West Glenn Manor

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by Administrators (ADs) Rosario Nazareno and Brian Nazareno and explained the reason for the visit. The facility is licensed for forty-eight ambulatory residents and fifty non-ambulatory with a hospice waiver for three. Currently there are eighty-five residents, and none are on hospice. LPA Tea reviewed six resident files and three staff files. Resident files and staff files contained all required documentation. Upon review of records, the facility is up to date with required quarterly emergency disaster drills, which were last conducted on December 13, 2025. AD Rosario administrator’s certificate has an expiration date of September 9, 2027. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a one-story building consisting of forty-eight resident bedrooms, two office rooms, twenty-six bathrooms, TV activities room, dining room, kitchen, and two outdoor covered patio areas. The fire alarm system of the facility is monitored and maintained by a third-party company. Fire extinguishers are fully charged throughout the facility. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and showers were free of mold/mildew. Water temperature measured between 105.4 and 111. 7 Fahrenheit degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards; doorways were free of obstructions. First aid kit had all the required elements including dressing, bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked (Annual continuation on LIC809-C) and adequately stocked at time of visit. LPA observed sharps locked and inaccessible to residents in a locked kitchen cabinet in a container. LPA also observed toxin substances secured in a closet. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade in the courtyards. LPA observed PPE supplies, emergency food and water stored in a storage shed outside of the building. LPA tested pull cord and staff responded within a minute. Facility provides games, arts and crafts and various exercises to residents for activities. At the time of the visit, LPA observed residents lounging in the activities room and doing morning exercises, playing bingo in the dining room. LPA reviewed medication storage and administration. Medications are stored in locked carts in the med-clerk area. Medications are being administered per physician order. P&I funds were accounted for and there were no discrepancies. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided. Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Administrator Rosario Nazareno and a copy of this report LIC809, along with the 809-C, LIC858, and LIC859 were read and provided to the facility.the state’s words, verbatim · CDSS document, Jan 26, 2026

Allegation investigated: Staff do not properly groom a resident while in care Resident is being over fed while in care Staff are not addressing a resident's medical conditions while in care Staff are not meeting a resident's incontinence needs

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the four allegations listed above. LPA was greeted and granted entry by facility staff after introducing himself and stating the purpose of the visit. Administrator Rosario Nazareno was present on the premises and presented with the allegations. An initial investigation visit was conducted on December 29, 2021. During the visit, LPA Jenifer Tirre toured the premises. Residents were observed relaxing in bedrooms and playing bingo in dining room. LPA conducted interviews with staff and residents at time of visit. LPA requested pertinent documents. During the present visit, LPA conducted five additional staff and five resident interviews and reviewed resident records for resident R1. LPA also requested the facility's current resident census and staff roster. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 Resident R1 was admitted to the facility on 03/31/2007 and discharged from West Glenn Manor in May 2024 after he was assessed to require a higher level of care. R1 was on the Assisted Living Waiver. Based on multiple physician reports reviewed, the latest of which was established on February 23, 2022, R1 was ambulatory and able to leave the facility unassisted, with a primary diagnosis of Major Depressive Disorder. R1 was not assessed to have any form of Major Neurocognitive Disorder at the time. Regarding the allegation that Staff do not properly groom a resident while in care, the following has been concluded: Based on multiple staff and witness interviews, it was determined that R1 required extensive assistance with toileting and grooming care. Staff interviews conducted all confirmed that facility staff was providing R1 with assistance with these activities of daily living. R1 was stated to have grown reticent to receive showers or change clothing during the final years of his admission at the facility, requiring additional prompting and occasionally being stated to have yelled at staff attempting to provide assistance. Regarding the allegation that Resident is being over fed while in care, the following has been concluded: Based on a wide majority of statements gathered, it was determined that facility staff was providing meal supervision to R1 while on the premises, however meals at the day program attended were not as closely monitored, resulting in R1 allegedly requesting to finish the plates of other program clients. Additionally, R1 was found to procure food in the community on a frequent basis as well. Weight gain observed during the resident's admission can therefore not be directly attributed to staff failing to supervise R1 adequately. Regarding the allegation that Staff are not addressing a resident's medical conditions while in care, the following has been concluded: A review of the resident's assessments and charting notes, frequent follow-ups with R1 primary care provider, behavioral specialist as well as hospitalization reports appears to document that medical conditions experienced by R1 were monitored and medical attention was sought whenever needed. CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C Regarding the allegation that Staff are not meeting a resident's incontinence needs, the following has been concluded: Based on staff interviews and assessments reviewed, it was determined that R1 was occasionally experiencing diarrhea episodes which required the use of incontinence supplies, however it was not a continuous need. Charting notes and physician visit reports dated December 2021 indicate that R1 suffered more frequent episodes while at program which appear to be related to R1's food intake while out of the facility. It cannot be confirmed whether the reported occurrence of a soiled diaper happened during one of these episodes rather than as a result of facility staff failing to ensure R1 was changed in due time. As a result, all four allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is no preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 22-AS-20211222122257

Type of visit: Required - 1 Year

On this day Licensing Program Analysts (LPAs) Michael Tea and Fred Arias made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 98 residents, of which 50 may be non-ambulatory. Facility has an approved hospice waiver for 3 residents and the facility currently has 85 residents. Administrator (AD) Rosario Nazareno and Licensee (LE) Brian Nazareno arrived shortly to conduct facility tour. AD Nazareno has a valid certificate that expires on 9/9/2025. AD provided updated liability insurance that expires on 3/19/2025. LPAs along with LE Nazareno toured the facility at 8:40 AM. LPAs toured the physical plant, checked food service, facility documentation and the first aid kit. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 100.9 degrees F and 112 degrees F in all restrooms. Common areas were clean and clear of hazards. LPAs toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detector system was tested by the fire authority on 11/14/2024. Fire extinguishers were fully charged. LPAs reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 9/28/2024. Outside grounds were toured. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise, arts & crafts, and bingo. There is shaded outdoor seating for residents. LPAs observed the emergency food and water supply. LPAs reviewed 8 resident files and 8 staff files. Reviewed resident files contained required documentation including admission agreements, physician reports, resident appraisals, LPAs interviewed 4 residents and 4 staff. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. CONTINUED ON LIC 809C DATED 1/7/2025 Medications are stored in a locked room. LPAs counted medication and confirmed accuracy for 8 residents. P&I funds were commingled for all residents. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Two technical violations were issued and one advisory was issued. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Jan 7, 2025

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dwayne Mason Jr arrived unannounced for the purpose of conducting the health and safety case management visit to follow up on the Incident Report concerning a client not returning to the facility following Day Program. LPA was granted entry and met with Administrators Benly Bandola (AD2) and Brian Nazareno (AD1). LPA explained the purpose of the visit. The Department received the incident report concerning the above dated October 17, 2024. The facility filed a police report, notified family and MD. LPA toured the facility with AD Nazareno. Facility was observed to be clean, sanitary, and in good repair. Facility maintains a 2-day supply of perishable and a 7-day supply of non-perishable food. Medications are not managed by clients and administered at the facility. Sharps, toxins, and cleaning supplies were secured and inaccessible to the clients. Facility license is currently active. LPA reviewed and obtained pertinent documentation: Client Rosters/Staff Rosters, Special Incident Reports (SIRs), Client's Physician's Report, Admission Agreement, Resident Status Summary Form, Medication Administration Record for October 2024, 2024 Progress Notes, Consultation Reports from PCP dated 10/8/2024 and 9/10/24, and Appraisals. LPA conducted interviews with Administrator, Staff and Clients. No health and safety violations were observed. An exit interview was conducted with Administrator (AD1) Brian Nazareno, and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Oct 23, 2024

Type of visit: Case Management - Annual Continuation

On May 31, 2024, at 8:10am Licensing Program Analyst (LPA) Edward Kim arrived to complete the required 1-Year annual visit that was started May 28, 2024. LPA Kim was greeted and granted entry by Administrator (AD) Rosario Nazareno and explained the purpose of the visit. During the visit, LPA Kim conducted an audit of staff files (S1-S9), resident files (R1-R9), nine (9) resident medication and medication administration record, nine (9) resident interview, and Nine (9) staff interviews. The first aid kit was reviewed and contained all the required items. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to Administrator Rosario Nazareno.the state’s words, verbatim · CDSS document, May 31, 2024

Type of visit: Required - 1 Year

On May 28, 2024 around 1:30PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Administrator (AD) Brian Nazareno and explained the purpose of the visit. The facility is licensed to operate for fifty (50) non-ambulatory and have a hospice waiver for three (3) residents. The facility is a single-story structure. It consists of the following: forty-eight (48) resident bedrooms, two (2) office rooms, twenty-six (26) bathrooms, living room, dining room, kitchen, and two (2) outdoor covered patio areas. LPA Kim toured indoor and outdoor of the physical plant with AD Nazareno. AD Rosario Nazareno arrived around 2:20pm to join in middle of the physical indoor and outdoor tour. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each client’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit . The following bedrooms were inspected: Resident Room 1, Resident Room 2, Resident 8, Resident Room 11, Resident Room 14, Resident Room 27, Resident Room 33, Resident Room 39, Resident Room 43 and Resident Room 46. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 106.3 degrees F and 114.0 degrees F. A comfortable temperature of 72 degrees F was maintained in the facility. LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA Kim reviewed the facility’s plan of operation, emergency and disaster plan, and fire/safety drill log. The facility conducted a Fire/Safety Drill on February 24, 2024. A working telephone (714-898-2131) remains available. The facility has eight (8) fire extinguishers that are charged and they were all serviced on March 7, 2024, smoke detectors, and carbon monoxide detectors were operable. Emergency food, emergency water, and emergency supplies were stored in the storage room near resident room 1. Additional emergency water were stored in an outdoor storage unit. Due to time constraints the following will be addressed on the continuation inspection on a later date: an audit of nine (9) resident files, nine (9) staff files, medication review, nine (9) resident interviews, staff interviews, and a first aid kit check. No deficiencies were cited during this inspection visit. An exit interview was conducted, and a copy of this report was provided to Administrator Rosario Nazareno.the state’s words, verbatim · CDSS document, May 28, 2024

Allegation investigated: Facility is knowingly administering a medication that a resident is allergic to.

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose to investigate into the above allegation. LPA was greeted and allowed entry by Assistant Administrator (AA) Brian Nazareno. Licensee/Administrator (L/A) Rosario Nazareno arrived shortly after to assist LPA with the investigation. During today's visit, LPA obtained interviews with resident/staff and copies of pertinent facility/resident records that were reviewed on site. The following was revealed during the course of the investigation: It is alleged that the facility is knowingly administering a medication that a resident is allergic to. While conducting a file review, Pencillin (PCN) is a known drug allergy for Resident #1 (R1) that was documented on two forms: Identification and Emergency Information (LIC601) dated January 2, 2023 and the Physician's Report dated April 18, 2023. Per the Medication Administration Record (MAR), LPA observed R1's allergies were not noted on the form. Augmentin, a derivative of PCN, was prescribed by the primary care physician and administered on October 12, 2023 and terminated on October 14, 2023 as noted on the MAR. Three out of the three staff confirmed the administration of Augmentin in Unsubstantiated accordance with the doctor's orders and due to R1's PCN allergy not mentioned on the MAR produced by the pharmacy. LPA is able to establish that although that the facility should have identified and cross-checked R1's allergies, facility did not knowingly administer a medication R1 was allergic to. Therefore, based on the interviews which were conducted and the records that were reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Facility is knowingly administering a medication that a resident is allergic to is deemed UNSUBSTANTIATED. An exit interview was conducted with Licensee/Administrator Rosario Nazareno Assistant Administrator Brian Nazareno, and a copy of this report including the LIC9099-C and the LIC811 were provided at the end of the visit.the state’s words, verbatim · CDSS document, Oct 25, 2023 · control 22-AS-20231020160710

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jessica Cho continued the visit after delivering the findings into Complaint Control Number: 22-AS-20231020160710. The purpose of this subsequent visit was to issue a citation after observing a deficiency while conducting a complaint investigation in connection to the above-mentioned complaint. LPA explained the reason for the Case Management-Deficiencies visit to Licensee/Administrator (L/A) Rosario Nazareno. During the complaint investigation, LPA observed that the facility did not report a medication error to the Department regarding Resident #1 (R1), therefore the preponderance of evidence standard has been met. A deficiency is being cited as per Title 22, Division 6, Chapter 8 of the California Code of Regulations. See the attached LIC809-D. L/A submitted the incident report to the Department on today's date during the visit. An exit interview was conducted with Licensee/Administrator Rosario Nazareno and Assistant Administrator Brian Nazareno, and a copy of this report along with the LIC809-D, LIC811, and the appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Oct 25, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Nov 1, 2023

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (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... This requirement was not met as evidenced by: Based on LPA's observation, interviews, and record review, the facility did not submit R1's medication error report to the Department within 7 days of the event which poses a potential Personal, Health, and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Administrator stated that they will submit the incident report regarding R1's medication error which was completed during the visit on today's visit.

Type of visit: POC

Licensing Program Analyst (LPA) Jessica Cho continued the visit after issuing a citation during a Case Management-Deficiencies visit conducted on today's date. LPA explained the reason for the Plan of Correction (POC) visit. *Deficiency cited under Title 22 Regulation 87211(a)(1) was pertaining to a written report sent to the licensing agency within seven days of any incidents. LPA verified that the incident report regarding Resident #1 (R1)'s medication error was reported to the Department during today's visit, therefore the Licensee/Administrator has complied with the POC. A copy of the Letter of Deficiency Citations Cleared form was provided during today's date. Licensee has been advised to maintain compliance in the item previously cited. An exit interview was conducted with Licensee/Administrator Rosario Nazareno, and a copy of this report including the LIC811 and the Letter of Deficiency Citations Cleared were provided at the end of the visit.the state’s words, verbatim · CDSS document, Oct 25, 2023