Westminster Terrace

Allegation investigated: Staff do not ensure resident’s care plan is being followed. Staff does not ensure soiled garments are removed from resident’s room. Staff do not ensure resident’s personal belongings were kept safely secured. Staff did not prevent resident’s personal property from being damaged.

Licensing Program Analyst (LPA) Garlli Tat made an unannounced visit to the facility to deliver the findings on the above allegations. LPA met with the Executive Director Carmen Galicia and explained the purpose of the visit. An initial complaint investigation visit took place on June 23, 2026. During the visit, LPA accompanied by staff conducted a tour of the facility's physical plant. LPA requested and obtained the resident and staff roster 06/09/2026, preplacement appraisal dated 05/01/2026, progress notes (03/26/2026-06/20/2026), admission agreement dated 03/26/2026, physician’s report dated 03/23/2026, service plan (03/26/2026), resident personal property and valuables, authorization and agreement to handle resident funds dated 03/26/2026. Four resident interviews and five staff interviews were conducted. The investigation revealed the following: Continued on LIC9099-C. Unsubstantiated Regarding the allegation that Staff did not ensure resident’s care plan is being followed, it was reported that resident is neglected and does not get changed for hours. Resident #1 (R1) stated that they are stuck in soiled briefs for a long time before staff comes and changes them. Per review of R1’s physician’s report, R1 is diagnosed with Multiple Sclerosis, is nonambulatory, and unable to care for their own toileting needs. Per review of progress notes, it was noted that resident has been refusing assistance with personal hygiene on March 31, April 15, April 19, April 22, May 4, May 5, May 14, June 5, and June 13, 2026. It was reported on multiple occasions that R1 is verbally aggressive and uses profanity against staff. Two out of four residents interviewed stated they are changed daily, or as requested. Two out of four residents responded with unrelated information. Five out of five staff, including the administrator, reported R1 refuses to be changed. The administrator reported that R1 has developed a rash due to the soil they have been sitting on. None of the evidence gathered supports the allegation. Regarding the allegation that Staff does not ensure soiled garments are removed from the resident’s room, it was reported that staff leaves soiled diapers and towels in resident’s room. Per review of R1’s admission agreement dated March 26, 2026, the facility will provide weekly housekeeping services and the resident agrees to keep their room in a clean and sanitary condition. One out of four residents stated that sometimes there are soiled diapers or towels left in the room. Two out of four residents denied the allegation. One out of four residents provided irrelevant information on the allegation. Three out of five staff denied the allegation. Two out of five staff stated that soiled garments are placed in a bag and disposed of at a later time because the washers are in use. Regarding the allegation that Staff do not ensure resident’s personal belongings were kept safely secured, it was reported that staff threw away personal towels and damaged clothing items while assisting resident with changing shirts. When LPA interviewed R1, it was reported that staff steal their clothes after washing them and comes into their room to take their pants and shirts. Per review of admission agreement, theft will result in staff’s immediate loss of privileges to enter the facility to provide services to any resident. It was further stated that the facility shall not be responsible for the loss of any personal property belonging due to theft, unless the loss or damage was caused by the facility’s negligence or that of employees. Two out of four residents stated they have had belongings stolen at the facility. Two out of four residents stated they have not had belongings stolen. Three out of five staff interviewed denied the allegation. One out of five staff interviewed did not provide relevant information. One out of five staff interviewed stated that there was a time where R1’s cushion pillow was washed and dried, but staff did not know who it belonged to because there was not a room number attached to the laundry bag. The item was later returned to R1. Cont. on LIC9099-C. Because the item was later returned to the R1, no personal belongings were stolen or thrown away by staff. Regarding the allegation that Staff did not prevent resident’s personal property from being damaged, it was reported that clothing items were damaged while assisting to change resident’s shirts. When LPA interviewed R1, it was reported that clothes get damaged after washing. Per review of R1’s admission agreement, the facility shall not be responsible for the loss of any personal property belonging due to theft, fire, or any other cause, unless the loss or damage was caused by the facility’s negligence or that of employees. Two out of four residents interviewed stated there have been instances where their laundry has been damaged after washing. One out of four residents denied the allegation. One out of four residents did not provide relevant information. Three out of five staff denied the allegation. Two out of five staff did not provide relevant information. There was no evidence stating that R1's belongings were damaged. Based on the evidence gathered during the investigation, the allegations are found to be Unsubstantiated, meaning that 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. An exit interview was conducted, and a copy of the present report was provided to the Executive Director. Appeal Rights were reviewed. . Regarding the allegation that Staff does not ensure residents are accorded access to their own money, it was reported that the facility staff won’t allow the residents control over their own money. R1 reported facility staff take too long to pay residents the difference after rent is deducted from their Social Security check. Per review of Authorization and agreement to handle resident funds dated March 26, 2026, R1 agreed to authorize the facility to transfer the P&I amount to their bank account after deducting the monthly rent. Three out of four residents interviewed denied the allegation that facility denies residents access to their money. One out of four residents interviewed did not provide relevant information. Four out of five staff did not provide relevant information regarding the allegation. One out of five staff reported that R1 signed an agreement to allow the facility act as their representative payee. R1 was unhappy with how late the P&I was deposited into their account. The rate in which the P&I is deposited is not under the control of the facility. It was reported that R1 will return to acting as their own payee starting next month. None of the evidence gathered supports the allegation. Regarding the allegation that Staff does not ensure resident is accorded rights to choose a room to share with another resident, it was reported that staff moved a resident to a different room without telling them why. R1 stated their roommate was moved to a different room without being told in advance or the reasoning behind it. Per review of admission agreement, residents in privately operated residential care facilities for the elderly shall have the right to reasonable accommodation of their preferences concerning room and roommate choices and to written notice of any room changes at least 30 days in advance unless a room change is agreed to by the resident, required to fill a vacant bed, or necessary due to an emergency. One out of four residents stated they were moved without prior notice. One out of four residents stated they have not been moved without prior notice. Two out of four residents did not provide relevant information. Two out of five staff interviewed, who had knowledge regarding the allegation, stated R1’s previous roommate requested to be moved to a different room because they didn’t want to share a room with R1. Three out of five staff interviewed did not provide relevant information. Based on the evidence gathered, the allegation is deemed Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Department has therefore dismissed the complaint. An exit interview was conducted with the Executive Director and a copy of this LIC9099 report was left at the facility.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 22-AS-20260616142820

Allegation investigated: Facility fail to obtain proper building permits for reported construction. Resident was moved to another room without proper notice while facility is under going construction.

On July 13, 2026, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced subsequent complaint visit and delivered findings at the facility for the above allegations. LPA Kim met with Administrator (ADMIN) Carmen Galicia and explained the purpose of the visit. Investigation consisted of the following: LPA Kim conducted a physical tour of the facility. LPA Kim reviewed and obtained copies of the resident roster, staff roster, staff schedule, and eight (8) resident records which include: Identification and Emergency Information, Physician's Report, Needs and Services Plans/Reappraisal, and other pertinent records. LPA Kim conducted interviews with five (5) residents, five (5) staff, and one witness. The investigation revealed the following: Continued on LIC9099C Unsubstantiated Allegation: Facility fail to obtain proper building permits for reported construction. It is alleged that the facility failed to obtain proper building permits for reported construction. Based on interviews, five out of five staff and one out of five residents denied the allegation. One witness could not confirm or deny the allegation. Four out of five residents confirmed allegation. S5 stated that there was no construction or permits required for the renovations in rooms 117, 118, 217, or 218 on March 2025. S5 stated that the only renovations would be to flooring throughout rooms 117, 118, 217, or 218, repainting the walls, and updating the flooring in each of the bathrooms. These were not done at that time because the facility was focused on other operational needs. S5 stated that there was an invoice from a third party about renovating room 218 which would require a building permit. The room was not converted with the scope of work described in the invoice because the facility was focusing their finances on other operational needs. Based on observations on March 20, 2025, and July 13, 2026, LPA did not observe construction or anything that would require a building permit for the renovations being done in rooms 117, 118, 227, or 228 at the facility. Based on record review, a work order dated September 27, 2024, describes a scope of work that included converting a kitchen back to a bathroom, demo cabinets and flooring, install new toilet flange, and new toilet, and new shower stall and shower valve. When LPA entered room 218 on March 20, 2025, and July 13, 2026, none of these alterations took place. There was no evidence that the kitchen was converted to a bathroom, any demolition, or any new toilets or showers were installed. There are no building permits because there was no construction was done or pursued. LPA confirmed this. Based on information gathered, there is not sufficient evidence to corroborate the above allegation. Allegation: Resident was moved to another room without proper notice while facility is undergoing construction. It is alleged resident#1 (R1) was told by Staff while walking in the hallway that R1 would have to leave their room either Saturday or Wednesday. It is alleged R1 is not well and cannot pack their own things. It is alleged that staff just packed R1’s belongings up and moved R1 to another room. It is alleged that R1 did not have a choice or asked for their consent for the move. It is alleged R1 does not know if this move is permanent. Continued on LIC9099C Based on interviews conducted, five out of five staff, one out of five residents, and one witness denied the allegation. Four out of five residents confirmed the allegation. All staff stated that R1 did not move to another room because of renovations. S2 stated that they met with R1 to discuss a move from their room to a new room because R1 requested a courtyard side room instead of the street side room. S2 also stated that R1 was not diagnosed with dementia, but showed other cognitive decline such as forgetfulness. R1 met with S2 and S4 about moving to a courtyard side room, but would forget the next day about it. S5 stated that R1’s room was not under renovation during the time they were residing at the facility. S5 also verified that R1 had some forgetfulness issues and moved for a courtyard side room instead of a street side room. S2 and S5 stated a notice was not provided for a move because R1 requested a move to another room. Based on record review, charting notes dated March 11, 2025, state that R1 requested a room change and R1 agreed to move to their new room on March 19, 2025. Charting notes dated March 18, 2025, R1 requested to be moved to a courtyard side room and was moved to Room 228. S2 stated they followed up with R1 on March 18, 2025, to check in on them. Based on information gathered, there is not sufficient evidence to corroborate the above allegation. Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the above allegations facility fail to obtain proper building permits for reported construction and resident was moved to another room without proper notice while facility is undergoing construction. 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 a copy of the report was provided to Administrator Carmen Galicia.the state’s words, verbatim · CDSS document, Jul 13, 2026 · control 22-AS-20250318130722

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today's visit was to conduct a case management. LPA Tea was greeted and granted entry into the facility by the staff. Executive Director (ED) Carmen Galicia arrive shortly to assist with the visit. On this day LPA Tea amended LIC809 and LIC809D dated 03/19/2026. LPA reviewed amended reports with ED Galicia. An exit interview was conducted with Executive Director Carmen Galicia. A copy of this report and amended LIC809 and LIC809D was provided to the facility.the state’s words, verbatim · CDSS document, Jul 9, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced Case Management – Health and Safety Check visit to follow up on a complaint received by Community Care Licensing (CCL) on May 27, 2026. LPA was granted entry into the facility by Executive Director (ED) Carmen Galicia, who assisted with the visit. LPA explained the purpose of the inspection. During the visit, LPA and ED toured the facility, including Resident 1 (R1) and Resident 2 (R2) shared bedroom. LPA conducted health and safety checks of residents present and observed that residents appeared well and exhibited no immediate health or safety concerns. LPA observed the facility to be clean, organized, and maintained in a safe condition. No health and safety hazards were observed during the inspection. LPA requested and reviewed records for R1 and R2. The records reviewed contained the required documentation. Based on observations made during today’s visit, no deficiencies are being cited at this time. An exit interview was conducted with Executive Director Carmen Galicia, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 29, 2026

Allegation investigated: - Unlawful eviction - Staff withheld resident medication

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude and deliver findings for a complaint investigation. LPA Tea was greeted and granted entry by Executive Director (ED) Carmen Galicia and explained the reason for the visit. The department received a complaint on February 12, 2026. LPA Tea spoke to residents and facility staff and reviewed and collected pertinent documents and information. Regarding the allegation of unlawful eviction, interviews with Executive Director (ED) Carmen Galicia and Wellness Director (WD) Veronica Mata stated that Resident 1 (R1) was not evicted from the facility. Staff reported that R1 returned from a medical appointment with a G-tube, which is a condition that the facility is not licensed to care for. Staff also stated that R1 did not provide discharge paperwork or doctor’s orders upon returning to the facility. (Complaint report continued on LIC9099C) Unsubstantiated Staff reported that due to the G-tube, they attempted to have R1 evaluated at the hospital to ensure proper care. R1 was later transferred to a skilled nursing facility for a higher level of care. Staff stated that R1 gathered their belongings and left the facility on their own. Staff also reported that R1 was informed they could return to the facility once the G-tube was no longer in place. Witnesses reported that R1 appeared distressed and felt they had limited time to leave. However, witnesses also confirmed that staff did not state that R1 was being evicted. Records reviewed show that R1 signed an Admission Agreement which explains that certain medical conditions, including the need for G-tube care, may require reassessment and possible termination of services. Regarding the allegation that staff withheld medication, staff reported that R1 was provided prescribed pain medication prior to returning to the facility with the G-tube. Facility records confirmed that medication was administered according to physician’s orders on the morning of January 26, 2026. Staff stated that after R1 returned with the G-tube, they did not administer medication because there were no doctor’s orders or instructions on how to safely provide medication with the newly placed device. Staff reported that this decision was made to ensure resident safety. While one witness stated that R1 was denied pain medication, this information was not supported by records reviewed. Staff consistently reported that medications are provided when there are proper physician orders in place. Based on interviews and records reviewed, there is insufficient evidence to support that the facility conducted an unlawful eviction and that staff withheld medication. Therefore, the allegations mentioned above has been determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with the facility. A copy of the report and list of confidential names were provided to the facility.the state’s words, verbatim · CDSS document, May 19, 2026 · control 22-AS-20260212154338

Allegation investigated: - Staff do not follow resident's special diet - Staff do not ensure residents room is clean

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude and deliver findings for a complaint investigation. LPA Tea was greeted and granted entry by Executive Director (ED) Carmen Galicia and explained the reason for the visit. The Department received a complaint on March 18, 2026. LPA Tea spoke to residents, witnesses and facility staff and reviewed and collected pertinent documents and information. Regarding the allegation that staff do not follow Resident 1’s (R1) special diet, the Department reviewed R1’s records, including the Physician’s Report dated June 25, 2025, which indicated a special diet of “pureed PRN,” as well as the facility’s Diet Clarification form listing a regular diet with chopped food. Additionally, kitchen documentation identified R1 as requiring a vegetarian/mechanical soft diet and included specific food preferences. These records demonstrate that dietary needs were identified and communicated to staff. (Complaint report continued on LIC9099C) Unsubstantiated Interviews with staff confirmed awareness of R1’s dietary preferences, including vegetarian choices and preferred snacks such as bananas and warm milk. Staff reported that R1 was offered appropriate meal options and had the ability to choose foods consistent with their preferences. While one witness reported that R1 was occasionally offered food items inconsistent with a vegetarian diet, this information was not corroborated by other sources. Interviews showed that R1 had memory issues and often chose to eat only a few preferred foods, even when other meal options were available. Interviews with residents showed that three out of five felt the facility meets their dietary needs. While food choices may sometimes be limited, other options are available. The Culinary Services Director (CSD) Freddie Harbor stated that residents can request changes to meals based on their preferences and that the facility is working to offer more food choices for those with diabetic restrictions. Regarding the allegation that staff do not ensure residents’ rooms are clean, LPA conducted observations of R1’s room and bathroom, which were found to be clean and well-maintained at the time of the visit. Although the complaint indicated concerns about bathroom cleanliness, the observed condition appeared related to the toilet not being flushed rather than a lack of cleaning. Interviews with residents indicated that four out of five residents were satisfied with the cleanliness of their rooms. Staff, including the Maintenance Director (MD) Daniel Guerrero, reported that rooms are cleaned on a scheduled basis and additionally as needed. Staff also indicated that some residents may refuse cleaning services, which can impact room conditions. Based on the evidence obtained, there is insufficient information to conclude that the facility failed to follow R1’s special diet. Also there is insufficient evidence to support the allegation that the facility failed to maintain resident room cleanliness. Therefore, the allegations mentioned above has been determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with the facility. A copy of the report and list of confidential names were provided to the facility.the state’s words, verbatim · CDSS document, May 19, 2026 · control 22-AS-20260318143002

Allegation investigated: Facility did not safeguard residents personal property

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, the department interviewed staff and resident as well as reviewed and obtained pertinent documentation such as inventory list. Regarding the allegation that facility did not safeguard residents personal property, the investigation revealed the following: Review of facility documents show that Resident 1 (R1) declined to fill out the resident inventory form on 09/27/2023. Resident subsequently filled out an inventory form and dated it 05/08/2024. However, R1 states that she gave the form to a facility representative for signature on 09/18/2024 despite stating the necklace went missing in July 2024. There was no necklace or any other items noted anywhere prior to 09/18/2024. Administrator indicates reporting the missing necklace to law enforcement as well and stated the facility did not receive a hard copy of inventory form from the resident until 03/11/2025. CONTINUED ON LIC 9099C DATED 05/09/2026 Unsubstantiated Based on records reviewed and interviews conducted, the department is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, May 9, 2026 · control 22-AS-20251113122953

Allegation investigated: Staff do not ensure smoking area is properly maintained

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, the department toured the facility and interviewed residents and Administrator. Regarding the allegation that staff do not ensure smoking area is properly maintained, the investigation revealed the following: The department toured the smoking area on two different occasions and observed the area to be clean and orderly as well as the non-smoking area. Three out of four residents interviewed denied smoking issues at the facility. One resident stated satisfaction with the smoking area. Administrator indicates smoking issues regarding residents smoking in their rooms have been resolved. Based on observation and interviews conducted, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and copy of the report was provided to the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 9, 2026 · control 22-AS-20251117140332

Allegation investigated: Staff did not provide resident records to residents authorized representative. Staff did not provide all resident medications to residents authorized representative. Staff did not provide adequate laundry services to resident in care. Staff did not update resident's care plan as necessary. Staff did not follow physician's orders regarding resident in care. Staff did not safeguard the personal possessions of resident in care. Staff did not respond to requests for communication from resident's responsible party. Staff forced resident in care to take medications. Staff did not provide adequate care and supervision as outlined in resident’s care plan.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator Carmen Galicia and explained the reason for the visit. The investigation into the allegation, staff did not provide resident records to residents authorized representative, revealed the following. It was reported that when Resident 1 (R1) moved out of the facility the Responsible Party requested the Physician Orders for Life-Sustaining Treatment (POLST) be given to them so they could provide it to the new facility R1 was moving to. The Wellness Director (WD) reported that they processed the discharge of R1 when they moved out of the facility and the Responsible Party did not request any documents including the POLST. The WD reported that the Responsible Party never provided the actual POLST, they provided a printout of a picture of the POLST even though the facility requested the original document. No evidence was provided to corroborate the allegation. Unsubstantiated The Administrator reported that the Responsible Party did not request any documents from them. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, staff did not provide all resident medications to residents authorized representative, revealed the following. It was reported that when R1 moved out of the facility on October 18, 2024, the Responsible Party was not provided with all R1’s medications. No specific medications were named and the number of medications not provided was not reported. Staff 1 (S1) and the Wellness Director (WD) both reported that when R1 moved out of the facility the Responsible Party was provided with all of R1’s medications and medication list. A review of records shows there is no sign out sheet showing the medication was provided to R1’s responsible party. There is no regulation that requires a resident or responsible party to sign for their medication when they leave the facility. At the time of the 10-day visit Staff 1 reported and LPA verified that there were no medications for R1 at the facility. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, staff did not provide adequate laundry services to resident in care, revealed the following. It was reported that R1’s laundry was not being done, and dirty laundry was piled on the floor. No dates or times were provided. Staff 2 (S2) reported that laundry is done once a week for residents except for those who do their own laundry, S2 reported that if required laundry is done more frequently based on need. S2 reported that on a few occasions R1 took all of their laundry out of the hamper and put it in the corner or the closet. S2 reported that they always did R1's laundry and made sure they put it in the proper place. S2 reported staff do a good making sure all the residents' laundry is done regularly and the residents always have clean clothes to wear. Photographic evidence was provided showing a pile of clothes. The condition of the clothes, clean or dirty cannot be determined by the picture and it is unknown how or why the clothes were in a pile. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, staff did not update resident's care plan as necessary, revealed the following. It was reported that after the care plan meeting for R1 was held on July 11, 2024, the care plan was not presented to the Responsible Party until September 2024 and was not signed until September 26, 2024. The Wellness Director (WD) reported that after the care plan meeting the Responsible Party did not agree with all of issues on the care plan and wanted changes. The Administrator reported that the Responsible Party contacted them after the care plan meeting and wanted changes to the care plan because they wanted to move R1 into a facility that was part of the Assisted Living Waiver (ALW) program that had a memory care unit, and they wanted an updated care plan to help facilitate the move. The Administrator and WD reported that care plan reflected R1’s current condition and the best care possible for R1. The Responsible Party denied that report and stated that the facility failed to provide the care plan in a timely manner. An email from the Responsible Party to the facility sent on Saturday August 31, 2024, shows that the Responsible Party requested changes be made before they sign the new care plan. The care plan meeting was conducted, and neither side could agree until changes were made that were acceptable to both parties, this delayed the process. Therefore, the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, staff did not follow physician's orders regarding resident in care, revealed the following. It was reported that when R1’s physician ordered a special diet for R1 that the facility did not follow the order. The Wellness Director (WD) reported that all orders must be provided by the doctor on a prescription order blank. The WD and Administrator reported that most special orders for residents are faxed in and are on a prescription form. An email was provided that shows R1’s Responsible Party sent the facility a PDF attachment reporting R1’s physician has ordered a special diet for R1. A review of the email dated August 13, 2024, and the attached document shows that a CMA (Certified Medical Assistant) reported that R1’s doctor has reviewed the message and has ordered a diet rich in iron because of anemia. The document provided does not have any type of signature and it is not clear if R1’s physician wrote the text of the message. LPA reviewed orders for special diets and medications, all the other orders were provided on prescription orders, electronically (email) or faxed in with clear instructions and signatures. None of the evidence gathered supports the allegation. Therefore, the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, staff did not safeguard the personal possessions of resident in care, revealed the following. It was reported that R1’s personal items, cell phone, tennis bracelet, prescription glasses and a State of California Disabled Person Parking Placard went missing because the facility did not safeguard R1’s possessions. The cell phone was reported missing on August 19, 2024, and was last seen by the Responsible Party on July 12, 2024. The 3 other items were reported missing on October 19, 2024, after R1 moved out of the facility. A review of records shows that the Responsible Party for R1 signed a form dated August 1, 2023, declining R1’s personal items to be inventoried and tracked. The WD reported that after the report, staff were instructed to look for the lost cell phone, but it was not located and R1’s Responsible Party was notified. The Responsible Party reported that none of the missing items were ever located. The WD reported that when the other items were reported missing staff checked R1’s former room but the items reported missing were not found, but staff found a gold watch and a butterfly pendant. The Administrator reported that they contacted the Responsible Party, but they never responded. The WD reported that they followed the theft and loss policy and communicated with the Responsible Party but they never acknowledged their messages. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, staff did not respond to requests for communication from resident's responsible party, revealed the following. It was reported that the facility did not regularly respond to calls or emails concerning R1 while they lived at the facility. The Administrator and WD reported that they regularly communicated with R1’s Responsible Party via email and phone messages. The Responsible Party reports they were not regularly called about anything concerning R1. The Administrator reported that any incident and any issues regarding care were addressed and were communicated to R1’s Responsible Party. California Code of Regulation (CCR) 87211 (a)(1) states, “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.” Item “D” of the regulation states, “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.” The Administrator reported that the facility complies with all reporting requirements concerning all residents. The WD reported that R1’s Responsible Party was notified concerning any issues, especially incidents requiring a report as stated in CCR 87211. R1’s Responsible Party verified they were notified when R1 had to go to the hospital and concerning any mediation changes and falls. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, staff forced resident in care to take medications, revealed the following. It was reported that after R1 returned from a hospital visit on July 3, 2024, R1 was forced to take multiple antibiotics for 3 days. A review of records shows that R1 was sent to the hospital on or around July 3, 2024, for a urinary tract infection and a head injury from a fall. R1 returned the same day. The only medication change listed in the hospital discharge paperwork is Ciprofloxacin 500 mg. The attending physician at the hospital prescribed Ciprofloxacin 500 mg 2 times a day for 7 days for R1. R1 was already prescribed Levaquin. It was reported that in response to R1’s new prescription of Ciprofloxacin 500 mg R1’s physician ordered Levaquin to be discontinued and Macrobid to be started on July 3, 2024. A review of records shows R1’s physician faxed an order to the facility on July 5, 2024. The WD reported that once they received the discontinuance order they stopped administering the medication in question. The WD reported that they had been in communication with R1’s doctor and R1’s Responsible Party concerning the medication changes. The WD reported that the new medication was received on July 6, 2024. The WD reported that they can’t just stop or start any medications unless there is a doctor’s order and the facility had to wait for R1’s doctor to make the changes before they could take action. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, staff did not provide adequate care and supervision as outlined in resident’s care plan revealed the following. It was reported that R1 did not receive assistance regarding putting on their glasses and hearing aids and being escorted to all meals. It was reported that R1 was not checked on every 2 hours as outlined in their care plan. It was reported that R1 would not always have their hearing aids in or have their glasses on. 5 out of 5 staff interviewed reported that many residents including R1 remove their glasses and hearing aids during the day and don’t like using them. A review of records shows R1’s most recent care plan dated September 26, 2024, states R1 needs no assistance with their glasses and self manages putting on their glasses. The care plan shows R1 requires moderate assistance with their hearing aid, R1 needs to be reminded to use their hearing aids. The care plan shows R1 needs to be reminded to go to meals. It was reported that when R1 returned from a hospital visit on June 15, 2024, at 8:00 pm, which caused them to miss dinner and they were not fed until the next day at lunch time. A review of records shows that R1 went to the hospital on June 8, 2024, and returned to the facility on June 15, 2024, at 6:00 pm. Staff reported that when residents return from the hospital, they ask them if they have eaten and if they haven’t the staff will get the resident food. 4 out of 4 staff interviewed reported they do not remember any incidents with R1 and don’t remember R1 ever missing a meal unless they were at the hospital. 4 out of 4 staff interviewed reported that R1 was checked regularly as per the care plan when they were not in the hospital. R1 moved out of the facility on October 18 to a new facility and their location is unknown. 4 out of 4 staff interviewed denied the allegation. No evidence was gathered to support the allegation, therefore the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Apr 8, 2026 · control 22-AS-20241022102800

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 15, 2026

The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not being met as evidenced by, Photographic evidence shows R1's floor in their room was not clean. This poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2026

Plan of correction: Licensee agrees to train housekeeping staff on CCR 87303 and to maintain all resident rooms in compliance with CCR 87303.

Allegation investigated: - Staff mismanage resident's medications

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude and deliver findings for a complaint investigation. LPA Tea was greeted and granted entry by Executive Director (ED) Carmen Galicia and explained the reason for the visit. The Department received a complaint on December 2, 2025. LPA Tea spoke to residents and facility staff and reviewed and collected pertinent documents and information. It was alleged that staff mismanage residents’ medications. While 2 out of 7 residents reported concerns regarding medication timeliness and availability of PRN medications, the information obtained during the investigation does not substantiate medication mismanagement by staff. Regarding Resident 1 (R1), it was alleged that medication was not provided. However, facility progress (Complaint Investigation Report continued on LIC9099C) Unsubstantiated notes confirmed that R1 did receive the medication on the same day prior to being transported to the hospital. The Wellness Director (WD) Veronica Mata explained that delays were related to challenges in obtaining physician orders and prescriptions, including receiving incorrect medication from the provider. Documentation and staff statements indicate that the facility made ongoing and reasonable efforts to resolve the issue by contacting the physician and pharmacy through multiple methods. All staff interviewed acknowledged that delays can occur due to factors outside of the facility’s control, particularly with physician response times. Staff reported following established protocols, including consistent follow-up via phone, fax, email, and delegation to ensure timely resolution. Based on documentation, staff interviews, and corroborating information, the facility demonstrated due diligence in managing resident medications. Therefore, the allegation mentioned above has been determined to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies cited at this time and an exit interview was conducted with the facility. A copy of the report and list of confidential names were provided to the facility. administration would require a physician’s order. Facility records, including progress notes, document that R2 refused hospital care. In accordance with protocol, staff notified both the resident’s family and primary care physician also noted in the facility progress notes. WD Mata confirmed that R2 stated that they believe their symptoms would go away on their own and declined further intervention, despite staff concern and continued encouragement to seek care. All staff interviewed stated that they promptly seek medical attention when needed and document refusals while placing residents on alert charting. Additionally, 6 out of 7 residents interviewed reported that the facility responds quickly to medical needs, including contacting emergency services when appropriate. Based on the evidence, staff took appropriate and timely action to address R2’s condition, and the delay in medical treatment was due to the resident’s refusal. Therefore, the allegation mentioned above has been determined as UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies cited at this time and an exit interview was conducted with Executive Director (ED) Carmen Galicia. A copy of the report was provided to the facility along with the list of confidential names.the state’s words, verbatim · CDSS document, Mar 26, 2026 · control 22-AS-20251202140517

Allegation investigated: - Staff do not ensure the facility is clean and sanitary - Facility is malodorous - Staff do not provide adequate food service

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude and deliver findings for a complaint investigation. LPA Tea was greeted and granted entry by Executive Director (ED) Carmen Galicia and explained the reason for the visit. The Department received a complaint on December 1, 2025. LPA Tea spoke to residents and facility staff and reviewed and collected pertinent documents and information. It was alleged that staff did not ensure the facility is clean and sanitary. While some residents expressed concerns regarding carpet cleanliness, particularly noting stains and a desire for improved floor care, LPA observations found that the first-floor carpets were clean, and carpets on the second and third floors showed noticeable improvement over the course of the investigation. (Complaint Investigation Report continued on LIC9099C) Unsubstantiated Staff reported problems with a temporarily non-functioning carpet cleaning machine, requiring manual cleaning efforts. Maintenance logs reviewed by LPA indicate that routine cleaning and upkeep of the facility, including carpets, are conducted on a weekly basis currently. The Maintenance Director (MD) Daniel Guerrero confirmed ongoing efforts to enhance record-keeping through electronic documentation with their corporate office. All staff interviewed emphasized the importance of maintaining a clean and sanitary environment and reported consistent efforts to uphold these standards despite high foot traffic and occasional staffing limitations. Additionally, 4 out of 7 residents interviewed stated that the facility is generally clean and that staff are making reasonable efforts to maintain sanitation. Therefore, although areas for improvement were identified, the preponderance of evidence does not support that staff failed to ensure the facility is clean and sanitary. It was alleged the facility is malodorous. The investigation revealed inconsistent accounts regarding odors within the facility. Two residents reported unpleasant odors, attributing them to carpets or bathrooms. However, most residents interviewed reported no persistent or concerning odors. Staff consistently denied the presence of ongoing odors and described prompt hygiene practices, including timely disposal of waste and incontinence products. One resident acknowledged that while incontinence among residents can occasionally contribute to temporary odors, staff respond promptly, minimizing any lasting impact. Based on LPA observations, staff interviews, and most of the resident feedback, there is insufficient evidence to conclude that the facility is malodorous. It was alleged that staff do not provide adequate food service. Although two residents expressed dissatisfaction with food service, citing delays, food temperature, and portion sizes, the majority of residents interviewed (5 out of 7) reported satisfaction with meal quality, portion sizes, and overall service. Residents noted that improvements have been made, including the ability to request additional servings and alternative meal options. (Complaint Investigation Report continued on LIC9099C) Staff interviews indicated that previous staffing shortages in the kitchen contributed to delays; however, these issues have since been resolved, and the kitchen is now adequately staffed. Staff reported accommodating residents by offering alternative food options if menu items are unavailable or preferred. While certain specialty items may have limited portions, residents are not denied food and are provided with substitutes when necessary. Given most positive resident feedback and staff explanations, there is insufficient evidence to support the allegation that food service is inadequate. While some concerns were identified, the facility has demonstrated ongoing efforts to address issues and maintain compliance with cleanliness, sanitation, and service standards. Based on interviews, observations, and records reviewed, there is insufficient evidence to support the allegations mentioned above and has been determined to be unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred No deficiencies cited at this time and an exit interview was conducted with the facility. A copy of the report was to provided to the facility.the state’s words, verbatim · CDSS document, Mar 26, 2026 · control 22-AS-20251201133927

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Michael Tea conducted a case management visit to follow up on an incident report received by Community Care Licensing (CCL) on March 4, 2026, submitted by Wellness Director (WD) Veronica Mata. LPA was greeted and granted entry by Executive Director (ED) Carmen Galicia, and the purpose of the visit was explained. During the visit, LPA toured the facility with ED Galicia and inspected Resident 1's (R1) room. R1's personal belongings remained in place, and facility staff reported that no items had been moved or disturbed. LPA conducted a health and safety inspection of the facility and observed no immediate health or safety hazards. Facility staff reported that R1 left the facility without staff supervision and has since stated they do not wish to return. Staff followed facility procedures by notifying local law enforcement that R1 was missing. Staff also reported that they were unaware R1 had previously left another assisted living facility without authorization until they were informed by the resident's family after this incident. LPA reviewed R1's records, including the Physician's Report, which specified that R1 was not permitted to leave the facility unassisted. During the incident, R1 left the facility without staff supervision, demonstrating that the required level of care and supervision was not provided. Based on LPA's observations, record review, and interviews, the facility failed to provide the care and supervision necessary to meet R1's assessed needs. The Physician's Report established that R1 required staff supervision when leaving the facility, and the facility was responsible for ensuring that the required supervision was provided. A deficiency is cited pursuant to California Code of Regulations, Title 22, Section 87464(f)(1), Basic Services, which requires, at a minimum, the provision of care and supervision. An immediate civil penalty of $1,000 is assessed. An exit interview was conducted with the facility. A copy of this report, along with the LIC 809-D and appeal rights, was provided to the facility at the time of the visit. ***THIS IS AN AMENDED REPORT***the state’s words, verbatim · CDSS document, Mar 19, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Mar 20, 2026

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by Based on LPA's review of records, Resident 1's (R1) Physician's Report indicated that R1 was not permitted to leave the facility unassisted. The facility failed to provide the necessary care and supervision, resulting in R1 leaving the facility without staff assistance. This posed an immediate health and safety risk to the resident.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: Facility will provide in-service training and proof of staff written up notice acknowledging elopement and understanding of violation. ED will provide a list of ideas or changes to prevent future elopements due by POC due date to LPA. ***THIS IS AN AMENDED REPORT***

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Michael Tea conducted a case management visit to follow up on an incident report regarding a medication error received by Community Care Licensing (CCL) on March 16, 2026. The report was submitted by Wellness Director (WD) Veronica Mata, LVN. LPA was greeted and granted entry by Executive Director (ED) Carmen Galicia, and the purpose of the visit was explained. During the inspection, LPA toured the facility with ED Galicia and observed Resident 1’s (R1) room. R1 was not present at the facility and is currently hospitalized. LPA conducted health and safety checks on residents in care and confirmed they were doing well, with no health or safety concerns observed. The facility was observed to be clean, organized, and free of hazards. WD Mata reported that R1 was transported to the hospital following the medication incident. Hospital staff later confirmed that R1 was cleared of medication intoxication. WD Mata further stated that additional, unrelated medical conditions were identified during hospitalization, and R1 remains admitted for treatment of those conditions. ED Galicia reported that the medication error occurred during the evening shift when Med Tech staff administered medication to the wrong resident due to confusion between residents with the same first name. Staff failed to verify the residents’ full names prior to medication administration, which resulted in the error. ED Galicia stated that both Med Tech staff involved were reprimanded for the incident and have been (Case Management Report continued on LIC809C) removed from medication administration duties pending completion of retraining. LPA requested and reviewed copies of R1’s resident file, including relevant medication records. Based on the information obtained, the following deficiency is being cited in accordance with Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted with Executive Director Carmen Galicia. A copy of this report, along with appeal rights, were provided to the facility.the state’s words, verbatim · CDSS document, Mar 19, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 20, 2026

87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall ... (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on LPA’s interviews, record review, and observations, the facility failed to ensure that Resident 1 (R1) received proper assistance with self-administered medications, as R1 was administered medication intended for another resident, resulting in a medication error. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: Facility will provide another in-service regarding medication error to staff and provide staff written up notice acknowledging medication error and understanding by POC due date to LPA.

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 Executive Director (ED) Carmen Galicia and explained the reason for the visit. Facility is licensed for 152 ambulatory residents, of which 96 may be non-ambulatory, with a hospice waiver for 30 residents, and 30 maybe bedridden on the first and second floor. Currently there are 116 residents and 13 are on hospice during today's visit. LPA Tea reviewed twelve resident files and six staff files. Resident files and staff files contained all required documentation. Administrator's certificate is currently pending renewal due to the backlog processing. Administrator completed all course work and submitted renewal. LPA Tea along with ED Galicia toured the facility. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a three-story building. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. The fire alarm system of the facility is monitored and maintained by a third-party company. Fire extinguishers are fully charged throughout the facility. Last disaster drill was conducted February 10, 2026. LPA observed evac chairs in every stairwell in the facility for emergencies. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured between 116.4 to 118.6 Fahrenheit degrees. LPA pulled emergency pendants in resident’s bathrooms; staff came to the room to respond to the alert within four minutes. LPA also tested the push pendant that residents press for assistance, staff came within two minutes. Common areas were clean and clear of hazards; doorways were free of obstructions. Facility kitchen and dining area were inspected. Perishable and non-perishable food supply was checked Annual inspection continued on LIC809-C and adequately stocked at time of visit. First aid kits had all the required elements including dressing, bandages, tweezers, thermometer, and scissors. LPA checked the outdoor area of the facility. There is a patio area with tables, chairs, benches and umbrella for residents to sit and relax. There is a designated outside area for residents that smoke that is far away from the facility. There is also a small garden for residents. LPA observed emergency food and water supplies stored in a room on the third floor. At the time of the visit, LPA Tea observed residents eating in the dining room, watching TV in the TV room and reading quietly in the library. The facility provides different activities for residents daily, which are posted throughout the facility. LPA reviewed medication storage and administration. Medications are stored in locked carts in the medication room. Medications are being administered per physician order. 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 An exit interview was conducted with Executive Director Carmen Galicia and a copy of this report was given to the facility along with a copy of the LIC858, 858C; and 859.the state’s words, verbatim · CDSS document, Mar 12, 2026

Allegation investigated: Facility lacks staffing in which resident needs are not being met

Regarding the allegation: Facility lacks staffing in which resident needs are not being met. During the investigation 5 of 6 individuals were able to provide information that supports the complaint allegation. Further, LPA Haley documented observations during the initial complaint visit that was consistent with information discovered during the complaint investigation. During an interview with a staff member, the staff member acknowledged there was an incident where a resident did not get their breakfast, and the resident's family member had to email the facility regarding the situation. The resident eventually got their breakfast; however, the resident received breakfast about two hours late. During an interview with Resident 1 (R1), they explained after a recent injury, they were left without assistance for at least two hours. R1 says their leg was hanging off the bed and they could not move it due to their recent injury. The resident pulled the pull-cord for assistance and explained it took about two hours before a caregiver came to “save me.” Continued on LIC9099C Substantiated R1 also observed that another resident is always brought down to the dining room late for their meals. Resident 2 (R2) also had concerns about staff responding to calls for assistance. R2 says when you use the call button the staff don’t respond. During the initial visit August 30, 2024, LPA Haley pulled a pull cord in the men’s restroom on the third floor. No staff member ever responded. LPA Haley set a timer and after about 16 or 17 minutes LPA Haley showed S1 and S2 the timer and explained the pulled cord was pulled over 15 minutes ago. Both staff members acknowledged no one responded to the call. S1 explained that staff was scolded and were told they were not responding to the one’s in the bathroom. S2 said they did not receive the notification, but it goes to the caregivers that have the phone. S2 said they're not sure if the pull cord was working or the staff just forgot to respond. Although it’s unclear if the failure to respond to pull cords/call buttons is related to a lack of staffing or caregivers forgetting to respond, it is clear that on more than one occasion calls for assistance have been answered late or not responded to at all. Based on the evidence gathered through interviews and LPA observations, the preponderance of evidence standard has been met, therefore, the allegation above is found to be SUBSTANTIATED. A violation is being cited per California Code of Regulations Title 22. An exit interview was conducted, and a copy of this report and appeal rights was provided.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 22-AS-20240826141418

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 25, 2026

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). Health and Safety Code section 1569.2(c) provides: (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement was not met as evidenced by: On more than one occasion facility staff has failed to respond to request for assistance. Including a request made by LPA Haley during the initial visit when a pull cord was pulled to see how long it would take for a caregiver to respond. There was no response and around the 16 or 17 minute mark LPA Haley contacted facility staff regarding the issue. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: Executive Director (ED) Galicia states she will conduct an in-service training on response to pull cords and call buttons for all staff. ED Galicia will email LPA Haley a description of the training, the duration of the training, and a sign in sheet for all in attendance by 12:00 noon on the POC due date.

Allegation investigated: Residents are not treated with respect and dignity

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to complete the complaint investigation and deliver the findings. LPA Haley explained the reason for the visit upon entry. The complaint investigation consisted of interviews with facility residents, facility staff, LPA observations, and document review. A total of six interviews were conducted, and two more interviews were attempted. Regarding the allegation: Residents are not treated with respect and dignity During the investigation 5 of 6 individuals failed to provide any information to corroborate the complaint allegation. Staff 1 (S1) denied the allegation and explained if they ever witnessed a staff member fail to treat a resident with respect, the staff member would be put on a Performance Improvement Plan (PIP) and management would check up on the employee’s progress in 30 days. Staff 2 (S2) denied the allegation and said staff are always polite and respectful to the residents. Resident 1 (R1) denied the allegation and said all staff treat them very nice. Continued on LIC9099C Unsubstantiated Resident 2 (R2) said resident are treated with respect, and said, “we have some good ones, especially from the agency.” Based on the information gathered during the investigation through interviews, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 22-AS-20240826141418

Allegation investigated: Staff did not provide adequate food service. Residents are not treated with treated with respect and dignity. Residents are not given a comfortable dining accommodation.

On February 19, 2026, Licensing Program Analyst (LPA) Sabrina Calzada contacted Administrator, Carmen Galicia, to deliver investigative findings to a complaint received on May 17, 2024. During the investigation, the dining room and kitchen were toured on multiple occasions, resident interviews were conducted, and documentation was reviewed. The results of the investigation are as follows: Allegation: Staff did not provide adequate food service. The allegation states that at the April 29, 2024 Resident Council meeting, it was unanimously agreed that the kitchen is not properly serving the residents, and residents are dissatisfied with the kitchen and food service. Residents complained that hot food was not served hot, and cold food was served at room temperature. *cont on 9099C-1. Unsubstantiated 9099C-1.. On May 22, 2024, the Ombusdman noted that residents complained at the recent Resident Council meeting that the food service and food temperature were the main conflicts of the discussion, with the food service being the first complaint and the temperature of the food being the second complaint. The Ombudsman stated residents also feel staff are rude in providing food service to them in the dining room, and staff don't clear dirty plates timely from the table. Specifically, residents state the hot food isn't always hot, and the cold food is always at room temperature. The LPA toured the physical plan on May 24, 2024, and there were no issues noted during the tour. A subsequent complaint was received on June 17, 2024, which included the allegation of: Dining areas are not maintained clean. On June 13, 2024, the LPA toured the dining room at the start and ending of the lunch period and noted the following observations: During the facility visit conducted on June 13, 2024, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted a tour of the facility's common areas and a sample of resident units. The dining room was visited at approximately 11:40am after lunch service was initiated. Floor surfaces appeared to be clean, and tables were also clean. Staff was observed bringing meals to the residents present. LPA and administrator also reviewed the facility's kitchen area which appeared clean and organized. LPA and administrator returned to the dining hall after conducting a tour of the facility at approximately 12:30pm. The room was clean overall, however used dishes were still in place in multiple locations. On September 4, 2024, an additional tour of the dining hall was conducted, and the allegation was determined,to be Unsubstantiated, as follows: Regarding the allegation that Dining areas are not maintained clean, the following has been concluded: Based on two visits of the facility's physical plant, it was observed that the dining areas were being cleaned during and/or after the meal service had been provided. LPA Calzada reviewed the Food Service Policy provided from the Resident Handbook which says in part: "All persons engaged in food service are knowledgeable and will observe personal hygiene and sanitary food service practices". LPA Calzada contacted an Ombudsman Manager in January 2026 to request any relevant notes from May 2024, but none were provided to LPA after records were searched. Based on information obtained, the Department finds this allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred. *cont on 9099C-2.. 9099C-2. Allegation: Residents are not treated with respect and dignity. The allegation states staff are rude and inattentive, often causing them to wait for over a half hour or longer to be served dinner, and residents are frequently told that the facility had run out of food items. Residents felt that this was not always the case and that the problems started about 6 months ago, on/around December 2023 or January 2024. A subsequent complaint was received by the Department on June 17, 2024, with the allegation that Kitchen management does not treat residents with dignity and respect. After multiple staff and resident interviews were conducted in June 2024 and September 2024, the allegation was determined to be Unsubstantiated. The report findings delivered on September 4, 2024 specifically read: Regarding the allegation that Residents are not treated with respect and dignity, the following has been concluded: Based on observations conducted in the facility as well as interviews with residents, no residents' statements indicated that they felt they were not receiving adequate treatment in respect of their personal rights. LPA Calzada contacted an Ombudsman Manager in January 2026 who indicated she didn't have access to the previously assigned Ombudsman's notes, but she would look in their database to see if she could locate any. No notes were provided to LPA as of this report being written. On February 19, 2026, LPA discussed with the Administrator about providing periodic staff training on resident's Personal Rights, as this is an area the Department receives significant complaints about. LPA also suggested the administrator reach out to their local Ombudsman to provide this training, which the Administrator agreed to do. The Administrator stated she provides a lot of in-person staff training, opposed to on-line training, to ensure staff's understanding. Based on information obtained, the Department finds this allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred. *cont on 9099C-3. 9099C-3... Allegation: Residents are not given a comfortable dining accommodation. The allegation states that all residents who attended the Resident Council meeting on April 29,2024 complained that they are not always allowed to sit at their table of choice. Residents also felt that the food was not as good as it used to be. On May 1, 2024, the Ombudsman spoke to the facility Administrator about the resident’s concerns, but the concerns have not improved. On February 11, 2026, Administrator, Carmen Galicia, confirmed that residents are able to sit at the dining table of their choice and it is on a "first come, first served basis". The administrator commented that "it has always been this way- residents prefer to have open seating", explaining that a few residents get there early to get the table they prefer. Additionally, the administrator stated that residents are "good at communicating with dining staff if another resident will be joining their table". Additionally, the Administrator stated, on February 11, 2026, that the Resident Council President at the time approached her twice with the Ombudsman, but she never received the Resident Council meeting notes following the meetings. Additionally, the administrator indicated she then began doing Town Hall meetings with residents and continued doing so through November, 2025, at which time the Resident Council officers began inviting her to their meetings. Additionally, the Ombudsman was invited to attend the meetings and is currently providing support, as needed. LPA Calzada reviewed the Food Service Policy provided from the Resident Handbook which says in part: "All food is of good quality and is stored and prepared in a healthy attractive manner." LPA also reviewed the Seven Day Sample Snack Menu and observed it to offer a variety of snack foods, including fruits, vegetables and yogurt. The Daily Menu was reviewed from April 28, 2024 to June 1, 2024. In addition to offering a variety of entrees for each meal, there is also a Soup of the Day. Additionally, the menu is written very clearly, with dinner specifically noting the starch, vegetable and dessert being served. LPA Calzada contacted an Ombudsman Manager in January 2026 who indicated she didn't have access to the previously assigned Ombudsman's notes, but she would look in their database to see if she could locate any. No notes were provided to LPA as of this report being written. Based on information obtained, the Department finds this allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred. Exit interview. Report was emailed to the Administrator to sign and return today, February 19, 2026.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 22-AS-20240517164547

Allegation investigated: Staff leaves residents soiled for extended periods. Staff does not respond to resident calls for assistance in a timely manner.

On February 11, 2026, Licensing Program Analyst (LPA) Sabrina Calzada contacted Administrator, Carmen Galicia, to deliver investigative findings to a complaint received on December 18, 2023. During the investigation, multiple staff and resident (R1) were interviewed and documentation that was obtained was reviewed. The results of the investigation are as follows: Allegation: Staff leaves residents soiled for extended periods. The complaint alleges that staff (S1) does not provide incontinent care at the end of their "am" shift, and residents must wait to be changed by incoming staff on the "pm" shift. *cont on 9099C-1.. Unsubstantiated 9099C-1.. Resident (R1) stated on December 27, 2023, that they are incontinent and wear diapers/pads. and has had issues with caregiver (S1) regarding not always receiving assistance with their bowel movements, since on/around October 2023. (R1) indicated that (S1) does not do their job because they were informed by another caregiver staff on the "pm" shift that they have to always change resident's diapers right after the shift change. A second resident was attempted to be interviewed on December 27, 2023 but was not able to participate. Staff (S1) stated on December 27, 2023 that they check on each resident every (2) to (2.5) hours, will receive alerts from residents needing assistance, and will chart all care provided to residents. (S1) stated that they assist with toileting/diaper changes within a reasonable time frame as long as they are not working with another resident and commented that they are responsible for (22) rooms on the first floor today. On December 27, 2023, the Wellness Director stated (S1) has received employee write-ups and confirmed she has spoken to (S1) several times about why their "daily sheet stack" is insufficient compared to (2) other caregivers. Documentation related to care provided to (R1) was not available for review, and LPA was not able to conduct a follow up interview as (R1) moved out prior to passing in early December 2025. On February 11, 2026, the administrator confirmed with the LPA that (S1) is still presently employed at the facility, "has been doing good on light duty" and is not doing care currently. Based on information gathered, the allegation was determined to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. *cont on 9099C-2.. 9099C-2..Allegation: Staff does not respond to resident calls for assistance in a timely manner. The allegation states that when (R1) requests staff assistance from (S1), (S1) does not come and check on (R1) and will claim they did not see the call light on. (R1) was interviewed on December 27, 2023 and stated they could not provide time/date of the incident but was told numerous times by (S1) that they would come back to check on (R1) needing to return to the toilet in 45 minutes to an hour, but (S1) would never come back and would not respond to the pendant either when (R1) pushed it. (S1) stated on December 27, 2023 that in September or October, 2023, the pendant/call button may have not been working due to the Wi-Fi server. (S1) confirmed that staff receive resident pendant alerts through their phone, and the alert includes the name/room number of the resident. When heard,staff will go to room to clear the alert with the magnet held onto by the caregiver, and confirmed staff will respond within (15) minutes, which is the facility protocol, but (S1) responds in approximately (10) minutes each time. (S1) stated that there was one time, around the end of August or early September 2023, when (R1) was calling for assistance, but (S1) was with a resident whose doctor was cleaning their bed sore. (S1) stated that while with the doctor and resident, the front desk lady called on the walkie-talkie to alert them that another resident needed help. (S1) explained that (R1) had already been helped when they went to attend to them, explaining they did not recall what (R1) needed, but was sure they were not neglecting (R1). The administrator stated on December 27, 2023, that all residents have a pendant and a call button in the bathroom, caregivers have their own cell phones that are primarily utilized as an alert system, and caregivers are required to respond to resident calls within a 7-15 minute time frame. On December 27, 2023, the LPA had requested the call light history for (6) residents starting from July 2023 through the request date; however, this documentation was not available for review when drafting the complaint findings. Based on information gathered, the allegation was determined to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. *cont on 9099C-3.. 9099C-3. An additional complaint allegation was received by the Department on February 21, 2024. The allegation states it took the facility (3) months to fix the broken air conditioner in (R1's) apartment. ((R1) was provided with a temporary air conditioning while the unit was being repaired/replaced, but (R1) did not like the temporary unit. The allegation states the administrator did not return calls to (R1's) family regarding the temporary air conditioning unit during this (3) month time period. The Department requested and was promptly provided with documentation related to the repair and replacement of the Air Conditioner (A/C) unit in (R1's) apartment. On February 2, 2026, LPA was provided with a copy of an invoice showing the A/C unit had been replaced on/around January 10, 2024. On February 3, 2026, LPA was provided with a repair estimate invoice for a gas leak check for the "whole system unit" in (R1's) apartment. Additionally, LPA reviewed an email sent by the facility Maintenance Director, on October 16, 2023, for approval to make the repair. In the email, the Director notes that the request is "urgent" as there is a resident currently living in (R1's) apartment. The request was promptly approved on October 17, 2023 (9:22 am). On February 11, 2026, LPA contacted Administrator, Carmen Galicia, who indicated she started working at the facility around the end of September, 2023. The administrator stated that (R1) already had a portable, temporary A/C unit in their apartment at this time, and she was not made aware any issues related to the temporary A/C unit until October 2023, when the Health and Wellness Director, informed her. The administrator stated that since the parts arrived late, the A/C unit was only partially fixed, as they couldn't complete the repair. The entire unit was replaced in January, 2024. Additionally, there was the delay of (R1) refusing to temporarily move to another apartment for 2+ days while the new unit was being installed. (R1) finally agreed to move to another unit due to dust coming through the window from the gardeners outside. The administrator stated that (R1's) family reached out to her by email and she responded back timely. Based on information gathered, the allegation was determined to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report was emailed to the Administrator, who agreed to sign/return by email by 2/11/2026.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 22-AS-20231218143445

Allegation investigated: - Staff did not follow doctor's orders - Staff mismanaged resident's medications - Staff did not administer resident medication as prescribed

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conduct a complaint investigation. LPA Tea was greeted and granted entry by Executive Director (ED) Carmen Galicia and explained the reason for the visit. The department received a complaint on January 30, 2026, and LPA Tea conducted the initial 10-day visit a week later on February 6, 2026. LPA Tea spoke to residents and facility staff and reviewed and collected pertinent documents and information. It was alleged that staff did not follow doctor’s order. The investigation determined the following: The facility received a physician’s order indicating that Resident 1 (R1) was to self-administer medication. Executive Director (ED) Carmen Galicia and Health & Wellness Director (HWD) Veronica Mata (Complaint Investigation continued on LIC9099C) Unsubstantiated acknowledged receipt of this order. However, the Physician’s Report dated December 16, 2025, indicated that R1 was unable to manage their own medications, with a side notation stating “certain medications.” ED Galicia and HWD Mata explained that R1’s primary physician later submitted an updated Physician’s Report dated February 3, 2026, revising the assessment to reflect that R1 is able to administer and manage their medications independently. ED Galicia reported that the facility awaited clear clarification regarding medication management responsibilities due to the conflicting documentation. Additionally, R1 had expressed a preference to self-administer one medication while having the facility manage the remainder; however, the physician ultimately ordered that R1 could self-administer all medications. As of February 5, 2026, with the updated Physician’s Report and physician’s order on file, R1 has been self-administering medications. LPA interviewed five staff members; all five stated that they follow physician orders and cannot administer medications without written authorization or clarification. Staff reported that all medication administration requires documented physician direction. LPA also interviewed four residents regarding medication management. Three residents stated that the facility follows physician orders. One resident reported waiting for clarification on their own orders but acknowledged understanding the need for physician authorization and clarification. It was alleged that staff mismanaged resident’s medications The investigation determined the following: Five out of five staff interviewed stated that the facility does not mismanage medications. Staff explained that medications are administered within an accepted one-hour grace period before or after the scheduled time, consistent with standard practice, and that residents are informed of this administration window. Staff reported that delays may occasionally occur due to the volume of residents requiring medication assistance; however, they stated that doses are not skipped or missed and that all administration is documented on the Medication Administration Record (MAR). Staff also indicated that residents sometimes refuse medications, which is documented accordingly. (Complaint Investigation continued on LIC9099C) ED Galicia reported an instance in which R1’s medications on hand did not match the physician’s order; therefore, staff could not administer the medication until the discrepancy was resolved. MAR documentation reflected occasions when R1 was not present in the community or declined to wake at the scheduled administration time. LPA interviewed four residents. One resident stated there was no medication mismanagement. Other residents expressed concerns about medications not being given exactly on the scheduled time or about last-minute reordering; however, they acknowledged staff workload and confirmed medications were generally received within the one-hour grace period. One resident emphasized the importance of timely medication due to medical conditions but did not report missed doses. It was alleged that staff did not administer resident medication as prescribed. The investigation determined the following: All five staff interviewed stated that medications are administered exactly as prescribed, following physician orders regarding dosage, timing, and instructions. One staff member specifically noted that residents receive the precise dosage ordered. LPA interviewed four residents, all of whom reported that staff administer medications as prescribed. Residents stated that dosages are provided correctly and generally within the appropriate timeframes. Examples included morning medications being administered in the morning and the correct number of pills being provided per physician direction. Some residents expressed concern about the proximity of certain dosage times and felt the facility should continue monitoring scheduling closely; however, no resident reported receiving incorrect dosages or medications inconsistent with physician orders. Therefore, based on LPA Tea's observations and interviews conducted and records reviewed the allegations mentioned above have been determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with Executive Director Carmen Galicia. A copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Feb 6, 2026 · control 22-AS-20260130122738

Allegation investigated: Facility staff failed to address a resident's prohibited health condition adequately

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint filed with the Regional Office. LPA was greeted and granted entry by the Concierge at 1pm. LPA met with Carmen Galicia, Executive Director (ED) and explained the purpose of the visit. LPA obtained documentation for Resident #1 (R1) which include: Unusual Incident Reports, Hospital discharge paperwork, Face Sheet and Emergency Info, Physician's Report dated 10/24/2024, Service Plan dated 04/02/2024 and a copy of the Assisted Living Waiver. It was alleged that Facility staff failed to address a resident's prohibited health condition adequately. LPA reviewed the Unusual Incident Reports submitted to the Department on 12/10/2025. On 12/05/2025 R1 was sent out of the community at 3pm due to continuous nose bleed. R1 was assessed at Emergency Room and returned to the facility on the same day with no new orders. (Continued on LIC 9099-C) Unfounded (Continued from LIC 9099) On 12/07/2025 at 7:30am, R1 had an unwitnessed fall and was sent out to the hospital for assessment. R1 returned to the community at 2:30pm on 12/07/2025. Staff reviewed discharge paperwork and noted there were tests done at the hospital for an infectious disease. Staff immediately contacted the Wellness Director (WD) and WD instructed staff to set up Personal Protective Equipment in front of R1's apartment and to send R1 back out to the hospital. It was not confirmed if R1 had an infectious disease but the discharge paperwork noted that R1 was tested for infectious disease and was being treated with medication for infectious disease. R1 was sent out by non-emergency ambulance on 12/7/2025 at 5pm per Incident Report. R1 was in the community for two-and-a-half hours and remained in a shared room with a roommate. Per staff interviews, facility was not informed of any infectious disease for R1's return to the community. On 12/11/2025 the hospital social worker spoke with WD regarding R1's return and was told infectious disease test for R1 was pending. WD stated R1 could not return until the results of the testing were done. If R1's test confirmed positive for infectious disease, R1 would need to go to a Skilled Nursing Facility (SNF). If R1's test was negative, WD would go to the hospital for assessment and R1 would be able to return to the community. As of December 18, 2025 neither ED or WD received confirmation for test results but R1 has not returned to the community and currently resides in a SNF. WD provided LPA with documentation that R1's roommate's family were notified of possible exposure to infectious disease and will test resident to confirm. A staff in-service regarding Infectious Disease Protocol will be conducted on Tuesday, December 23, 2025 and will be submitted to the Department. Currently there are no cases of infectious disease reported and facility did not receive confirmation of diagnosis from hospital. LPA interviewed two of two staff who denied the allegation that Facility staff failed to address a resident's prohibited health condition adequately. When facility staff realized possible exposure to infectious disease, staff members initiated infection control protocol and sent resident back to the hospital for possible treatment. LPA interviewed three of three residents. Three of three residents did not have any knowledge of an infectious disease going around the community. (Continued on LIC 9099-C1) (Continued from LIC 9099-C) LPA toured the community and observed residents watching television in the downstairs communal room, residents playing Bingo on the 2nd floor Activities Room and residents in the Library on the third floor. LPA did not observe any PPE stations in front of apartments, which would indicate a resident in isolation due to an infectious disease. Based on LPA's observations, record review and interviews the allegation that Facility staff failed to address a resident's prohibited health condition adequately is Unfounded. The allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Executive Director Carmen Galicia and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 22-AS-20251216155721

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Michael Tea conducted a case management incident visit to follow up on an incident report received by Community Care Licensing (CCL) on November 4, 2025, submitted by Health & Wellness Director (HWD) Veronica Mata. LPA was greeted and allowed entrance into the facility by Executive Director (ED) Carmen Galicia and explained the reason for the visit. During the inspection, LPA and Business Office Manager (BOM) Lakhena Lor toured the facility and inspected Resident 1 (R1)’s room. LPA conducted health and safety checks on R1 and observed no health and safety issues. LPA toured and observed the rest of the facility and found no health and safety issues. R1 had eloped and was found at a Target store and sent to hospital due to injuries. R1 does not recall the incident and sustained a minor nasal fracture. R1's physician report shows resident can not leave the facility unassisted. Based on LPA's review of records, observations and interview, the facility failed to supervise resident in which the resident left the facility unassisted. A deficiency and immediate $500 civil penalty are being given per California Code of Regulations 87464(f)(1). An exit interview was conducted with the facility and a copy of this report, along with the LIC809D, and appeals right was provided at exit.the state’s words, verbatim · CDSS document, Nov 14, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Nov 17, 2025

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by Based on LPA's review of records Resident 1 (R1) is unable to leave the facility unassisted and eloped from the facility in which the resident was found far away from facility and was hospitalized. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2025

Plan of correction: Facility provided R1 with a Wander guard to wear for elopement precaution. Facility has conducted an Elopement drill on 11/05/25 and another in-service on 11/13/2025. Staff have continued to monitor and observe R1 for any changes in condition. Facility is to send LPA proof of elopment in services and statement of understanding of the regulation, signed by all staff by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Michael Tea conducted a case management incident visit to follow up on an incident report received by Community Care Licensing (CCL) on Oct 1, 2025, submitted by Executive Director (ED) Carmen Galicia. LPA was greeted and allowed entrance into the facility by staff. Business Office Manager (BOM) Lakhena Lor arrived shortly to assist with the visit. LPA explained the reason for the visit. During the inspection, LPA and BOM Lor toured the facility and inspected Resident 1 (R1)’s room. LPA conducted health and safety checks on R1 and observed no health and safety issues. R1 was leaving facility for personal matters. LPA toured and observed the rest of the facility and found no health and safety issues. LPA requested and reviewed copies of R1’s resident file. Based on the observations made during today’s inspection, no deficiencies are being cited at this time. An exit interview was conducted with Business Office Manager Lakhena Lor and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Oct 3, 2025

Allegation investigated: - Staff did not provide adequate medication assistance to resdient in care - Staff did not attend to resident's call in a timely manner - Staff did not safeguard resident's personal belongings

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude and deliver findings for a complaint investigation. LPA Tea was greeted and granted entry by facility staff and explained the reason for the visit. Executive Director (ED) Carmen Galicia arrived shortly to assist with the visit. The Department received a complaint on May 21, 2025, and LPA Tea conducted the initial 10-day visit the following week on May 30, 2025. LPA Tea spoke to residents and facility staff and reviewed and collected pertinent documents and information. It was alleged that staff did not provide adequate medication assistance to residents in care. It was alleged that a resident did not receive their medication on time, specifically a purple steroid pill. The (Complaint Report continued on LIC9099-C) Unsubstantiated staff interviewed said they never speak inappropriately to residents or about residents as well. All staff spoken to have said that every staff meeting has in-services and reiterate the importance of treating the residents with respect and how to speak to them with good communication. It was alleged that staff refused to take out trash from resident’s room. Eight out eight residents confirmed that they have no problems with staff refusing to pick up trash. Residents stated that staff have been good at picking up their trash every day. They routinely pick it up at least twice a day, during the day and at night. ED Galicia and Wellness Coordinator Sharon Perez and all staff interviewed said that it is part of their job duties at the end of their shift to make their rounds on the floor to throw away the resident’s trash. Therefore, based on LPA Tea's observations, interviews conducted, and records reviewed the allegation that staff spoke inappropriately to residents in care and staff refused to take out trash from resident’s room has been determined as UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies cited at this time and an exit interview was conducted with Executive Director (ED) Carmen Galicia. A copy of the report was provided to the facility. Wellness Coordinator, Sharon Perez does not recall any residents taking a purple-colored steroid pill. Five out of eight residents interviewed agree that they are receiving great assistance from staff with their medication. The ones that disagree said that sometimes they do not receive their medication on time or have to remind staff about taking their medication. All MedTech staff interviewed said that they try their best to assist the residents with medication and giving it on time. Sometimes they are delayed or behind because they have things to attend like medical emergencies or a caregiver needs assistance with another resident. But they try to give the medication in a timely manner. Residents sometimes would talk a lot to them or get upset and refuse to take medication. They receive a great amount of training, and in-service in regard to effective communication with residents. It was alleged that staff did not attend to residents’ call in a timely manner. Based on observations of the call log for when a resident’s push their pendants or the pull cords in their rooms, the staff responds within 15 minutes or less, which is an adequate time to respond to residents. There were times recorded when the call button time did not end because the residents did not allow them to push their pendants off for the call. The residents wanted the facility staff to complete their tasks before allowing them to turn off the call. Five out eight residents agreed that staff came to assist them in a timely manner. One resident said they come in pairs to help them. Other residents mention that on the nocturnal shift, the staff were slow to respond than the other shifts. A resident has mentioned that nocturnal shifts have been more attentive and have improved. Other residents have voiced their concerns that the facility is short-staffed. ED Galicia has confirmed that there is enough staff at the facility and she checks periodically on the nocturnal shift staff. It was alleged that staff did not safeguard resident’s personal belongings. Five out of eight residents spoke to felt that the facility is safeguarding their personal belongings, they have no concerns. One resident stated that it was an issue with resident’s personal belongings stolen or missing. The resident states it is not just staff who are stealing, but residents are also stealing. Despite there are issues with safeguarding resident’s personal belongings, she does feel that staff are following protocols. Doing searches to check to make sure it was misplaced and giving them a form to list an inventory of their personal belongings. ED Galicia said that residents who report things were stolen, the staff would conduct a search and they would be able to find the items they misplaced, or it would reappear on the same day reported. She stated that many residents have declining cognitive memory. (Complaint Report continued on LIC9099-C) Therefore, based on LPA Tea's observations and interviews conducted and records reviewed the allegations that staff did not provide adequate medication assistance to resident in care, staff did not attend to resident’s call in a timely manner, and staff did not safeguard resident’s personal belongings has been determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with Executive Director Carmen Galicia. A copy of the report and confidential names list were provided to the facility.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 22-AS-20250521082740

Allegation investigated: - Facility staff is interfering with resident council - Facility staff did not safeguard resident's personal belongings

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude and deliver findings for a complaint investigation. LPA Tea was greeted and granted entry by facility staff and explained the reason for the visit. Executive Director (ED) Carmen Galicia arrived shortly to assist with the visit. The Department received a complaint on May 20, 2025, and LPA Tea conducted the initial 10-day visit the following week on May 30, 2025. LPA Tea spoke to residents and facility staff and reviewed and collected pertinent documents and information. It was alleged that facility staff is interfering with resident council. The allegation elaborated that a staff was interfering in the resident council by stealing a notebook with the resident council meeting minutes and making copies and retaliating a resident for advocating for the residents. A witness assumed the (Complaint Report continued on LIC9099-C) Unsubstantiated staff yell at them and mock them. All staff interviewed said they never speak inappropriately to residents or about residents as well. All staff spoken to have said that every staff meeting has in-services and reiterate the importance of treating the residents with respect and how to speak to them with good communication. It was alleged that a staff was reading resident council meeting minutes in the Med-Tech room, laughing and mocking residents. LPA spoke to Med-Tech staff and the Wellness Coordinator and all of them do not recall any staff talking, laughing, and mocking residents in their room and confirms no one has ever done that. Therefore, based on LPA Tea's observations, interviews conducted, and records reviewed the allegation that facility staff speaks inappropriately to residents has been determined as UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies cited at this time and an exit interview was conducted with Executive Director (ED) Carmen Galicia. A copy of the report was provided to the facility. notebook was discovered from Resident 1’s (R1) room when staff were following protocol looking for a missing item of R1. They assumed that alleged staff spotted the notebook while searching for the missing item, came back to the R1’s room on another day and took the notebook and made copies and came back to place the notebook back in the room. LPA spoke to seven facility staff members and agree that facility staff do not interfere with resident council and their meetings. Staff said they just set up the room for the resident council meeting and assist residents in escorting them to the meeting, especially residents who use a wheelchair. Staff are not even allowed at meetings unless invited or asked to speak at the meeting, which was rare before. Five out of eight residents also confirm that staff do not interfere with the resident council meeting. Some residents have said that resident council meetings are not productive because all residents do is complain and talk bad about management. A few residents stopped attending the meetings. Resident 2 (R2), who is the newly elected resident council, explained that the resident council has been through a rough time with how the meetings were run. Currently R2 has decided not to run it like previous times and has made an effort to have management, like ED Galicia sit in the meetings. R2 said that ED Galicia has been trying to make things right and addressing issues with corporate for the residents. R2 said that facility staff interfering with resident council and retaliating against residents is false, they have never seen any sort of retaliation. It was alleged that facility staff did not safeguard resident’s personal belongings. Five out of eight residents spoke to feel that the facility is safeguarding their personal belongings, they have no concerns. LPA interviewed R1 who believes facility staff stole valuable items from their room. R1 reported that they listed in their inventory form. When R1 moved to the facility September 2023, R1 did not declared anything on the LIC 621 Client /Resident Personal Property and Valuables Inventory List. It was not until September 2024, R1 handed an updated list, which was signed off by a facility representative in September 18, 2024. ED Galicia stated that the facility gives a blank LIC 621 form to residents if they want to update their inventory list on file. R2 stated that it was an issue with resident’s personal belongings stolen or missing. R2 states it is not just staff who are stealing, but residents are also stealing. Despite there are issues with safeguarding resident’s personal belongings, R2 does feel that staff are following protocols. Doing searches to check to make sure it was misplaced and giving them a form to list an inventory of their personal belongings. ED Galicia said that residents who report things stolen they would conduct a search and they would be able to find the items they misplaced, or it would reappear on the same day. She stated that many residents have declining cognitive memory. (Complaint Report continued on LIC9099-C) Therefore, based on LPA Tea's observations and interviews conducted and records reviewed the allegations facility staff is interfering with resident council and facility staff did not safeguard resident’s personal belongings has been determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with Executive Director Carmen Galicia. A copy of the report and confidential names list were provided to the facility.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 22-AS-20250520114226

Allegation investigated: - Staff are mismanaging resident's medications - Staff do not ensure resident's room is clean and sanitized

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude the investigation and to deliver findings for the allegations mentioned above. LPA Tea was greeted and granted entry into the facility by Executive Director (ED) Carmen Galicia and explained the reason for the visit. It was alleged that staff are mismanaging resident’s medication. During the investigation LPA interviewed residents and facility staff, checked and review resident files and charting. The investigation determined the following: It was reported that staff are not following the medication orders and directions prescribed for Resident 1(R1). Witnesses have stated that they know when R1 is not given their medication because R1 stays up at night, watching television and eating. ED Galicia and Wellness Director (WD) Brittainy Prieto explained to R1’s family that R1 has advanced dementia, and their health is gradually declining. They explain that R1 needs a higher level of care, suggesting maybe a board and care or memory care facility will provide the care R1 needs. The family of R1 believe she could be at a big facility like Continuation of Report on LIC9099C Unsubstantiated Westminster Terrace, and nothing was wrong R1’s health. WD Prieto stated the family had asked for a chemical restraint for R1 from the Psychiatric doctor who manages R1’s psych medication. She also said the family of R1 also wanted them to place R1 on medication that is high risks with adverse reactions. Per interviews, 2 out of 2 Medtech staff said there were no mismanaging of medications. Meditech 1 (M1) interviewed said they follow the family’s directive order to crush the medication and have her take it at the specific time requested. LPA observed the signs in the medtech room addressing medication orders specifically for R1 posted on the wall. LPA reviewed R1’s Medication Administration Record (MAR) and discovered no discrepancies, medication was given as prescribed. All medications were accounted for and checked. Any discontinuation of medication and resident refusal was noted and documented correctly. Medtech 2 (M2) has said that they give medication as prescribed and indicated in the MAR, they go only by the MAR itself. LPA interviewed residents, 9 out of 11 residents interviewed agreed that medication was given as prescribed and felt the staff did not mismanage their medications. Some residents felt they were on top of their medication and always on time when giving their medication. It was alleged that staff do not ensure resident’s room is clean and sanitized. The investigation determined the following: It was reported that no one cleans R1’s room, witnesses have said that housekeeping does not clean the room and bathroom. They never cleaned the diarrhea on the carpet and the fecal matter left on the toilet. During the initial investigation LPA did visit R1’s room and found it to be neat and tidy and organized. There were a few small torn scraps of paper on the carpet. LPA did not observe diarrhea stains on the carpet. Bathroom was clean and the toilet had no fecal residue in or around the toilet at the time of the visit. All staff interviewed stated the housekeeping was done once a week for residents and as needed afterwards. The facility changes the resident’s sheets on a weekly basis. Maintenance Director Daniel Guerrero said he walks around the building and attend to any housekeeping calls. He stated some rooms are more demanding than others. He also explained they do random inspections to make sure rooms are clean. Per interviews, 8 out of 11 residents felt the facility did a good job cleaning their rooms. Some residents praised the facilities for sanitizing well, giving extra linens and footpads as requested and frequently changing the beddings. Therefore, based on LPA Tea's observations and interviews conducted and records reviewed the allegations that staff are mismanaging resident’s medication and staff do not ensure resident’s room is clean and sanitized has been determined to be unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with ED Carmen Galicia. A copy of the report and confidential names list was provided to the facility.the state’s words, verbatim · CDSS document, Apr 25, 2025 · control 22-AS-20250113124540

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Michael Tea conducted a case management visit to follow up on a co-complaint report received by Community Care Licensing (CCL) on April 8, 2025, in regard to the facility not changing resident’s sheets on a regular weekly basis. LPA spoke to Executive Director Carmen Galicia regarding linens and bedding. She said that facility does change the residents’ sheets on a weekly basis. Per interview with Staff 1 (S1), they reiterate that housekeeping does change the sheets at least once a week, in some cases, some residents do need reminders to change their sheets. ED Galicia stated some residents do refuse to change their bedding sheets, but she redirects those residents stating its for health and hygienic problems and they do comply with changing their bedding. ED Galicia provided LPA invoices from Mission Linen Supply, who supplies their weekly bedding and linen supplies for the facilities. From the inventory invoices it shows they maintain on average of 160 quantities of various types of bedding, sheets and linens that is replenished weekly for the 110 residents currently residing at the facility. LPA interviewed residents, per interviews 8 out of 11 residents interviewed said that the facility does change the sheets at least once a week. Some residents have also stated they can request new sheets whenever they want. Based on LPA Tea's observations and interviews conducted, and records reviewed the allegation facility is not changing residents sheets on a regular weekly basis has been determined to be unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with ED Carmen Galicia. A copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 25, 2025

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. At around 8:00 AM, LPA Tea was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 152 ambulatory residents, of which 96 may be non-ambulatory, with a hospice waiver for 30 residents, and 30 maybe bedridden on the first and second floor. Currently there are 108 residents and 12 are on hospice during today's visit. The Executive Director (ED), Carmen Galicia is on leave. Business Office Manager (BOM) Lakhena Lor and Executive Director (ED) Kenya Carlton filling in for ED Galicia arrived shortly to assist with the visit. LPA Tea reviewed eleven resident files and seven staff files. Resident files and staff files contained all required documentation. LPA Tea along with BOM Lor toured the facility. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a three-story building. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. The fire alarm system of the facility is monitored and maintained by a third-party company. Fire extinguishers are fully charged throughout the facility. Last disaster drill was conducted January 15, 2025. LPA observed evac chairs in every stairwell in the facility for emergencies. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured between 108.3 Fahrenheit degrees and 109.4 Fahrenheit degrees. LPA pulled emergency pendants in resident’s bathrooms; staff came in the room as promptly as they could. Common areas were clean and clear of hazards, doorways were free of obstructions. Facility kitchen and dining area was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed emergency food and water supplies stored in a room on the third floor. Annual inspection continued on LIC809-C LPA Tea observed residents eating in the dining room, watching TV in the TV room and reading quietly in the library. The facility provides different activities for residents daily, which are posted throughout the facility. LPA reviewed medication storage and administration. Medications are stored in locked carts in the medication room. Medications are being administered per physician order. 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 An exit interview was conducted with BOM Lakhena Lor and a copy of this report was given to the facility along with a copy of the LIC858, 858C; 859, 859C and 9102TV.the state’s words, verbatim · CDSS document, Mar 19, 2025

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.

Allegation investigated: - Facility has a scabies infestation - Facility staff is not administering resident's medication as prescribed - Facility staff are not following the Infection Control Plan

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude the investigation and to deliver findings for the allegations mentioned above. LPA Tea was greeted and granted entry into the facility by Business Office Manager (BOM) Lakhena Lor and explained the reason for the visit. Executive Director (ED) Carmen Galicia arrived later to assist with the visit. It was alleged that facility has a scabies infestation. During the investigation LPA interviewed residents and facility staff, checked, and reviewed resident files and charting. The investigation determined the following: It was reported a resident had scabies and that there was a possible scabies infestation at the facility. Per investigation and review of records, LPA Tea determined only one resident, Resident 1 (R1) had been diagnosed with scabies from hospital discharge paperwork and was prescribed medication to treat for scabies. From information obtained there were a total of five residents who allegedly had scabies, LPA spoke to the residents. Three out of five said they did not have, or recall having been infected by scabies. Resident 2 (R2) said that they thought they have scabies and was prescribed ointments and it Continuation of Report on LIC9099C Unsubstantiated cleared up. R2 said the staff came to check their chest and determined it was a rash. R2 alert charting report does not show anything about scabies except for a roommate disturbance at night. Also, R2 shows no treatment for scabies in their file. One of the residents, Resident 3 (R3) who denied they had scabies showed on their alert charting report that they were treated for possible scabies. R3 said they felt itchy but there were no pest or mites in their room. LPA Tea reviewed their medical file and there is no paperwork indicating scabies. LPA spoke to the Health and Wellness Director (HWD), Brittainy Prieto, that since the 8 months she’s been here there has not been any residents diagnosed with scabies. Despite there is one resident who is diagnosed with scabies by the doctor there are no other indications showing there is an infestation. It was alleged that facility is not administering resident’s medication as prescribed. The investigation determined the following: LPA checked and audited medications for R1 and Resident 4 (R4). All medications were accounted for and checked. LPA Tea checked the Medication Administration Record (MAR) which shows medication was given to residents as prescribed. Any discontinuation of medication and resident refusal was noted and documented correctly. HWD Prieto indicated there is no mismanaging of medications. Per interview with MedTech 1 (M1), stated they give medication as prescribed in the MAR and they follow and go by it. R1 stated that their medication was given as prescribed and had no problems. R1 also states they ask staff what medications they are taking most of the time. It was alleged that facility staff are not following the Infection Control Plan. The investigation determined the following: It was indicated that facility was not following infection control plan. R1 indicated facility did not clean and sanitized their room when they had scabies. Per staff and management interviewed, right when R1 indicated they might have scabies they immediately followed protocol to treat the scabies. All the staff that were interviewed said they cleaned R1’s room following the orders of ED Galicia. They steam clean to kill the scabies mites on curtains and furniture. Staff also indicated that they washed R1’s laundry and bedding with hot water and high temperatures and kept secured in bags away from other residents’ laundry. Staff also placed a PPE supply bin for staff to use when cleaning or interacting with R1. On the initial unannounced visit of the complaint investigation on January 14, 2025, LPA Tea observed a PPE supply bin outside by the door of R1’s room. LPA also observed the room to be clean and sanitized at the time of initial visit. Therefore, based on LPA Tea's observations and interviews conducted and records reviewed the allegations that facility staff has a scabies infestation, facility staff is not administering resident’s medication as prescribed, facility staff are not following the Infection Control Plan been determined to be unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with ED Carmen Galicia. A copy of the report and confidential names list was provided to the facility.the state’s words, verbatim · CDSS document, Feb 26, 2025 · control 22-AS-20250108143820

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Michael Tea conducted a case management visit to follow up on a co-complaint report received by Community Care Licensing (CCL) on January 16, 2025, submitted by Orange County Health Agency (OCHCA). LPA was greeted and allowed entrance into the facility by the Business Office Manager (BOM), Lakhena Lor and explained the reason for the visit. Executive Director (ED) Carmen Galicia arrived shortly to assist during the visit. The OCHCA received a complaint about a scabies outbreak. Public Health attempted to follow up about infection control and did not hear anything from the facility or any reports about an infection. This is in violation of failure to report to the local health officer/agency. Based on the report received the following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Executive Director, Carmen Galicia and a copy of this report and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Feb 26, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Mar 12, 2025

Reporting requirements ... Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours ... the local health officer when appropriate. This requirement is not met as evidenced by: Based on a report received by CCLD from Orange Public Health Care Agency in regards to infection control of an outbreak. This could pose as a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 26, 2025

Plan of correction: Facility will provide a written statement of understanding of the regulation, signed by all facility staff and personnel and forward to LPA by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Michael Tea conducted a case management incident visit to follow up on an incident report received by Community Care Licensing (CCL) on January 24, 2025, submitted by Health and Wellness Director (HWD) Brittainy Prieto, LVN. LPA was greeted and allowed entrance into the facility by facility staff. Executive Director Carmen Galicia arrived shortly to assist with the visit. LPA explained the reason for the visit. During the inspection, LPA and ED toured the facility and inspected Resident 1 (R1) and Resident 2's (R2) shared room. LPA conducted health and safety checks on residents present and confirmed they were doing well and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA checked perishable and non-perishable food supply and it was adequately stocked at time of visit. The electricity and water were running, the facility had soap and paper towels, and the medications, sharps, and toxins were properly stored. LPA requested and reviewed copies of R1 and R2's resident file. Based on the observations made during today’s inspection, no deficiencies are being cited at this time. An exit interview was conducted with Executive Director, Carmen Galicia and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Jan 27, 2025

Allegation investigated: Facility mismanaged resident's medication Facility has bedbugs

Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Hanna Gough conducted an unannounced visit to deliver findings on the above allegations received on November 18, 2024. LPAs were greeted and granted entry into the facility and met with Executive Director (ED) Carmen Galicia. LPAs explained the reason for the visit. This Department has investigated the complaint alleging that facility mismanaged resident's medication. Resident 1 (R1) was admitted to the facility on October 24, 2024. Documents reviewed included the Physician Report (LIC602) dated November 18, 2024, for R1. Per Physician report R1’s diagnosis is Type 2 Diabetes. Regarding the allegation that facility mismanaged resident's medication, the following was revealed: During the investigation LPA reviewed documents including the Physician Report (LIC602A) dated September 27, 2024, for R1. Per Physician Report R1 is able to administer own prescribed medications. Per Physician Report (LIC602) dated November 18, 2024, R1 can manage own medications except CONTINUED ON LIC9099-C... Unsubstantiated narcotics. During the course of the interviews with staff, Staff 1 (S1) reported that R1 has not been prescribed narcotics and stated that the resident continues to manage their regular prescribed medications. During the course of the interviews with residents, R2 reported that staff handle his medications. Per R2 staff do not mismanage his medications and reported that he gets his medications on-time. Regarding the allegation that facility has bedbugs, the following was revealed: One of eight individuals interviewed confirmed the allegation. During the course of the investigation LPA reviewed documents including the Ecolab invoice customer service report dated November 11, 2024. Per Ecolab customer service report, it states that bedroom #305 was inspected and it states that no bedbug activity noted during inspection. During the course of the interviews with residents, R1 reported that they noticed bedbugs within a few days of moving in. Per R2 he has not seen bedbugs. During the course of the interviews with staff, S1 reported that the pest control company did not find bedbugs and stated that no other resident has complained about bedbugs. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with ED Galicia, and a copy of this report was provided to the facility. During the course of the interviews with residents, R2 reported that she received a copy of her Admission Agreement. R3 reported that he got a copy of the Admission Agreement when he moved in. During the course of the interviews with staff, Staff 1 (S1) reported that R1 got a copy of the Admission Agreement the same day and stated that the residents and family can get a paper copy of the Admission Agreement or receive a copy via email. Therefore, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. LPAs conducted an exit interview with ED Galicia, and a copy of this report was provided to the facility. Per R2 some residents complaint that it is lukewarm water. Based on observations and the interviews which were conducted, the preponderance of evidence standard has been met, therefore the following allegation: facility's restrooms and sinks do not have hot water is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with ED Galicia and a copy of this report along with the Appeal Rights were provided at the time of this visit.the state’s words, verbatim · CDSS document, Jan 17, 2025 · control 22-AS-20241118130839

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jan 21, 2025

87303 Maintenance and Operation (e)(2) Faucets used by residents for personal care...shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F. This requirement was not met as evidence by: Based on observations and interviews conducted the hot water tested between 91.2 to 102.3 degrees Fahrenheit. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 17, 2025

Plan of correction: Licensee to regulate the hot water between 105 degrees F and not more than 120 degrees F. Licensee to log in the hot water temperatures and email LPA POC by POC due date.

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

Allegation investigated: Facility staff failed to provide a resident with privacy Residents are not accorded comfortable accommodations due to the use of air fresheners Retaliation and/or punitive measures are taken against some residents Facility call system is not answered in a timely manner

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on October 11, 2024. LPA was greeted and granted entry into the facility and met with Administrative Services Coordinator Ashanti Minor. Executive Director (ED) Carmen Galicia arrived shortly after. LPA explained the reason for the visit. This Department has investigated the complaint alleging that facility staff failed to provide a resident with privacy. Resident 1 (R1) was admitted to the facility on September 26, 2023. Documents reviewed included the Physician Report (LIC602) dated September 20, 2023 for R1. Per Physician report R1’s diagnosis is Stage 3 chronic kidney disease (CKD). Regarding the allegation that facility staff failed to provide a resident with privacy, the following was revealed: One of nine individuals interviewed confirmed the allegation. During the course of the interviews with residents, R2 reported that she has no issues with privacy. Per R3 staff provide the residents with privacy. CONTINUED ON LIC9099-C... Unsubstantiated R4 stated that staff always knock on his door before they enter his bedroom. During the course of the interviews with staff, Staff 1 (S1) reported that the facility staff always provide the residents with privacy. Per S2 residents are given privacy. During the course of the investigation LPA reviewed documents including the Relias training transcripts for S1 through S6. Per Relias transcripts for S1 through S6, S1-S6 have completed training on Resident Rights in Assisted Living. Regarding the allegation that Residents are not accorded comfortable accommodations due to the use of air fresheners, the following was revealed: One of nine individuals interviewed confirmed the allegation. During the course of the interviews with residents, R3 reported that residents are accorded comfortable accommodations and stated that the air fresheners have a neutral smell. Per R4 the air fresheners make it smell better and stated that residents are accorded comfortable accommodations. During the course of the interviews with staff, S1 reported that no resident has complained about the air fresheners since she began working here. Per S2 the residents are being accorded comfortable accommodations since the air fresheners use natural essentials. LPA reviewed documents including the Aire-Master Scent Marketing and Odor Control. Per Aire-Master Scent Marketing and Odor Control under Scent Facts it states that the scents are made of a combination of natural and essential oils plus fine aromatics, no petroleum carriers or harsh propellants. Regarding the allegation that retaliation and/or punitive measures are taken against some residents, the following was revealed: Five of nine individuals interviewed denied the allegation. During the course of the interviews with residents, R2 reported that staff do not retaliate against the residents and stated that the caregivers are nice. Per R4 staff do not retaliate or take punitive measures against the residents and stated that staff do a good job. During the course of the investigation LPA reviewed documents including the Westminster Terrace, LLC Employee Handbook. Per Employee Handbook on Section 3 under conduct it states the following are examples of conduct that are prohibited and will not be tolerated: being threatening, intimidating, coercing…, rude, discourteous condensing, unprofessional or otherwise socially unacceptable behavior toward a resident. During the course the interviews with staff, S1 reported that the facility does not retaliate against the residents and stated that staff have a good relationship with the residents. CONTINUED ON LIC9099-C... Regarding the allegation that facility call system is not answered in a timely manner, the following was revealed: During the course of the investigation LPA reviewed documents including the Westminster Terrace call system past calls dated October 05, 2024 through October 10, 2024. Per call system past calls on average staff answer the call system between five minutes to 35 minutes. During the course of the interviews with residents, R2 stated that when she uses her call button that staff respond within 24 minutes. Per R4 he uses his call button all the time and reported that the average respond time is 30 minutes. During the initial visit on October 18, 2024 LPA tested the call system in random resident bedrooms. The average call system response time was between six to 25 minutes. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with ED Galicia, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 16, 2025 · control 22-AS-20241011163346

Allegation investigated: Staff did not ensure residents personal property was safely secured

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 allegations listed above and delivering findings to facility staff. LPA was greeted and granted entry by front desk staff after stating the purpose of the visit. Carmen Galicia, Administrator was present and assisted with the visit. The initial complaint investigation visit took place on September 24, 2024. During the visit, LPA requested and obtained the current facility census. Resident records including admission agreements, personal property inventories and theft and loss policy for 5 currently admitted individuals were requested and obtained. A copy of the facility's resident handbook was also provided. Follow up interviews conducted via telephone after the initial visit. CONTINUED ON FORM LIC9099-C Substantiated CONTINUED FROM LIC9099-A Regarding the allegation that Staff does not ensure resident receives mail deliveries, the following has been concluded: Postal mail is being delivered to the facility directly in individual mailboxes located in the facility lobby, with one mailbox assigned per dwelling unit in the facility. Resident or residents living in that specific unit are then provided with a key to their assigned mailbox as confirmed by staff and resident interviews. Staff does not possess keys and does not have access to resident's mailboxes. No specific and/or documented instances of mail being tampered with were provided during the investigation. Regarding the allegation that Staff does not ensure residents laundry is returned undamaged, the following has been concluded: The evidence gathered during the investigation through staff and resident interviews along with records review did not provide sufficient evidence to identify any instances of facility staff being responsible for damaging or destroying a resident's laundry through established negligence. As a result, both allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff did not ensure residents personal property was safely secured, the following has been concluded: Based on staff and resident interviews conducted, reports of missing or alleged stolen items are gathered by facility staff and generally result in corrective measures being taken such as involving staff to search for the missing items or funds, or reevaluating unit assignments if the issue appears to be triggered by residents sharing the same living unit. However, according to an interview with facility administrator conducted during the initial complaint investigation, facility staff does not maintain the required documentation of missing property including a description of the article, its estimated value, the date and time the theft or loss was discovered, if determinable, the date and time the loss or theft occurred as well as the action taken as described in section 1569.153(c) of the Health and Safety Code. As a result, facility staff was unable to provide detailed information on potential theft or loss incidents being investigated when requested by the Department. As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A type B deficiency is cited on the attached form LIC9099-D. An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.the state’s words, verbatim · CDSS document, Dec 5, 2024 · control 22-AS-20240918160103

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.153(c) · Plan of correction due date: Jan 3, 2025

"A theft and loss program shall be implemented [which] shall include (...):(c) Documentation of lost and stolen resident property with a value of twenty-five dollars ($25) or more (...) and, upon request, the documented theft and loss record for the past 12 months shall be made available (...) (...) to the State Department of Social Services(...) in response to a specific complaint." This requirement was not met as evidenced by the absence of a facility log being maintained, which constitutes a potential risk to the healh, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: Facility staff to establish a log and provide LPA with evidence of its use before the plan of corrections due date.

Allegation investigated: Residents are not being provided with clean linen.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to follow up on the investigation into the six allegations listed above. LPA was greeted and granted entry by front desk staff after introducing himself and stating the purpose of the visit. Executive Director Carmen Galicia was present to assist. An initial visit wa conducted on June 13, 2024. LPA requested and obtained the facility's current resident census, conducted a tour of the facility, including the dining hall, kitchen, activities room, private dining and TV room in addition to a sample of eighteen different living units throughout the three levels. LPA conducted a total of eight resident interviews during the visit. Administrator provided LPA with pest control reports dated March 8, 2024 and June 12, 2024. During the follow up visit, an additional tour of the facility's dining hall was conducted as well as 8 staff interviews. CONTINUED ON FORM LIC9099-C Substantiated CONTINUED FROM FORM LIC90990-A Regarding the allegation that Residents are left soiled, the following has been concluded: Based on interviews conducted with staff and residents as well as observations conducted, it has been witnessed on multiple occasions that staff was attending to residents having soiled themselves or their bedding. Additional staff and residents interviews did not provide any evidence of staff neglecting to attend residents in need of assistance with toileting care in a timely manner. It cannot therefore be corroborated that on any instances residents were left unattended after having become soiled. Regarding the allegation that Facility is not addressing pest infestations, the following has been concluded: Upon follow-up visit there has been no evidence of continuing issues with pest at the facility. Staff interviews did not confirm any ongoing infestation either. Based on documents and evidence provided by facility staff during the initial visit, it can be confirmed that any occurrences of pests have been addressed timely. Regarding the allegation that Residents are not treated with respect and dignity, the following has been concluded: Based on observations conducted in the facility as well as interviews with residents, no residents' statements indicated that they felt they were not receiving adequate treatment in respect of their personal rights. Regarding the allegation that Dining areas are not maintained clean, the following has been concluded: Based on two visits of the facility's physical plant, it was observed that the dining areas were being cleaned during and/or after the meal service had been provided. Regarding the allegation that Residents are not being provided with a way to activate the facility's call system, the following has been concluded: Based on observations conducted during the visits of the physical plant as well as interviews with staff and residents, it was determined that a majority of residents were aware of having been provided with a pendant and of the location of pull cords throughout their units. It cannot be corroborated that any incidents have occurred as a consequence of any resident not being provided with an adequate way of activating the call system. As a result, the five allegations listed above are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC9099 Regarding the allegation that Residents are not being provided with clean linen, the following has been concluded: During the initial visit, eighteen living units were visited and reviewed. While a majority of units were observed to have linens that appeared to be clean, two units were observed to have visibly stained and/or dirty linen that had not been replaced and one additional unit was found to have no linen present altogether during the visit. Upon follow-up visit, one staff interview corroborated occasional complaints from families visiting residents about bedding being soiled or wet during their visits and not having been replaced in a timely manner. As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A type B citation is issued on the attached LIC9099-D. An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 22-AS-20240607161443

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: Oct 2, 2024

Per CCR 87307(a)(3)(C) "the licensee shall assure provision of: Clean linen(...). The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. " This requirement is not met as evidenced by: Based on interviews conducted and a tour of the facility's physical plant, it was observed that multiple living units had either soiled linen or absent linen altogether. This constitutes a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Sep 4, 2024

Plan of correction: Licensee conducted an in-service regarding weekly changes of linen with housekeeping staff. A similar training either has or will be provided to caregiving staff as well before the Plan of Corrections due date.

Allegation investigated: Residents are afraid to express themselves due to retaliation Facility is understaffed

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility for the complaint and to deliver the findings. LPA De Perio explained the purpose of today's visit and was greeted by Facility Administrator (AD) Carmen Galicia. During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that residents are afraid to express themselves due to retaliation. LPA De Perio conducted a total of 7 resident interviews, of which 7 out of 7 resident interviews did not corroborate with the allegation and denied of any forms of retaliation. 3 of the resident interviews specified that there is a resident council meeting held monthly, to present to facility management regarding concerns. Continued on LIC9099-C... Unsubstantiated 1 out of 1 interview conducted with staff (S1) stated that resident 1 (R1) was talking negatively about other residents, to either staff or other residents, and that S1 advised R1 to go directly to the facility administrator if there were any resident health and safety concerns. It was alleged that facility is understaffed. LPA De conducted a total of 7 resident interviews, of which 7 out of the 7 interviews did not corroborate with the allegation by stating that staffing is adequate enough to suffice the needs of residents. 2 out of 2 staff interviews stated that for the morning and evening shift, there are a total of 4 caregivers, and 2 med-tech hybrids (med-techs who are trained to care give) per shift, and for the noc shift, there are a total of 2 caregivers and 1 med-tech hybrid. LPA De Perio conducted a record review of the April 2024 staff schedule and verified this information. It was also observed via staff schedule that facility utilizes Great Comfort, which is a staffing agency to ensure that there is an adequate amount of direct care staff present, and that if facility is unable to find coverage, either AD Galicia or Health and Wellness Director will cover the shift. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, these allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with AD Galicia. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, May 6, 2024 · control 22-AS-20240501112436

Allegation investigated: Staff do not provide resident with laundry service Staff do not provide the resident with clean bed linen

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day inspection to begin the investigation into the allegations listed above. LPA met with Administrator Carmen Galicia and explained the reason for the visit. The investigation into the allegation, staff did not provide resident with laundry service revealed the following. It was alleged that Resident 1 (R1) wore blood stained clothing when family visited and the facility does not wash R1's clothing regularly. A review of records shows that R1's laundry service was stopped on January 1, 2024. The Administrator reported that only R1's responsible party can stop the laundry service. The Administrator reported that starting on March 8, 2024 they started doing R1's laundry once a week to assist R1. The Administrator reported that R1 had skin redness and the cause was reported to be Anthropod bites according to R1's doctor. The Administrator provided a copy of the letter from the doctor to verify this report. The Administrator reported that the facility has been doing the laundry for R1 and cleaning their room twice a week since the report of issues concerning R1's skin. R1 verified that the facility has been helping them with Laundry recently but does not remember the exact date they started. Staff interviewed reported that R1's laundry is currently being done Unsubstantiated once a week. Staff interviewed that laundry service did stop January 1, 2024 but resumed sometime around March 8, 2024. R1's family reported that they had been doing R1's laundry and washing R1's linens the majority of the time since January 2024. Based on the information gathered through record review and interviews the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff do not provide the resident with clean bed linen, revealed the following. It was alleged that the facility staff do not regularly change R1's bed linens. Staff interviewed reported that the bed linens are washed and changed once a week. R1's responsible party stated that they have washed R1's bed linens and changed the sheets but do not know how often the facility changes them. R1 reported that their bed linens are changed around once a week by family or facility staff but can't provide exact dates. LPA inspected R1's room and observed clean linens on R1's bed. Based on the evidence provided the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Apr 22, 2024 · control 22-AS-20240412143259