The Village

Type of visit: Required - 1 Year

On 9/17/2026, Licensing Program Analyst (LPA) Mia Lankford conducted an unannounced required annual visit at the above location. LPA met Administrator Caleb Schultz and explained the purpose of the visit.and the LPA was granted entry. PHYSICAL PLANT: The Licensee appears to be operating the facility within the conditions and limitations specified on the license. Residents appear to be protected against immediate hazards. Outdoor and indoor passage ways are kept free of obstruction. According to Caleb, there are no weapons kept on the property. Disinfectants, cleaning solutions, and poisons were inaccessible to unauthorized individuals. A comfortable temperature was being maintained in the building. There was sufficient lighting in resident bedrooms to ensure the comfort and safety of residents. Resident bedrooms had all required furniture in place. The hot water was tested in several resident bedrooms and observed to be within regulatory requirements. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. Additional equipment for physically handicapped residents is available. The carbon monoxide alarms were tested and observed to be operable. The fire alarm panel was inspected in the Assisted living buildings and observed to be operating normally. The interior and exterior areas of the facility were observed to be exceptionally clean and well maintained. FOOD SERVICE: There was a variety of food which appeared to be selected and stored in a safe and healthy manner. Food supply of nonperishable and perishable foods was sufficient. Sufficient supplies for resident's dinning use was observed to be available. Cont... Cont.... RECORD REVIEW: Staff files had required training; including, but not limited to, Reporting Requirements, and Emergency and Disaster Training. Training on special health conditions was observed on file. Admission Agreements, Medical Assessments (Physician's Reports), Assessments, and Service Plans were observed on file for residents in care. Resident and facility files were observed to be well organized. Administrator Caleb has an active Administrator's certificate, which expires on 11/18/2026. The facility currently has 7 residents in care receiving hospice services; which is within their Hospice Waiver limit. Per Caleb , the Licensee corporation is active with the California Secretary of State and proof of current Limited Liability Insurance was observed to be in place. MEDICATION: One of one medication carts was inspected. Medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be safe, locked, and inaccessible to residents in care. No deficiencies have been cited at this time. This report was reviewed with Administrator Caleb Schultz and and a copy was provided.the state’s words, verbatim · CDSS document, Sep 17, 2026

Type of visit: Case Management - Other

On 05/08/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross arrived at the facility unannounced to conduct a case management visit for the purpose of obtaining signatures on an amended report, and to add an allegation to a complaint visit (control # 18-AS-20260218153457) that was conducted on 02/20/2026. LPA met with Yolanda Chandler, Resident Services Director, and the purpose of the visit was discussed. There were no deficiencies cited during today's visit. An exit interview was conducted and a copy of this report was provided to Yolanda Chandler, Resident Services Director.the state’s words, verbatim · CDSS document, May 8, 2026

Type of visit: Case Management - Other

On 04/22/2026, Program Analyst (PA) Lovina Aquino, Financial Analyst (FA) George Rizk and Manager, Jennifer Houston arrived at the facility and met with Executive Director (ED) Danai Vergara to complete the required triennial visit for Plymouth Village, a Continuing Care Retirement Community (CCRC). Prior to the visit, the PA and FA reviewed documentation requested and provided by the ED to ensure that the provider is operating the CCRC in compliance with the statutes and is performing the services specified in its continuing care contracts. During today’s visit, PA, FA, and ED discussed the documentation received prior to the visit and toured the CCRC to ensure all postings and required documents were accessible to residents and visitors. This included verifying the Certificate of Authority is valid and properly displayed in the Assisted Living unit and adjacent to the Lobby. Staff also toured the community, observing the Assisted living, Independent Living and Skilled Nursing Units. During the tour, CCCB staff confirmed that the required postings and meetings, as outlined in H&SC 1771.7 and 1771.8, were in place and compliant. As a result of today’s visit, no compliance issues pursuant to the Continuing Care Contract Statutes were cited. CCCB staff will follow up with a thank you letter, and summary provided to the ED within 7 days of visit. Exit interview conducted with ED. Due to connectivity issues CCCB staff completed LIC 809 when returned to HQ and emailed ED for signature.the state’s words, verbatim · CDSS document, Apr 22, 2026

Allegation investigated: Facility staff handle resident in a rough manner

Licensing Program Analysts (LPA), Armando Perez and Robert Cambpell, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with Executive Director Danai Vergara, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and witnesses and file reviews. On January 29, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that facility staff handled resident in a rough manner. It was alleged that staff members forcibly restrained a resident in care, disregarding the resident’s expressed objections. It was reported that Resident #1 (R1) was inappropriately restrained by staff. During an interview, Health Facility Evaluator Nurse, Tamera Wiles (AW1), an employee of California Department of Public Health reported that on January 28, 2025, she observed multiple staff members aggressively restraining R1 in a chair during an attempted elopement. Continued on LIC 9099-C. Substantiated AW1 noted that R1 verbally instructed staff to stop and subsequently began yelling for help. AW1 intervened to de-escalate the situation. Interview with Director of Assisted Living, Michelle Flores (DAL), corroborated statements provided by AW1. Additionally, DAL reported that an internal investigation was conducted and appropriate steps were taken, such as termination of involved staff and staff training on Dementia Behavior and Resident Personal Rights. Interview with Responsible Party (RP) confirmed they were made aware of the incident involving R1. RP emphasized the issue with staff was isolated and there were no further concerns. LPA attempted to interview R1 and R1 refused to be interviewed. LPA documented a review of the surveillance video, confirming that the footage corroborated the alleged events. LPA noted the video lacked audio; however, the footage was adequate to establish the sequence of events. Based on interviews, record reviews, and observation, the allegation that staff handled resident in a rough manner is Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met, which poses a risk to the health and safety of the clients in care. The facility will be cited. An exit interview was conducted. A copy of this report was provided to Executive Director Danai Vergara, along with a copy of the LIC9099-C, LIC9099D, and Appeal Rights.the state’s words, verbatim · CDSS document, Dec 5, 2025 · control 18-AS-20250129091300

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Dec 19, 2025

87468.1Personal Rights of Residents in All Facilities(a) Residents…shall have all of the following personal rights(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as…interfering with daily living functions. This requirement was not met as evidenced by:Through interviews observations and records review staff did not respond in a proper manner resulting in a personal rights violation which is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2025

Plan of correction: Administrator will provide in-service training to staff regarding Dementia Behavior and Resident Personal Rights and email a copy to LPA

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was greeted and allowed to enter the facility to conduct the inspection. On today’s visit the LPA met with Administrator, Bill Fredricksen, and Assisted Living Director, Michelle Flores. They were notified of the purpose for the visit. PHYSICAL PLANT: The Licensee appears to be operating the facility within the conditions and limitations specified on the license. Residents appear to be protected against immediate hazards. Outdoor and indoor passageways are kept free of obstruction. According to Flores, there are no weapons kept on the property. Disinfectants, cleaning solutions, and poisons were inaccessible to unauthorized individuals. A comfortable temperature was being maintained in the building. There was sufficient lighting in resident bedrooms to ensure the comfort and safety of residents. Resident bedrooms had all required furniture in place. The hot water was tested in several resident bedrooms and observed to be within regulatory requirements. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. Additional equipment for physically handicapped residents is available. The carbon monoxide alarms were tested and observed to be operable. The fire alarm panel was inspected in the assisted living and independent living buildings and observed to be operating normally. The interior and exterior areas of the facility were observed to be exceptionally clean and well maintained. FOOD SERVICE: There was a variety of food which appeared to be selected and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient. Sufficient supplies for resident's dinning use was observed to be available. RECORD REVIEW: Staff files had required training; including, but not limited to, Reporting Requirements, and Emergency and Disaster Training. Training on special health conditions was observed on file. Admission Agreements, Medical Assessments (Physician's Reports), Assessments, and Service Plans were observed on file for residents in care. Resident and facility files were observed to be well organized. Administrator Fredricksen has an active Administrator's certificate, which expires on 09/30/2026. The facility currently has 6 residents in care receiving hospice services; which is within their Hospice Waiver limit. Per Fredricksen, the Licensee corporation is active with the California Secretary of State and proof of current Limited Liability Insurance was observed to be in place. MEDICATION: One of one medication carts was inspected. Medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be safe, locked, and inaccessible to residents in care. No deficiencies have been cited at this time. This report was reviewed with Administrator Fredricksen and AL Director Flores and a copy was provided.the state’s words, verbatim · CDSS document, Sep 8, 2025

Type of visit: Required - 1 Year

On September 04, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with Assistant Living Director, Michelle Flores. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for 52, but is operating 38 (741), Facility Type. LPA Mixson toured the facility and made observations pertaining to the annual visit. LPA inspected the facility inside and outside there were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. The facility is a single-story building located at 2200 West Acacia Hemet Ca. 92545 Physical Plant: The facility phone number is (951) 766-5116 and it is operable. LPA Mixson observed a sampling of the living units and those sampled were equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and the hot water temperature tested within regulations. LPA reviewed a sample of the restrooms and those sampled were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something" Ombudsman's and the "Personal Rights." The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked. Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. The overall facility is clean, the furniture is in good condition. The facility cooling system and other appliances were operable currently at the time of this visit. The facility is made up of two buildings. One building is designated for Independent Living, and the other building is designated for Skilled Nursing and Assisted Living. LPA was informed that the facility has 35 rooms designated for assisted living. LPA observed fire alarm systems, carbon monoxide detectors and fire extinguishers throughout the facility. FOOD SERVICES: LPA Mixson toured the kitchen and observed that food was stored in a safe and healthful manner. A regular sample menu was available for review as well as menus for residents with special dietary needs. The facility had a two-day supply of perishable food items and seven-day supply of non-perishable food items. Knives were secured in the kitchen. DISASTER PREPAREDNESS: Last Fire Drill was conducted 2024 and are conducted monthly with the Fire Marshall, and training binder was made available for review. RECORD REVIEW & STAFF & RESIDENT FILES: LPA review five staff files and five resident files. Files reviewed had criminal clearances and updated CPR and other training's. Resident files possessed required documents currently, for safe guarding belongs there is a safe with a code, and file for logging. The facility has various activities available for resident leisure. LPA Mixson observed residents in their rooms and in common areas. LPA observed that cleaning supplies were secured in storage rooms. Medications were stored in medication carts only accessible to the Licensed Vocational Nurses and Medication Technicians on duty. LPA toured a sample of the resident rooms. The resident bedrooms had the required furniture and functional lighting. LPA observed grab bars and nonskid mats in the showers. The facility had a supply of additional linen and extra hygiene items for the residents. LPA also observed emergency supplies and complete first aid kits. Outside shaded seating is available for resident use. Indoor and outdoor passageways are free of obstruction. The facility's last fire drill was conducted on August 2024 There were no deficiencies observed or cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed and given to Assistant Living Director, Michelle Floresthe state’s words, verbatim · CDSS document, Sep 4, 2024