Villa Fontana

Allegation investigated: Facility does not ensure call bells are operable. Staff are not ensuring to provide assistance to residents in a timely manner.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finds and met with Executive Director (ED) Marife Duewel. On 01/20/2026, the Department received a complaint with the above two allegations. On 01/27/2026, the Department conducted an initial investigation visit. LPA interviewed ED and 9 staff. LPA toured 8 resident rooms and test the call button system. LPA requested the facility email logs. Continue on LIC9099-C. Page 1 of 3. Unfounded Facility does not ensure call bells are operable: Staff are not ensuring to provide assistance to residents in a timely manner: The allegations are the facility call button system is not working and residents did not receive assistance within timely manner. On 01/27/2026, LPA interviewed Executive Director (ED) Marife Duewel. ED stated in end of December 2025, the facility had an unannounced power outage which damaged the facility call button system. ED stated the facility contacted the contracted maintenance company of the facility call button system. ED stated the company came to the facility to check/repair and stated it needed to replace the hardware and parts. ED stated the company stated it needed to order the hardware and parts to fix the problem. ED stated the call button alarm notifications are still sent to the system's computer in real time but does not radio the alarm notifications to caregivers and Med Tech in real time. ED stated front desk staff were instructed to read the call button alarm notification log and notify caregivers and Med Tech to help residents. ED stated caregivers are instructed to tour resident rooms constantly to check if residents need assistance. ED stated management team and staff were instructed to help front desk to read call button alarm notification log and to call caregivers and Med Tech to help residents. ED stated the facility notified residents and families the issue of call button system. LPA interviewed 9 facility staff. 9 Out of 9 staff stated the power outage damaged the facility call button system. 9 Out of 9 staff stated the call button alarm notification are still sent to the computer and the front desk staff notifies caregivers and Med Tech to help residents. 9 Out of 9 staff stated management team and staff help front desk to read the call button alarm notifications and call caregivers and staff to help residents. LPA toured 8 resident rooms and interviewed 8 residents. LPA requested the 8 residents to press the call buttons and staff were observed coming in around 5 minutes. LPA interviewed 8 residents, 1 Out of 8 residents stated he/she yelled out and staff in the hallway came to help immediately. 2 Out of 8 residents stated they called front desk and staff came in to help. Both stated calling front desk for help is faster than using call button to receive assistance. 5 Out of 8 residents stated staff came in to help when they pressed call button. Continue on LIC9099-C. Page 2 of 3. On 02/26/2026, LPA interviewed Assisted Living Director (ALD) and Wellness Director (WD), both stated the call button system is working. LPA toured 8 resident rooms with ALD. LPA requested 8 residents to press the call buttons. Staff were observed coming to help around 5 minutes and showed they received radio of alarm notifications.. LPA interviewed Executive (ED). ED stated he/she still instructs front desk to notify caregivers and Med Tech the call button alarm notification to make sure residents receive assistance. ED stated he/she still instructs caregivers to tour resident rooms to make sure residents receive assistance. ED stated the facility is still waiting the contracted maintenance company to complete the upgrade of the call button system. ED stated the facility did not receive complaints from residents. Based on the review of the email log that the facility communicate with the contracted maintenance company, the facility actively requested the company to fix/repair the call button system. The Department has investigated the above allegations. Based on the investigation, observation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citations noted at today’s compliant investigation visit. Exit interview conducted with Executive Director (ED). This report was provided to review and for signature. A copy of this report was provided to ED. Page 3 of 3.the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 26-AS-20260120143805

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management - incident visit and met with Executive Director (ED) Marife Duewel. On 01/02/2025, the Department received a notice that resident R1 had a fall and was sent to hospital on 12/31/2025 and R1 had a fall on 12/202025. The Department interviewed R1's family member (FM). FM stated that he/she does not find the facility staff had fault for the incident on 12/31/2025 and stated the facility provides good care to R1. FM confirmed R1 had a fall on 12/20/2025. LPA requested R1's physician report and appraisal needs and service plan. LPA interviewed ED. ED stated on 12/20/2025,around 6:30AM after R1's morning care, R1 had a fall at memory care unit hallway. ED stated staff found R1 was on the floor and called 911 immediately. R1 was sent to hospital. ED stated on 12/31/2025, around 12:30AM, staff saw R1 was walking at the memory care unit hallway. Staff S1 saw R1 was falling and tried to help but was unable to stop R1's falling. S1 called Med Tech (S2). S2 came on site and assessed R1 and called 911 immediately. R1 was sent to hospital. ED stated R1 still at hospital today. Continue on LIC809-C. Oage 1 of 2. LPA interviewed Wellness Director (WD). WD stated resident R1 had fall on 12/20/2025 and 12/31/2025. WD stated staff found R1 was on the floor on 12/20/2025 and 12/31/2025 and called 911 immediately. The facility did not send incident report for R1's fall and was sent to hospital on 12/20/2025 to CCL office. Based on the review of R1's appraisal/needs and service plan, the facility did not update R1's care plan after R1's fall on 12/2025. Deficiencies were noted for today's visit, please see LIC809-D. Exit interview was conducted with ED. The report was provided to ED for reveiw. A copy of the report was provided to ED.the state’s words, verbatim · CDSS document, Jan 6, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jan 13, 2026

87211 Reporting Requirements(a)(1)(D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on interview and record review, The facility did not send incident report of R1's fall and was sent to hospital on 12/202025 which poses/posed an potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 6, 2026

Plan of correction: Executive Director stated to submit a plan of correction by the POC due date to ensure to send incident report to CCL office within 7 days of the incidents.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Jan 13, 2026

87463 Reappraisals (a)...The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to... This requirement is not met as evidenced by: Based on record review, R1 did not have a reappraisal after the fall on 12/20/2025 and appraisal needs service plan was not updated after R1's incident on 12/20/2025 which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 6, 2026

Plan of correction: Executive Director stated to submit a plan of action understanding regulation by POC due date ensure residents' care plan was updated as needed.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Annual Inspection visit today, and met with Administrator(ADM) Marife Duewel and Assist Living Director (ALD) Roselily Cacas.. LPA reviewed 10 resident files and 5 staff files. PA observed license, personal rights posters in the facility. Administrator certificate was observed to expire tomorrow, ADM provided the documents that he/she already renewed it. LPA toured the facility inside and out with ALD. LPA toured the common areas including dining room, activity rooms, social room, hallways, kitchen, laundry rooms, Ice Cream Parlor, public restrooms, library, beauty salon, and offices. LPA toured the resident rooms in Assistant Living Unit, and Memory Care Unit. The exit doors of memory care unit were tested. The alarm sounded when pushed the exit door without pin, and delayed 15 seconds to open. Medication carts were observed locked. Medication rooms were observed locked. Chemical room, housekeeping rooms were observed locked. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Knives storage was observed locked. Room temperature was at 72 degree F, and hot water temperature was at 112 degree F in facility. Fire extinguishers were serviced on 1/23/2025. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Carbon monoxide detectors were tested and they were working. LPA toured the courtyard, nothing was observed abnormal. The last time the facility conducted the emergency drill is 11/08/2025. No citation was noted today. Exit interview was conducted with ADM. A copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 14, 2025

Allegation investigated: Facility transportation vehicles used to transport residents are not maintained in a safe operational condition.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Executive Director (ED) Marife Duewel. On 8/6/2025, the Department received a complaint with the allegation that facility transportation vehicles used to transport residents are not maintained in a state of safe operational condition. On 8/13/2025, the Department conducted an initial investigation visit. LPA interviewed ED, 4 staff and 4 residents. Continue on LIC9099-C. Page 1 of 3. Unfounded On 8/13/2025, LPA interviewed Executive Director (ED) Marife Duewel. ED stated the facility bought a new VAN in January 2025. ED stated the facility has an old bus for several years. ED stated the facility bus is a class B vehicle and the facility VAN is a class C vehicle. ED stated the facility most of time uses the facility VAN for the transportation of residents. ED stated the facility has 2 drivers. ED stated driver 1 (D1) only drives the VAN on Monday, Tuesday, Thursday, and Friday. ED stated driver 2 (D2) drives the VAN on Wednesday and sometimes drives the facility bus. ED stated there is no car accidents for both the facility VAN and the facility bus for recent 2 years. ED stated the facility bus is under California Highway Patrol (CHP) monitor/regulated. ED stated CHP checks the facility bus every year. ED stated the facility new VAN is new vehicle and under one year. ED stated the facility VAN is maintained by facility drivers based on the VAN's dash board shown message. ED provided the maintenance log of the facility VAN. LPA interviewed the facility driver 1 (D1). D1 stated the facility bought a new VAN in January 2025. D1 stated he/she drives the facility VAN on Monday, Tuesday, Thursday, and Friday to transport residents. D1 stated the facility VAN did not have any car accident. D1 stated the facility VAN only had a flat tire incident 3 weeks ago but he/she had it fixed immediately. D1 stated the facility VAN is new and under one year, he/she has a maintenance log but does not have daily checking log. LPA interviewed driver 2 (D2). D2 stated he/she works for the facility as a driver for 7 years. D2 stated he/she was full time staff before. D2 stated after January 2025, he/she works for the facility as par time because he/she works for another facility 4 days per week. D2 stated he/she drives the facility VAN on Wednesday to transport residents. D2 stated most of time he/she drives the facility VAN to transport residents. D2 stated sometimes he/she drivers the facility bus when needed. D2 stated he/she maintained the facility vehicle checking log when he/she was a facility full time driver. D2 stated the facility VAN did not have any car accident. LPA interviewed 2 staff (S1, S2). Both stated they take the facility VAN when they go with residents for outings. Both stated the facility VAN did not have any car accident. Both stated the facility VAN is well maintained and clean to ride. Continue on LIC9099-C. Page 2 of 3. LPA interviewed 4 residents (R1 - R4) who regularly take the facility VAN for transportation. 4 out of 4 residents stated the facility VAN never had car accident. 4 out of 4 residents stated the facility VAN is always maintained in a good condition and clean condition for residents to ride. LPA checked the facility bus and facility VAN with ED and D2. Both facility vehicles are maintained in good and clean condition for residents to ride. LPA did not observed any damage or dent for both vehicles. Both vehicles have front bumper and back bumper without any damage or dent. D2 turned on the engines and air conditions of both facility vehicles and both vehicles were working. ED provided the facility VAN's DMV records which does not show any car accident and ED provided the car insurance document. The Department has investigated the above allegations. Based on the investigation, observation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citations noted at today’s compliant investigation visit. Exit interview conducted with Executive Director (ED). This report was provided to review and for signature. A copy of this report was provided to ED. Page 3 of 3.the state’s words, verbatim · CDSS document, Sep 26, 2025 · control 26-AS-20250806143614

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Administrator (ADM) Marife Duewel. The purpose of today's visit is to deliver an amended LIC9099 and LIC9099D report which were incorrectly issued on 3/6/2025 that should have been a case management.. Below is the exact component in LIC9099 and LIC9099D: On 3/6/2025, Licensing Program Analyst (LPA) Steve Chang conducted an unannounced initial investigation visit and met with Administrator (ADM) Marife Duewel. LPA requested resident roster and LIC500 Personnel Report. LPA requested the physician reports, appraisal needs and service plans, and progress notes of resident R1. On 2/27/2025, resident R1 had a fall resulting in fracture and was sent to hospital. The Department did not receive incident regarding R1's incident on 2/27/2025. ADM stated the facility did not send the incident report yet but is planing to send the incident report. LPA reminded ADM the incident report needs to send within 7 days. Citation was issued today. See LIC9099-D. The report was provided to ADM for signature. A Copy of the report was provide to ADM. Exit interview was conducted with ADM. The report was provided to ADM for review and for signature.the state’s words, verbatim · CDSS document, Jun 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 24, 2025

87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency... including, (1) A written report shall be submitted to the licensing agency ... within seven days ...(D)Any incident which threatens the welfare, safety or health of any resident ... The requirement was not met as evidenced by: Based on the records reviewed, the facility did not send the incident report of resident R1 within 7 days of the incident occurrence, this poses a potential health, safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: Administrator stated to read the regulation and send plan of correction by the POC due date to ensure the facility to send incident report to CCL office within 7 days. POC for 87211 (a)(1)(D) has been corrected on 3/14/2025.

Allegation investigated: Resident sustained a fracture due to lack of care from staff

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Executive Director (ED) Marife Durewel. On 3/5/2025, the Department received a complaint with the allegation that resident sustained a fracture due to lack of care from staff. On 3/6/2025 and 4/4/2025, the Department conducted investigation visits. LPA requested resident roster and LIC500 Personnel Report. LPA requested the physician reports, appraisal needs and service plans, progress notes of resident and incident reports. LPA interviewed ED and 5 staff. LPA toured resident R1's room, interviewed R1's private caregiver and R1. Continue on LIC9099-C. PAge 1 of 3. Unsubstantiated The allegation is that resident sustained fracture due to staff lack of supervision. On 4/4/2025 and 5/12/2025, LPA interviewed Executive Director (ED) Marife Durewel. ED stated on 2/23/2025, after dinner, around 5:45PM, resident R1 was found on the floor in his/her room. ED stated R1 stated he/she fell when tried to get his/her back bag. 911 was called by staff and R1 was sent to hospital. ED stated on 2/24/2025, around 2:20AM R1 returned to the facility. ED stated the facility contacted R1's responsible party to have 1:1 24x7 caregiver for R1 after R1 returned to the facility. ED stated the facility has a caregiver sits on a chair by the door of R1's room to monitor R1 and lets R1's door remain open after R1 returned back to the facility. ED stated on 2/27/2025, at 6:30AM, R1 was found in the bed in his/her room. ED stated on 2/27/2025, around 6:45AM, R1 was found on the floor in his/her room. 911 was called immediately and R1 was sent to hospital. On 3/5/2025, R1 returned to the facility. ED stated R1 has 1:1 24 x 7 caregiver staring from 3/5/2025. On 4/4/2025, LPA interviewed Health and Wellness Director (HWD). HWD stated the facility contacted resident R1's responsible party to suggest R1 to have a 1:1 24 X 7 caregiver after 2/23/2025. HWD stated R1's responsible party confirmed R1 to have 1:1 24 X 7 caregiver starting 3/5/2025. LPA interviewed staff S1. S1 stated after 2/23/2025, the door of R1's bedroom is remained open, and there is a caregiver sits on the chair by the door of R1's room to monitor R1 when R1 is in the room. LPA interviewed staff S2. S2 stated on 2/27/2025, around 6:30AM a NOC shift caregiver told him/her that he/she just checked R1 and R1 was in the bed. LPA interviewed R1's 1:1 private caregiver (PC1). PC1 stated he/she works from 8:00AM - 8:00PM every day and another 1:1 private caregiver works from 8:00PM - 8:00AM every day. LPA observed a caregiver sat on the chair by the door of R1's room. Continue on LIC9099-C. Page 2 of 3. On 5/12/2025, LPA interviewed a Med Tech (MT1). MT1 stated on 2/27/2025, around 6:30AM, a caregiver (S2) reported to him/her that he/she checked R1 on 2/27/2025 around 6:00AM and R1 was observed in the bed. MT1 stated on 2/27/2025 around 6:30AM he/she saw R1 was in the bed. LPA interviewed a Med Tech (MT2). MT2 stated on 2/27/2025,a round 6:30AM, he/she saw R1 was in the bed. MT2 stated on 2/27/2025, around 6:45AM, he/she saw R1 was on the floor in his/her room. MT2 stated he/she called 911 and nurse, and R1 was sent to hospital. LPA interviewed resident R1 in his/her room. R1 stated for his/her last fall incident on 2/27/2025, he/she got up from bed around 6:40AM. R1 stated he/she just wanted to walk in the room for exercise and fell on the floor. R1 stated staff came in to help him/her immediately. LPA observed R1's 1:1 caregiver in R1's room helping R1. LPA observed a caregiver sat on the chair by the door of R1's room. Based on the review of R1's Appraisal needs and service plan dated 11/10/2024, R1 is able to ambulate with standby assist. R1 uses wheelchair for mobility. Based on the interview and observation, the facility lets the door of R1's room open and has a caregiver sitting on the chair by the door of R1's room to monitor R1 after 2/23/2025. The facility suggested to R1's responsible party to have 1:1 24 X 7 private caregiver for R1 after 2/23/2025. On 2/27/2025 around 6:30AM, 2 staff observed R1 was in the bed. Around 6:40AM, R1 tired to get up from bed by self and fell. Around 6:45AM, R1 was found by staff. Staff called 911 immediately and R1 was sent to hospital. The department has investigated the above allegation. Based on the observations, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with ED. A copy of this report was provided to ED. Page 3 of 3.the state’s words, verbatim · CDSS document, May 30, 2025 · control 26-AS-20250305170352

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Annual Inspection visit today, and met with Administrator(ADM) Marife Duewel and Assist Living Director (ALD) Roselily Cacas.. LPA reviewed 5 resident files and 5 staff files. LPA observed license, personal rights posters in the facility. Administrator certificate was observed expired. ADM provided the document that he/she already renewed it. LPA toured the facility inside and out with ADM and ALD. LPA toured the common areas including dining room, activity room, social room, hallways, kitchen, laundry room, Ice Cream Parlor, public restrooms, library, and offices. LPA toured the resident rooms in Assistant Living Unit, and Memory Care Unit. The exit doors of memory care unit were tested. The alarm sounded when pushed the exit door without pin, and delayed 15 seconds to open. LPA pulled room 251 emergency call, staff came within 8 minutes. Medication closet in Medication carts were observed locked. Medication rooms were observed locked. Chemical room, housekeeping rooms were observed locked. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Knives storage was observed locked. Room temperature was at 70 degree F, and hot water temperature was at 107 degree F in facility. Fire extinguishers were serviced on 1/24/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Carbon monoxide detectors were tested and they were working fine. LPA toured the courtyard, nothing was observed abnormal. The last time the facility conducted the emergency drill is 08/30/2024. No citation was noted today. Exit interview was conducted with ADM. A copy of this report was provided to ADM..the state’s words, verbatim · CDSS document, Nov 20, 2024

Allegation investigated: A resident was inappropriately touched by another resident due to neglect and lack of supervision.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver an investigation finding and met with Executive Director (ED) Marrife Duewel. On 11/07/2023, the Department received a complaint with the allegation that a resident was inappropriately touched by another resident due to neglect and lack of supervision. On 11/15/2023, the Department conducted an initial investigation visit. LPA interviewed ADM, 2 staff, and 1 resident. LPA requested physician report, Appraisal Needs and Service Plan and care conference documents, Continue on LIC9099-C. Page 1 of 3. Substantiated A resident was inappropriately touched by another resident due to neglect and lack of supervision: The allegation is that the facility neglected and lack of supervision resulting in a resident wandering to another resident's room and inappropriately touching another resident. On 11/15/2023, LPA interviewed Executive Director (ED) Marrife Duewel. ED stated on 10/24/2023 around 2:00PM, resident R1 entered resident R2's room without permission. R1 exposed self to R2. and asked for oral sex. R1 inappropriately touched R2's breast and private areas. R2 asked R1 to stop. R1 stopped and left the room. ED stated he/she went to resident R2's room immediately after he/she received the report. ED stated he/she saw R1 walked down the hallway away from R2's room. ED stated no injury noted on resident R2 after the facility staff assessed R2. ED stated after the incident, all staff were instructed to closely monitor R1's behavior and to ensure residents' safety. ED stated the facility notified R1's POA to come to the facility for a care conference on 10/24/2024, at 6:00PM. ED stated the facility notify R1's doctor the incident and to work on R1's medications. ED stated after the incident, R1's doctor prescribed new medications for R1. R1 was provided a 1:1 private caregiver and R1 goes home with R1's family after dinner or R1' family to keep R1 company at night in the facility. ED stated the facility is working with R1's family to move R1 to another facility on the coming weekend. LPA interviewed staff S1. S1 stated he/she sometimes saw R1 watching porn video in his/her room, and brought the concern to R1's care conference before this incident. S1 stated sometimes he/she saw R1 wandering in the hallway. S1 stated he/she asked caregivers to watch R1. S1 stated R1 did not have sexual incident before. S1 stated he/she knows some residents lock their door, but he/she know R2 does not lock the door. LPA interviewed staff S2. S2 stated R1 and R2 are friends in the facility. S2 stated R1 and R2 sometimes have lunch or dinner together at the same table. S2 stated R1 and R1 did not have any inappropriately behavior before. S2 stated R1 usually go home with family on weekend or on holidays. S2 stated R1's care plan should be update to have more supervision and monitoring. Continue on LIC9099-C. page 2 of 3. LPA interviewed R2. R2 stated he/she does not want R1 to get punishment. R2 stated he/she wanted to participated the scheduled facility activity. The conversation was stopped. Based on review of the law enforcement task report date 11/19/2023, the finding is R1 did enter R2's room and inappropriately touched R2's private areas. Based on review of R1's physician report dated 6/23/2022, R1 has neurocognitive impairment, and has wandering behavior. Based on review of R1's addendum to appraisal needs and service plan dated 10/02/2023, R1 had 2 incidents entering other resident's room on 10/15/23 and 10/17/2023, but the facility did not have effective action plan for it. Based on the interview with staff S1, S1 observed R1 watching porn in R1's room and was naked in R1's room, and brought S1's concern in R1's care conference meeting, but the facility did not update R1's care plan. Based on the interviews, and records reviewed, the facility lack of supervision resulting resident R1 wandering to resident R2's room and conducted inappropriately behavior and touched R2's private areas. The Department has investigated the above allegation. Based on documents reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Citations were noted today. Please see LIC9099-D. Appeal right was provided. Exit interview was conducted with ED. A copy of the report was provide to ED. Page 3 of 3.the state’s words, verbatim · CDSS document, Oct 18, 2024 · control 26-AS-20231107163604

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Oct 25, 2024

87464 Basic Services(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interview and record review, The facility did not provide the necessary care and supervision to resident R1 to meet R1's care needs and leading to R1's wandering into R2's room and had inappropriately behavior and touched R2's private areas, which poses/posed an potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 18, 2024

Plan of correction: Executive Director stated to submit a plan of correction by the POC due date to ensure residents to receive necessary care and supervision, and to provide staff training to prevent similar incident to happen. ED to submit the staff training log to CCL office.

Allegation investigated: Facility did not have non-perishable foods for a minimum of a week. Facility staff are not properly supervising residents when administering medications. Residents centrally stored medications are expired.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Executive Director (ED) Marife Duewel. On 3/17/2023, the Department received a complaint with the above allegations. On 3/22/2023, the Department conducted an initial investigation visit. LPA interviewed ADM, 11 staff (S1 - S11), and 6 residents (R1 - R6). LPA obtained roster of residents, and requested 6 residents medical document. On 4/7/2023, LPA conducted an investigation visit and interviewed 3 residents. Continue on LIC9099-C. Page 1 of 5. Unfounded Facility did not have non-perishable foods for a minimum of a week: The allegation is that the facility did not have non perishable food for a minimum of a week for residents during the power outage period on 3/14/2023. On 3/22/2023, LPA interviewed Executive Director (ED) Marife Duewel. ED stated the facility had a power outrage on 3/14/2023 and 3/15/2023. ED stated the facility has generator and some small gas stoves, so only had a minimum impact for the food service to residents. ED stated the facility usually has 1-2 weeks non perishable food supplies in stock. ED stated usually non perishable food supplies are delivered on Wednesday every week. ED stated on 3/15/2023, Wednesday, the food delivering company was unable to deliver the non perishable food property due to the facility power outage but the facility still had over than one week non perishable food supplies in stock. ED stated the facility provided enough food for residents during the power outage period. ED stated he/she did not receive any complaint from residents regarding the food service during the power outage period. LPA toured with ED to check the food supplies. LPA observed perishable food supplies are sufficient for a minimum of 2 days, and non perishable food supplies are sufficient for a minimum of 7 days. LPA interviewed Dietary Manager (DM). DM stated the facility has power outage emergency food menu if power outage occurs. DM stated the facility provided sufficient food supplies to residents during the power outage period on 3/14/2023 and 3/15/2023. LPA interviewed a cook (C1). C1 stated he/she cooked on 3/14/2023 and 3/15/2023. C1 stated the facility provided sufficient food supplies for residents during the power outrage period. LPA interviewed a kitchen server (K1). K1 stated there were 2 cooks cooked food and 5 servers delivered the food to residents during the power outrage period. K1 stated residents were well fed during the power outrage period. LPA interviewed 5 residents. 5 out 5 residents stated they did not have any complaint against the facility during the facility power outrage period. Based on the interviews and observation, no evidence to indicate the facility did not have no perishable food supplies for a minimum of a week during the facility power outrage period. Continue on LIC909-C. page 2 of 5. Facility staff are not properly supervising residents when administering medications: The allegation is that Med Techs left medications in resident rooms unattended. On 3/22/2024, LPA interviewed ED. ED stated Med Techs deliver mediation to residents and assist residents to administer medications. ED stated Med Techs take the medications with them when residents refuse medications. ED stated Med Techs are not allowed to leave medications in resident rooms unattended LPA interviewed 2 Med Techs. Both stated they deliver medications to residents and assist to administer medications to residents. Both stated they take the medications out from the resident rooms and discard the medications if residents refuse the medications 3 times. Both denied they put the medications in resident room unattended. LPA interviewed 5 residents. 5 out of 5 residents stated Med Techs never left the medications in their room and left the rooms. LPA toured and checked 5 resident rooms, and did not observe any medications left in the resident rooms. On 4/7/2023, LPA interviewed 2 residents. 2 out 2 residents stated Med Techs did not leave the medications in the room unattended. LPA toured and checked 2 resident rooms and did not observe medications left in resident rooms unattended. Based on the interviews and observation, there is no evidence to indicate facility staff are not properly supervising residents when administering medications. Residents centrally stored medications are expired: The allegation is that the centrally stored medications delivered to residents are expired. On 3/22/2024, LPA checked the medications of medications carts. LPA randomly picked up 10 medications to check the expiration, LPA did not find any expired medications in medications carts. LPA checked two medication rooms, LPA randomly picked up 10 medications to check the expiration, and did not find any expired medications. Continue on LIC9099-C. page 3 of 5. LPA interviewed Assist Living Unit Director (ALD). ALD stated Med Techs check the medications for expiration. Med Techs put the expired medications in the "expired medication box" in the corner of the medication room, and document it. ALD stated the Director of Memory Care, Director of Assist Living, and Coordinator of Memory Care/Assist Living review the document and medications to approve to dispose the expired medications. ALD stated the approved expired medications are moved from the expired medication box to Medication destruction room. ALD stated only Director of Memory Care and Director of Assist Living have the key of the expired medication destruction room. LPA observed the expired medication box was locked. Staff S6 toured LPA to the medication destruction room. LPA observed the room was locked and the big box inside the room was locked. LPA interviewed Memory Care Director (MCD). MCD stated every 3 months, the expired medication destruction company comes to pick up the expired medications. Based on the observation and interview, the facility has standard procedure to process the expired medication and LPA did not find any expired medications after inspection the medication carts and medication rooms. Residents centrally stored medication records are incomplete: The allegation is that the residents centrally stored medication records are incomplete. On 3/22/2023, LPA interviewed Executive Director (ED). ED stated Med Techs are trained and instructed to document centrally stored medication records and MAR. ED stated the Directors of Memory Care Unit, Director of Assist Living Unit and facility nurses also monitor on that. LPA randomly picked up 5 residents centrally stored medication records and medications to check. 5 Out of 5 residents medications did not have mismatch , incorrect, or inaccuracy. Page 4 of 5. Residents were administered insulin injection by non appropriately skilled professional: It has been alleged that residents were administered insulin injection by staff S1 who has no nurse license. On 3/22/2023, LPA interviewed ED. ED stated the facility always has at least 1 nurse at facility, sometimes more than 1 nurses at the facility. ED stated if nurse calls sick, the facility finds other facility nurse to cover or other nurse from other agencies to cover. LPA interviewed Resident Care Coordinator S1. S1 stated he/she received nursing training but does not have nurse license. S1 stated he/she does not administer insulin injection to residents. S1 stated he/she supervises caregivers and provides help for resident medications and provides help for arrange doctor appointment for residents. S1 stated the facility has 1 LVN for the AM shift and 1 RN for the PM shift to administer insulin injection for residents. S1 sated the facility has another one RN and two LVNs as part time staff to administer insulin injection for residents. S1 stated on 3/17/2023, he/she was on duty but he/she does not know who was the nurse to administer insulin injection for residents that day. LPA interviewed Health and Wellness Director S2. S2 stated he/she is a LVN. S2 stated he/she works Monday to Friday from 7:30AM to 3:30PM. S2 stated he/she administers insulin injection for residents. S2 stated on 3/17/2023, he/she was off and did not know who to administer insulin injection for residents that day. S2 stated the facility has 2 RNs and 1 LVN work for the PM shift to administer insulin injection for residents, and one LVN works for the weekend to administer insulin injection for residents. LPA interviewed 6 residents. R1 does not have insulin injection. R2 was unable to remember if he/she has insulin injection. R3 was unable to remembered the names of the nurses who administered insulin injection. R3 remembered a male staff who is not a nurse helped to administer insulin injection. R3 was unable to confirm that the male staff did the injection or the male staff just helped him and R3 did the injection self. R4 remembered the names of the nurses administered insulin injection and S1 also helped to administer insulin injection. R4 was unable to confirm that S1 did the injection or S1 helped R4 and R4 did the injection self. R5 was unable to remember the names of the staff who administered insulin injection. R6 refused to be interviewed. Continue on LIC9099-C. Page 2 of 3. Based on the interviews, the facility sometimes has staff without nurse license to help residents for insulin injection. There is no evidence to indicate staff without nurse license conduct the insulin injection to residents. Residents centrally stored medication records are incomplete: The allegation is that the residents centrally stored medication records are incomplete. On 3/22/2023, LPA interviewed Executive Director (ED). ED stated Med Techs are trained and instructed to document centrally stored medication records and MAR. ED stated the Directors of Memory Care Unit, Director of Assist Living Unit and facility nurses also monitor on that. LPA randomly picked up 5 residents centrally stored medication records and medications to check. 5 Out of 5 residents medications did not have mismatch , incorrect, or inaccuracy. Based on the interview and record reviewed, there is no evidence to indicate residents centrally stored medication records are incorrect or incomplete. Based on documents reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. No citations noted for today’s visit. Exit interview was conducted with ED. The report was provided to ED for signature. A copy of this report was provided to ED. Page 3 of 3. The Department has investigated the above allegations. Based on the investigation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citations noted at today’s compliant investigation visit. Exit interview conducted with Executive Director (ED). This report was provided to review and for signature. A copy of this report was provided to ED. Page 5 of 5.the state’s words, verbatim · CDSS document, Oct 18, 2024 · control 26-AS-20230317143144

Allegation investigated: Resident sustained unexplained burn(s) while in care.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Executive Director (ED) Marife Duewei. On 12/27/2021, the Department received a complaint with the allegation that Resident sustained unexplained burn(s) while in care. On 12/30/2021, the initial investigation visit was conducted, LPA interviewed ED and 3 staff (S1 - S3). Resident physician report and Apprasial Needs and Service Plan were obtained. Continue on LIC9099-C. Page 1 of 2. Unsubstantiated Resident sustained unexplained burn(s) while in care: On 12/30/2021, LPA interviewed Executive Director (ED) Marife Duewel. ED stated resident R1 usually had shower around 4:00PM - 8:00PM, twice per week, but R1 did not have shower on 12/24/2021. ED stated R1 needed 2 caregivers to help with the shower. ED stated R1's right hand was found blisters before breakfast on 12/25/2021. R1 was sent to hospital after assessment. ED stated R1's right hand was paralyzed, was unable to stand up by self, and electrical blankets were not allowed in the facility. ED stated no hot coffee spilled on R1's right hand. On the same day, LPA interviewed 3 staff (S1 - S3). 3 out of 3 stated R1 was normal before breakfast on 12/25/2021 and on the previous day 12/24/2021, there were no incidents such as hot water or hot coffee spilled on R1's right hand. S2 stated it might be the issue of infection or allergy on R1's right hand. On 12/30/2021, LPA toured R1's room, there were no electric blankets observed. LPA measured the temperature of water of R1's bathroom, and it was 107-degree Fahrenheit. LPA measured the hot water temperature of a common bathroom, and it was 119-degree Fahrenheit. On 1/31/2023, LPA interviewed staff S4. S4 stated he/she was on duty on 12/25/2021 morning shift, and found R1's right hand had blisters, but not on the whole right arm, before breakfast in the dining room. S4 stated there was no hot water or hot coffee spilled on R1's right hand. S4 stated he/she did not know that R1's right hand's blisters were due to burn, infection, or allergy. Based on reviewing of R1's medical documents, R1's right hand was paralyzed, R1 needed help for showering, R1 was non-ambulatory, and R1 needed help to transfer. The department has investigated the above allegation. Based on the observations, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with ED. A copy of this report was provided to ED. Page 2 of 2.the state’s words, verbatim · CDSS document, Oct 18, 2023 · control 26-AS-20211227120322