The Terraces at Via Verde-A Memory Care Community

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual inspection utilizing the Compliance and Regulatory Enforcement (CARE) Tool. Upon arrival, LPA was greeted by facility staff, who were informed of the purpose of the visit. Facility Administrator Subashasi Kumar arrived thereafter and participated in the inspection. The facility is licensed to provide care and supervision for sixty (60) non-ambulatory residents. All resident bedrooms are approved for non-ambulatory use. The facility is approved to retain no more than twenty (20) residents receiving hospice services. At the time of the inspection, there were five (5) residents receiving hospice care. This version improves grammar, readability, and follows the formal style typically used in Community Care Licensing inspection reports. Physical Plant and Environmental Safety: The facility is a two-story building consisting of forty-three (43) resident bedrooms, two (2) activity rooms, an outdoor courtyard, two (2) dining rooms, a first-floor side patio, a second-floor terrace patio, a conference room, lobby, kitchen, employee lounge, and administrative offices. LPA inspected the interior and exterior physical plant. Exit doors were observed to be free of obstructions and accessible for emergency evacuation. Cleaning supplies and other toxic substances were observed to be stored in a manner that made them inaccessible to residents. LPA inspected ten (10) resident bedrooms and their associated bathrooms. All bedrooms contained the required furnishings in accordance with licensing regulations. Resident bathrooms were equipped with grab bars and non-slip flooring to promote resident safety. During the walkthrough, LPA observed housekeeping and maintenance issues that require correction. A deficiency will be issued. Water temperature readings taken during the inspection did not measure within the required range of 105°F to 120°F. The facility is equipped with evacuation chairs located in the stairwells for use during emergencies to assist residents in safely exiting the building. The facility also has an operational fire sprinkler system, smoke detectors, carbon monoxide detectors, and fully charged fire extinguishers. The most recent fire inspection was conducted by the California State Fire Marshal on January 20, 2025. (continued on 809C) Food Service: LPA toured the kitchen and food storage areas. The kitchen was observed to be clean, organized, and in good sanitary condition. Refrigerators and freezers were maintained at proper temperatures, with refrigerators at or below 40°F and freezers at 0°F. The facility maintained a sufficient supply of at least two (2) days of perishable food and seven (7) days of non-perishable food. The facility utilizes Grove Menus by Aline, which provides dietitian-approved menus and recipes for kitchen staff to follow. The facility also has a system to ensure residents with physician-ordered special diets receive the correct meals. Planned Activities: LPA observed residents participating in scheduled activities, including music therapy. Weekly and monthly activity calendars were posted and included a variety of recreational activities for residents. LPA observed adequate outdoor recreational space for residents. Resident Rights/Information: LPA observed the required postings displayed throughout the facility's common areas, including the Complaint Poster (PUB 475), Personal Rights, and the Nondiscrimination Notice. Health-Related Services & Records Six (6) resident files were reviewed. Files contained current required documentation, including Admission Agreements, signed consents, Needs and Services Plans, Physician's Reports documenting TB results and ambulatory status, and signed Resident Rights acknowledgments. Residents' medications were reviewed. Medications were observed to be centrally stored in the facility's medication room in locked medication cabinets, locked medication carts, and a locked medication refrigerator. All medications observed were maintained in a secure manner and inaccessible to residents. During the medication review, LPA observed missed medication documentation in resident records. A deficiency will be issued. Disaster Preparedness LPA reviewed the facility's LIC 610D, Emergency Disaster Plan. Emergency disaster supplies, nonperishable food, flashlights, batteries, and first aid supplies, were observed and appeared sufficient to meet emergency preparedness requirements. (continued on 809C) Personnel Records & Training Five (5) staff files were reviewed and included criminal record clearances, CPR/First Aid, required training and TB screenings. Administrator Certificate for Subashasi Kumar, Administrator was valid through December 27, 2027. An exit interview was conducted with Subashasi Kumar, Administrator. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and appeal rights will be provided.the state’s words, verbatim · CDSS document, Jul 30, 2026

Allegation investigated: Staff did not address a resident's change in medical condition.

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit regarding the allegations listed above. LPA met with Subashsani Kumar, Executive Director and explained the reason for the visit. The investigation consisted of the following: On 03/24/2025, LPA Pena obtained a copy of the Staff/Resident rosters, facility sketch and conducted a tour of facility and common areas. LPA also obtained pertinent files for Resident #1 (R1). On 05/30/2025, LPA conducted a tour of the facility focusing on the Memory Care unit, obtained staff/resident roster, additional facility files and Resident #1 (R1) files. LPA also interviewed Staff #1 (S1) - Staff #4 (S4), Resident #1 (R1) - Resident #5 (R5) and telephonically interviewed Staff #5 (S5). During today's visit, LPA obtained a copy of the Staff/Resident rosters and delivered findings. ******CONTINUED ON LIC-9099C***** Substantiated Allegation: “Staff did not address a resident's change in medical condition.” It is alleged that facility staff did not report R1’s change in condition. Interviews conducted by Investigator Hector revealed that R1's cognitive and behavioral responses, which would become more intense at night, had gotten worse. Additionally, R1 had (6) unwitnessed falls, (4) of which resulted in hospitalizations. However, the only change the facility staff made to R1's supervision was to increase their monitoring of R1. (1) of the staff interviewed confirmed that R1 needed a higher level of care. The current facility administrator was unable to provide any documentation from the previous administration's reappraisal of R1, except for a documented statement that R1’s “Assessment will be updated.” The failure of the staff to address and document R1’s change in medical condition corroborates this allegation. Based on statements and interviews conducted, as well as reviewed files and documentation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to Subashsani Kumar, Executive Director along with the Appeals Rights.the state’s words, verbatim · CDSS document, Feb 13, 2026 · control 28-AS-20250324101021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(b)(1) · Plan of correction due date: Feb 20, 2026

87463 Reappraisals.(b)The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. (1) Significant changes in condition, as defined in Section 87101,.... This requirement is not met as evidenced by: Based on interviews and record reviews, the licensee did not comply with the section cited above in which the staff failed to address and document R1’s change in medical condition which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2026

Plan of correction: Administrator/Licensee to ensure to document and update reappraisals of residents for changes in their physical, medical, mental and social condition. Administrator will send a signed self certification that they read, reviewed and understood Title 22 Regs. 87463 and send it to LPA/CCL by POC due date.

Allegation investigated: Resident sustained a fracture while in care.

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit regarding the allegations listed above. LPA met with Subashsani Kumar, Executive Director and explained the reason for the visit. The investigation consisted of the following: On 03/24/2025, LPA Pena obtained a copy of the Staff/Resident rosters, facility sketch and conducted a tour of facility and common areas. LPA also obtained pertinent files for Resident #1 (R1). On 05/30/2025, LPA conducted a tour of the facility focusing on the Memory Care unit, obtained staff/resident roster, additional facility files and Resident #1 (R1) files. LPA also interviewed Staff #1 (S1) - Staff #4 (S4), Resident #1 (R1) - Resident #5 (R5) and telephonically interviewed Staff #5 (S5). During today's visit, LPA obtained a copy of the Staff/Resident rosters and delivered findings. ******CONTINUED ON LIC-9099C***** Substantiated This investigation was completed by Investigator Hector with the Investigations Branch and revealed the following: Allegation: Resident sustained a fracture while in care. It is alleged that due to neglect/lack of supervision, R1 sustained a fracture in care. During the investigation, IB Investigator Hector contacted the Ombudsman office and the Sheriff Department; neither agency investigated the incident. A facility staff (S1) that witnessed/discovered the resident fallen and submitted internal Incident Reports was interviewed. The Incident Reports confirm that R1 sustained 6 unwitnessed falls. S1 revealed that prior administration instructed facility staff to “do more safety checks” and have R1 present in the dining room more where there was more staff supervision. However, there were no additional treatment plan changes to justify keeping R1 after continuing to sustain more falls. The current facility administrator was unable to provide any documentation from the prior administration regarding treatment plan changes. Moreover, the current facility administrator confirmed the facility does not have the staff to provide 1:1 supervision and the staff to provide the proper level of supervision for R1. The medical records confirmed that R1 sustained a hip fracture. There is sufficient evidence to support the facility had a lack of supervision of R1 that resulted in R1 sustaining injury; therefore, the allegation is SUBSTANTIATED. ***An immediate civil penalty will be issued today, in the amount of $500 due to neglect/lack of supervision of R1 that resulted in R1 sustaining a left hip fracture. *** At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(f) and may be assessed at a later date. An exit interview was conducted, and a copy of this report was provided to Subashsani Kumar, Executive Director along with the Appeal Rights. The investigation revealed the following: Allegation: “Staff did not ensure a resident was properly groomed while in care.” It is alleged that on March 2, 2025, R1 was sitting in a wheelchair in front of the TV with other residents with unkempt hair, bare feet, and a runny nose. All (5) staff interviewed denied the allegation. Interviewed staff stated that caregivers use a task/ADL sheet to monitor residents' personal hygiene. Staff indicated that the residents' bathing schedule is either twice a week or as needed. If a resident refuses to shower, staff document it on the task sheet and some staff use a different way to encourage a resident to take a bath. Interviewed staff mentioned that R1 was usually in bed until early afternoon, but they ensure that caregivers help groom R1 before bringing R1 out. All residents interviewed denied the allegation and stated that staff assist them with their personal hygiene and do laundry for them regularly. Residents also denied seeing untidy residents. During the visit, LPA observed that residents were neat, properly dressed and odor free. Therefore, there was insufficient evidence to corroborate with this allegation. Allegation: “Staff did follow proper general food service requirements.” It is alleged that a resident ate dinner next to another resident with the urine bag on their table. All (5) staff interviewed denied the allegation. Staff stated that in addition to following proper food and safety procedures, they also received training about infection control and personal rights. Staff also stated that they have never seen any resident’s urine/catheter bag placed on surfaces where food is served. All (5) residents interviewed denied the allegation. Residents stated that they have never seen anyone put a urine/catheter bag on the dining table. Some residents also indicated that staff treat them with respect. During the visit, LPA did not observe any urine/catheter bag on the dining table or public areas. Therefore, there was insufficient evidence to corroborate with this allegation. Allegation: “Staff do not provide adequate care and supervision to the residents.” It is alleged that around the week of January 6, 2025, (2) residents were seen having difficulty using the community bathrooms with walkers and one of them called for help before a caregiver arrived. Staff indicated that some residents are safe to move independently with a walker and some require one-on-one assistance. Staff interviewed stated that the facility has enough staff to assist residents with their activities of daily living (ADLs). Staff stated that they perform scheduled checks especially for high-fall-risk residents. Staff stated that they received training on fall prevention, safe transfer techniques, and the proper use of walkers. Interviewed residents stated that they were not aware of this incident but confirmed that staff assist them with their activities of daily living (ADLs) such as toileting. Residents interviewed indicated that they feel there is sufficient staff to provide adequate supervision and monitoring to meet their needs. Residents interviewed indicated they feel safe and comfortable at this facility. LPA observed that the facility’s community restrooms have appropriate grab rails and enough space for a walker. Therefore, there was insufficient evidence to corroborate with the allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Subashsani Kumar, Executive Director.the state’s words, verbatim · CDSS document, Feb 13, 2026 · control 28-AS-20250324101021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 14, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews, records review conducted by Investigator Hector, the licensee did not comply with the section cited above in which due to lack of care and supervision, R1 sustained a left hip fracture as a result of a fall while under the care of the facility which poses an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2026

Plan of correction: Licensee/Administrator shall ensure to comply with Title 22 Section 87468.2 at all times. Additionally, Licensee/Administrator shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 87468.2(a)(4). Written POC must be submitted to CCL/LPA by POC due date. An immediate Civil Penalty of $500.00 is being issued today, due to a resident sustaining injury while in care. Refer to LIC 421IM.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Deficiencies in conjunction with a complaint visit (Complaint Control #28-AS-20250324101021). The purpose of this visit is to issue deficiency that was not part of the complaint allegation. During the investigation of Investigator Hector, it was revealed that the facility failed to report all the incidents involving Resident #1 (R1) to CCL. R1 sustained multiple unwitnessed/witnessed falls in care, however, only (2) Unusual incident/injury reports were submitted to CCL by the facility administration. The current facility administrator was unable to locate any additional SIRs sent for the other reported Incident Reports after checking the facility files and computer database. Deficiency is noted on LIC 809D. Exit interview, a copy of this report and Appeal Rights were provided to Subashsani Kumar, Executive Director.the state’s words, verbatim · CDSS document, Feb 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Feb 20, 2026

87211 Reporting Requirements..(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident.. This requirement is not met as evidenced by: Based on interviews, records review conducted by Investigator Hector, the Licensee/Administrator did not comply with the section cited above in which the facility failed to report and send all incidents involving R1’s falls to CCL which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2026

Plan of correction: Licensee/administrator to ensure written reports shall be submitted to the licensing agency and to the person responsible for the residents and comply with Title 22 Regs. Section 87211. Licensee/Administrator shall develop a written Plan of Correction to ensure compliance with CCR Title 22, Section 87211. Written POC must be submitted to CCL/LPA by POC due date.

Allegation investigated: Staff installed cameras in resident rooms preventing them from having a reasonable level of personal privacy in their accommodations.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 01/26/2026 regarding the above allegation. On 12/19/25, LPA Ramirez conducted an unannounced initial complaint investigation, and a need further investigation was documented. During today’s visit LPA Ramirez was greeted by Administrator Subashsan Kumar and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster (LIC 500), Staff#1 - 4 interviews (S1 – S4), Attempted Resident#1-4 interviews (R1-R4), Email correspondence to residents’ families (dated 11/12/2025), Informational flyer on mobile app, and physical plant tour. See 9099-C Unsubstantiated The investigation revealed the following: regarding the allegation “Staff installed cameras in resident rooms preventing them from having a reasonable level of personal privacy in their accommodations.” It is alleged the facility installed cameras in residents’ rooms. Four (4) out of the four (4) staff interviewed denied the allegation. Interview with S1 revealed the facility installed fall detection sensors in residents’ rooms and not video cameras. S1 revealed these fall detection sensors do not record video or audio. Interview with S2 revealed that fall detection monitors were installed in November 2025 but are not yet operational. S2 revealed the fall detection sensors will send a notification if it senses a sudden stop in movement or jolt. S2 revealed all residents’, and their families were notified in writing about the fall detection sensors in November of 2025. S2 revealed all fall detection sensors will be operation once all staff are trained. Review of records revealed a letter addressed to resident families regarding fall detection sensor installation in or around November 24, 2025, and the benefits of the fall detections sensors. During facility tour, S1 showed LPA the fall detection sensors in resident rooms. LPA Ramirez observed these sensors with a cover blocking the lens. According to S1 the sensors are all covered and not yet being operational. S1 revealed that residents and their families will sign consent forms before the fall detection sensors are operational. LPA Ramirez attempted to interview four (4) residents, due to cognitive impairments, these interviews were unreliable. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jan 26, 2026 · control 28-AS-20251218115912

Allegation investigated: Questionable death

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to deliver findings on the above allegation. LPA met with Activities Director Anne Atrach and discussed the purpose of the visit. The investigation consisted of the following: On 2/10/25 LPA Wesley toured the facility and completed a 24 hour Health and Safety check, there were no concerns and LPA Wesley explained that either she or a respresentative from the Department of Social Services will complete the investigation on a later date. On 3/6/25 IB Investigator A.Luckett obtained a copy of R1's Death Certificate. On 12/17/25 IB Investigator A.Luckett received the toxicology report. During todays visit LPA Herrera delivered findings on the reported allegation. (continued on LIC9099-C) Unsubstantiated The Investigation Revealed the following: Allegation: Questionable death. It is alleged that R1's death is questionable due to being over medicated. This allegation was investigated by IB Investigator A.Luckett who began the investigation on 2/7/25. On 3/6/25 IB Investigator A.Luckett went in person to the Pasadena Public Health Department and obtained a copy of R1's Death Certificate with a date of death of 2/3/25 and cause of death listed as: Cardiac Arrest and Alzheimers Disease. On 3/11/25 a request for R1's toxicology report was sent. On 12/17/25 IB Investigator A.Luckett received the toxicology report, the laboratory results that were completed on 2/10/25 showed that tests completed on medications were Not Detected. After a thorough review of documents obtained, IB investigator A.Luckett did not see anything unusual or concerning with the cause of death. Based on statements and interviews conducted, review of R1's file, facility records and medical records by IB investigator A.Luckett, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 17, 2026 · control 28-AS-20250207091124

Allegation investigated: Facility staff did not dispense medications as prescribed Resident sustained unexplained injuries in care Facility staff did not ensure that resident was adequately fed Facility staff did not ensure that resident had clean linens

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to investigate the above allegations. LPA met with Executive Director Suby Kumar and discussed the purpose of the visit. The investigation consisted of the following: On 2/10/25 LPA Wesley conducted initial visit, toured facility, Interviewed Administrator, staff, and residents, received copies of facility food menu's, and requested specific documents from Resident (R1) file. Furher investigation needed. During todays visit 12/15/25 LPA Herrera conducted the supsequent visit and obtained copies of the resident/ staff rosters, copy of December 2025 menus, and copies of the following documents from R1's file: MAR, Charting Notes (observations), and weight record. LPA toured facility, inspected food supply,a total of 5 resident rooms were entered and inspected, LPA observed storage with incontinence supplies and linen supply, LPA interviewed 4 staff (S1-S5) and 5 residents (R1-R6), and deleivered findings on the reported allegations. R1 and S1 are no longer affiliated with facility therefore interviews were not conducted with them. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Facility staff did not dispense medications as prescribed. It is alleged that staff at facility were not dispensing resident’s medications as prescribed and administered PRN to R1 without consulting with responsible party before or after administering the medication. LPA conducted medication review, a total of 5 resident medications were reviewed with no issues observed. LPA reviewed R1’s MAR (Medication Administration Record) and did not observe any issues notations of medication being administered outside of the doctors’ instructions. LPA interviewed 4 staff and each denied the allegation, interviews with S3-S5 revealed that the Medication System that is used is very precise and does not allow medications to administer a medication before the allowed time. Staff also stated that contacting responsible parties is not a requirement when administering PRN unless the resident is not responding well to the medication, in which they will call family/responsible party/doctor and meet with them to create a plan/medication routine that will work best for the resident. LPA interviewed 5 residents and each denied the allegation and stated they do not have issues with the medication and believe medication is being given to them as prescribed. Allegation: Resident sustained unexplained injuries in care. It is alleged that R1 had an unwitnessed fall, sustained injuries from the fall and could not provide reasons or details of what happened. LPA reviewed R1’s file and within the Charting Notes (observations) R1 experienced a fall on 1/27/25 where resident was observed on floor near bed at 9pm with redness on right hip area and no major injuries, it is noted that family were contacted about the fall. LPA interviewed 4 staff and each denied the allegation and stated that falls at the facility are always documented and reported to the resident’s family and doctor (hospice if needed). Staff stated that residents are monitored post fall at all times and if the resident is injured, hits their head or complains of pain they call 911 to have the resident accessed. LPA interviewed 5 residents, and each denied the allegation and stated they have not had any unexplained injuries at the facility. (Continued on LIC9099-C) Allegation: Facility staff did not ensure that resident was adequately fed. It is alleged that R1 was not adequately fed and appeared extremely thin. LPA reviewed R1’s file and observed that there were no major fluctuations in weight from admission to discharge (November 2024-January 2025) with weight beginning at 84.5lbs (admission weight) and ending at 84.1lbs (discharge month weight). LPA interviewed 4 staff and each denied the allegation and stated the residents are being fed well with meals and snacks provided. Staff stated that there is a meal record kept for each residents that will monitor if they have a loss of appetite and when that is noticed the family and doctor are notified. LPA asked Suby for a copy of the meal chart for R1, however, this is a new procedure that began in April 2025, 3 months after R1 was discharged from facility. LPA interviewed 5 residents and each denied the allegation and stated that they like the food and are provided with 3 meals a day and snacks are offered throughout the day. Additionally, LPA reviewed the food menu and food supply and did not see any issues, snacks were being prepared during visit and included ice cream with chocolate syrup, fruit and yogurt, meal served for lunch was a BBQ Chicken Sandwich with Baked Beans and Coleslaw. Allegation: Facility staff did not ensure that resident had clean linens. It is alleged that facility staff left R1’s bed soaked in urine. LPA toured facility, a total of 5 resident rooms were entered and LPA observed all rooms to be clean with clean/dry linens, no foul odors were observed and spare clean linens were stored in resident closets along with incontinence supplies. LPA observed a sufficient amount of incontinence care items in the facility storage. LPA interviewed 4 staff and each denied the allegation and stated that when a residents linens are soiled the caregivers immediately strip down the bed and wash the linens, and prepare the residents bed with the spare clean linens. Staff stated that there are weekly linen changes, however, the linens will also be changed on an as needed bases. LPA interviewed 5 residents and each denied the allegation and stated that their rooms and bed are maintained clean and do not have any issues with linens being soiled. Based on statements and interviews conducted with staff/residents, review of R1's file and facility records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 15, 2025 · control 28-AS-20250207091124

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced Case Management Visit- deficiencies on 11/07/2025, stemming from incident report received on 10/16/2025. LPA was greeted by Office Manager Courtney Cortez and the purpose of the visit was explained. Director of Nursing Nicole Stinson joined shortly after. On 10/30/25, LPA Gonzalez toured the facility’s medication room, obtained staff and client rosters, obtained copies of documents related to the incident, interviewed staff #1-3 (S1-S3) and attempted to interview residents #1-2(R1-R2). During today’s visit LPA interviewed S1 and S2, reviewed second floor med cart and reviewed R1’s medications. According to LIC 624- Unusual Incident/Injury Report received on 10/16/2025, staff self reported that during a routine medication audit, it was discovered that R1 was not administered morning medications on 09/01/25. A deficiency is noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Director of Nursing Nicole Stinson and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 7, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Nov 7, 2025

87465(a)(4)Incidental Medical and Dental Care A plan for incidental medical...The plan shall encourage routine medical ...care and provide for assistance in obtaining such care... (4) The licensee shall assist residents with self-administered medications as needed .This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above in that R1’s morning medication were not administered on 09/01/25.the state’s words, verbatim · CDSS document, Nov 7, 2025

Plan of correction: Licensee immediately demoted employee responsible for the serious error. Med techs will continuously receive quarterly med training.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced Case Management Visit-Incident on 10/30/2025, stemming from incident report received on 10/16/2025. LPA was greeted by Director of Nursing Nicole Stinson and the purpose of the visit was explained. During today’s visit, LPA Gonzalez toured the facility’s medication room, obtained staff and client rosters, obtained copies of documents related to the incident, interviewed staff #1-3 (S1-S3) and residents #1-2(R1-R2). According to LIC 624- Unusual Incident/Injury Report received on 10/16/2025, staff self-reported that during a routine medication audit, it was discovered that R1 was not administered morning medications. Staff interviews and record review revealed the facility schedules two (2) med techs per shift and one (1) overnight. On the morning shift of 09/02/25, S2 observed morning medications had not been administered for R1 on 09/01/25. S2 immediately informed S1. R1’s doctor and family were also notified. R1 was monitored and did not have any adverse reaction and remained in stable condition. No further action is required at this time. LPA Gonzalez may return to gather additional documents. No deficiencies were cited during today's visit. Exit interview was conducted. A copy of this report was provided to Director of Nursing Nicole Stinson.the state’s words, verbatim · CDSS document, Oct 30, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Galarza and Gabriela Castro conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to Executive Director Subishsani Kumar. The Residential Care For Elderly (RCFE) facility serves cognitively impaired residents ages 60 and over. The following were observed/inspected: Infection Control: The Infection Control Plan was reviewed. The facility has sufficient supply of Personal Protective Equipment (PPEs). Operational Requirements: The facility has a hospice waiver for 20 residents. All bedrooms are approved for non-ambulatory residents. Facility does not handle resident monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 2/1/2026. The facility entire facility serves residents with Dementia. Physical Plant/Environment Safety: Facility is a 2-story building consisting of 43 resident rooms, 2 activity rooms, outdoor courtyard, 2 dining rooms, side patio in 1st floor, 2nd floor terrace patio, conference room, lobby room, kitchen, employee lounge, and office.The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There is a water fountain located in the 1st floor. Cleaning supplies and toxic substances are inaccessible to residents. Most beds had required bedding, linens, and mattress pads with the exception of 10 beds. The signal system was tested and is operational. Water temperature readings did not measure within tthe required 105 - 120 degrees Fahrenheit. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has charged fire extinguishers. The last fire inspection was conducted on 3/13/25 by State of CA Fire Marshall. Rooms 110, 115, and 210 had oxygen tanks in the rooms but no signs of "No Smoking-Oxygen in Use". Staffing: A total of 37 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 12/27/2025.. Staff have criminal background clearance. 10 staff files were reviewed. They contained 1st Aid/CPR training, criminal background clearance, health/TB screenings, 1st Aid/CPR training, and training records. Administrator on record is not current. A citation was issued. Resident Records/Incident Reports: 10 resident files were reviewed. They contained admission agreements, Service Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. Centrally stored medication records were reviewed. R6's medical assessment is dated 7/28/23; a citation was issued. RCFE & Ombudsman complaint posters are posted near the main entrance. A technical advisory was issued pertaining to the size of the RCFE poster. Planned Activities: Facility activity calendar was posted. Sufficient space to accommodate both indoor and outdoor activities was observed. Food Service: Food supply was checked in the kitchen and pantry storage areas, consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. 18 residents have physician orders for modified diets. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Director of Culinary Services Food Handling Certificate is current. Incident Medical and Dental: Centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family or facility van. R1 & R2 were missing medications. A citation was issued. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 9/3/2025. Residents with Special Health Needs: There are currently 16 residents receiving hospice services, 2 receive home health services, and no residents have prohibited health conditions. Individual Service Plans and Appraisals are on file. Postural support physician orders are on file. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview, copy of report/appeal rights was conducted with Executive Director Subishsani Kumar.the state’s words, verbatim · CDSS document, Sep 5, 2025

Allegation investigated: Staff did not check on residents in a timely manner Staff inappropriately removed the signal systems from residents’ rooms Staff are not answering the facility phone

Licensing Program Analysts (LPA) Luis De Leon conducted an initial unannounced complaint investigation visit for the allegation listed above. LPA met with the Office Manager Courtney Cortez and explained the reason for the visit. Executive Director Subashsani Kumar joined the visit sometime after. The investigation consisted of the following: On today’s visit, LPA De Leon toured the physical plant, random rooms in the first and second floor, and common areas with Environmental Service Director Mark Chisum. LPA obtained staff/resident roster, Resident #1 (R1) files such as: Identification and Emergency Information/Face sheet, Physician's Report, Pre-placement Appraisal, and Admission Agreement. CONTINUED ON LIC-9099C Unsubstantiated Regarding allegation: Staff did not check on residents in a timely manner It is alleged that staff did not ensure resident’s well-being when resident had fallen to the ground. Staff did not respond in a timely manner to aid residents, instead another resident provided assistance to a resident who had fallen. The investigation reveals the following: Residents interviews revealed that four (4) out six (6) stated that they have not experienced any issues with staff responding in a timely manner. The remaining two residents were unable to respond to LPA’s question. R1 stated that R1 has used the bathroom call button and staff has responded to provide assistance. LPA interviewed R1, who stated that there was one instance where R1 had fallen in R1’s bathroom. R1 yelled out for assistance since the call button was out of R1’s reach, however, staff managed to hear R1’s calls for assistance and provided R1 with assistance. Staff interviews revealed that six (6) out of six (6) staff denied not responding to residents’ calls in a timely manner. LPA observed that during facility activities staff were providing assistance to residents in the common area. LPA tested call buttons in two random residents’ rooms, and the response time was less than five (5) minutes. Staff stated that wellness checks are done every two hours, but if residents have special needs, wellness checks are done more frequently. Based upon the investigation, client and staff interviews, and LPA observations, there was insufficient evidence to corroborate the allegation. Regarding allegation: Staff inappropriately removed the signal systems from residents’ rooms. It is alleged that the signal system pull cords have been removed from residents’ rooms and bathrooms and that residents may not be able to summon staff for assistance when needed. The investigation reveals the following: The signal system was replaced in May/June; however, the new system was operational on the same day that the previous signal system was removed. There was no downtime experienced at the facility during installation and replacement of signal system. Residents’ interviews revealed that three (3) out of six (6) residents stated that they have not needed to use the call button to summon staff for assistance. R1 stated that R1 has used the bathroom call button and staff has responded to provide assistance. R1 stated that there was one instance where R1 had fallen in R1’s bathroom. R1 yelled out for assistance since the call button was out of R1’s reach, however, staff managed to hear R1 calls for assistance and provided R1 with assistance. Two (2) out of six (6) residents were not able to understand questions about the call system. LPA tested the call system on each floor and staff responded in a timely manner, in less than five (5) minutes. Staff interviews revealed that six (6) out of six (6) staff denied not responding to residents’ calls when the signal system button is pressed. CONTINUED ON LIC-9099C LPA observed signal system application on each caregiver mobile phone. The caregiver was able to reset call alert only when the caregiver was physically in the room and press the same call button where the alert was activated. Executive Director Kumar explained that all managers have access to mobile signal system alerts and if a caregiver does not respond in a timely manner, the managers will contact the caregiver directly to respond to the signal system call even after business hours. Based upon the investigation, client and staff interviews, and LPA observations, there was insufficient evidence to corroborate the allegation. Regarding allegations: Staff are not answering the facility phone. It is alleged that the facility is not answering the facility phone. The investigation revealed the following: During business hours, the facility has a receptionist at the front desk answering incoming phone calls. Staff stated that managers will answer phones if the receptionist steps away from the front desk. For after-hour shifts, the main phone line is transferred to night shift MedTech who is responsible for answering the phone. Executive Director Kumar explained that if the main phone line is busy, residents’ families or responsible party may call the facility’s nurse phone line that is available 24x7. In addition, the facility has provided families and/or residents responsible parties with phone numbers of all managers. R1’s trustee confirmed that the trustee had the managers’ phone numbers. Residents interviewed revealed that four (4) out of six (6) residents do not receive phone calls since they don’t have anyone that would call residents. Two (2) out of six (6) residents stated that family prefers to visit them. Staff interviews revealed that six (6) out of six (6) staff denied not answering phone calls. MedTech confirmed that phone calls are transferred to MedTech mobile phone. Staff stated that phone calls may not be answered if the line is busy with another call. However, staff stated that it is unusual to receive telephone calls at night. During the visit, LPA observed that telephone calls were being answered by receptionist. Based upon the investigation, client and staff interviews, and LPA observations, there was insufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview was held with Executive Director Subashsani Kumar. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 26, 2025 · control 28-AS-20250819141728

Allegation investigated: Licensee does not provide a safe environment for residents in care.

Licensing Program Analyst (LPA) Daniel Konishi conducted an subsequent unannounced initial complaint visit at the facility and met with Mark Chism to discuss the purpose for today's visit. The Executive Director, Subishsani Kumar arrived shortly after and LPA explained the purpose of the visit. The purpose of the visit is to investigate the above allegation. On 05/27/2025, the initial investigation visit was conducted. The investigation consisted of the following: LPA interviewed the Executive Director, Maintenance Director, Staff #1 (S1) - Staff #7 (S7). LPA also interviewed Resident #3 (R3) – Resident #7 (R7). LPA attempted to interview Resident #1 (R1) and Resident #2 (R2), however, due to the residents’ inability to answer questions, LPA terminated the interviews. LPA obtained copies from R1’s to R2’s file, including the Physician's Report, Identification and Emergency Information LIC 601 form, Pre-placement Appraisal, Admission Agreement, Personal Rights and Internal Incident Reports. LPA also obtained the staff and residents rosters, and the facility’s House Rules. LPA toured the facility with the Maintenance Director. Unsubstantiated During today's visit, LPA obtained the following documents: staff and client rosters. Regarding allegation: Licensee does not provide a safe environment for residents in care. it is alleged that a resident is abusing another resident and staff are not addressing the resident’s behavior, which is creating an unsafe environment for residents in care. Six (6) out of nine (9) staff interviewed denied the allegation. Two (2) out of nine staff interviewed corroborated the allegation and stated being concerned about the multiple occurrences of R1’s physical altercations with R3. One (1) out of nine (9) staff interviewed could not confirm nor deny the allegation. However, nine (9) out of nine (9) staff stated that if residents are involved in an altercation, the staff would immediately intervene, separate, and re-direct the residents being involved. Nine (9) out of nine (9) staff stated that there have been no reported injuries from any resident-on-resident physical or verbal altercations. Nine (9) out of nine (9) staff stated that R1 only able to speak a different language which causes R1 to become more agitated and become physically aggressive. However, nine (9) out of nine (9) staff stated that R1’s family does visit daily and also able to help communicate by the phone to provide assistance. Executive Director also stated that they use their cellphone apps to help communicate with R1. Based on record review, R1’s current physician’s report does not have a history of aggressive behavior. However, R1’s Pre-placement appraisal does state mild nervousness or anxiousness. The Executive Director and (2) out of eight (8) staff stated that R1 is adjusting due to recently moving into the facility and that medications taken also take time for R1 to become stable. Executive Director confirmed that in order to ensure safety, R1 and R3 were moved to different rooms on 05/28/2025. Executive Director stated that if resident’s aggressive behavior continues, they would continue to address and work with residents who have aggressive behaviors. Executive Director stated that R1 moved out of the facility on 06/06/2025. Five (5) out of five (5) residents interviewed denied the allegation and stated that they feel safe at the facility. None of the residents interviewed stated being physically or verbally abused by another resident or staff. Based on interviews conducted with facility staff, facility client, witnesses, and record review, there was not enough supportive evidence to concur with the reported allegation. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to the Executive Director, Subishsani Kumar.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 28-AS-20250522082507

Allegation investigated: Staff left residents in wet diapers for extended periods of time Staff did not ensure resident's showering needs were met

Licensing Program Analyst (LPA) Alberto Lopez conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced and met with the Executive Director, Suby Kumar and Mark Chisum, Environmental Services Director. The purpose of the visit was explained. LPA toured the facility with staff Mark Chisum, including common areas and all the rooms on the second floor and five random rooms on the first floor, obtained copies of documents, and held interviews with eight (8) residents (R#1-R#8) and six (6) staff (S#1-S#6), and four (4) witnesses W#1-W#4 The investigation revealed the following: Allegation: Staff left residents in wet diapers for extended periods of time. It is alleged that some residents are left in wet diapers for extended periods of time. LPA interviewed eight (8) residents, and all eight (8) residents were not able to corroborate the allegation. (Continued on 9099C) Unsubstantiated (continued from 9099) LPA interviewed six (6) staff and three (3) of six (6) staff members denied the allegation. Three (3) staff members stated that occasionally they will discover resident in soaking wet diapers. One (1) staff member stated that is not very often and that it is just one resident who may be too heavy and burdensome to tend to. LPA interviewed four (4) witness, two (2) are family members and all four (4) witness stated that witnesses do not have any evidence of residents left in wet diapers. One (1) witness stated things have improved since witness verbally brought the issue to staff and stated that witness has no issues with the care at facility at this time. LPA did not observe any residents with bad odor and all the residents. LPA observed residents were clean and in clean clothes during the visit. LPA reviewed the May 2025 Electronic Charting Program (ECP) for three residents in question, and it showed that staff are making their rounds, and providing residents hygiene and bathing services and documenting it on the ECP. LPA observed the rooms to be very clean. LPA observed staff providing care and activities for residents during the visit. There is not sufficient evidence to substantiate this allegation. Allegation: Staff did not ensure resident's showering needs were met. It is alleged that residents are not being showered as required. LPA interviewed eight (8) residents, and all eight (8) residents were not able to corroborate the allegations. LPA interviewed six (6) staff and five (5) of six (6) staff denied the allegations. All staff stated they provide showering for all residents unless they refuse. LPA interviewed four (4) witness and four (4) of four (4) were not able to corroborate the allegation. LPA reviewed the May 2025 Electronic Charting Program (ECP) for three residents in question, and it showed that staff are making their rounds, and providing residents hygiene and bathing services and documenting it on the ECP. LPA observed all residents to be clean and did not omit and body odor. Two (2) residents stated that they bathe themselves. LPA observed that the showers in most rooms inspected were recently used as there was current water residue left behind in the shower and adjacent floor that provided evidence that residents are being showered. There is not sufficient evidence to substantiate this allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with the Executive Director, Suby Kumar. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Jun 19, 2025 · control 28-AS-20250609145039

Allegation investigated: Staff do not safeguard resident's personal belongings while in care. Staff do not ensure that resident is provided with clean clothing while in care. Staff do not ensure that resident's room is maintained in a clean condition while in care. Staff do not ensure that communications to the facility from resident's representative are answered promptly and appropriately.

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced complaint investigation visit regarding the above allegations. LPA Margaryan met with Executive Director and the porpose of the visit was explained. During today's visit LPA obtained copies of staff & residents Rosters, reviewed R1's file and collected relevant documents. Interviews conducted with Executive Director, Staff 1 - Staff 4 (S1 - S4) and Residents 1 - Residents 5 (R1 - R5). LPA conducted a tour of facility including R1's room and randomly chossen 5 other residents room. Continue 9099C Unsubstantiated Regarding the allegation: Staff do not safeguard resident's personal belongings while in care. It was alleged that staff steal / use R1’s personal supplies (Depends, panties, wipes, gloves, wash cloths) for other residents. Also pair of shoes was missing for R1. Interviewed staff denied the allegation. They stated that personal supplies and belongings didn't take from one resident and use for another. They stated staff never stole residents personal belongings. S1 indicated that there was one occasion that one of resident was missing a pair of shoes but was letter found and returned to them. Interviewed Executive Director stated that the community maintains an adequate inventory of hygiene, incontinence supplies to meet the needs of all residents. Interviewed staff mentioned that there are some residents family members who prefer to bring their own supplies but if they run low there are ample of house supplies that can be provided until family members bring items. LPA toured the facility and verified stock available of personal care items. LPA also checked R1's and randomly chosen residents room (incontinent care) and seen that each resident had their own items / supplies. Residents interviewed could not corroborate the allegation. Resident interviews revealed that staff did not steal residents supplies. They stated that their personal belongings are not missing. Regarding the allegation: Staff do not ensure that resident is provided with clean clothing while in care. It was alleged that staff not laundering R1’s clothing and R1 wearing dirty clothing. Interviewed staff denied the allegation. They stated that they will ensure residents were placed in clean clothing every day. They stated that they would change residents clothing often because some residents got food on their clothing at the time of meals. Staff would encourage residents to change clothes if residents declined to be changed. Interviewed Executive Director stated that staff adhere strictly to the assigned laundry schedule for each resident. Interviewed staff stated that residents didn't leave unattended and wearing dirty clothes. They stated that laundry for residents done on weekly basis and as needed. Interviewed residents stated that staff change their clothing every day. LPA observed residents at the common areas and in their rooms, and found they looked clean and properly dressed. Per LPA's observation, R1's and other residents clothes were clean. Staff did not leave residents in dirty clothing. Continue 9099C Regarding the allegation: Staff do not ensure that resident's room is maintained in a clean condition while in care. It was alleged that R1’s room is often very dirty. Interviewed staff denied the allegation. They stated facility and rooms are cleaned daily, and residents rooms are deep cleaned once a week and/or as needed. They stated there are accidents happened on a daily basis; however they communicate to each other and areas cleaned as soon as they see it is needed. Executive Director stated that staff clean the facility daily, and deep cleaning of resident rooms is done once a week and/or as needed. At the time of visit residents rooms including R1's room and common areas were inspected. R1's room and all other rooms and common areas were observed to be clean. Regarding the allegation: Staff do not ensure that communications to the facility from resident's representative are answered promptly and appropriately. It was alleged that family member trying to speak with Administrator about their concern, but Administrator not returning their calls. Interviewed Executive Director / Administrator and staff denied the allegation. Executive Director stated that residents are their priority. Any concerns raised by family members are taken seriously and addressed promptly. Stated that allays returned family members / responsible party's calls. Interviewed S2 stated when they answer the phone if someone not available, they will take a message with call back number and what the call is regarding. They let the person know they had a call as soon as possible and person / staff get back to them / caller as soon as they can. Interviewed Executive Director and staff stated that residents family members have their cell phone numbers and can contact to them directly (call, text). Also email was provided to family members. Based on interviews conducted and observations made, there was insufficient evidence to prove the allegation(s). Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted, and a copy of this report was provided Executive Director.the state’s words, verbatim · CDSS document, Jun 19, 2025 · control 28-AS-20250610144343

Allegation investigated: Allegation - Staff do not provide adequate supervision to residents.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced and met with the Executive Director, Suby Kumar. The purpose of the visit was explained. LPA toured the facility, obtained copies of documents, and held interviews. The investigation revealed the following: Allegation - Staff do not provide adequate supervision to residents. During the visit today, LPA interviewed the Executive Director, 4 Staff, and 4 Residents. Staff interviewed stated that there are always staff supervising residents. The morning and afternoon shifts have a med tech and 2 caregivers on each floor, and the overnight shift consists of a med tech and 2 caregivers. Unsubstantiated Staff stated the residents come out to the communal area (dining area) to do activities and have their meals. For those who choose to remain in their rooms, staff would do room checks at least every 2 hours. Staff indicated that all employees, including kitchen, housekeepers, and maintenance, are also monitoring residents as they are doing their duties. If they see anything usual with the residents, they will ask caregivers or med techs to assist the residents. According to staff, most of the residents go out to the dining area for their meals. They know which residents have a restricted diet and kitchen staff are aware of their diets and allergies. They monitor if residents are eating and ensure they are given their proper restricted diets. LPA interviewed 4 residents, and they all stated that the staff provide good care and supervision. There is always a staff available when needed. Staff bring them out to the common area and supervise them during mealtime. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with the Executive Director. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 28-AS-20250603080828

Allegation investigated: Staff transported a resident to a different hospital emergency room. Staff left harmful material accessible to a resident. Staff did not meet a resident's catheter needs while in care.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent visit regarding the allegations listed above. LPA met with Mark Chisum, Maintenance Director and explained the reason for the visit. Shortly after, Subishsani Kumar, Executive Director assisted LPA with the investigation. The investigation consisted of the following: On 03/24/2025, LPA Pena obtained a copy of the Staff/Resident roster, facility sketch and conducted a tour of facility and common areas. LPA also obtained pertinent files for Resident #1 (R1). During today's visit, LPA conducted a tour of the facility focusing on the Memory Care unit. LPA obtained staff/resident roster, Resident #1 (R1) files such as: Identification and Emergency Information/Face sheet, Physician's Report, Pre-placement Appraisal, Admission Agreement, Personal Rights, Kaiser after visit summaries, Medication Administration Records (MARs) from July 2024-March 2025 and Incident Reports related to this investigation. Between 10:40am and 1:30 pm, LPA interviewed Staff #1 (S1) - Staff #4 (S4), Resident #1 (R1) - Resident #5 (R5) and telephonically interviewed Staff #5 (S5). ******CONTINUED ON LIC-9099C***** Unsubstantiated The investigation revealed the following: In regards to the allegation: "Staff transported a resident to a different hospital emergency room." It is alleged that R1 was taken to the hospital on 11/27/2024 where family members waited for 2 hours, but later found out that R1 was moved to a different emergency room after they called the facility several times for confirmation. (3) out of (5) staff remembered an incident where upon leaving the facility, paramedics informed the facility staff that R1 will be taken to Pomona Valley Hospital, which was then communicated to the family. However, the facility did not receive calls from the paramedics nor the hospital regarding the hospital change. (5) staff interviewed indicated that location changes can happen, but it is the responsibility of the paramedics or hospital staff to inform the family/POA or responsible party or facility staff about such changes. (5) residents interviewed had no comments about the allegation as they were unaware of the incident. Based on records reviewed, former Administrator had informed a family member on 12/04/2024 that R1 was meant to be transported to Pomona hospital. However, while en route, R1 was redirected to a different hospital and the facility did not receive this information from the paramedics, hence was not shared to the family member. Therefore, there was insufficient evidence to corroborate with the allegation. In regards to the allegation: "Staff left harmful material accessible to a resident." It is alleged that a resident had dinner and placed a urine bag on the table while another resident ate nearby. All staff interviewed denied seeing or hearing about this incident. (5) out of (5) staff interviewed stated that they would never allow such a situation to happen and they are committed to maintaining a clean dining environment to ensure safety and prevent contamination. (5) out of (5) residents interviewed cannot corroborate the allegation. All (5) residents stated that they did not witness or hear anything related to the incident. LPA observed the dining area to be clean and no urine bag was seen on the dining table. Therefore, there was insufficient evidence to corroborate with the allegation. In regards to the allegation: "Staff did not meet a resident's catheter needs while in care." It is alleged that during the week of 01/06/2025, a resident was seen walking barefoot while dragging what appeared to be a urine bag attached to a catheter. All staff interviewed denied seeing or hearing about this incident. Staff interviewed denied knowing about the incident and stated they prioritize resident safety, including protecting catheters. Staff also stated that their job is to assist all residents in the community to ensure they are not at risk of tripping or falling and if they have seen such an incident, that they will assist the resident immediately. (5) out of (5) residents interviewed denied seeing anyone dragging a urine bag. All residents interviewed stated that if they have seen it, they will call someone or a caregiver to help the resident. LPA did not observe any resident walking barefoot with visible urine bags. Therefore, there was insufficient evidence to corroborate with the allegation. Based on observations, statements and interviews conducted with staff, residents and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Subishsani Kumar, Executive Director.the state’s words, verbatim · CDSS document, May 30, 2025 · control 28-AS-20250324101021

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.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted required annual inspection. LPA met with Environmental Director of Services- Mark Chisum and purpose of today’s visit. This facility is licensed to serve sixty (60) non-ambulatory residents and all bedrooms are approved for non-ambulatory. This facility may retain no more than twenty (20) hospice residents. There are six (6) residents under hospice care at this time. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected eight (8) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observe postings encouraging proper handwashing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. The facility is approved for delay egress doors. LPA Ramirez tested and observed doors to be in good repair. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). Planned Activities: Facility has an activities director and LPA Ramirez observed staff conducting seated exercises with residents during physical plant tour. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed a facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D) in place. Last documented emergency drills were conducted on 06/26/2024 and 05/23/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply. SEE 809-C for continuation of report Residents with Special Needs: No large bodies of water or pools were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps, or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. The facility provides incidental medical services. Staffing: Administrator Certificate for Robert Jakini expires 07/24/2025. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for five (3) out of the five (5) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for five (5) out of the five (5) personnel records reviewed. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for sixty (60) non-ambulatory. This facility may retain no more than twenty (20) hospice residents. There are six (6) residents under hospice care. Resident Records/Incident Reports: LPA reviewed Resident files for eight (8) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. No deficiencies were cited during this inspection. Exit interview was conducted and a copy of this report was provided via email due to printer problems.the state’s words, verbatim · CDSS document, Jul 11, 2024

Allegation investigated: Staff mismanaged residents' medication

** This report supersedes the previous report dated 05/23/24. The reason for the visit was to provide additional information not documented on the 9099 dated 5/23/24 and to conduct interviews of residents. Licensing Program Analyst (LPA) Nune Margaryan conducted a visit to supersede the report dated 05/23/24 for the allegation listed above. LPA met with Robert Jakini, Administrator and explained the purpose of the visit. The investigation consisted of the following: During the visits on 03/07/45 and 05/23/24 LPA Nune Margaryan obtained a copy of the resident and staff roster, copy of Med Staff Schedule. Medication Administration Records (Quick MAR) were reviewed. LPA also conducted interviews with Administrator and Staff #1 - Staff # 4 (S #1 - S #4). During todays visit LPA conducted a tour of the facility, interviewed Resident #1 - Resident #6 (R#1 - R#6). Continue 9099C Unsubstantiated The investigation revealed the following: in regard to the allegation " Staff mismanaged residents' medication.” It is alleged that medication administered without proper sign offs and medication being shared between patients / residents. Interviewed Administrator and staff denied the allegation. They stated that staff did not shared medications between residents and all medications are administrated as prescribed and are noted electronically through a "Quick MAR" program. All residents’ medications are registered under the "Quick MAR" program. However, staff indicated they only have written MARs for new residents until their profile will be created in the system. All medications are administered on a consistent schedule. When residents refuse medication, Med Tech / LVNs document refusals, contact Resident's responsible party and contact the Prescribing Physician. Interviewed staff demonstrated to LPA how is worked "Quick MAR" program. LPA observed that residents medications are registered under the "Quick MAR" program. LPA also reviewed written MAR and observed medications are documented properly and given as prescribed. Residents interviewed stated that staff administrated medication. They were unable to provide other information due to their diagnosis. Administrator and staff indicated that each Med. Tech. / LVNs have their own log in passwords. The information gathered does not corroborate the allegation noted above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report was provided Administrator Robert Jakinithe state’s words, verbatim · CDSS document, Jul 1, 2024 · control 28-AS-20240304141910

Type of visit: Case Management - Deficiencies

During the course of investigation of complaint # 28-AS-20240304141910, a deficiencies were observed and cited per California Code of Regulations, Title 22 and recorded on LIC 809D. At the time of visit LPA observed that R1's medications were unlocked in R1's room. Also observed scissors, shaving razors and perfumes, deodorants and other hygiene items unlocked in R#1's bathroom cabinet. Per R1's Physicians Report, R#1 is at risk at allowed direct access to personal grooming and hygiene items. An exit interview was conducted, and a copy of the Report and Appeal Rights were provided to Robert Jakini.the state’s words, verbatim · CDSS document, Jul 1, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Jul 2, 2024

87705 Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above. LPA observed R#1s medication unlocked in R3!'s roomthe state’s words, verbatim · CDSS document, Jul 1, 2024

Plan of correction: Licensee/ Administrator remove all medications during the visit. Additionally, licensee / administrator will conduct an in-service training about this section code with all staff and submit an attendance sheet with staff signatures to CCLD by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(1) · Plan of correction due date: Jul 2, 2024

87705 Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s) LPA observed scissors, shaving razors and perfumes, deodorants and other hygiene items unlocked in R#1's bathroom cabinet. Per R1's Physicians Report, R#1 is at risk at allowed direct access to personal grooming and hygiene items.the state’s words, verbatim · CDSS document, Jul 1, 2024

Plan of correction: Licensee/ Administrator remove scissors, shaving razors during the visit Additionally, licensee / administrator will conduct an in-service training about this section code with all staff and submit an attendance sheet with staff signatures to CCLD by POC due date. Licensee / Administrator will contact to R#1's Pyshician to deternine that R1 not at the risk to keep parfumes in her room.

Allegation investigated: Facility did not notify appropriate doctor of resident's change in condition.

*This report is a corrected version for report dated 6/11/24 to correct missing census and executive director's last name.* Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint visit regarding the above allegation. LPA met with Robert Jakini and explained the reason for the visit. The investigation consisted of the following: On 8/22/22, LPA Galarza and Ramirez conducted a health and safety check visit at the facility, no concerns were observed. Interviews with 2 staff were conducted and copies of incident report and other documents were obtained. On 8/23/22, LPA Galarza interviewed Resident #1’(R1’s) representative and Skilled Nursing Facility over the phone. On 8/25/22, Investigation Bureau of the department accepted assignment to request medical records for R1. On 2/26/24, LPA Flores was re-assigned complaint investigation. On 3/8/24, LPA Flores requested additional records from the facility. On 3/13/24, LPA Flores subpoenaed medical records for hospitalization and skilled nursing facility. On 5/24/24, LPA Flores interviewed 6 staff over the phone. (CONTINUED ON LIC 9099C) Substantiated On 6/3/24, LPA Flores contacted Guardian Pharmacy. On 6/11/24 LPA Flores delivered findings for complaint. The investigation revealed the following: Regarding allegation: Facility did not notify appropriate doctor of resident’s change in condition. It is alleged incorrect doctor was notified of resident’s change in condition. Record review revealed that upon R1’s return to the facility on 6/3/22 family representative notified facility of change of physician. The change was noted in the facility’s face sheet under resident’s contacts – medical, previous physician was crossed out and new physician was written in ink with contact phone number. On 6/7/22 facility staff notified a different physician of change in condition per records reviewed. The physician notified was not previous or R1’s current physician. Per interviews conducted with staff, physician notified is not under the same medical group as R1’s physician at the time. Staff also stated that any changes are noted in the hard copy file as well as the facility’s digital database. The facility staff that notified the physician does not recall the incident. However, per records reviewed the staff made a mistake and notified the wrong physician. Notes revealed physician who was notified, then contacted the correct physician of R1’s change in condition. Based on LPAs interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Robert Jakini and a copy of this report, LIC 9099D, and appeal rights were provided. On 6/3/24, LPA Flores contacted Guardian Pharmacy. On 6/11/24 LPA Flores delivered findings for complaint. The investigation revealed the following: Regarding allegation: Resident suffered a fracture while in care due to lack of supervision. It is alleged that on 4/11/22, while under the care of the facility R1 fell, was transported to the hospital where R1 was diagnosed with a hip fracture. Documents reviewed revealed the following: R1 was admitted to the facility on 3/25/22. Preplacement Appraisal Information dated 3/20/22 notes R1 requires checks due to not being able to balance. There is no previous history of falls recorded on preplacement appraisal or needs and care plan. Per physician’s report dated 8/4/21, R1 does not have any motor impairment or history of falls. Per incident report dated 4/16/22, on 4/11/22 R1 had an unwitnessed fall in R1’s room at around 6:45pm. Facility staff contacted 911 “immediately” and notified R1’s representative and physician. Medical Records revealed R1 was hospitalized on 4/11/22 due to a mechanical fall which resulted in a left proximal femur fracture. Per interviews with staff, R1 was last seen in the dining room around 5:00pm and went back to the room. Staff conducts checks on residents at least every 2 hours or based on each individual needs. R1 was heard screaming and therefore a staff that was walking by heard R1 and responded to R1. Although, R1 did sustain a fracture during the fall, there is insufficient evidence that R1 required assistance due to a history of falls or that there was no staff to provide assistance. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff did not notice a change in resident's condition. It is alleged during the 4 days from June 3rd to June 7th R1’s condition deteriorated with a weight loss of 12 lbs. Records reviewed revealed R1 was hospitalized on 4/11/22 due to a fracture. On 4/18/22, R1 was discharged to a skilled nursing facility. On 4/28/22, R1 was hospitalized due to severe anemia. On 4/19/22, Skilled nursing noted R1’s weight as 156 lbs. On 5/18/22, skilled nursing noted abnormal weight loss for R1. On 5/20/22, skilled nursing noted R1 had lost 10 lbs. On 5/31/22, R1’s weight was noted as 152 lbs. R1 was discharged from skilled nursing to residential facility by physician on 5/31/22, “The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility”. On 6/2/22, Physician ordered to discharge R1 to residential facility. On 6/3/22, R1 was re-admitted to residential facility. On 6/4/22, facility staff noted R1 refused a meal. On 6/5/22, facility staff noted R1 has a decrease of appetite and noted that Health Residential Services (HRS) staff will continue to monitor R1. On 6/6/22, facility staff noted that R1 had refused meals. (CONTINUED ON LIC 9099C) On 6/7/22, physician and R1’s representative was notified of R1’s change in condition. R1’s physician visited R1 and by 4:30pm R1 was transferred back to Skilled Nursing Facility per physician’s request. On 6/8/22 it was noted by Skilled Nursing staff that R1 was weighing 140 lbs. Although R1 did lose 12 lbs. between 5/31/22 and 6/8/22, R1 had a history of abnormal weight loss. Weight loss began in SNF and was noted as abnormal weight loss during the stay at the SNF. In addition, R1 had a history of anemia. Per records review facility staff encouraged R1 to eat meals between 6/3/22 and 6/6/22. However, R1 refused meals on 6/6/22 and facility staff notified physician within 24 hours of R1 refusing meals. Interviews with staff revealed that when residents refused a meal staff notifies HRS to monitor and once a resident continues to refuse all three meals staff notifies physician. Facility staff followed the facility’s procedures for the change in condition. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Resident developed a wound while in care. It is alleged R1’s surgical wound re-opened, new wound on lower back, and a hematoma on heel of left foot was discovered once arrived at SNF. On 4/11/22, R1 was hospitalized due to hip fracture and required surgery. On 4/27/22, Advantage Wound Care was in place for R1, who provided care for wound on left hip and thigh upper area for surgical wounds. On 6/1/22, Advantage Surgical Wound Care visited R1 and managed wounds in multiple locations which were not described in records reviewed. On 6/3/22, facility noted that R1 is receiving wound care for a stage 2 wound upon readmission. The location of the wound was not identified. On 6/7/22, R1 was readmitted to SNF. On 6/8/22, SNF staff noted the following regarding R1’s skin. R1 had “multiple sites of skin discoloration; left hip surgical wound, sacrum pressure Deep Tissue Injury (DTI), right 1st toe trauma, and left heel DTI”. Physician noted care for R1 to monitor left heel for signs of infection, monitor surgical hip for signs of infection, monitor right toe, and order heel protectors to prevent from opening. On 6/15/22, Advantage Surgical and Wound care notes the following four wounds “(1) pressure left heel DTI no drainage, (2) surgical left hip wound was resolved, (3) pressure sacral coccyx DTI debris, surgical, and (4) trauma to right 1st toe no drainage and monitor”. On 6/15/22, pressure sacral coccyx developed into a stage 3 wound. Based on documents reviewed, R1 had two surgical wounds when admitted at SNF on 4/18/22 for which R1 was receiving care. On 6/1/22, R1 continued to receive care for surgical wound. On 6/3/22, facility noted the surgical wounds. On 6/8/22, R1 had three sites of deep tissue injury. (CONTINUED ON LIC 9099C) However, the sites were not staged. The sacral coccyx wound got first stage on 6/15/22 while R1 was at the skill nursing. Therefore, there is not enough evidence to say that R1’s wounds developed while in care at the facility. Deep Tissue Injuries(DTI) can develop as soon as within 24 hours due to friction while moving or transferring a resident. R1 returned to skill nursing on 6/8/22 and did not return to the facility. Therefore, it cannot be determined that DTIs were caused by a lack of care of facility staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegations: Facility did not administer medications to resident and Facility did not ensure resident's medications were ordered. It is alleged R1’s responsible party provided physical list of updated medications to facility’s management staff (Staff #2 S2) and the listed medications were not ordered or administered to R1. Document review revealed the following, on 6/3/22, R1 returned to residential facility after being discharged from SNF. Facility’s medication sheet for June 2022 lists a total of 21 medications, of which 9 were started on 6/7/22. On 6/3/22, SNF medication listed 17 medications at the time of discharge. The additional medications observed were vitamins and an antibiotic. Interviews conducted with facility staff revealed facility works with a pharmacy which provides the profile and dispenses the medication. Once the entry of the medication list is inputted the medication is then ordered and delivered to the facility. Delays of medication are usually caused by medication error or new orders that need to be verified with the physician. Per staff, R1 came with some medication which was noted in the medication sheet. Interview with pharmacy representative revealed that although R1 used their profile system to list the medication sheet, R1 did not use their pharmacy to dispense R1’s medication. There was a delay of providing 9 of the medications. However, it is uncertain if the reason for the delay of medication dispensed to R1 between 6/4/22 – 6/6/22 was due to the pharmacy used by R1 not providing refills, physician needed to clarify the medication, or if the facility failed to request the medication. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Regarding allegation: Facility did not ensure resident received Home Health Care. It is alleged no Home Health Care was ordered for R1 by the facility. On 5/31/22, Physician’s discharge notice notes, “The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility” (Skill Nursing Facility). (CONTINUED ON LIC 9099C) On 6/2/22, Physician’s order notes to discharge R1 to the Terraces with the following note, “may have home health, OT, RN for evaluation”. Interviews conducted with facility’s staff revealed that usually when a resident is discharged from a SNF the resident is discharged with home health care if needed. If the resident needs to have home health care while at the facility, usually the family will contact and place home health due to financial decisions, or in some instances the facility will assist. In R1’s case due to the timeframe of the change in condition of R1, it was uncertain whether there was a need for home health and/or if home health had been requested for R1 by SNF. Per the physician’s statement upon discharge of R1 “may” have home health but it was not determined R1 needed to have home health upon discharge. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Robert Jakini and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 14, 2024 · control 28-AS-20220818172814

Allegation investigated: Facility did not notify appropriate doctor of resident's change in condition.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint visit regarding the above allegation. LPA met with Robert … and explained the reason for the visit. The investigation consisted of the following: On 8/22/22, LPA Galarza and Ramirez conducted a health and safety check visit at the facility, no concerns were observed. Interviews with 2 staff were conducted and copies of incident report and other documents were obtained. On 8/23/22, LPA Galarza interviewed Resident #1’(R1’s) representative and Skilled Nursing Facility over the phone. On 8/25/22, Investigation Bureau of the department accepted assignment to request medical records for R1. On 2/26/24, LPA Flores was re-assigned complaint investigation. On 3/8/24, LPA Flores requested additional records from the facility. On 3/13/24, LPA Flores subpoenaed medical records for hospitalization and skilled nursing facility. On 5/24/24, LPA Flores interviewed 6 staff over the phone. On 6/3/24, LPA Flores contacted Guardian Pharmacy. On 6/11/24 LPA Flores delivered findings for complaint. (CONTINUED ON LIC 9099C) Substantiated The investigation revealed the following: Regarding allegation: Facility did not notify appropriate doctor of resident’s change in condition. It is alleged incorrect doctor was notified of resident’s change in condition. Record review revealed that upon R1’s return to the facility on 6/3/22 family representative notified facility of change of physician. The change was noted in the facility’s face sheet under resident’s contacts – medical, previous physician was crossed out and new physician was written in ink with contact phone number. On 6/7/22 facility staff notified a different physician of change in condition per records reviewed. The physician notified was not previous or R1’s current physician. Per interviews conducted with staff, physician notified is not under the same medical group as R1’s physician at the time. Staff also stated that any changes are noted in the hard copy file as well as the facility’s digital database. The facility staff that notified the physician does not recall the incident. However, per records reviewed the staff made a mistake and notified the wrong physician. Notes revealed physician who was notified, then contacted the correct physician of R1’s change in condition. Based on LPAs interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Robert and a copy of this report, LIC 9099D, and appeal rights were provided. The investigation revealed the following: Regarding allegation: Resident suffered a fracture while in care due to lack of supervision. It is alleged that on 4/11/22, while under the care of the facility R1 fell, was transported to the hospital where R1 was diagnosed with a hip fracture. Documents reviewed revealed the following: R1 was admitted to the facility on 3/25/22. Preplacement Appraisal Information dated 3/20/22 notes R1 requires checks due to not being able to balance. There is no previous history of falls recorded on preplacement appraisal or needs and care plan. Per physician’s report dated 8/4/21, R1 does not have any motor impairment or history of falls. Per incident report dated 4/16/22, on 4/11/22 R1 had an unwitnessed fall in R1’s room at around 6:45pm. Facility staff contacted 911 “immediately” and notified R1’s representative and physician. Medical Records revealed R1 was hospitalized on 4/11/22 due to a mechanical fall which resulted in a left proximal femur fracture. Per interviews with staff, R1 was last seen in the dining room around 5:00pm and went back to the room. Staff conducts checks on residents at least every 2 hours or based on each individual needs. R1 was heard screaming and therefore a staff that was walking by heard R1 and responded to R1. Although, R1 did sustain a fracture during the fall, there is insufficient evidence that R1 required assistance due to a history of falls or that there was no staff to provide assistance. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff did not notice a change in resident's condition. It is alleged during the 4 days from June 3rd to June 7th R1’s condition deteriorated with a weight loss of 12 lbs. Records reviewed revealed R1 was hospitalized on 4/11/22 due to a fracture. On 4/18/22, R1 was discharged to a skilled nursing facility. On 4/28/22, R1 was hospitalized due to severe anemia. On 4/19/22, Skilled nursing noted R1’s weight as 156 lbs. On 5/18/22, skilled nursing noted abnormal weight loss for R1. On 5/20/22, skilled nursing noted R1 had lost 10 lbs. On 5/31/22, R1’s weight was noted as 152 lbs. R1 was discharged from skilled nursing to residential facility by physician on 5/31/22, “The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility”. On 6/2/22, Physician ordered to discharge R1 to residential facility. On 6/3/22, R1 was re-admitted to residential facility. On 6/4/22, facility staff noted R1 refused a meal. On 6/5/22, facility staff noted R1 has a decrease of appetite and noted that Health Residential Services (HRS) staff will continue to monitor R1. On 6/6/22, facility staff noted that R1 had refused meals. On 6/7/22, physician and R1’s representative was notified of R1’s change in condition. R1’s physician visited R1 and by 4:30pm R1 was transferred back to Skilled Nursing Facility per physician’s request. (CONTINUED ON LIC 9099C) On 6/8/22 it was noted by Skilled Nursing staff that R1 was weighing 140 lbs. Although R1 did lose 12 lbs. between 5/31/22 and 6/8/22, R1 had a history of abnormal weight loss. Weight loss began in SNF and was noted as abnormal weight loss during the stay at the SNF. In addition, R1 had a history of anemia. Per records review facility staff encouraged R1 to eat meals between 6/3/22 and 6/6/22. However, R1 refused meals on 6/6/22 and facility staff notified physician within 24 hours of R1 refusing meals. Interviews with staff revealed that when residents refused a meal staff notifies HRS to monitor and once a resident continues to refuse all three meals staff notifies physician. Facility staff followed the facility’s procedures for the change in condition. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Resident developed a wound while in care. It is alleged R1’s surgical wound re-opened, new wound on lower back, and a hematoma on heel of left foot was discovered once arrived at SNF. On 4/11/22, R1 was hospitalized due to hip fracture and required surgery. On 4/27/22, Advantage Wound Care was in place for R1, who provided care for wound on left hip and thigh upper area for surgical wounds. On 6/1/22, Advantage Surgical Wound Care visited R1 and managed wounds in multiple locations which were not described in records reviewed. On 6/3/22, facility noted that R1 is receiving wound care for a stage 2 wound upon readmission. The location of the wound was not identified. On 6/7/22, R1 was readmitted to SNF. On 6/8/22, SNF staff noted the following regarding R1’s skin. R1 had “multiple sites of skin discoloration; left hip surgical wound, sacrum pressure Deep Tissue Injury (DTI), right 1st toe trauma, and left heel DTI”. Physician noted care for R1 to monitor left heel for signs of infection, monitor surgical hip for signs of infection, monitor right toe, and order heel protectors to prevent from opening. On 6/15/22, Advantage Surgical and Wound care notes the following four wounds “(1) pressure left heel DTI no drainage, (2) surgical left hip wound was resolved, (3) pressure sacral coccyx DTI debris, surgical, and (4) trauma to right 1st toe no drainage and monitor”. On 6/15/22, pressure sacral coccyx developed into a stage 3 wound. Based on documents reviewed, R1 had two surgical wounds when admitted at SNF on 4/18/22 for which R1 was receiving care. On 6/1/22, R1 continued to receive care for surgical wound. On 6/3/22, facility noted the surgical wounds. On 6/8/22, R1 had three sites of deep tissue injury. However, the sites were not staged. The sacral coccyx wound got first stage on 6/15/22 while R1 was at the skill nursing. Therefore, there is not enough evidence to say that R1’s wounds developed while in care at the facility. Deep Tissue Injuries(DTI) can develop as soon as within 24 hours due to friction while moving or transferring a resident. R1 was away from the facility from 4/11/22 to 6/2/22. (CONTINUED ON LIC 9099C) R1 returned to skill nursing on 6/8/22 and did not return to the facility. Therefore, it cannot be determined that DTIs were caused by a lack of care of facility staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegations: Facility did not administer medications to resident and Facility did not ensure resident's medications were ordered. It is alleged R1’s responsible party provided physical list of updated medications to facility’s management staff (Staff #2 S2) and the listed medications were not ordered or administered to R1. Document review revealed the following, on 6/3/22, R1 returned to residential facility after being discharged from SNF. Facility’s medication sheet for June 2022 lists a total of 21 medications, of which 9 were started on 6/7/22. On 6/3/22, SNF medication listed 17 medications at the time of discharge. The additional medications observed were vitamins and an antibiotic. Interviews conducted with facility staff revealed facility works with a pharmacy which provides the profile and dispenses the medication. Once the entry of the medication list is inputted the medication is then ordered and delivered to the facility. Delays of medication are usually caused by medication error or new orders that need to be verified with the physician. Per staff, R1 came with some medication which was noted in the medication sheet. Interview with pharmacy representative revealed that although R1 used their profile system to list the medication sheet, R1 did not use their pharmacy to dispense R1’s medication. There was a delay of providing 9 of the medications. However, it is uncertain if the reason for the delay of medication dispensed to R1 between 6/4/22 – 6/6/22 was due to the pharmacy used by R1 not providing refills, physician needed to clarify the medication, or if the facility failed to request the medication. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Regarding allegation: Facility did not ensure resident received Home Health Care. It is alleged no Home Health Care was ordered for R1 by the facility. On 5/31/22, Physician’s discharge notice notes, “The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility” (Skill Nursing Facility). (CONTINUED ON LIC 9099C) On 6/2/22, Physician’s order notes to discharge R1 to the Terraces with the following note, “may have home health, OT, RN for evaluation”. Interviews conducted with facility’s staff revealed that usually when a resident is discharged from a SNF the resident is discharged with home health care if needed. If the resident needs to have home health care while at the facility, usually the family will contact and place home health due to financial decisions, or in some instances the facility will assist. In R1’s case due to the timeframe of the change in condition of R1, it was uncertain whether there was a need for home health and/or if home health had been requested for R1 by SNF. Per the physician’s statement upon discharge of R1 “may” have home health but it was not determined R1 needed to have home health upon discharge. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Robert and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 11, 2024 · control 28-AS-20220818172814

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 18, 2024

87468.2 Additional Personal Rights of Residents...: (a)... All Facilities...(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on records reviewed licensee did not ensure staff notified the correct physician of R1’s change in condition which poses a potential risk to the persons health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Jun 11, 2024

Plan of correction: Administrator will provide in-service training to staff regarding notifying and reviewing physician appropiately by POC due date 6/18/24.

Allegation investigated: Staff mismanaged residents' medication

Licensing Program Analyst (LPA) Nune Margaryan conducted a subsequent unannounced complaint visit to deliver finding to the above mentioned allegation. LPA met with Robert Jakini and explained the reason for the visit. The investigation consisted of the following: On 03/07/24 LPA Nune Margaryan obtained a copy of the resident and staff roster, copy of Med Staff Schedule, Medication Administration Records (Quick MAR) were reviewed. LPA also conducted interviews with Administrator and Staff #1 - Staff # 4 (S #1 - S #4). Continue 9099C Unsubstantiated The investigation revealed the following: in regard to the allegation " Staff mismanaged residents' medication.” It is alleged that medication administered without proper sign offs and medication being shared between patients / residents. Interviewed Administrator and staff denied the allegation. They stated that staff did not shared medications between residents and all medications are administrated as prescribed and are noted electronically through a "Quick MAR" program. All residents’ medications are registered under the "Quick MAR" program. However, staff indicated they only have written MARs for new residents until their profile will be created in the system. All medications are administered on a consistent schedule. When residents refuse medication, Med Tech / LVNs document refusals, contact Resident's responsible party and contact the Prescribing Physician. Interviewed staff demonstrated to LPA how is worked "Quick MAR" program. LPA observed that residents medications are registered under the "Quick MAR" program. LPA also reviewed written MAR and observed medications are documented properly and given as prescribed. Administrator and staff indicated that each Med. Tech. / LVNs have their own login passwords. The information gathered does not corroborate the allegation noted above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report was provided Robert Jakini.the state’s words, verbatim · CDSS document, May 23, 2024 · control 28-AS-20240304141910

Allegation investigated: Questionable deaths Residents had severe UTI. Staff did not seek medical attention for residents. Staff did not follow prescribed meals for residents. Staff did not report incidents to CCL. Staff did not document residents falls.

Licensing Program Analyst (LPA) Luis Mora conducted a subsequent complaint investigation visit regarding the above mentioned allegations. LPA met with Robert Jakini (Executive Director) and explained the reason for the visit. Investigation consisted of the following: On 07/18/2022, LPA requested copies of Emergency and Identification Information, Most current Physician report, Admission Agreement, Most current Needs and Services Plan, Most current incident reports, Hospice notes or Home Health Notes, Case Notes, Death Report for Resident 1 - Resident 6 (R1 - R6). LPA conducted a tour of facility and common areas. LPA observed a sufficient supply of perishable and non-perishable foods and observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns. On 02/13/2024, LPA interviewed Executive Director, Staff 1 - 4 (S1 - S4), and Resident 7 - Resident 15 (R7 - R15). LPA also obtained a copy of the shower schedule. During today's visit, LPA interviewed Executive Director, Staff 1, Staff 2, Staff 4 (S1, S2, S4), and Resident 16 - Resident 18 (R16 - R18). (Continued to LIC 9099-C) Unsubstantiated The investigation revealed the following: Regarding the allegation "questionable deaths”, it is alleged that Resident 1 (R1) - Resident 6 (R6) did not seem to be ill and upon developing a medical diagnose they passed away within days. Complainant is not aware if any of the residents had any underlining conditions. Staff interviewed stated these residents had underlying conditions and were placed on hospice, and that their death were not due to neglect. Review of records all residents were on hospice. LPA obtained copies of death certificates for all residents. R1 (80 years old) passed away on 06/12/2022: immediate cause of death was cardiopulmonary arrest, and the underlying causes were acute respiratory failure and Covid-19. R2 (86 years old) passed away on 06/06/2022: immediate cause of death was Alzheimer’s Disease. During the investigation, LPA could not determine the true name of R3. Staff stated there has been no resident with that name or a resident that matches the details provided by the complainant. R4 (84 years old) passed away on 12/05/2021: immediate cause of death was cardiopulmonary arrest, and the underlying cause was senile dementia. R5 (82 years old) passed away on 03/17/2022: immediate cause of death was cardiopulmonary arrest, and the underlying cause were urosepsis and atherosclerosis of coronary artery. R6 (83 years old) passed away on 12/18/2021: immediate cause of death was cardiac arrest, and the underlying cause were respiratory failure and Parkinson’s disease. Residents interviewed did not express that they are being neglected. Regarding the allegation "residents had severe UTI”, it is alleged that R4, R5 and R6 had UTI. Staff interviewed stated that residents do get UTI, but it is not due to neglect. They stated all residents that need diaper change receive incontinence assistance every 2 hours or as needed and staff are trained to properly cleaned the residents to avoid UTI. Residents interviewed did not express that they are being neglected. Regarding the allegation "staff did not seek medical attention for residents”, it is alleged that R3's tube (unsure type of tube) that was attached to R3's stomach looked infected. Complainant did not provide a last name for R3. During the investigation, LPA could not determine the true name of R3. Staff stated there has been no resident with that name or a resident that matches the details provided by the complainant. Residents interviewed could not corroborate the allegation. (Continued to LIC 9099-C) Regarding the allegation "staff did not follow prescribed meals for residents”, it is alleged that R3 was on mechanical soft food diet, but staff kept feeding R3 regular food. Complainant did not provide a last name for R3. During the investigation, LPA could not determine the true name of R3. Staff stated there has been no resident with that name or a resident that matches the details provided by the complainant. Staff interviewed denied the allegation stated that they follow a list that is on the kitchen that has all the residents with modified/prescribed diets. Residents interviewed could not corroborate the allegation. LPA observed the list for modified/prescribed diets in the kitchen. Regarding the allegation "staff did not report incidents to CCL” and "staff did not document residents falls", it is alleged that a resident had a fall and it was not documented or reported to Community Care Licensing (CCL). There is no records of this resident having a fall and staff could not remember if this resident had a fall either. Staff stated that the procedure regarding falls is as follows: contact the med-techs to come and assess the resident, write a report and submit it to supervisor. S1 is in charge of completing the licensing incident report and submitting it to the Executive Director for signature and the Executive Director submits it to CCL. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Apr 23, 2024 · control 28-AS-20220714141442

Allegation investigated: Unqualified staff are administering insulin.

On 3/05/24 at 9:10 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to the facility. Upon arrival LPA met with the Executive Director Robert Jakini and explained the reason for the visit. During the visit LPA toured the facility with Staff #1 and obtained the resident roster and staff roster. LPA also conducted file review for a former resident (R1) and obtained the following documents: Physicians report, centrally stored medication and destruction record dated 5/04/2020 and 9/30/2021, and Medication administration record that included discontinue request. LPA conducted file review for former staff and obtained the following documents: Staff #4 personnel record, signed SOC 341, and training. Staff #5 copy of Registered Nurse PN license. Staff# 6 through Staff #7 Vocational nursing details. LPA conducted file review for current staff and obtained the following documents: Staff #1 copy of Vocational nursing details. Staff #2’s personnel record, and trainings. LPA also interviewed the executive director and a total of 3 staff who shall be referred to as S1 through S3. LPA interviewed a total of 6 residents who shall be referred to as R2 through R7. (Report continued on 9099c) Substantiated The investigation reveals the following: Regarding " Unqualified staff are administering insulin”. It is alleged that med techs are administering insulin injections to residents. LPA conducted file review and interviews and observed the following. Based on the interviews there was one (1) resident (R1) who has since passed away that needed insulin injections. LPA observed that R1 received Novolog injections subcutaneously for the month of September in 2023. The injections were administered by seven (7) different staff members during the month of September. LPA confirmed 2 out of the 7 staff was med techs that did not have the required licensed to administer insulin injections. Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D. Exit Interview Conducted with Executive Director/ Appeal Rights Provided / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Mar 5, 2024 · control 28-AS-20240228132910

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69 · Plan of correction due date: Apr 5, 2024

1569.69 of the Health and Safety Code. It requires direct care staff in RCFEs, excluding licensed medical professionals, to meet specified training requirements, including passing an examination, in order to be able to assist residents with the self-administration of medications. It does not authorize unlicensed personnel to directly administer medications. This requirement was not met as evidence by: Based on observation, interview and record review, the licensee did not comply with the section cited above in that two (2) Staff administered insulin to resident #1 without a license to administer medications, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 5, 2024

Plan of correction: The licensee shall conduct in-service training regarding medications administration and the role of med techs. The In-service training is due to LPA by POC due date.

Allegation investigated: Staff did not follow COVID protocol. Staff did not aid residents with incontinence needs. Staff did not observe change in residents condition. Staff did not feed bedridden residents Staff did not aid residents with hygiene needs

Licensing Program Analyst (LPA) Luis Mora conducted a subsequent complaint investigation visit regarding the above mentioned allegations. LPA met with Robert Jakini (Executive Director) and explained the reason for the visit. Investigation consisted of the following: On 07/18/2022, LPA requested copies of Emergency and Identification Information, Most current Physician report, Admission Agreement, Most current Needs and Services Plan, Most current incident reports, Hospice notes or Home Health Notes, Case Notes, Death Report for Resident 1 - Resident 6 (R1 - R6). LPA conducted a tour of facility and common areas. LPA observed a sufficient supply of perishable and non-perishable foods and observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns. During today's visit, LPA interviewed Executive Director, Staff 1 - 4 (S1 - S4), and Resident 7 - Resident 15 (R7 - R15). LPA also obtained a copy of the shower schedule. (Continued to LIC 9099-C) Unsubstantiated The investigation revealed the following: Regarding the allegation "staff did not follow COVID protocol”, it is alleged that staff failed to follow COVID-19 guidelines. Staff interviewed denied the allegation and stated that full PPE supplies were used when there was a COVID-19 positive case. Residents interviewed could not corroborate the allegation. Regarding the allegation "staff did not aid residents with incontinence needs”, it is alleged that staff were not changing the diaper for R1, R4, and R5. Staff interviewed denied the allegation. They stated all residents that need diaper change receive incontinence assistance every 2 hours or as needed. Even if the resident has COVID-19 the staff are expected to wear full PPE supplies and provide the incontinence assistance. Residents interviewed could not corroborate the allegation. Regarding the allegation "staff did not observe change in residents condition”, it is alleged that staff did not check on R1 for 6-7 hours. Staff interviewed denied the allegation. They stated that R1 was severely ill and was placed on "alert charting" which meant that staff had to check on R1 every hour and complete a chart behind the resident's bedroom door. Residents interviewed could not corroborate the allegation. Regarding the allegation "staff did not feed bedridden residents”, it is alleged that staff did not feed R1 and R2 because R1 had COVID-19 and staff did not want to get near R1 and R2 would eat slow so the staff would get impatient. Staff interviewed denied the allegation. They stated that all residents are provided food and assisted with eating if the resident needs assistance. If a resident has COVID-19 then the staff are expected to wear full PPE supplies and assist the residents with feeding. Residents interviewed could not corroborate the allegation. Regarding the allegation "staff did not aid residents with hygiene needs”, it is alleged that staff did not shower R4. Staff interviewed denied the allegation. They stated all residents receive shower assistance up to 2-3 times a week or as needed. LPA reviewed the shower schedule and observed all residents name listed 2-3 times throughout the week. Residents interviewed could not corroborate the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Feb 13, 2024 · control 28-AS-20220714141442

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.