of understanding regarding reporting requirements, including Mandated Reporting, to CCL, LPA Mosley via email by 07/02/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(d)(2)(5) · Plan of correction due date: Jul 2, 2025

87405(d)(2)(5) Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(5) Good character and a continuing reputation of personal integrity.This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above. Administrator did not follow the reporting requirements for suspected abuse which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2025

Plan of correction: Administrator agrees to review Reg.87405(d)(2)(5) Submit memo of understanding regarding regulation by 07/02/2025 and train staff on 87405(d)(2)(5) and submit proof to CCLD , LPA Mosley by 07/16/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a) · Plan of correction due date: Jul 16, 2025

87307(a) Personal Accommodations and Services (a)Living accommodations and grounds shall ...comfortable living accommodations and privacy for the residents, staff... (1) There shall be ...prevent such activities from interfering with other functions. This requirement is not met as evidenced by: Based on interviews and observation, the licensee did not comply with the section cited above. Staff are sleeping in the basement room which also serves as a lounge for employees, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2025

Plan of correction: Licensee/Administrator agreed to not allow staff sleeping in this area and clear out all furniture (bed) and submit photos to LPA Mosley by 07/16/2025. Licensee/Administrator agreed to submit 24hr staffing schedule (LIC500) by POC date.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 10:15AM for a Case Management Annual Continuation visit. Executive Director (ED) Lito Vitug arrived at 10:57AM, met with LPA Huynh and LPA explained the reason for the visit. Entrance interview conducted. At 11:10AM, the LPA and ED briefly toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. At this time, no immediate health and safety hazards were observed. MEDICATION: Medication review began at 11:16AM. The LPA reviewed medications for four (4) residents. Medications are maintained locked inaccessible to residents in an attached room behind the concierge desk located on the first floor. Four (4) out of four (4) resident medications reviewed were documented and stored in compliance with regulation at this time. Report Continued on LIC 809-C PLAN OF OPERATION/INFECTION CONTROL: LPA reviewed the facility's Plan of Operation and Infection Control Plan at 11:49AM and is in compliance with regulation. The facility maintains a current and written definitive Plan of Operation that includes all required topics per regulation. LPA observed the facility’s Infection Control was reviewed and signed recently. RECORDS: Resident records were reviewed at 12:27PM. The LPA reviewed five (5) resident records for, but not limited to: admissions agreements, medical assessments, and appraisals. LPA observed one (1) out of five (5) residents did not have a TB test completed. Personnel records were reviewed at 12:56PM. The LPA reviewed six (6) personnel records, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid/CPR certification, and staff trainings. Two (2) out of six (6) staff did not have a completed health screening signed by a physician, and one (1) out of six (6) staff did not have a TB test. Documents obtained: Infection Control Plan. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. A copy of today's report and appeal rights were reviewed and provided.the state’s words, verbatim · CDSS document, May 23, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 10:45AM for a required one-year visit. Executive Director (ED) Lito Vitug arrived at 11:54AM, met with LPA Huynh and LPA explained the reason for the visit. Entrance interview conducted. At 12:05PM, the LPA and ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: RESIDENT ROOMS: The LPA observed ten (10) randomly selected rooms with private restrooms on the first and second floor and no immediate health or safety hazards were observed. Restrooms were clean, with properly installed grab-bars in resident bathrooms and non-skid strips in showers. Resident rooms were furnished with all required furniture within regulation. Water temperature was tested throughout the units and measured between 113.7 degrees F and 120 degrees F, which is within the required range per regulation. Report Continued on LIC 809-C COMMON AREAS: The facility is a two-story building with a total of eighty-eight (88) units. On the first floor, there are the kitchen facilities, dining room, laundry room, emergency food and water storage, lobby, outdoor lobby/smoking area, medication room, staff offices, common restrooms, and outdoor courtyard. On the second floor, there are common restrooms, a conference room, a library, and common/activity space. The LPA observed common areas to be clean and contain furniture in good condition. There were no obstructions and/or tripping hazards throughout the facility. There were cameras in the common areas, outdoor courtyard, and exterior perimeter. Required postings were found in the hallways on the first floor. LPA observed electric stair lifts in the staircases in the event of an emergency and elevators are out of order. There were no bodies of water observed during today’s visit. There are fire extinguishers throughout the facility, which were serviced 03/13/2025. Fire alarm system is tested annually with the last inspection on 11/26/2024 and a retest on 05/06/2025 by Advance Building Protection. KITCHEN: There is one kitchen located on the 1st floor attached to the dining room. Facility dining room and commercial kitchen were inspected and in compliance with Title 22 regulations. Facility receives food deliveries twice a week from Costco and F&W food services. There was a sufficient supply of perishable and non-perishable food. Food appeared to be of good quality and labeled appropriately. Emergency food and water are stored in the hallway closet nearby the dining room. EMERGENCY DISASTER: LPA reviewed the facility's Disaster plan at 1:20PM. LPA noted that the facility is in compliance with regulation. Facility conducts emergency disaster drills as required with drills conducted quarterly. Report Continued on LIC 809-C Six (6) staff, twelve (12) residents, and one (1) family member of a resident were interviewed throughout the duration of the visit. No complaints or immediate safety concerns noted. Due to time constraints, LPA Huynh will return at a later date for an Annual continuation. Documents obtained: LIC 500 Personnel Report, Resident Roster, Emergency Disaster Plan, and most recent Fire Inspection. No deficiency cited. Exit interview conducted. A copy of today’s report was reviewed and provided.the state’s words, verbatim · CDSS document, May 22, 2025

Allegation investigated: Staff did not bathe resident in care Staff did not change resident's undergarments in a timely manner

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to investigate the above allegations. The purpose of this visit is to deliver findings for the above allegations. At 9:48 a.m., LPA was greeted by staff and Assistant Administrator. LPA met with Rizaandrea Vitug - Assistant Administrator (AA) and explained the reason for the visit. The Executive Director (ED) Lito Vitug arrived during the visit. On 01/03/2025 the Department received a complaint regarding the following allegations, Staff did not bathe resident in care and Staff did not change resident's undergarments in a timely manner. On 01/08/2025 LPA Sandra Urena conducted an unannounced initial 10-day complaint visit. At approximately 9:45 a.m. LPA interviewed the ED and collected documents pertinent to the investigation. Report continued on LIC 9099-C page 2..... Unsubstantiated (Page 2) Report continued from LIC 9099... On 02/26/2025 LPA Mosley conducted an unannounced subsequent complaint visit. At 9:40 a.m. LPA along with AA conducted a physical plant tour to ensure there were no immediate health and safety concerns. From 10:30 a.m. - 2:30 p.m. LPA conducted interviews with ten (10) residents and six (6) staff including the ED and obtained copies of pertinent documents relevant to the investigation. On 04/07/2025 at 2:45 p.m. LPA conducted a telephonic interview with Resident #1 (R1). During today’s visit, at 9:55 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations. On the allegation Staff did not bathe resident in care it is the concern of the reporting party (RP) that the facility staff did not bathe R1 for several days. To investigate this complaint, LPA conducted in person interviews with ten (10) residents and six (6) staff including the ED, conducted a telephonic interview with R1, conducted a file review and record review of facility documents including resident shower schedule, and bath service code log sheet. Interview with R1 revealed that they are bathed regularly at least once a week. They have not had any issues or concerns with the facility staff not bathing them. R1 stated they are in and out of the hospital but when they are at the facility the staff ensure they are bathed. Interviews with residents revealed that they are assisted twice weekly with showers. They are on a weekly shower schedule with specific days during the week where they are assisted with showers. They can refuse showers at any time, but staff will typically try and reschedule the shower for a different time or day. They have not had any issues with receiving a shower or have concerns or issues with the shower care they are provided. Interviews with staff revealed that residents receive showers at a minimum of two (2) times per week. Residents are on a weekly schedule where they have specific days of the week they receive shower assistance. Staff state that R1 receives showers on Mondays and Thursdays regularly however has refused in the past. Staff are unaware of R1 not being bathed as they follow the shower schedule to the best of their ability. Interview with ED revealed that R1 regularly receives showers on Mondays and Thursdays. R1 has recently had some health concerns and has been in and out of the hospital. Due to the irregularity in R1’s availability the shower schedule has adjusted for R1 to accommodate when R1 is at the facility. ED is unaware of R1 not being bathed. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff did not bathe resident in care is deemed unsubstantiated at this time. Report continued on LIC 9099-C page 3... (Page 3) Report continued from LIC 9099... On the allegation Staff did not change resident's undergarments in a timely manner it is the concern of the reporting party (RP) that the facility staff did not change R1’s undergarments in a timely manner. To investigate this complaint, LPA conducted in person interviews with ten (10) residents and six (6) staff including the ED, conducted a telephonic interview with R1, conducted a file review and record review of facility documents. Interview with R1 revealed that they have no issue with staff response time. R1 did not have any concerns or issues with their undergarments not being changed in a timely manner. Interviews with residents revealed that they are assisted in a timely manner. Staff assist them with changing including undergarments when requested or needed. Staff check on them regularly. They use their call button when requiring assistance. They have no concerns or issues with response time from staff. Interviews with staff revealed that residents who require assistance with Activities of Daily Living (ADL’s) such as changing are checked on every two (2) hours. Residents typically use their call buttons when requiring immediate assistance. Staff state that R1 regularly uses the call button when requiring assistance and is assisted in a timely manner. Staff are unaware of R1’s undergarments not being changed in a timely manner. Interview with ED revealed that residents are checked on every two (2) hours but depending on the resident’s needs can be more often. R1 will typically use their call button when requiring assistance. ED is unaware of R1’s undergarments not being changed in a timely manner. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff did not change resident's undergarments in a timely manner is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 15, 2025 · control 29-AS-20250103132331

Allegation investigated: Staff are not addressing pests at the facility

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced 10-day complaint visit for above allegation. Upon arrival, LPA met with Assistant Administrator Riza Vitug and explained the reason for the visit. During todays visit, starting at 12:15 p.m., the LPA conducted a physical plant tour, inspected the kitchen, conducted one (1) witness, eight (8) staff and ten (10) resident interviews, and conducted a file review. Report continued on LIC9099-C, 2ND PAGE. Substantiated On the allegation that, “Staff are not addressing pests at the facility”; it is the concern of the reporting party that the facility kitchen is infested with cockroaches even though the facility receives pest control services. It was further reported that there were three live adult German cockroaches on the kitchen floor, under the ice machine, one live Nymph German cockroach on the kitchen wall, and approximately ten dead cockroaches on the floor, throughout the kitchen. Three photos were submitted as evidence. To investigate the allegation, the LPA inspected the kitchen, conduced resident and staff interviews, conducted a file review and requested records of the facility’s ongoing pest control services and maintenance records. Photos submitted were reported to be of the cockroaches in the kitchen at the facility. Photo #1 shows a close-up view of the floor where it meets the wall. You can see dirt, debris, a black cable, along with a metallic structure. Additionally, there is a cockroach in the center of the image, positioned on the floor, close to the black cable resting on the floor. Photo #2 shows a textured, patterned surface, with a small insect on it that appears to be a cockroach nymph or another small pest, with long antennae extending outward. Photo #3 shows a section of a floor, with noticeable dirt, debris, cockroaches, droppings and small objects scattered around. There are also signs of pest activity, as evidence by what appear to be multiple cockroaches and black droppings in the photo. At 12:25 p.m. the LPA observed a dead cockroach on the floor beneath a table next to the ice machine while inspecting the kitchen. One (1) out of ten (10) residents and one (1) witness revealed that they have observed cockroaches in the residents’ rooms, however the witness revealed that when they notify staff, they will put the residents’ room on the list to spray and take care of it. Five (5) out of eight (8) Staff interviews revealed that they have observed cockroaches in the kitchen and in residents’ rooms from time to time, however pest control services are performed monthly and as needed. Interview with the Assistant Administrator revealed that a health inspector had been at the facility on 03/17/25 and recommended for pest control services to be conducted, however the Assistant Administrator was not aware of the reasons why the services were recommended and revealed that a pest control company services the facility every two (2) weeks. The Assistant Administrator provided the LPA with documentation of the scheduled appointment made with Pest Rangers for 03/17/25, following treatment appointment on 04/01/2025, and invoices for services provided by them on 01/08/25, 02/04/25, and 03/04/25. Report will LIC9099-C, 3rd page. Furthermore, file review revealed that the Administrator submitted an Incident Report (LIC624) reporting that on 03/17/2025, an LA County Dept. of Public Health Inspector conducted a physical plant inspection of the facility and found evidence of bug infestation in the kitchen. Additionally, the Administrator informed the inspector that a Pest Control Maintenance Service was conducted two weeks prior and provided copy of the invoice. Based on the information obtained and interviews there is sufficient evidence to support the allegation occurred; therefore, the above allegation is deemed Substantiated at this time. The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Assistant Administrator was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 29-AS-20250318150354

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(27) · Plan of correction due date: Mar 28, 2025

General Food Service Requirements (b)The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on LPA and witness observation, interviews, file review and pictures obtained, the licensee did not comply with the section cited above as roaches were observed in kitchen areas. This poses a potentail health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 19, 2025

Plan of correction: Licensee will ensure kitchen will be thoroughly cleaned and sanitized, will submit a plan for the next 3 months to ensure all regular and preventive professional treatments are taken. Administrator will submit proof to CCL by 03/28/2024.

Type of visit: Case Management - Other

Licensing Program Analyst Trevor Bryne conducted an unannounced Case Management inspection regarding a self-reported Death Report (LIC 624) received. LPA met with facility Administrator Lito Vitug at 09:59 AM and explained the reason for the inspection. On 01/27/2025, Community Care Licensing (CCL) received a self-reported Death Report (LIC 624) pertaining to the death of Resident #1 (R1) which occurred on 01/27/2025. During today’s visit between 10:02 AM and 11:35 AM, the LPA conducted an interview with the facility Administrator, two (2) staff members. LPA also conducted a brief physical plant tour and obtained copies of pertinent information. No deficiencies were observed during today’s inspection. If warranted upon further review of information and documentation received, the LPA will return to investigate this further. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 31, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst Trevor Bryne (LPA) conducted an unannounced Case Management inspection regarding a self-reported Unusual Incident/Injury Report (UIR) incident report received. LPA met with Executive Director Lito Vitug at 12:02 PM and explained the reason for the inspection. On 01/08/2025, Community Care Licensing (CCL) received a self-reported Unusual Incident/Injury Report (UIR) pertaining to an incident that allegedly occurred on 12/29/2024 regarding Resident #1 (R1) and Staff #1 (S1). During today’s visit, the LPA conducted an interview with Executive Director Lito Vitug, conducted a brief physical plant tour, and obtained copies of pertinent information. A referral has been submitted to CCL’s Investigations Branch and Investigator Veronica Padilla has been assigned to this investigation. No immediate health and safety concerns were observed during the visit. Further investigation is needed. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jan 9, 2025

Allegation investigated: Staff do not ensure that resident's incontinence needs are met. Staff do not provide resident with housekeeping services. Staff do not routinely monitor resident. Staff do not serve residents food of good quality. Staff do not treat resident with dignity and respect.

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced initial 10-day complaint visit to investigate the above allegation. Upon arrival at 9:50 a.m. LPA Mosley was greeted by front desk staff and Assistant Administrator who called the Executive Director to inform them of the visit. The LPA met with Assistant Administrator Rizaandrea Vitug and Manager, Joselito Vitug explained the reason for the visit. The Executive Director was unable to attend today and designated staff to sign the report. On 10/31/2024, the Department received a complaint regarding the following allegations, Staff do not ensure that resident's incontinence needs are met, Staff do not provide resident with housekeeping services, Staff do not routinely monitor resident, Staff do not serve residents food of good quality, and Staff do not treat resident with dignity and respect. LPA toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. Report Continued on LIC9099C... 2nd page Unsubstantiated 2nd page On the allegation, Staff do not ensure that resident's incontinence needs are met, it is the concern of the Reporting Party (RP) that the facility is not addressing Resident #1’s (R1) incontinence needs and R1 was left soiled and had to clean up themselves. To investigate this complaint, LPA conducted in person interviews with the Assistant Administrator, Manager, five (5) staff members, and seven (7) residents between 10:39am – 2:50pm. LPA attempted to interview R1 during the inspection, but they refused to be interviewed at this time. LPA also obtained pertinent documents to the investigation and reviewed facility records. Interviews with staff revealed that incontinent residents are checked frequently. Staff do rounds to check on incontinent residents every two hours. It was noted that most incontinent residents use their call button when they need assistance or need to be changed. Staff are quick to respond to resident calls and assist in a timely manner. Interviews with incontinent residents revealed that they are regularly monitored and assisted. They are attended to in a timely manner and have no issues with the time response that staff come to assist them as it is relatively quick. Staff interviews also revealed R1 does need assistance with incontinent care although they were not aware of R1 ever being soiled and needing assistance with incontinent care and staff not providing it. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not ensure that resident's incontinence needs are met is deemed unsubstantiated at this time. On the allegation, Staff do not provide resident with housekeeping services, it is the concern of the Reporting Party (RP) that the facility is not providing housekeeping services for R1. To investigate this complaint, LPA conducted in person interviews with the Assistant Administrator, Manager, five (5) staff members, and seven (7) residents between 10:39am – 2:50pm. LPA attempted to interview R1 during the inspection, but they refused to be interviewed at this time. LPA also obtained pertinent documents to the investigation and reviewed facility records. Report Continued on LIC9099C...3rd page 3rd page Interview with staff revealed that the resident rooms are cleaned on a daily basis. Each room on both floors receive basic cleaning services consisting of trash being thrown out, bed being check if sheets need to be replaced due to accident, bed being fixed, carpet vacuumed, and bathroom is wiped down. Once all rooms have received the basic cleaning service 5-7 rooms receive a deep clean with all rooms receiving a deep clean weekly. The deep clean consist of sheets being replaced, carpets being shampooed, rooms being dusted, surfaced wiped down, refrigerator being cleaned, bathroom being cleaned, sink, toilet, shower along with the basic services. Documents obtained support that the facility has a set schedule of rooms being deep cleaned on a weekly basis. Resident interviews revealed that staff come daily to clean their rooms. Resident interviews support that their rooms are cleaned regularly on a daily basis. During the inspection, the LPA attempted to view R1’s room but R1 did not want any visitors at this time. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not provide resident with housekeeping services, is deemed unsubstantiated at this time. On the allegation, Staff do not routinely monitor resident, it is the concern of the Reporting Party (RP) that the facility is not routinely monitoring R1. To investigate this complaint, LPA conducted in person interviews with the Assistant Administrator, Manager, five (5) staff members, and seven (7) residents between 10:39am – 2:50pm. LPA attempted to interview R1 during the inspection, but they refused to be interviewed at this time. LPA also obtained pertinent documents to the investigation and reviewed facility records. Interview with staff revealed that residents are check on periodically during mealtimes, and for those who are not at meals are check on in their rooms. Residents are monitored and checked on about every two (2) hours. Resident interviews revealed that staff periodically check in on them during mealtimes or in their rooms. Resident interviews support that staff are checking in on them periodically. Documents obtained revealed that every time staff come to a resident room a bar code is scanned documenting how many times staff enter the resident’s room. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not routinely monitor resident is deemed unsubstantiated at this time. Report Continued on LIC9099C...4th page 4th page On the allegation, Staff do not serve residents food of good quality it is the concern of the Reporting Party (RP) that the facility is not providing quality food to residents in care. To investigate this complaint, LPA conducted a tour of the kitchen and food service, checked refrigerators and food that was being prepared, conducted in person interviews with the Assistant Administrator, Manager, five (5) staff members, and seven (7) residents between 10:39am – 2:50pm. LPA attempted to interview R1 during the inspection, but they refused to be interviewed at this time. LPA also obtained pertinent documents to the investigation and reviewed facility records. The physical plant tour revealed that the food the facility is all dated and at the time of the visit of good quality. The food that was being prepared for the day was fresh and being prepared with quality ingredients. The food service menu was reviewed and matched what was being served. Interviews with staff revealed that the food is being delivered regularly with fresh and top-quality products. Interviews with residents revealed that the food is of good quality and the facility gives the residents the option to substitute parts of their meal if something is not of their liking. Resident interviews regarding food support that the facility serves tasty, good quality food with options. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not serve residents food of good quality is deemed unsubstantiated at this time. Report Continued on LIC9099C...5th page 5th page On the allegation, Staff do not treat resident with dignity and respect it is the concern of the Reporting Party (RP) that the facility does not respect R1 and makes a lot of noise when in their room. To investigate this complaint, LPA conducted in person interviews with the Assistant Administrator, Manager, five (5) staff members, and seven (7) residents between 10:39am – 2:50pm. LPA attempted to interview R1 during the inspection, but they refused to be interviewed at this time. LPA also obtained pertinent documents to the investigation and reviewed facility records. Interviews with residents reveled that the staff at the facility are respectful and attentive to the residents needs and residents’ rights. Resident interviews support that the staff are respectful and treat them with dignity and respect had they no concern with staff or with the way they are being treated at the facility. Interviews with staff revealed that they are knowledgeable in resident rights and respect the residents. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not treat resident with dignity and respect is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 5, 2024 · control 29-AS-20241031111659

Allegation investigated: Staff neglect resulted in resident's death Staff did not seek medical attention for resident Staff did not meet residents needs

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA Cortez met with facility owner Lito Vitug and explained the reason for the visit. On 04/19/2024, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint alleging facility employees failed to seek timely medical treatment for Resident #1 (R1) and R1 died due to neglect by facility employees, and staff did not meet residents needs. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) to adress the first two allegations and assigned to Investigator Douglas Real. Report will continue on LIC9099-C 2nd page. Unsubstantiated On 04/22/2024, from 11:47am to 4:30pm, Licensing Program Analyst (LPA), Esther Cortez conducted the unannounced initial complaint visit. Upon arrival LPA Cortez met with the administrator Lori McKay and owner Lito Vitug and explained the reason for the visit. Between 12:00pm and 4:30pm the LPA toured the physical plant with the administrator, interviewed three (3) staff, conducted a file review and obtained copies of pertinent documents relevant to the investigation. The LPA determine further investigation was required. The administrator and staff were advised that a referral was submitted to Community Care Licensing Division (CCLD) Investigations Branch (IB). During today's visit LPA Cortes conducted staff and resident interviews, and obtained copies of pertinent documents relevant to the investigation. On 06/04/2024, from approximately 10:30am to 12:20pm, Investigator Real conducted interviews with the administrator and staff; on 06/11/24, from approximately 11:00am to 12:20pm, with residents; on 07/15/2024, at approximately 12:00pm, with R1’s resident representative; and on 07/22/2024, from approximately 10:30am to 2:25pm, with Corinthian Health Care Services, Inc. home health office manager and nurse. In addition, the investigator reviewed Sherman Oaks Hospital medical records, Corinthian Health Care Services, Inc. home health records, and facility file documents pertinent to the investigation. A review of R1’s physician’s report, dated 11/09/2023, indicated R1’s primary diagnoses was listed as history of sepsis, urinary tract infection, and pneumonia. The report indicated R1 had mild cognitive impairment, was able to follow instructions as well as communicate needs, R1 could leave the facility unassisted, dress and eat on their own, was able to transfer to and from bed independently and was identified as ambulatory. A summary of R1’s home health records obtained from Corinthian Home Health revealed R1 was placed on Corinthian Home Health Services on 02/02/2024 and was discharged on 04/01/2024 due to R1’s hospitalization. According to the records, R1 presented as alert & oriented, who received minimal to moderate assistance to perform activities of daily living (ADLs) safely, medication and meal preparation. R1 was recently discharged from Sherman Way Village Center (skilled nursing facility) related to a urinary tract infection (UTI) and weakness. R1 was admitted to Corinthian Health Care Services for RN assessment, medication, recon, pain management, fall precautions, and home safety. Skilled nurse performed evaluation and assessment of vital signs and overall body systems. The records indicate R1 used a walker for ambulation. Report will continue on LIC9099-C 3rd page. R1 has right lower extremities pain, poor balance, and unsteady gait. The home health notes did not identify any signs of illness and on 03/26/2024 home health was notified R1 had a fall incident. Multiple x-rays were done and showed negative results. On 03/28/2024, R1 was taken to the Sherman Oaks Hospital emergency room due to increased confusion. R1 was admitted to the hospital on 03/29/2024 and was discharged from home health. No abuse or neglect concerns were noted in R1’s home health records. According to the Sherman Oaks Hospital medical records, R1 was seen in the Emergency Department on 03/28/2024 at 8:20pm due to being more confused than R1’s baseline (history of confusion). R1 was awake, alert and denied being in any pain. R1 did not have any chest pain or shortness of breath and R1 denied fever or chills. R1 did not have abdominal pain, nausea, vomiting or diarrhea. R1 informed hospital staff that they felt cold. A physical exam revealed R1 was well developed and in no apparent distress. A urinalysis was done and showed no signs of infection, but some blood was seen. A chest x-ray revealed patchy air space opacites in both lungs which was noted as compatible with multifocal pneumonia. R1’s EKG was noted as abnormal. Lab work indicated R1 had slight leukocytosis, was anemic with low sodium, and was noted as having some acute renal failure. R1 was also noted as having encephalopathy and was admitted 03/29/2024 to the hospital for the pneumonia with a temperature of 98.4. R1 was not noted as having malnutrition at the time of hospital admission. During the hospital stay, R1 tested positive for MRSA and R1’s health declined. R1 was noted with worsening acute kidney injury leading to multiple organ failure and R1 passed away on 04/13/2024. A review of the Unusual Injury/Incident report, dated 03/26/2024, documented that on 03/25/2024, at approximately 4:45pm, while returning from an outing with R1’s resident representative, both R1 and R1’s resident representative stumbled and fell as they were walking up the stairs to the facility. The administrator immediately assessed R1 and R1’s resident representative. There were no injuries noted for R1. On 03/27/2024, an x-ray was ordered for R1’s right leg, right foot, right elbow, left hand, and right pelvic region. The results revealed no fractures and listed the diagnosis as pain and swelling. Report will continue on LIC9099-C 4th page. This page of the report is being amended to remove private information. Report will be emailed to the facility owner for signature, and hardcopy with signature will be on file. On the allegation “Neglect/Lack of Care: Facility employees failed to obtain timely medical treatment for Resident #1 (R1)”. Information obtained from the interviews conducted revealed R1 was sent to the Emergency Room on 03/28/2024 when R1 was more confused than usual. A review of R1’s hospital records revealed R1 was not in any serious distress and only reported feeling cold. The information and evidence obtained during the Department’s investigation did not sufficiently support the allegation, therefore, the allegation is deemed Unsubstantiated at this time. On the allegation “Neglect/Lack of Care: Facility employees failed to provide an appropriate level of care resulting in Resident #1 (R1’s) death”. The Department’s investigation revealed R1 had a history of numerous health conditions including pneumonia. Upon R1’s admission to the hospital on 03/29/2024, R1’s chest x-rays found R1 had pneumonia. Despite R1 being diagnosed with pneumonia R1 was not in any distress upon admission to the hospital. R1 was admitted to the hospital for treatment and later tested positive for MRSA and R1’s health declined. R1 passed away in the hospital approximately two weeks later, on 04/13/2024. The information and evidence obtained during the investigation did not sufficiently support the allegation, therefore, the allegation is deemed Unsubstantiated at this time. On the allegation " Staff did not meet resident’s needs"; it is the concern of the reporting party that Resident #2 (R2) had a rash on their body 4-5 times, had a UTI several times and they were not getting any treatment and the facility doctor was supposed to see R2 but did not. Residential Care Facilities for the Elderly (RCFE) are non-medical facilities that are not required to have nurses or doctors on staff, however staff revealed that the facility has an LVN on call that primarily sees ALW clients. A review of R2’s file revealed that R2 was admitted to the facility on 11/25/2023. A review of R2’s physician’s report, dated 11/09/2023, indicated R2’s primary diagnoses was listed as base of left femur fracture s/p surgery. The report indicated R2 had dementia, had a history of skin condition or breakdown with history of surgical wound, was able to follow instructions as well as communicate needs, R2 could leave the facility unassisted, dress and eat on their own, was able to transfer to and from bed independently and was identified as ambulatory. Report will continue on LIC9099-C 5th page. A review of R2’s Corinthian home health records obtained from the facility revealed R2 was receiving services from Corinthian Home Health starting on 12/29/2023. Corinthian Healthcare Services communication note revealed that on 02/12/2024, R2 started Keflex 500 mg four times a day for 7 days related to UTI, and they completed the antibiotics. Skilled nursing clinical visit not from Corinthian Healthcare services revealed that on 02/28/2024, a SN assessed R2’s condition, R2’s diagnosis was alteration in GU status related to UTI and that R2 was placed on ATB therapy: Bactrim DS 1 tablet twice a day oral starting that day (02/28/2024), and lastly, R2/caregiver were provided health teachings regarding measures to prevent or manage UTI. Skilled nursing clinical visit not from Corinthian Healthcare services revealed that on 04/05/2024, a SN assessed R2’s condition, and R2’s diagnosis were impaired skin integrity due to rashes on both arms and legs. SN cleansed the areas with normal saline, pat dry and applied Calmoseptine, and left open to air and reported R2’s condition to MD/HHA. Staff interviews revealed that shortly after R2 was taken to the hospital for a separate reason and never returned to the facility. A review of the Unusual Injury/Incident report, dated 03/29/2024, documented that on 03/28/2024, 9-1-1 Paramedics were contacted due to R2 exhibiting some confusion. R2 was transported to Sherman Oaks Hospital and the nature of the treatment was unknown at the time. There were no injuries noted for R1. A review of the Unusual Injury/Incident report, dated 04/09/2024, documented that on 04/07/2024, non-emergency transportation was arranged for R2 to get them to Sherman Oaks Hospital due to complaints of bodily pain. On the allegation “Staff did not meet resident’s needs” Information obtained from file reviewed conducted revealed R2 did present UTI infections and rashes, however R2 was being seen and treated by home health, and their physician. Staff interviews also revealed that R2 was not seen by the facilities LVN because R2’s daughter, doctor and home health were heavily overseeing R2’s health. In addition all resident's interviewed revealed that their needs are met by staff. The information and evidence obtained during the Department’s investigation did not sufficiently support the allegation, therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issuedthe state’s words, verbatim · CDSS document, Oct 3, 2024 · control 29-AS-20240419114637

Allegation investigated: Staff are not providing a comfortable environment for resident.

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced 10-day visit to investigate the allegation listed above. The LPA met with staff and explained the reason for the visit. The Administrator Lori McKay arrived shortly thereafter, and LPA explained the reason for the visit. The LPA and the administrator conducted a tour of the physical plant at 10:24 a.m. The LPA checked for temperature readings recorded on the temperature thermostats found throughout the hallways in the facility. The LPA interviewed the residents from approximately 10:17 a.m. to 10:52 a.m., and the administrator at approximately 11:15 a.m. Continues on LIC 809C… Unsubstantiated Staff are not providing a comfortable environment for resident. On the allegation that ‘Staff are not providing a comfortable environment for resident’; it is the concern of the reporting party (RP) that the temperature in the residents' rooms is hot, and the residents have to call the staff to turn on the air conditioning (AC). Per the RP the thermostat in one room was recorded at 80 degrees. The LPA interviewed the RP and the RP stated that the AC has been on since the concern was brought up to the facility staff the week of June 10th, 2024. The AC continues to run, and the rooms are now too cold. The LPA interviewed residents about the temperature in their rooms, and in the facility overall; some residents stated that the room temperature was colder than what they like it to be and have asked staff to turn the AC down or off. The LPA interviewed staff about the overall facility temperature, and staff interviews revealed that the facility keeps the temperature set the highest at 78 degrees. The thermostat is on automatic setting. Based on interviews and observation, the facility has made efforts to keep the facility at a comfortable temperature on hot days. And although the RP observed the temperature to be at 80 degrees Fahrenheit, there is not sufficient evidence to support that ‘Staff are not providing a comfortable environment for resident. Regulations state the following: The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jun 19, 2024 · control 29-AS-20240610145601

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived unannounced to conduct a required annual visit. The LPA met with Administrator Lori McKay and informed them of the reason for the visit. The LPA toured the physical plant areas inside, and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. Common Areas: Upon entry to the facility,the LPA observed that the facility maintains a comfortable temperature at 74 degrees Fahrenheit. There are fire extinguishers throughout the facility, which were charged and last serviced on 09/06/2023. Planned activities are offered. Activity schedule is posted throughout the facility. The LPA observed staff engaging residents in group activities. All activity rooms and common spaces appeared clean and in good repair. Outdoor Areas: The LPA toured the outside area of the facility. The LPA observed appropriate outdoor furniture, with covered shaded areas for residents in the courtyard. Due to time constraints, LPA Urena will return on another date to complete the Annual inspection. Exit interview was conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 21, 2024

Allegation investigated: Staff did not maintain a comfortable temperature for residents in care.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent unannounced visit to investigate the allegation listed above. The LPA met with the Administrator Lori McKay and explained the reason for the visit. On 04/17/2024, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced 10-day visit to investigate the allegation listed above. The LPA met with the Administrator Lori McKay and explained the reason for the visit. The LPA and the manager conducted a tour of the physical plant at 2:11 p.m. The LPA checked for temperature readings recorded on the temperature thermostats found throughout the hallways in the facility on the first and second floor. The LPA interviewed the residents at approximately 3:00 p.m. Continues on LIC 809C... Unsubstantiated Staff did not maintain a comfortable temperature for the residents in care. On the allegation that ‘Staff did not maintain a comfortable temperature for the residents in care’; it is the concern of the reporting party (RP) that the temperature in the facility has been very hot, and the facility staff are not turning the air conditioning (AC) on. The LPA noticed that some residents’ rooms receive the glare of the sun that hits the opposing building wall, which can be felt radiating though the window, making the facility residents’ rooms feel warm. Air did not seem to be flowing from the AC vent into R1’s room. Manager stated that they would ask the maintenance person to check the vent for proper ventilation. At 2:49 p.m., the LPA and the manager observed the temperature recorded in a floor fan, at 80 degrees Fahrenheit inside a residents’ room. The LPA interviewed residents about the temperature in their rooms, and in the facility overall. Nine out of ten residents’ interviews revealed that the temperature is o.k., some said it was colder than what they like it to be. The LPA interviewed staff about the overall facility temperature, and staff interviews revealed that the facility keeps the temperature set the highest at 78 degrees. The thermostat is on automatic setting. The temperature can be controlled manually by moving the dials found in the hallways. The facility temperature can also be controlled via cell phones, which are managed by administrative staff. The AC repairman will be called to check on the AC air vents to ensure that the temperature is being kept at a comfortable for all residents. The facility tour revealed that on the first floor, six out to six thermostats, read between 72 to 76 degrees Fahrenheit. The second-floor thermostats read between 74- and 75-degrees Fahrenheit. The thermostats are located in the hallways of the facility. Based on interviews and observation, the facility has made efforts to keep the facility at a comfortable temperature on hot days. And although R1 observed the temperature to be at 83 degrees Fahrenheit, there is not sufficient evidence to support that ‘staff do not provide a comfortable temperature for the residents in care’. Regulations state the following: The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 4, 2024 · control 29-AS-20240412132611

Allegation investigated: Staff emotionally abusing resident.

Licensing Program Analyst conducted a subsequent unannounced visit to investigate the allegation listed above. The LPA met with Executive Director Lito Vitug and explained the reason for the visit. On 12/28/2023, Licensing Program Analyst (LPA) Sandra Urena conducted an initial visit to investigate the allegation listed above. LPA Urena met with Administrator Joey Vitug and explained the reason for the visit. At 10:19 a.m., the LPA requested records pertinent to the investigation and at 10:25 a.m. interviewed residents. The LPA determined further investigation was required prior to issuing findings. On 01/03/2024, LPA Urena conducted additional interviews with the Administrator, staff (S1), and the Executive Director from 1:13 p.m. to approximately 2:25 p.m. Additionally, the LPA interviewed a relative of R1 at approximately 12:16 p.m. The LPA interviewed the Reporting Party (RP) on 12/28/2023 at 9:56 a.m. Continues on LIC 9099C... Unsubstantiated Page 2... On the allegation that ‘Staff is emotionally abusing resident’, it is the reporting’s party concern that the resident is being bullied by a staff (S1) at the facility, and the bullying is escalating. The RP stated that the R1 stated to the RP that S1 has told R1 to be ‘quiet’ and ‘shut up’ in front of other people in the lobby. RP stated that they were reporting what R1 reported to them, and that they have not witnessed the bullying, or the emotional abuse. The RP reported the incident because R1 appeared to be depressed and was crying. Furthermore, RP stated that when they asked R1 why they thought the bulling was happening, the R1 stated that they ‘did not know why’, and that they felt that S1 does not like R1. The LPA interviewed R1, and the interview revealed R1 felt that S1 does not like R1. When asked why they felt S1 did not like R1, R1 stated that there have been occasions, when R1 will ask a question and S1 will reply, ‘I can’t talk with you right now’, and R1 feels that they can’t even ask S1 a question. R1 could not provide specifics of the occasions when they felt R1 was being ignored by S1. R1 added that S1 constantly yells at them in the lobby. When the LPA asked R1 if S1 has yelled to R1 in any other part of the facility (e.g., bedroom), R1 stated, “No, only in the lobby”. When asked what happened when S1 yelled, R1 said that they were just talking to someone else. The LPA asked R1 if there were other residents who have witnessed S1 yelling at R1 in the lobby? R1 provided one name, but added that that witness would not say anything, ‘because they like S1’. The LPA asked R1 how long the yelling has been going for? the R1 stated that they could not tell but added that it happens all the time. R1 added at the end of the interview that they love it here (facility), that everyone is very nice, and R1 likes the ED very much. The LPA interviewed five residents, and five out of five stated that they have not felt disrespect nor have been yelled at by S1. The LPA interviewed the administrator about the allegation, and the administrator stated that they have not witnessed S1 yell at anyone, and specifically in the lobby area. The LPA interviewed the ED, who stated that they were aware of the situation. The ED stated that R1 tends to get in the middle of other residents’ business while in the lobby, and consequently S1 might have brought it to R1’s attention. Additionally, the administrator and the ED explained that S1 could not yell due to a condition that prevents S1 from talking loudly. Continues on LIC 9099 C.. page 3 Page 3. The interview with the S1 revealed that on more than one occasion, R1 has used inappropriate language/comments out loud about another resident while the residents line up by the nurse’s station in the lobby. The residents line up to get their blood pressure and sugar levels checked by the nurse. Of the eight to nine residents, one resident tends to cut in the line, causing R1 to make remarks about the resident out loud. Per S1, ‘R1 is not even in the line, they are sitting by the window in the lobby when R2 cuts in line; S1 takes care of addressing the resident cutting in line by speaking with them directly. However, R1 still comments out loud, ‘They do that all the time’. The comments made by R1, prompted S1 to tell R1 (while in the lobby), to ‘Stop meddling’. Furthermore, S1 stated that indeed there have been times when R1 has questions, but S1 may be busy attending to other businesses/residents, consequently they might have said to R1 ‘I can’t speak with you now’. There are many occasions when R1 has requested assistance from S1 and S1 has provided the assistance, as part of their job. S1 denied being emotionally abusive or disrespectful to R1 or any other resident. The LPA spoke with a relative of R1, and stated that they were of the situation as explained by R1. However, the relative has not visited R1 in the facility, they do not live close by. They added that R1 sometimes has a tendency to exaggerate. Based on the information obtained through interviews and although the allegation may have happened, there is not sufficient evidence to support the allegation. Therefore, the allegation that staff are emotionally abusing residents, is deemed Unsubstantiated at this time. Exit interview was conducted with the Executive Director. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 3, 2024 · control 29-AS-20231222094141

Allegation investigated: Staff molested resident in care.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to deliver findings for the allegation listed above. LPA met with the Executive Director Lito Vitug and explained the reason for the visit. On 08/21/2023, the Department received a complaint reporting the alleged sexual abuse of a facility resident #1 (R1) by a staff #1 (S1). R1 reported that S1 touches R1 in their private areas and has made R1 touch S1’s private areas. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Dennis Douglas. Continues on LIC 9099C... Unsubstantiated On 08/22/2023, from 3:05pm to 4:45pm, Licensing Program Analyst (LPA) Sandra Urena conducted an initial visit to investigate the allegation listed above. LPA Urena met with Executive Director Lito Vitug and Administrator Lori McKay and explained the reason for the visit. At 3:15pm, the LPA requested records pertinent to the investigation and interviewed the Administrator and Executive Director between 3:15pm and 4:30pm. The LPA determined further investigation was required prior to issuing findings. Investigator Douglas conducted interviews on 08/24/2023, at approximately 2:45pm, with R1 and the Administrator; on 10/02/2023, at approximately 1:00pm, with S1; and on 11/15/2023, at approximately 1:40pm, with Staff #2 (S2). In addition, the investigator reviewed the facility file documents related to R1. The investigator also contacted the Los Angeles Police Department North Hollywood station and was informed that detectives determined no crime was committed in reference to the allegation. According to R1’s Physician’s Report, dated 03/17/2023, the primary diagnosis was indicated as Hypertension, Congestive Heart Failure, and Bipolar. The secondary diagnosis was indicated as Arthritis. The report documented Mild Cognitive Impairment. In the Mental Condition section of the report, under Confused/Disorient, neither yes nor no was indicated by R1’s doctor. Whether R1 was able to bathe and/or dress /groom self was also not indicated by R1’s doctor. The doctor did indicate that R1 was not able to care for their own toilet needs. The Individual Service Plan (ISP) dated 12/22/2022, indicated R1’s needs and concerns included risk for impaired social interaction and anxiety related to Parkinson’s disease, risk for impaired social interaction related to depression, risk for self-directed violence related to depression and history of 5150 secondary to psychosis, and risk for disturbed thought process related to nonreality based thinking and impaired judgement. Per the Unusual Incident Report submitted by the facility, on 08/15/2023 R1 was observed to be disoriented and confused. R1’s perception of time, date and location was not correct. When engaged in a conversation, R1 uttered inappropriate words and other incomprehensible words. The report stated that R1’s primary care physician was contacted, and the facility staff were instructed to send R1 to the hospital. R1 was admitted to St. Joseph’s hospital. The report listed the person(s) who observed the incident as the Facility Manager, Executive Director, and the Administrator. The report did not mention R1’s allegation against S1. Continues on page 2 LIC 9099C... Page 3. The investigation revealed it was initially reported that on 08/15/2023, R1 alleged they were sexually assaulted by S1. It was reported that R1 alleged S1 had been sexually molesting them for approximately two years. R1 alleged S1 would touch R1’s private area (vagina) and that S1 would also make R1 touch S1’s private area. During the course of the Department’s investigation, R1 maintained their claim that S1 sexually assaulted R1. However, there were inconsistencies in R1’s disclosure of the sexual assault as R1 was now claiming S1 entered R1’s room and got on top of R1 while R1 was naked attempting to engage in sexual intercourse with R1. R1 stated they kicked S1 in the groin, and S1 stopped. R1 also disclosed that they would willingly perform oral sex on S1, because that is what R1 “liked to do from time to time.” During the interview with R1, R1 made other statements regarding their hobbies and daily activities which were later learned not to be true. R1 disclosed that they have a “garden” at the facility in which they grow various flowers. However, the facility Administrator later verified R1 did not have a garden at the facility. During the IB investigator’s visit to the facility, they did not observe a garden on the premises. Although R1 has never been diagnosed with Dementia or Alzheimer’s Disease, it was disclosed by the facility Administrator that R1 had recently begun smoking marijuana and drinking alcohol, along with taking their regular medication. As a result, a mild cognitive impairment was noticed with R1. During the Department’s investigation, S1 was also interviewed and denied any sexual abuse of R1. S1 claimed they only interacted with R1 on one occasion (approximately a year ago) when S1 and another staff member S2 cleaned and changed R1’s diaper and clothes after R1 defecated on themself in the bathroom. During the investigation, S2 was also interviewed and acknowledged assisting S1 with R1 after R1 had an accident in R1’s bathroom approximately a year ago. S2 stated they did not observe S1 touch R1 inappropriately. Based on the information obtained during the course of the investigation, the Department does not have sufficient evidence to support the above allegation. Therefore, the allegation “Sexual Abuse – A facility resident was sexually assaulted by a facility staff member” is deemed Unsubstantiated at this time. Exit interview, and a copy of the report was given.the state’s words, verbatim · CDSS document, Jan 3, 2024 · control 29-AS-20230821084701

Allegation investigated: Resident was inappropriately touched in a sexual manner by staff.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with the Executive Director, Lito Vitug and explained the reason for the visit. On 08/24/2023, the Department received a complaint regarding an allegation of Sexual Abuse. It was alleged that facility Staff #1 (S1) inappropriately touched Resident #1 (R1) in a sexual manner while assisting R1 in the shower. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Douglas Real to conduct interviews to determine if a full investigation was warranted. Continues on LIC 9099C... Unsubstantiated On 08/29/2023, from 10:00am to 12:10pm, Licensing Program Analyst (LPA) Sandra Urena conducted an initial visit to investigate the allegation listed above. LPA Urena met with administrator Lori McKay and explained the reason for the visit. The LPA requested records pertinent to the investigation at 10:00am and interviewed the administrator between 10:30am and 11:40am. The LPA determined further investigation was needed prior to issuing the findings. On 08/30/2023, from approximately 11:20am to 2:15pm, Investigator Real conducted interviews with R1 and S1; on 09/05/2023, from approximately 3:10pm to 4:30pm, with facility residents, and on 09/12/2023, at approximately 6:20pm, with the reporting party. The interviews revealed that R1 did not disclose any sexual abuse; however, R1 reported S1 did not wear gloves while assisting R1 in the shower. S1 denied the allegation and reported they always wear gloves while showering residents. The residents who were interviewed reported all the facility employees wear gloves (S1 included) when assisting them in the shower. The reporting party advised that R1 disclosed that S1 did not wear gloves while assisting R1 in the shower but did not disclose any sexual abuse by S1. The information obtained during the investigation revealed there was insufficient evidence to support the allegation occurred. Therefore, the Department has determined the allegation “Sexual Abuse – Resident was inappropriately touched in a sexual manner by staff” is deemed Unsubstantiated at this time. Exit interview was conducted, a copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 3, 2024 · control 29-AS-20230824092613

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced case management-deficiency visit. The LPA met with Lito Vitug, Executive Director (ED) and explained the reason for the visit. During the complaint investigation of complaint #29-AS-20230821084701, the following deficiencies were observed: During an interview conducted on 08/24/2023 by the Department, the Administrator stated that R1 had recently begun smoking marijuana and drinking alcohol along with taking their regular medication. The Administrator stated they have noticed mild cognitive impairment in R1 since then. There was no Reappraisal done for R1’s change in condition. The Individual Service Plan (ISP) the facility submitted to the Department during the complaint investigation was dated 12/22/2022. The Unusual Incident Report submitted by the facility, dated 08/15/2023, did not reflect that R1 had made an allegation against S1 for sexual abuse. The Executive Director, Facility Manager, and the Administrator were made aware of the allegations on 08/15/2023 and suspended S1 during the complaint investigation. The licensee did not submit a Report of Suspected Dependent Adult/Elder Abuse (SOC341) form. Citations issued, exit interview was conducted and a copy of the report and Appeal Rights were issued..the state’s words, verbatim · CDSS document, Jan 3, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(c) · Plan of correction due date: Jan 19, 2024

87211(c) Reporting Requirements. Any suspected physical abuse that does not result in serious bodily injury... shall be reported to the local ombudsman, the licensing agency, and the local law enforcement agency within twenty-four (24) hours. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above, as facility staff did not fulfill reporting requirements to appropriate parties, including Mandated Reporter requirements by reporting suspected abuse, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 3, 2024

Plan of correction: The licensee will schedule training on Mandated Reporting Requirements for all staff. Training must be conducted by an outside vendor. Submit training date to CCL by Training must be conducted within the next 14 days. Submit confirmation of training, sign in sheet and training materials.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a)(3) · Plan of correction due date: Jan 19, 2024

87463(a)(3) Reappraisals(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a… This requirement is not met as evidenced by: Based on record review, R1’s Reappraisal was not updated when R1 began drinking alcohol, smoking marijuana and had a change of mental condition, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 3, 2024

Plan of correction: The licensee will submit a plan, detailing how the facility will maintain compliance of 87463(a)(3). Submit to CCL by due date

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced case management-incident visit at 2:45 p.m. The LPA met with Lito Vitug, Executive Director (ED) and explained the reason for the visit. On 10/05/2023, The LPA received a phone call from the facility administrator to inform of an incident that took place on 10/04/2023 at approximately 2:30 p.m. At 2:45 p.m., the LPA interviewed the Executive Director, Lito Vitug about the incident and a visit from detectives from the Los Angeles Police Department (LAPD), North Hollywood Detective Division (NHDD). The administrator stated that on 10/04/2023 at approximately 2:30 p.m., three detectives visited the facility to investigate an alleged sexual assault incident on a facility resident. The detectives received the alleged incident report from a staff member at the hospital were the resident was admitted due to an unrelated incident. At the time of the LPA's visit, the ED stated that they had already received a call at approximately 12:30 p.m. from the hospital and the detectives stating that there was a lab error and the hospital had erroneously reported the sexual assault. Consequently the investigation was closed by the LAPD, NHDD. At 3:10 p.m., the LPA contacted the hospital staff to inquire about the information received in regards to the erroneous report. The hospital staff confirmed the information provided. Additionally the hospital staff provided the LAPD report number, and the name and number of the lead detectives. No further investigation is needed at this time. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 5, 2023