Westmont at San Miguel Ranch

Allegation investigated: Facility does not have adequate staffing to meet resident's needs. Staff does not ensure resident is turned resulting in resident sustaining pressure injuries. Staff does not ensure resident's hygiene needs are being met.

On September 16, 2026, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings regarding the above-referenced complaint. LPA met with Executive Director Jessica Zepeda, and the investigative findings were discussed. The Department's investigation consisted of interviews with facility staff, direct-care staff, responsible parties for other Memory Care residents, and outside sources, as well as a review of resident and facility records, including Physician's Reports, Service Care Plans, Outside Medical Provider/Agency (OMP) records maintained at the facility, wound-care documentation, progress notes, medication-related documentation, skin assessments, personal-care and incontinence-care documentation, Memory Care census information, employee schedules, and employee time-entry records. An LIC 811 identifying R1 was provided to facility management. Page 1 of 6 (Continue at LIC9099C) Substantiated (Continue from LIC9099) During R1's residency, R1 experienced progressive cognitive, functional, and medical decline and began receiving additional medically related services from an OMP. OMP services supplemented facility services and did not remove the licensee's responsibility to coordinate care and ensure R1's assessed needs were met. Records established that R1 was admitted in May 2022 and was ambulatory and capable of independently transferring at admission. R1's condition later declined substantially. A June 2024 Physician's Report documented Alzheimer's disease/dementia-related impairment, bowel and bladder incontinence, poor physical health, a history of skin breakdown, nonambulatory status, and inability to independently transfer. R1 was not designated bedridden. Service Care Plans reflected that R1 eventually required Level 7, the facility's highest assessed Memory Care service level. R1 required full or maximum assistance with bathing, dressing, grooming, oral hygiene, toileting and incontinence care, mobility and transfers, eating, medication management, skin protection, monitoring, and other activities of daily living. Allegation: Facility does not have adequate staffing to meet resident's needs. The complaint alleged that Memory Care was chronically understaffed and that staffing was insufficient to timely meet R1's Level 7 needs and the needs of other Memory Care residents. LPA reviewed the November 2024 Memory Care census, which reflected approximately 29 residents, including R1. LPA also reviewed planned Caregiver and Medication Technician schedules and actual employee time-entry records covering the period surrounding the complaint. As a representative comparison, the planned November 14, 2024, schedule reflected three caregivers and one Medication Technician on the AM shift, three caregivers and two Medication Technicians on the PM shift, and two caregivers on the NOC shift. This schedule was consistent for the period relevant to this investigation. The Department did not determine staffing adequacy by numerical ratio alone and compared the staffing records with resident acuity and actual care demands. Page 2 of 6 (Continue at LIC9099C) (continue from LIC9099C) The staffing records initially raised concern but did not, by themselves, establish that resident needs went unmet. Direct-care interviews provided corroborating evidence regarding the effect of staffing levels on resident care. During interviews, direct-care staff members described ongoing staffing shortages, approximately four caregivers for 28 to 30 Memory Care residents, and occasions with fewer available caregivers. The staff interviewed reported repeated delays in toileting and incontinence care, double shifts when call-outs could not be covered, and difficulty obtaining replacement coverage. The interviews were considered primarily as evidence of the unit-wide staffing condition because some of the staff members interviewed did not identify a specific R1 incident. Two additional direct-care staff independently described Memory Care as severely understaffed during the relevant period. The interviews described occasions with only two or three caregivers for approximately 30 residents, Medication Technicians routinely providing direct resident care, extended or double shifts, and required rounds, repositioning, and incontinence care not always completed timely because insufficient staff were available. LPA also obtained independent information from a responsible party for another Memory Care resident admitted shortly after the complaint date. The responsible party reported delayed responses to resident-assistance requests, including waits of approximately 20 to 30 minutes for incontinence care, and reported that caregivers stated other residents were being assisted. This resident was admitted two days after the complaint date, and this information was used only as corroboration of continuing conditions shortly after the complaint period. The Department finds that the resident census and staffing records are corroborated by multiple direct-care staff who independently described the same persistent staffing problem and identified specific care affected by insufficient staffing, including rounds, repositioning, toileting/incontinence care, and response to resident needs. Page 3 of 6 (continue at LIC9099C) (continue from LIC9099C) When the resident census, staffing records, R1's Level 7 needs, direct-care interviews, independent responsible-party information, and contrary evidence are considered together, the evidence establishes that available staffing was not consistently sufficient in number to timely provide the services necessary to meet resident needs. The preponderance-of-evidence standard was met. Therefore, the allegation is SUBSTANTIATED. Allegation: Staff does not ensure resident is turned resulting in resident sustaining pressure injuries. The complaint alleged that R1 developed pressure injuries because facility staff did not consistently turn and reposition R1. The investigation established that R1 was nonambulatory, unable to independently transfer, incontinent, in poor overall physical health, and had a history of skin breakdown. R1 required extensive assistance with mobility, transfers, skin protection, and personal care. OMP records documented buttock/coccyx-area skin breakdown and repeated skilled wound treatment beginning in November 2024. Two direct-care Medication Technicians independently provided substantially similar firsthand observations regarding R1. Staff recalled administering afternoon medications and later returning during the evening medication pass to find R1 in the same position. Staff described occasions in which R1 remained in the same position for several hours and stated that required repositioning and rounds were not consistently completed because sufficient caregiver coverage was not available. Direct-care staff also reported that R1 could not independently use the resident-assistance call system and depended on routine staff monitoring to identify repositioning, incontinence, and other care needs. The Department considered facility and OMP records documenting wound treatment, skin monitoring, barrier cream, wedges or other pressure-relief measures, and later occasions when staff completed turning and repositioning. These records establish that repositioning and skin care were provided on some occasions and were considered as contrary and mitigating evidence. Page 4 of 6 (continue at LIC9099C) (continue from LIC9099C) Those episodic records do not establish that required repositioning occurred consistently between documented care events. The two independent Medication Technician interviews described the same pattern of finding R1 in the same position between afternoon and evening medication passes and are consistent with the staffing evidence showing that required rounds were not always completed timely. Considering R1's inability to independently reposition, documented skin-breakdown risk, actual pressure-related wounds, mutually corroborating firsthand observations of prolonged periods without repositioning, and staffing-related inability to complete required rounds, the evidence more likely than not establishes that R1's repositioning needs were not consistently met and that prolonged pressure contributed to the development or persistence of R1's pressure-related skin breakdown. The preponderance-of-evidence standard was met. Therefore, the allegation is SUBSTANTIATED. Allegation: Staff does not ensure resident's hygiene needs are being met. The complaint alleged that R1's hygiene needs, including toileting/incontinence care and oral hygiene, were not consistently met. R1's Service Care Plans documented bowel and bladder incontinence and required full or maximum assistance with toileting/incontinence, bathing, grooming, and oral hygiene. R1 depended on routine staff monitoring for these needs. Direct-care staff identified toileting and incontinence care as a recurring area affected by staffing shortages throughout Memory Care. Staff interviews described a unit-wide pattern of delayed incontinence care. Two other direct-care staff provided R1-specific firsthand evidence that incontinence care was not always completed timely and that R1 at times remained wet or soiled for extended periods. Independent information from the responsible party for another Memory Care resident also described delayed incontinence assistance and feces odors in resident rooms during the same complaint period. In addition, this same resident sustained several unwitnessed falls in less than two months which resulted in a voluntary relocation from the facility. The responsible party stated that staff were not able to meet the resident’s supervisory needs. This information was used as corroboration of continuing conditions and not as proof of a specific R1 incident. Page 5 of 6 (continue on LIC9099C) (continue from LIC9099C) The Department considered contrary evidence, including OMP Home Health Aide records documenting showers, bed baths, and personal-care services, as well as facility and OMP documentation of brief changes, cleansing, barrier cream, oral swabbing, and other hygiene services on multiple dates. These records establish that hygiene care was provided on many occasions. The finding is not that all hygiene care was omitted. The direct-care evidence nevertheless establishes that required incontinence care for R1 was delayed or missed on other occasions. Multiple interviews independently described delayed incontinence care associated with staffing shortages, including R1-specific observations. The evidence therefore establishes by a preponderance that R1's toileting/incontinence hygiene needs were not consistently met timely. The investigation did not establish that every oral-hygiene task was omitted; the Substantiated finding is principally supported by untimely incontinence and toileting hygiene care. The preponderance-of-evidence standard was met. Therefore, the allegation is SUBSTANTIATED. Based on records reviewed, interviews conducted, and all information obtained during the investigation, all three allegations are SUBSTANTIATED. Deficiencies were cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations and are detailed on the LIC 9099-D. Plans of Correction (POCs) were jointly developed with Executive Director Jessica Zepeda. An exit interview was conducted with Executive Director Jessica Zepeda. A copy of this report, the LIC 9099-D, the Licensee Appeal Rights (LIC 9058), and LIC 811 were provided electronically at the conclusion of the virtual visit. Page 6 of 6the state’s words, verbatim · CDSS document, Sep 16, 2026 · control 08-AS-20241114091207

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 16, 2026

87411(a) Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on staffing records, resident census information, and interviews, the licensee did not comply with the section cited above. Multiple direct-care staff described persistent staffing shortages and delayed or incomplete rounds, repositioning, and toileting/incontinence care because sufficient staff were not available. This posed a potential health, safety, and personal-rights risk to R1 and (92) other residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: ED agreed to review current hospice care plans for repositioning and pressure-relief needs, train staff responsible for implementation, and complete a 14-day supervisory audit of required repositioning. Proof of correction will be submitted to CCL by the POC deadline.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(d) · Plan of correction due date: Oct 16, 2026

87633(d) Hospice Care for Terminally Ill Residents.The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the resident's care needs are being met at all times. This requirement was not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above. R1 was nonambulatory, unable to independently reposition, had pressure-related skin breakdown, and required pressure-relief care. Direct-care staff independently observed R1 remaining in the same position for several hours and reported that repositioning was not consistently completed. This posed a potential health and safety risk to R1 and (92) other residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: ED agreed to review current hospice care plans for repositioning and pressure-relief needs, train staff responsible for implementation, and complete a 14-day supervisory audit of required repositioning. Proof of correction will be submitted to CCL by the POC deadline.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Oct 16, 2026

87625(b)(3) Managed Incontinence The licensee is responsible for ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above. R1 required full assistance with incontinence care, and direct-care staff reported that R1 at times remained wet or soiled for extended periods. Additional interview information described delayed incontinence assistance in Memory Care. This posed a potential health, safety, and personal-rights risk to R1 and (92) other residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: ED agreed to review current incontinence-care needs, train staff on timely incontinence care and CCR 87625(b)(3), and complete a 14-day supervisory audit to ensure residents are kept clean and dry. Proof of correction will be submitted to CCL by the POC deadline.

Allegation investigated: Staff do not prepare a resident's food to meet their needs while in care

On September 16, 2026, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to the facility to deliver investigative findings regarding the above-referenced complaint. LPA explained the purpose of the visit, and met with Executive Director Jessica Zepeda. The investigative findings were discussed. The Department's investigation consisted of a review of resident and facility records, Service Care Plans, dietary information, progress notes, Outside Medical Provider/Agency (OMP) documentation, Speech-Language Pathologist (SLP) records, physician orders, feeding documentation, photographs, information received by Community Care Licensing (CCL), and interviews with facility staff and outside sources. An LIC 811 identifying R1 was provided to facility management. Page 1 of 4 (continue at LIC9099C) Substantiated (continue from LIC9099) The complaint alleged that staff did not prepare R1's food to meet R1's dietary needs and physician-ordered food consistency while R1 was in care. Records reviewed established that R1 required a pureed diet and full assistance with eating. OMP and swallowing records further established that R1 had significant swallowing impairment and required precautions intended to reduce choking and aspiration risk. These precautions included puree texture, thickened liquids, supervision during feeding, upright positioning, slow feeding, small portions, and later an express instruction that food contain no chunks. LPA identified multiple pieces of evidence showing that food provided to R1 did not consistently meet the required puree consistency. Facility documentation dated January 16, 2025 recorded a food-consistency concern from January 15, 2025. The note reflected that an outside source and a caregiver observed visible solid pieces in food provided to R1 as a pureed meal. The concern was reported to facility staff and Dining Services at the time of the incident. A second incident occurred on or about February 2, 2025, when a meal provided to R1 as pureed food contained a solid piece or chunk that had not been fully pureed. Information received during the investigation reflected that R1 was able to spit out the solid piece. LPA reviewed photographs provided during the investigation. The photographs depicted visible solid food pieces or chunks in meals identified as pureed food provided to R1. The photographs were consistent with the reported food-consistency concerns and were considered with the facility documentation and witness interviews. On January 31, 2025, an SLP performed a swallowing evaluation and meal/medication analysis. The SLP documented puree texture, thickened liquids, crushed medications, upright positioning, small portions, slow feeding, and supervision due to R1's high aspiration/choking risk. The meal observed during that specific clinical assessment was documented as appropriately prepared. This was considered as contrary evidence demonstrating that the facility was capable of providing an appropriate puree consistency. Page 2 of 4 (Continue at LIC9099C) (continue from LIC9099C) On February 3, 2025, an OMP issued additional aspiration-prevention instructions that specifically directed that R1's food contain no chunks, among other precautions. The order reinforced the medical importance of providing R1 food at the prescribed texture. During staff interviews, staff confirmed two food-consistency incidents on or about January 15 and February 2, 2025, in which food provided to R1 contained pieces or chunks inconsistent with the required puree texture. Staff acknowledged that food intended to be pureed should not contain the pieces or chunks described and confirmed that staff spoke with and apologized to an outside source after the first incident. Additional direct-care evidence was obtained from staff who remembered R1 and regularly worked in Memory Care. Staff recalled that R1's pureed food was at times too thick or sticky and required additional water and mixing before R1 could safely eat the food. Staff described one occasion when R1's food was taken back, additional water was added, and the food was mixed to create a softer consistency. Staff also stated that an outside source requested further mixing because R1 had difficulty swallowing food that was not adequately prepared. During an interview, facility management denied that staff failed to follow R1's dietary requirements. Facility management stated that the facility followed physician orders, used specific puree preparation methods and molds, and did not believe corrective action or additional training was necessary. LPA also reviewed later feeding and progress documentation that generally reflected appropriate pureed food, thickened liquids, upright positioning, and feeding assistance. The Department considered this contrary evidence. The allegation is not that every meal provided to R1 was improperly prepared. Evidence that compliant meals were provided on other dates and that the facility had procedures for preparing puree meals did not negate the specific failures established by facility documentation, photographs, staff admissions and firsthand observations, and R1's medical orders. Page 3 of 4 (Continue at LIC9099C) (Continue from LIC9099C) The investigation did not establish that R1 developed aspiration pneumonia or another diagnosed injury as a result of the food-consistency incidents. An injury is not required to establish whether the facility provided the physician-prescribed modified diet. The evidence established that, on specific occasions, food provided to R1 did not meet the puree consistency required for R1's identified medical and dietary needs. Based on records reviewed, photographs, interviews with facility staff and outside sources, and all information obtained during the investigation, the preponderance-of-evidence standard was met. Therefore, the allegation that staff did not prepare a resident's food to meet their needs while in care is SUBSTANTIATED. A deficiency was cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations and is detailed on the LIC 9099-D. A Plan of Correction (POC) was jointly developed with Executive Director Jessica Zepeda. An exit interview was conducted with Executive Director Jessica Zepeda. A copy of this report, the LIC 9099-D, the Licensee Appeal Rights (LIC 9058), and LIC 811 were provided at the conclusion of the visit. Page 4 of 4the state’s words, verbatim · CDSS document, Sep 16, 2026 · control 08-AS-20250115145001

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: Oct 16, 2026

CCR 87555(b)(7) General Food Service Requirements. Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by: Based on records review, photographs, and interviews, the licensee did not comply with the section cited above. R1 required a physician-ordered pureed diet, and it was established that food provided to R1 on specific occasions was not adequately mixed to the required puree consistency. This posed a potential health and safety risk to R1 and (92) other residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: ED agreed to: (1) review current physician-ordered modified diets against kitchen/dietary lists and care records; (2) provide in-service training on CCR 87555(b)(7), modified diets, puree consistency, and choking/aspiration precautions; (3) complete a staff competency check for puree preparation; and (4) monitor modified-diet meals for 14 days. Proof of correction will be submitted to CCL by the POC deadline.

Allegation investigated: Staff did not provide records to a resident's authorized person Facility illegally evicted a resident

On September 16, 2026, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings regarding the above-referenced allegations. LPA explained the purpose of the visit, and met with Executive Director Jessica Zepeda. The investigative findings were discussed. The Department's investigation consisted of a review of resident and facility records, Service Care Plans, Power of Attorney (POA) documentation, written and certified records requests, proof of delivery, facility and family correspondence, outside-provider and mortuary correspondence, progress notes, information received by Community Care Licensing (CCL), and interviews with facility staff and outside sources. An LIC 811 identifying R1 was provided to facility management. Page 1 of 5 (Continue at LIC9099C) Substantiated (Continue from LIC9099) Allegation: Staff did not provide records to resident's authorized person. The complaint alleged that facility staff failed to provide requested resident records to R1's authorized representative after repeated requests. Early in the investigation, an outside source repeatedly requested numerous documents from the facility, including resident-file information, injury-related records, behavioral incident information, medication administration records, progress notes, Service Care Plan information, and other records. The investigation also established that the outside source was not R1's POA. This evidence was considered because the facility had a legitimate basis to verify authorization before releasing confidential resident records directly to the outside source. LPA reviewed documentation identifying R1's spouse as R1's POA/authorized representative. A handwritten communication dated February 5, 2025 identified an outside source as the POA's advocate/spokesperson and requested that communications be directed through the outside source. The communication specifically requested R1's June 2023 Service Care Plan. A facility notation documented that the June 2023 Service Care Plan was provided, which was considered as evidence that the facility fulfilled at least one specific request. Additional evidence obtained later in the investigation materially changed the records-access analysis. Following R1's death, the POA submitted written requests directly to the facility. A March 21, 2025 certified request was received on or about March 26, 2025. The request included a death-related document later clarified as the official death certificate. The investigation did not establish that the official death certificate was a facility-generated or facility-maintained resident record; therefore, the death certificate is not used as the basis for this finding. LPA also reviewed the POA's May 1, 2025 written second request. The May 1 request directly sought multiple categories of facility-maintained information concerning R1, including records and reports regarding unexplained injuries, behavioral incident information, medication records, R1's Memory Care file, and records concerning assessments and appraisals. Page 2 of 5 (continue at LIC9099C) (continue from LIC9099C) The request also referenced the facility's Plan of Operation. Because some requested items were facility-wide documents rather than resident records, LPA distinguished those items from the facility-maintained resident records that form the basis of this allegation. CCL records documented repeated follow-up in March, April, and May 2025 stating that requested resident records remained outstanding. During a subsequent interview, an outside source stated that the POA requested records in person, by email, and by certified mail and that requested facility-maintained resident records remained outstanding. The outside source also reported that facility staff stated some requested information would not be provided because management did not consider the information part of R1's resident file. Before finalizing the finding, LPA provided facility management an additional opportunity to identify what records responsive to the written requests had been provided, the date and method of production, the recipient, and the reason any requested facility-maintained resident records were not produced. The evidence available for final review did not include documentation establishing that the facility provided the requested facility-maintained resident records, nor did it establish a timely supported response for withholding those records. The Department considered the contrary evidence that the initial outside source was not the POA, that the June 2023 Service Care Plan was documented as provided, and that some requested documents, including the official death certificate and facility-wide Plan of Operation, were analytically distinct from facility-maintained resident records. Those facts do not overcome the later written requests made directly by the POA for facility-maintained resident records or the absence of documentation establishing that those records were provided. Based on the direct written requests from the POA, proof that the facility received the requests, repeated follow-up that resident records remained outstanding, corroborating interview information, and the absence of documentation establishing production of the requested facility-maintained resident records, the preponderance-of-evidence standard was met. Therefore, the allegation is SUBSTANTIATED. Page 3 of 5 (continue at LIC9099C) (continue from LIC9099C) Allegation: Facility illegally evicted a resident. The complaint alleged that facility management illegally evicted, or attempted to compel the involuntary transfer of, R1 during R1's decline and end-of-life period. LPA reviewed records and correspondence concerning R1's changing needs and the facility's proposal that R1 transition to a higher level of care. Facility management stated that updated care information and involvement of an Outside Medical Provider/Agency supported consideration of a higher level of care, including possible skilled-nursing placement. Facility management later maintained that R1 was not evicted and that a higher level of care was recommended because R1's needs had increased. The Department considered this explanation. However, a February 14, 2025 email chain contained material evidence showing that facility management described R1's move to a higher level of care as necessary, referenced a possible placement, stated that legal counsel had been consulted, and communicated that eviction proceedings would be pursued if the family did not provide communication or cooperation with the proposed transfer. Outside sources objected to the proposed relocation while R1 was experiencing substantial decline and receiving end-of-life services. The communication therefore went beyond a general recommendation to explore another placement. Facility management expressly tied cooperation with the proposed transfer to the initiation of eviction proceedings. Records established that no completed physical eviction occurred before R1's death. LPA did not identify a final written eviction notice, effective move-out date, or completed involuntary discharge. R1 remained at the facility and continued receiving facility and outside-provider services until February 17, 2025, when R1 died at the facility. This evidence was considered as contrary evidence. The absence of a completed physical removal does not negate the facility's written communication that eviction proceedings would be initiated if cooperation with the proposed transfer was not received. The communication used the threatened initiation of eviction proceedings to obtain cooperation with a licensee-initiated transfer. Page 4 of 5 (continue on LIC9099C) (continue from LIC9099C) After review of the written management communication, outside-source responses, higher-level-of-care records, facility management's contrary statement that no completed eviction occurred, and the fact that R1 died before a formal process was completed, the Department determined that the evidence more likely than not established an improper involuntary-transfer/eviction action as alleged. The preponderance-of-evidence standard was met. Therefore, the allegation is SUBSTANTIATED. Deficiencies were cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations and are detailed on the LIC 9099-D. Plans of Correction (POCs) were jointly developed with Executive Director Jessica Zepeda. An exit interview was conducted with Executive Director Jessica Zepeda. A copy of this report, the LIC 9099-D, the Licensee Appeal Rights (LIC 9058), and LIC 811 were provided electronically at the conclusion of the virtual visit. Page 5 of 5 (continue from LIC9099A) The complaint alleged that R1 was not treated with dignity and respect. The concerns focused primarily on facility management's conduct immediately after R1's death, including an alleged lack of condolences or personal acknowledgment, the absence of a memorial photograph or tribute, and concerns regarding facility social-media postings. LPA reviewed R1's Service Care Plans and resident records. The records reflected significant cognitive and functional impairment, Level 7 care, full assistance with activities of daily living, and continued coordination of care through the end of R1's residency. The records reviewed and interviews conducted did not document degrading, humiliating, retaliatory, or intentionally disrespectful treatment of R1 while R1 resided at the facility. During an outside-source interview, it was reported that direct-care staff expressed sympathy and respect after R1 died, while facility management did not personally acknowledge the family or offer condolences during the period the family remained at the facility waiting for the mortuary. The outside source stated that a private religious observance did not occupy the entire waiting period. The concern was also raised in writing on February 18, 2025, the day after R1's death. Facility documentation included written correspondence following R1's death that expressed condolences and addressed administrative matters. This was considered as evidence that the facility provided a written expression of sympathy, although the correspondence did not establish whether facility management personally acknowledged the family while present at the facility. During a follow-up interview, facility management stated that R1's family remained in R1's room while waiting for the funeral home and engaged in a private religious observance. Facility management stated that staff entered the room as needed but otherwise allowed privacy. The response did not establish whether verbal condolences were expressly offered by facility management. Facility management also stated that the facility had no formal or consistent protocol requiring a memorial photograph or tribute following every resident death and described memorial displays as a courtesy when a family expressed interest. Page 2 of 3 (continue at LIC9099C) (continue from LIC9099C) Facility management reported that 13 residents died at the facility between November 2024 and February 2025, but the facility did not maintain a log identifying which residents received memorial displays or who initiated each request. Records reviewed did not establish that a memorial photograph or tribute for R1 was requested and refused. The Department finds the concerns regarding management's post-death interaction credible and supported by records and interview information. The evidence supports that the family perceived management's response as lacking personal compassion and acknowledgment. However, the strongest evidence concerns management's interaction with the family after R1's death, rather than degrading, disrespectful, or undignified treatment of R1 while R1 was a resident. The investigation did not establish that R1 was intentionally excluded from activities, denied care because of disrespect, subjected to degrading comments or conduct, or otherwise treated in a manner inconsistent with R1's personal dignity. Although compassionate personal acknowledgment and condolences are appropriate when a resident dies, the evidence obtained did not establish by a preponderance that facility staff violated R1's personal right to dignity and respect. Based on records reviewed, interviews conducted, and all information obtained during the investigation, the Department determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Jessica Zepeda. A copy of this report, the Licensee Appeal Rights (LIC 9058), and LIC 811 were provided electronically at the conclusion of the virtual visit. page 3 of 3the state’s words, verbatim · CDSS document, Sep 16, 2026 · control 08-AS-20250218125138

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Oct 16, 2026

CCR 87468.2(a)(19)Additional Personal Rights of Residents ...Residents have the right to prompt access to review all records ...shall be provided within two business days ... This requirement was not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above. R1's authorized representative submitted written requests for facility-maintained resident records, and the facility did not provide documentation establishing that the requested resident records were made available or provided within the required timeframe. This posed a potential personal-rights risk to R1 and (92) other residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: ED agreed to provide all outstanding facility-maintained resident records required for release, implement a written records-request procedure addressing the two-business-day requirement, and train staff responsible for records requests. Proof of correction will be submitted to CCL by the POC deadline.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(20) · Plan of correction due date: Oct 16, 2026

CCR 87468.2(a)(20)Additional Personal Rights of Residents... have the right to be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict a resident for reasons other than those permitted by law ...This requirement was not met as evidenced by: Based on records review and interviews, facility management communicated that R1's move to a higher level of care was necessary and that eviction proceedings would be pursued if cooperation with the proposed transfer was not received. Although a completed physical eviction did not occur before R1's death, the written communication constituted an improper licensee-initiated involuntary-transfer/eviction action and posed a potential personal-rights risk to R1 and (92) other residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: ED agreed to implement a written involuntary-transfer/eviction procedure consistent with CCR 87468.2(a)(20), prohibit coercive eviction threats outside the permitted process, and train management staff involved in transfer or eviction decisions. Proof of correction will be submitted to CCL by the POC deadline.

Allegation investigated: Staff did not speak to resident in an appropriate manner. Staff threatened eviction to resident in care. Staff did not ensure resident was provided with clean bedsheets. Staff did not ensure resident was served meal in a timely manner. Staff did not ensure resident was provided bathing assistance. Staff did not ensure altercations between residents were handled appropriately.

On May 29, 2026, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to the facility to deliver findings regarding the above-referenced allegations. LPA was greeted by Business Office Director, Ellen Arguello with whom the investigative findings were discussed. The Department’s investigation included facility inspections, record reviews, and interviews with staff, residents, responsible parties, and outside sources. On November 12, 2025, Community Care Licensing (CCL) received a complaint alleging that staff did not speak to Resident 1 (R1) in an appropriate manner and threatened R1 with eviction. Additional allegations included staff not ensuring R1 received clean bedsheets, timely meals, bathing assistance, and appropriate intervention during resident altercations. Staff were provided with an LIC811 Confidential Names List identifying R1, S1, and S2. (continue at LIC9099C) Unsubstantiated (Continue from LIC9099) Background Information Review of R1’s admission agreement and other relevant records did not disclose any diagnosis or condition related to dementia. Records reviewed during the investigation confirmed that R1 moved into the facility in April 2025 and voluntarily moved out in October 2025, residing at the facility for approximately six months. Multiple interviews conducted during the investigation described R1 as alert and oriented to person, place, and time, capable of advocating for themselves, and considered a credible witness. Records and interviews further disclosed that R1 had a history of verbal disagreements with staff and other residents and was frequently described as difficult to redirect. Staff and outside sources consistently described R1 as unhappy living at the facility. During an interview conducted on May 28, 2026, R1 stated that S1 spoke inappropriately to them and threatened eviction. R1 alleged that on or about October 1, 2025, S1 told R1 “to get out by the end of the month or else they would wish they had.” R1 also stated that S1 brought dogs into the facility and that during one incident, a dog approached R1, causing R1 to lift their legs to avoid contact. According to R1, S1 yelled across the room, “Don’t you dare kick my dog.” R1 stated they were attempting to move away from the dog and denied attempting to kick it. R1 further alleged that following this incident, S1 instructed staff to withhold certain services, including clean bedsheets, timely meals, and shower assistance. However, during the investigation, R1 was unable to provide specific dates, times, or examples when services were allegedly not provided. R1 stated that residents and staff witnessed the incident but was unable to recall names or additional identifying information. R1 stated that S2 advocated on their behalf and often intervened during disagreements involving R1 and S1. On May 28, 2026, during an interview, S2 recalled assisting with de-escalating situations involving R1 and staff or other residents in general. S2 stated that R1 frequently became upset during interactions with others and that de-escalation interventions were often effective. However, S2 denied ever witnessing or hearing S1 threaten, mistreat, or speak inappropriately to R1. (continue at LIC9099C) (continue from LIC9099C) Interviews conducted with residents, staff, responsible parties, and outside sources did not produce corroborating evidence to support the allegations. During an interview, S2 stated that staff made significant efforts to accommodate R1’s preferences and care needs. S2 explained that R1 requested showers at approximately 5:30 a.m., and the facility accommodated the request by arranging for designated staff to arrive early once or twice weekly. Review of shower schedules and care records confirmed that R1 received showers twice weekly, consistent with R1’s service plan. Interviews with R1’s responsible party did not disclose concerns regarding the care or services provided by staff. The responsible party acknowledged staff efforts to accommodate R1’s requests and needs. Records reviewed during the investigation confirmed that R1 voluntarily moved out of the facility on October 20, 2025. There was no evidence that R1 was served with a 30-day eviction notice, and no corroborating evidence was obtained indicating that staff threatened eviction. It was also alleged that staff failed to appropriately intervene during altercations between residents. However, no specific dates, times, or details regarding alleged resident altercations were provided during the investigation. Interviews conducted with residents, staff, and outside sources did not disclose any incidents involving resident altercations. Additionally, a review of incident reports submitted to CCL during the relevant period did not disclose any resident-to-resident altercations. Staff interviews consistently indicated that direct care staff receive training regarding resident care, activities of daily living, and de-escalation techniques to ensure resident health and safety. Staff reported that care and supervision are provided in accordance with residents’ individualized service plans. Staff denied the allegations and stated they were unaware of any incidents involving inappropriate treatment of residents or unaddressed resident altercations. Interviews conducted with residents and responsible parties did not disclose concerns regarding unmet care needs. Residents and responsible parties stated that bedsheets were changed weekly or as needed when soiled, meals were served according to schedule, and shower schedules were followed in accordance with individualized service plans. (continue at LIC9099C) (continue from LIC9099C) During facility visits conducted on November 25, 2025, and February 11 and 25, 2026, resident rooms were observed to be clean and organized. Beds inspected during the visits contained clean sheets and linens. LPA also observed staff interactions with residents and did not observe concerns regarding staff conduct or resident care. Staff appeared attentive and responsive to residents’ needs. Additionally, sufficient staff were observed present during the visits to meet residents’ care and supervision needs. Based on observations, interviews, and record reviews conducted during the investigation, there was insufficient evidence to support the allegations that staff spoke inappropriately to R1, threatened eviction, failed to provide clean bedding, failed to provide meals in a timely manner, failed to provide bathing assistance, or failed to appropriately address resident altercations. Although R1 reported concerns regarding staff conduct and care, the allegations were not corroborated through interviews, records, or observations conducted during the investigation. Therefore, the allegations are deemed unsubstantiated. An exit interview was conducted with Business Office Manager, Ellen Arguello. A copy of this report, LIC811 Confidential Names List, and Licensee Appeal Rights (LIC 9058, 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 29, 2026 · control 08-AS-20251112112706

Allegation investigated: Resident sustained multiple unexplained injuries in care. Resident sustained multiple falls due to lack of supervision. AMENDED COMPLAINT INVESTIGATION REPORT DELIVERED ON 3-5-2025

AMENDED COMPLAINT INVESTIGATION REPORT On February 25, 2026, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to the facility to deliver amended findings regarding the above-referenced allegations. LPA met with Executive Director, Jessica Zepeda, and discussed the purpose of the visit and elements of the complaint. This complaint investigation was previously completed on March 5, 2025. The complaint was subsequently reassigned to the undersigned LPA for further investigation. Community Care Licensing (CCL) conducted an amended investigation consisting of an additional review of facility and medical records, as well as interviews with facility staff who were present during the timeframe of the allegations, residents’ family members, and outside sources. (Continue at LIC9099C) Unsubstantiated AMENDED REPORT DELIVERED ON 3-5-2025 It was alleged that Resident 1 (R1) sustained multiple unexplained injuries while in care and sustained multiple falls due to lack of supervision. Regarding the allegation: Resident sustained multiple unexplained injuries while in care It was alleged that R1 sustained a skin tear to the forearm in June 2022, a bruise to the buttocks in August 2022, and a bruise to the forearm in October 2023. Record review revealed that during the timeframe of the alleged incidents, R1 was receiving services from an external health care provider and was bedbound. Records documented that R1 experienced intermittent skin integrity issues. Documentation indicated that each incident involving a skin issue was reported to R1’s responsible party, external health care provider, and R1’s primary care physician. Records further showed that R1’s skin conditions were monitored and treated in accordance with physician and external health care provider orders. Additional interviews conducted with facility staff who were present during the timeframe of the alleged incidents did not disclose concerns regarding unexplained injuries or neglect in care. Interviews with outside sources, including responsible parties of residents who were in care during the same timeframe, did not reveal concerns related to repositioning practices or the level of care provided by facility staff. Review of available medical records did not disclose any corroborating evidence indicating that the reported injuries were the result of neglect or improper care. Regarding the allegation: Resident sustained multiple falls due to lack of supervision It was alleged that R1 sustained multiple falls due to lack of supervision. Record review indicated that R1 had a witnessed fall on July 19, 2023, which did not result in injury. Documentation showed that the responsible party, external health care provider, and R1’s primary care physician were notified in accordance with reporting requirements as required in Tittle 22 regulations. Records further reflected that following the incident, R1’s fall risk was reassessed and addressed through updates to the facility’s service plan. (Continue at LIC9099C) AMENDED REPORT FROM 3-5-2026 (Continue from LIC9099C) Mitigation measures were implemented in response to the reassessment, including increased supervision, assistance with activities of daily living, and staff monitoring consistent with R1’s assessed needs to reduce the risk of future falls. Ongoing reassessment of R1’s fall risk and supervision needs was documented and incorporated into care planning as appropriate. Additional interviews conducted with staff present during the timeframe of the alleged incident did not disclose concerns regarding lack of supervision. Interviews with residents’ responsible parties and outside sources did not indicate concerns related to staffing levels, supervision, or the implementation of fall prevention measures for residents in care. Based on observations, interviews, and record reviews conducted during the course of both the initial and amended investigations, there was insufficient evidence to support the allegations that R1 sustained unexplained injuries due to neglect or sustained multiple falls due to lack of supervision while in care. The preponderance of evidence standard was not met; therefore, the allegations are deemed Unsubstantiated. An exit interview was conducted with Executive Director, Jessica Zepeda. A copy of this amended report, LIC811, and the Licensee Appeal Rights (LIC 9058, 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Feb 25, 2026 · control 08-AS-20240412101930

Allegation investigated: Staff handled resident in a rough manor causing injury

On February 25, 2026, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to the facility to deliver the findings regarding the above-referenced allegation. LPA was greeted by Executive Director Jessica Zepeda, with whom the investigative findings were discussed. The Department’s investigation included a facility tour, record review, and interviews with staff, residents, and outside sources. On May 22, 2025, Community Care Licensing (CCL) received a complaint alleging that staff handled Resident 1 (R1) in a rough manner, resulting in injury. Specifically, it was alleged that during toileting assistance, R1 was handled with excessive force, causing swelling and bruising to the left wrist. Staff were provided with an LIC811 to identify R1. No specific dates, times, staff names, or additional details regarding the alleged incident were provided. (Continue at LIC9099C) Unsubstantiated (Continue from LIC9099) A review of facility and resident records revealed that R1 has a documented diagnosis of mild cognitive impairment. R1 was unable to recall specific details of the alleged incident. However, during interviews, R1 stated that staff were nice, treated them with respect, and did not intentionally hurt them, but were attempting to assist with incontinent care. Interviews conducted with residents, staff, and outside sources did not disclose any corroborating evidence to support the allegation. Residents and outside sources did not express concerns regarding staff mishandling residents in an inappropriate manner. Staff interviews consistently indicated that direct care staff receive appropriate training, including proper techniques for assisting with transfers and activities of daily living, to ensure the health and safety of residents. Staff reported that care is provided in accordance with residents’ individualized service plans. Staff denied the allegation and stated they were not aware of any incidents involving residents reporting pain or sustaining injury following toileting assistance. During a visit to the facility on February 11, 2026, R1 was observed with no visible signs of abuse or neglect. Additionally, a review of R1’s daily notes for the relevant time period did not reveal any documentation supporting the allegation. Based on observations, record reviews, and interviews conducted with staff, residents, and outside sources, there was insufficient evidence to support the allegation that staff handled R1 in a rough manner causing injury. The preponderance of evidence standard was not met; therefore, the allegation is deemed Unsubstantiated. An exit interview was conducted with Executive Director, Jessica Zepeda. A copy of this report and the Licensee Appeal Rights (LIC 9058, 03/22) and LIC811, were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Feb 25, 2026 · control 08-AS-20250522101123

Allegation investigated: Staff did not provide adequate supervision of resident resulting in AWOL and serious bodily injury

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. Upon arrival, LPA was greeted by Business Office Director, Ellen Arguello. LPA identified herself and explained the purpose of the visit. Regarding the allegation of Staff did not provide adequate supervision of resident resulting in AWOL and serious bodily injury, Reporting Party (RP) stated that R1 wears a security bracelet due to R1 having wandering tendencies, RP states on 09/14/2024, staff allowed R1 to sit outside in the front area of the facility, and they turned off the alarm for R1s bracelet so that it would not continue to go off. RP states R1 was able to walk away and made it approximately 1000 yards down the street, slipped and fell, injuring R1s right knee. During the investigation, staff members were interviewed, and records were reviewed. (continue at LIC9099C) Substantiated (Continue from LIC9099) According to R1s records, facility staff will support the resident with orientation, redirection, and wayfinding. It is also noted R1 cannot leave the facility unassisted. The facility utilizes a system that activates alarmed doors when the sensor the resident is wearing is in close proximity to exiting the area. S1 stated R1 had this sensor and staff would watch R1 sit outside the front of the facility. S2 stated he/she saw R1 walk outside through the computer screen and called for staff assistance. From S2s vantage point behind the concierge’s desk, there is no line of sight to the bench in front of the facility. S3 responded to S2s call for assistance. While outside of the facility, S2 and S3 called out for R1. S3 stated, “We found R1 by the bus stop on the public street corner.” S2 and S3 did not see R1, nor did R1 say he/she fell or was injured. However, on initial assessment, S2 stated that S2 saw a wound on R1s right knee. R1 was able to elope from the facility on 09/14/2024. No supervision was being provided to R1 which allowed R1 to make his/her way to the bus stop and sustain an unwitnessed fall that resulted in serious injury. Based on observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency was cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations and is detailed on LIC 9099-D. A Plan of Correction (POC) was developed with Business Office Director, Ellen Arguello. An immediate civil penalty of $500 was assessed today. In accordance with Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Community Care Licensing Division. An exit interview was conducted with Business Office Director, Ellen Arguello, who was provided with a copy of this report, the LIC 9099-D Deficiency Report, the LIC 811 Confidential Names List, and the LIC 9058 Licensee Appeal Rights. (Continue from LIC9099A) The facility staff denied R1 exhibited signs and symptoms of serious injury upon return to the facility, and the days following the unwitnessed fall. The facility staff also denied R1 requested for emergency medical services as well. R1 received day care center services offsite. On 09/16/2024, a Licensed Vocational Nurse (LVN) assessed R1 right knee as it was scraped and swollen. A Registered Nurse (RN) documented the R1s fall at the facility on 09/14/2024. Basic wound care was provided for knee abrasion and complaints of right knee pain. During the interview with health care provider, Director of Quality and Compliance (DQC), stated R1 was seen each day at the clinic from 09/16/2024 to 09/19/2024, and the scrapes to the knee were cleansed. Documentation shows facility staff provided first aid to R1s knee on 09/14/2024, and the resident was also assessed by licensed medical professionals on 09/16/2024. Based on interviews and records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Business Office Director, Ellen Arguello, who was provided with a copy of this report, and the LIC 9058 Licensee Appeal Rights. (continue from LIC9099A) Also on the records, it was noted that an RN from the hospital reviewed the care plan for R1 with the facility resident services director (RSD) and reported the services delivered are consistent with the care plan. For the allegation of Staff did not follow reporting requirements, the facility submitted an incident report to Licensing and also to R1s doctor. Responsible parties were also contacted. Regarding the allegation of Unlawful eviction, records show that upon discharge to the hospital, R1 hasn’t come back to the facility. Transition of care (TOC) team met with RSD on 9/25/24 and noted that RSD understands R1 needs to be discharged from skilled nursing facility and they are willing to accept R1 back temporarily while a new facility is found for her, due to R1 having a higher level of care needed. Per facility, R1, will have to move from the assisted living side and go to memory care side. On the same day, RSD noted that a call from a family member regarding expediting R1s discharge from skilled nursing, RSD educated family member regarding discharge process and resident's care. On 9/26/24, an inter disciplinary team (IDT) contacted responsible party to discuss the recommendation of memory care placement. Responsible party agreed with the plan to move R1. Based on records review, the department has determined that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. An exit interview was conducted with Business Office Director, Ellen Arguello , who was provided with a copy of this report, and the LIC 9058 Licensee Appeal Rights.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 08-AS-20241017162021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Mar 13, 2026

87464 (f)(1)Basic Services Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This was not met as evidenced by: Based on interviews and records review, R1 was able to elope from the facility on 09/14/2024 due to lack of care and supervision which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: The licensee agreed to conduct staff training on regulations regarding providing care and supervision to meet residents' needs by an independent contractor. Documentation of the training will be submitted to CCL by the POC due date.

Allegation investigated: Facility failed to provide resident with higher level of care

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. Upon arrival, LPA was greeted by Business Office Director, Ellen Arguello LPA identified herself and explained the purpose of the visit. Regarding the allegation of Facility failed to provide resident with higher level of care, Reporting Party (RP) stated that resident (R1) was found to have buttocks abscess (boil) and will need wound care for 2-4 weeks. During the investigation, staff members were interviewed, and records were reviewed. On 02/07/2025, R1 had what appeared to be a small, red, bump similar to a pimple, which staff had reported. (Continue at LIC9099C) Substantiated (Continue from LIC9099) On 03/11/2025, it was noticed by the caregivers, that R1s abscess had some kind of drainage, but R1 was not complaining of pain or discomfort, the facility attempted to contact the hospital but there was no contact made. On 03/14/2025, a caregiver let a staff, S1, know there were two spots on R1s coccyx area, and one was open, but R1 had no complaints of pain or discomfort. An ointment was put on the area for comfort and the facility was observing the area. That same day S1 left a message for R1s doctor regarding the abscess discharge on R1s right buttock. Later that evening R1s doctor wanted to see R1, an appointment was scheduled for 03/15/2025, at 11:10 a.m. The facility contacted R1s family member but the appointment was cancelled for 11:10 a.m. On 03/15/2025, S1, then made arrangement for R1 to be sent out as a non-emergency transport, arriving at hospital at approximately 4:00 p.m. Records stated that R1s abscess looked quite large with possible extension to the muscle tissue, however on further evaluation the abscess did not extend into the muscle tissue and did not require operating room surgical intervention. The report stated there was no evidence of necrotic or infected tissue, however, R1 did have sepsis due to right gluteal abscess and cellulitis. Based on the information and evidence obtained, the facility did not meet the needs of R1 as R1s condition had changed due to the abscess having some kind of discharge. Even though staff did provide the required care the facility should have sent R1 out of the facility immediately, as the discharge from the open wound was now a portal for an infection as R1 had sepsis. Based on interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency was cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations and is detailed on LIC 9099-D. A Plan of Correction (POC) was developed with Business Office Director, Ellen Arguello. (Continue at LIC9099C) (Continue from LIC9099C) An immediate civil penalty of $500 was assessed today. In accordance with Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Community Care Licensing Division. An exit interview was conducted with Business Office Director, Ellen Arguello who was provided with a copy of this report, the LIC 9099-D Deficiency Report, LIC411 IM, the LIC 811 Confidential Names List, and the LIC 9058 Licensee Appeal Rights. (Continue from LIC9099A) For the allegation of Staff did not meet resident's bathing needs, RP stated that R1 is only bathed 2x per week. S3 stated that R1s Service Plan says two times a week for showers. S8 added that R1 didn’t like showers, so R1 would have bed baths. Based on interviews and records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Business Office Director, Ellen Arguello, who was provided with a copy of this report, and the LIC 9058 Licensee Appeal Rights. (Continue from LIC9099A) Based on interviews and records review, the department has determined that the allegation was false, could not have happened and/or is without a reasonable basis, therefore the allegation is UNFOUNDED. An exit interview was conducted with Business Office Director, who was provided with a copy of this report, and the LIC 9058 Licensee Appeal Rights.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 08-AS-20250317133349

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 13, 2026

87465(a)(1) Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility.....The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This was not met as evidenced by: Based on interviews and records review, the facility did not meet the needs of R1 as R1s condition had changed due to the abscess having some kind of discharge. Even though staff did provide the required care the facility should have sent R1 out of the facility immediately, as the discharge from the open wound was now a portal for an infection as R1 had sepsis, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: The licensee agreed to conduct staff training on regulations regarding providing assisting and arranging medical attention to meet residents' needs. Documentation of the training will be submitted to CCL by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA identified herself upon arrival and was greeted by Executive Director Jessica Zepeda. The purpose of the visit was discussed with Executive Director Zepeda and Business Office Director Ellen Arguello. According to the facility license, the approved capacity is 105 residents, all non-ambulatory, with up to seven bedridden residents permitted on the first floor only. At the time of inspection, facility records indicated 89 residents in care, including 45 non-ambulatory residents and 23 residents in the memory care unit. No residents were bedridden. During the visit, the LPA toured the interior and exterior of the facility with Executive Director Zepeda, inspected common areas and a sample of resident bedrooms, reviewed staff and resident records, and conducted private interviews with staff and residents. All reviewed records contained the required documentation. The facility was clean, sanitary, and in good repair. Pathways were clear of obstructions and slip hazards. Resident bedrooms contained required furnishings. Doors, windows, screens, toilets, and showers were in working order. Adequate linens, hygiene supplies, and personal protective equipment were available. (Continue at LIC809C) (continue from LIC809) The facility had sufficient space and equipment to support dining, laundry, visitation, meetings, and resident activities. Confidential records and centrally stored medications were secured in locked areas. Food supplies met regulatory requirements, including at least two days of perishable food and seven days of nonperishable food. Cooking and dining utensils were sufficient for meal service. The walk-in refrigerator temperature measured 40°F and the walk-in freezer measured 0°F, both within required ranges. Emergency food and water supplies sufficient for three days for 110 persons were maintained. The facility’s ambient indoor temperature measured between 72°F and 74°F. Hot water temperatures in resident-use taps were within the compliant range. No sharp objects, toxic chemicals, poisons, fireplaces, or open-faced heaters were accessible to residents with dementia. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are stored at the facility. Smoke detectors, fire alarms, carbon monoxide detectors, emergency lighting, and the facility telephone were operational. Fire extinguishers were serviced within the past 12 months. A complete first aid kit was present and readily accessible. Proof of current business liability insurance was provided. Required licensing postings were observed in visible areas. Based on LPA observation and staff interview, the facility utilizes delayed-egress doors in the secured memory care unit. No deficiencies were cited during today’s visit. An exit interview was conducted with Business Office Director Ellen Arguello. A copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) was provided during the visit.the state’s words, verbatim · CDSS document, Feb 11, 2026

Allegation investigated: Staff financially abused a resident while in care

On January 27, 2026, LPA visited the facility and interviewed residents, staff and the alleged victim (AV) about the alleged incident. Staff 1 (S1) explained that a resident had accused a staff member of stealing valuables from their room. S1 subsequently contacted R1’s responsible person (RS) to be aware of the situation, who then mentioned that AV had a history of accusing other people of stealing from them. RS also stated that those items “never existed”. When LPA asked about the staff being accused (S2), S1 clarified that they are not someone who usually enters residents rooms, but AV has a fixation with them. [CONTINUED ON LIC9099-C] Unsubstantiated [CONTINUED FROM LIC9099] S2 corroborated what was told by S1, and explained the fixation that AV had with them is due to AV’s mental state and the fact that when the resident first started with the facility, they were friendly with each other. On one occasion, AV mentioned that they lost money in their room and S2 offered to help, after which the accusations started. Resident 1 (R1), was familiar with AV and explained that AV had made accusations of stolen items in the past. R1 did not report the incidents due to doubts of the accusations being real, and due to AVs memory loss. LPA attempted to interview AV, however they were disoriented and not able to qualify for an interview, as they were not aware of the day nor were they able to confirm approximately how long they had lived in the facility. AV said they had no complaints against the facility at first, but after a while they stated that their objects and money was stolen and accused S2 of theft. On January 28, 2026, LPA interviewed AV’s responsible party (RS). RS stated that AV has a history of continuously reporting lost or stolen items and then finding them back. Per RS, that behavior has been repeated constantly affecting AV’s personal life due to accusing people close to them and loved ones. AV had also accused family members of stealing the same items for which they now accuse S2. RS was confident the items were not stolen. RS had no complaints about the facility or any of the staff and felt that AV could not be in a better place. On a visit on January 30, 2026, LPA interviewed the facility administrator (ADM) who provided records of the resident complaint as well as notes of the meeting held with AV and RS which corroborated that RS was aware of the situation and the proper actions were taken. Based on records reviewed, LPA observations, and interviews conducted with the victim, the victim’s POA, clients, and staff, the preponderance of evidence standard has not been met, and the allegation is deemed unsubstantiated. No deficiencies were cited in accordance with the California Code of Regulations. An exit interview was conducted with Facility Administrator Jessica Zepeda. A copy of this report and the Licensee Appeal Rights (LIC 9058, 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 08-AS-20260126121801

Allegation investigated: Questionable death

On 11/10/2025, LPA Grace Donato conducted a telephone interview with the facility to deliver findings. LPA spoke with Business Office Director Ellen Arguello and explained the purpose of the call. Regarding the allegation of questionable death, reporting party (RP) stated that aspiration occurred due to routine medications being given to the resident by facility staff (not hospice) which led to aspiration pneumonia and the death of the resident. R1 was under hospice care. Facility staff were following doctors’ orders in administering medication. On 2/16/2025, around 12:41pm, facility received fax from doctor to discontinue medication. On the evening of same date, other medications were administered. R1 was routinely checked until passing on 2/17/2025. Death certificate did not indicate that R1 passed due to aspiration pneumonia. Based on records review, the department has determined that 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. Report is reviewed and copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 10, 2025 · control 08-AS-20250318135957

Allegation investigated: Resident charged for services not rendered

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA was greeted by, identified herself to, and discussed the purpose of the visit with Business Office Director, Ellen Arguello. The Department investigated the above-listed complaint allegation. The investigation consisted of a tour of the facility, multiple interviews with staff and residents, and a detailed records review, including medical records, health and service evaluation/assessment reports, service care plans, invoice billing statements and other relevant evidence pertinent to this investigation. On May 31, 2024, Community Care Licensing (CCL) received a complaint alleging that Resident (R1) was charged for services not rendered. [an LIC 811 Confidential Names List was provided to staff to identify the Resident]. (Continue at LIC9099) Unsubstantiated (Continue from LIC9099) It was specifically alleged that R1 was charged for a level of care increase on December 20, 2023, despite no documented change in R1’s medical condition per R1’s attending physician. However, a detailed review conducted on June 4, 2024, of R1’s medical records, health and service evaluations, and service care plans from May 16, 2022, through June 1, 2024, indicated a significant decline in R1’s medical condition (see details of the change in R1’s condition below). Additionally, a comprehensive review of R1’s account summaries and billing statements for the period in question (October 24, 2023, through June 1, 2024) confirmed that the charges accurately reflected the level of care provided by facility staff (see details of the billing statements below). Lastly, interviews with staff and with external sources did not corroborate the claim that R1’s level of care remained unchanged. Details of R1’s change in condition: The physician's report at the time of admission, dated July 6, 2022, indicated that R1 was diagnosed with Alzheimer’s disease, secondary diagnosis dementia with behavioral disturbance, hypertension, (high blood pressure), hyperlipidemia (abnormally high levels of cholesterol, triglycerides or other lipids in the blood), DYNA (group of serious and complex conditions that are caused by malfunction of the autonomic nervous system), CHF (congestive heart failure), COPD (chronic obstructive pulmonary disease), A-fib atrial fibrillation (irregular and rapid beating of the ventricles. On May 16, 2022, when R1 moved into the facility under the Memory Care level 2 service care plan. R1's responsible party reviewed and signed the service care plan on July 12, 2022. On September 27, 2022, R1’s assessment indicated a change in condition and an increase in level of care due to increased checks to 4x additional checks per shift. The prior assessment showed that R1 did not need additional checks. The service care plan was signed by R1’s responsible party on October 1, 2022. (Continue at LIC9099C) (Continue from LIC9099C) On March 24, 2023, R1’s assessment indicated a significant change in condition. R1's level of care increased to MC- level 3. The main contributing factor for the increase in the level of care was due to incontinence care increased to maximum assistance. R1’s prior assessment showed that R1 was independent in this category. In addition, R1 required daily assistance with special medications (creams and hydrocortisone cream). In the earlier assessment, R1 did not require any special medications. The service care plan was reviewed and signed by R1’s responsible party on March 24, 2023. On June 8, 2023, R1’s assessment showed a significant change in condition. R1's level of care increased to MC - Level 5, R1 required a higher level of care due to several medical condition changes. R1 required maximum assistance with special care needs, and R1 required daily assistance with oxygen use. The care team assisted in meeting R1's care needs with oxygen use to improve R1's quality of life. In addition, R1's change in condition required moderate assistance to provide frequent help due to disorientation, memory loss, difficulty completing tasks, increased episodes of memory, and/or cognitive impairment. Moderate assistance with wandering to other residents' rooms and R1 attempting to leave the building. R1 required daily intervention due to disruptive, aggressive, or socially inappropriate behavior. R1 care team was required to intervene due to R1's uncooperative and resistance to care, R1 had significantly increased levels of depression, anxiety, and/or mood disorder. The assessment and service care plan were reviewed with R1’s responsible party on June 8, 2023. On December 20, 2023, R1’s assessment showed a significant change in condition. R1's level of care increased to MC Level 7 (highest level of care). R1 required maximum assistance in all areas of care to meet R1’s needs. R1’s level of care increased with transfers from 0 to 60 maximum assistance due to requiring 2-person assistance due to R1 becoming non-weight-bearing. Assistance with mobility increased from 0 to 65 maximum assistance requiring 2-person assistance with observation and fall management. R1’s meals and nutrition needs increased from 0 to 30 maximum assistance requiring special cutting/preparing food (mechanically soft) and/or prompting throughout the meal. R1’s responsible party reviewed and signed the assessment and service plan on April 13, 2024. (Continue at LIC9099C) (Continue from LIC9099C) On 2/16/2025 LPA Garcia-Centeno reviewed the invoice billings from October 24, 2023, to June 2024. The allegation was that the resident was charged for services not rendered for this period. (Continue to LIC9099C) (Continue from LIC9099C) Based on the review of R1's billing statements and account summaries from October 24, 2023, through May 21, 2024, R1 was billed correctly according to R1's level of care as indicated on service care plans. Based on observations, interviews with key staff and outside sources, and a review of pertinent records there was insufficient evidence found to support the allegation that R1 was charged for services not rendered. Due to a lack of evidence, the allegation is deemed to be unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence that the alleged violation occurred. An exit interview was conducted with Business Office Director, Ellen Arguello to whom a copy of this report, LIC 811, and Licensee Appeal Rights (9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 10, 2025 · control 08-AS-20240531124436

Type of visit: Required - 1 Year

Licensing Program Analyst’s (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Administrator Jessica Zepeda. According to the facility’s license, the facility has a maximum capacity of 105 residents, all which will be non-ambulatory and twelve may be bedridden, approved for delayed egress. During today’s inspection, according to records, there were a total of 80 residents in care, LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected a sample of resident rooms. The facility was clean, sanitary, and in good repair. Hot water temperature was compliant. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Smoke alarms, carbon monoxide detectors, emergency lighting, facility telephone, fire extinguisher and first aid kit were present. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and client records/files. Files reviewed contained required documents. Required licensing postings were observed in visible areas of the facility. No deficiencies were cited during today's annual inspection. An exit interview was conducted with Administrator to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Feb 20, 2025

Allegation investigated: Staff is intoxicated of alcohol while caring and supervising residents in care.

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Administrator Jessica Zepeda and discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside agency. It was reported to CCL that facility staff (S1) was intoxicated while caring for and supervising residents in care. [Continued on LIC 9099-C] Unsubstantiated Regarding the allegation, it was alleged that facility staff (S1) smelled of alcohol and was seen yelling loudly and not being professional at the front desk. Records review revealed that S1 is in the sales department and job description does not include any caring for or supervising of residents. Interviews with facility staff confirmed that S1 does not provide care or supervision of residents. Interviews with staff revealed conflicting statements on whether or not S1 appeared to be under the influence of alcohol while at the facility. Staff interviews revealed there was a day when S1 showed up at the facility and was upset about a personal matter and was seen speaking loud due to being upset. Interviews with staff availed no witnesses to S1 consuming alcohol. Some staff interviews revealed that S1 generally speaks in a high pitch. Interview with outside source revealed no accounts of witnessing facility staff under the influence of alcohol while at the facility. Interviews with residents revealed no concern for staff being under the influence of alcohol at the facility. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Zepeda. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Zepeda whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Oct 17, 2024 · control 08-AS-20240515104136

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Jessica Zepeda. Today's visit was in response to Licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 9/20/2024. [See LIC 811 Confidential Names List for a description of R1]. Per the report, R1 passed away on 9/9/2024. During today’s visit, LPA conducted health and safety check, finding no safety concerns. LPA also collected copies of and reviewed pertinent care records, and interviewed staff. No deficiencies were observed or cited during today’s visit. An exit interview was conducted with Zepeda, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Oct 17, 2024

Allegation investigated: Neglect/ Lack of supervision resulted in resident sustaining injuries

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced visit to deliver complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Jessica Zepeda. Throughout the investigation the Department requested records, and conducted interviews with external and internal sources, including staff and residents. It was alleged staff neglect resulted in a resident sustaining injury while in care. A source alleged Resident # 1 (R1) suffered multiple falls, including one on June 4th, 2018, and a second fall on January 31st, 2019, that resulted in hospitalization, and lacerations requiring stitches. R1, a Seventy-Nine (79) year old memory care resident, was diagnosed with Dementia and assessed as a high fall risk during admission to the facility. A medical assessment revealed R1 could be confused and agitated at times. A service plan dated February 19th, 2019, revealed the facility assisted the resident with incontinence care, escorting, dressing, medication management, a puree diet, and hygiene, including two-person assistance with baths and showers. (See LIC 9099C form for continuation of report.) Substantiated Throughout R1 residing at the facility, interviews with staff and R1’s family revealed R1’s health declined from being ambulatory with the use of a walker, to eventually wheelchair bound. Assessments conducted by the facility for R1 on 1/4/18, 2/6/18, 8/1/18, 1/31/19, 8/16/19, 2/15/20, and 6/24/20, consistently revealed R1 was at high risk for falls. Narrative charting records documented on June 3rd, 2018, R1 sustained a witnessed fall, R1 hit a wall, and staff summoned medical attention due to R1 sustaining a skin tear to the head. On January 31st, 2019, during the overnight shift, staff found R1 on the floor next to R1’s bed with a laceration to the head, and staff summoned medical attention. R1 was transported to the hospital on both occasions, with the fall on 1/31/2019 requiring stitches. Review of photographs obtained from R1’s medical provider, confirmed R1 suffered lacerations on both occasions. From approximately March 24th, 2018, to October 11th, 2019, R1 sustained approximately twelve (12) witnessed and unwitnessed falls. On at least seven of the twelve noted falls, R1’s falls were unwitnessed. A Service Plan for R1 dated January 31st,2019, did not reveal any measures addressing R1's falls. On subsequent visits the Department requested records, but the facility was not able to produce such records, including service plans addressing R1’s falls. Although staff reported checking in on R1 every two hours, the facility did not implement any fall prevention measures for R1 until after the fall on January 31st, 2019, which resulted in a hospital visit and R1 sustaining a laceration requiring stitches. By January 31st, 2019, review of records revealed R1 had sustained approximately ten (10) falls with no severe injuries. Interviews with multiple staff and R1’s family corroborated the facility implemented fall prevention measures after January 31st, 2019. The measures included placing bed rails and lowering of the bed. An Outside Agency Form dated January 31st, 2019, revealed fall prevention measures were discussed with staff on that date. The measures discussed with the external agency included lowering R1’s bed, conducting frequent checks and cleaning R1’s room to minimize trip hazards. During the investigation the facility produced assessments and service plans for R1, but these did not indicate what fall mitigating measures were implemented, nor what staff actions were implemented to mitigate R1’s falls. (See additional LIC 9099C form for continuation of report.) R1’s diagnoses included Hypernatremia (High Concentration of sodium in blood) due to Hypovolemia (decreased volume of circulating blood). There were no diagnoses related to, nor suspecting lack of fluid intake noted in the discharge summary. At the time of discharge form the hospital, R1’s diet had changed to nothing by mouth, until R1 was “more awake, and passes swallow eval”. The hospital's progress notes dated June 25th, 2020, noted R1 was hospitalized from June 22nd, 2020, to June 24th, 2020, with bilateral pneumonia and hypernatremia. Although Hypernatremia was noted as a admitting diagnoses, there were mentions of dehydration being a diagnosis. Additional interviews with multiple residents did not reveal there were concerns with lack of assistance with food, nor with lack of fluids available to residents. It was alleged neglect resulted in pneumonia. A source reported R1 was hospitalized and diagnosed with Pneumonia. The reporting party questioned how R1 suddenly developed Pneumonia as it could not happen overnight. Records obtained from R1’s medical care providers, including a hospital discharge summary and progress notes dated June 25th, 2020, and a hospice agency revealed the Pneumonia was likely bacterial and the suspected cause was aspiration (inhalation of foreign object or substance into the airways). Interviews with staff revealed R1 was assisted and seated at 90 degrees, as there was concerns of aspiration due to R1’s difficulty swallowing. Interviews with staff also revealed R1 had developed a cough for approximately a week prior to being hospitalized on June 20th, 2020. Staff notified R1’s family and R1’s primary care physician. On June 205th,/20, emergency medical services were summoned as R1 presented low oxygen levels and was congestion. It was alleged staff did not administer medication as prescribed. A source alleged the facility staff over medicated R1, as R1 seemed to sleep more and was less responsive. Interviews with residents, staff, resident’s responsible parties, and the Long-Term Care Ombudsman office did not reveal any concerns with staff over medicating residents. The LPA reviewed the Department’s Guardian system to locate the staff who was mentioned, but contact attempts were not successful. Additionally, the LPA requested additional records for review, but the facility was not able to produce such records. Based on the investigation, there was not enough evidence to prove the alleged violations occurred, therefore, the allegations were Unsubstantiated. An exit interview was conducted with Zepeda, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058) were provided. Based on evidence obtained, the allegation of staff neglect resulting in resident sustaining injury, was Substantiated. The deficiency was cited in accordance with California Code of Regulations, Title 22, and listed on the LIC 9099D form. An immediate $500 civil penalty was assessed, and a plan of correction was jointly formulated with Executive Director Jessica Zepeda. Per Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted with Zepeda, to whom a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Sep 30, 2024 · control 08-AS-20200625151823

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Sep 30, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by: Based on review of records, and interviews, the licensee did not ensure R1 was free of neglect, which resulted in R1 sustaining injuries, this posed an immediate health, safety, and personal rights risk to 1 of 89 residents in care.the state’s words, verbatim · CDSS document, Sep 30, 2024

Plan of correction: Executive Director agreed to provide in service training to all care staff/ Med techs regarding the following topics; proper record keeping, change of condition, service planning, and internvention implementation, by 10/11/2024. The ED agreed to provide the LPA a log of who attended the trainings, by 10/11/24.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Jessica Zepeda. Today's visit was in response to Licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 8/26/2024. [See LIC 811 Confidential Names List for a description of R1]. Per the report, R1 passed away on 8/19/2024. During today’s visit, LPA conducted health and safety check, finding no safety concerns. LPA also collected copies of and reviewed pertinent care records. No deficiencies were observed or cited during today’s visit. An exit interview was conducted with Zepeda, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 27, 2024

Allegation investigated: Resident's care plan does not accurately represent the care provided

Licensing Program Analyst Becky Kennedy concluded the investigation which began on 3/18/21. LPA Kennedy made an unannounced visit to the above facility today and met with Ellen Argullo, Business Office Manager. LPA advised them of the reason for today's visit and delivered the investigation findings on the above allegation. It was alleged that Resident 1’s (R1) care plan does not accurately represent the care provided. The investigation included interviews with internal and external sources, review of records, and a virtual tour of the facility. Interviews revealed that R1 had an insurance Policy that would reimburse R1 for some services. R1 had multiple conversations with facility administration to modify the care plan so that R1 could access insurance reimbursements. It was further revealed that R1 would periodically refuse services that were on the care plan and request services that were not on the care plan. Unsubstantiated R1 was concerned about what care required an extra fee and what would be reimbursed. The primary concern raised in the investigation was what, and how services were written on the case plan to receive reimbursement form R1’s insurance company. The investigation did not reveal evidence that the care plan was not accurate regarding the services R1 was offered or received. The preponderance of evidence standard has not been met and this allegation is unsubstantiated. An exit interview was conducted with Ellen Argullo, Business Office Manager. A copy of this report along with Licensee Rights (LIC9058 01/2016) was left at the facility.the state’s words, verbatim · CDSS document, May 22, 2024 · control 08-AS-20210212154050

Allegation investigated: Staff mismanaged resident's medication

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Executive Director Jessica Zepedaand discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside agency. It was reported to CCL that facility staff mismanaged resident’s medication. [Continued on LIC9099-C] Unsubstantiated [Continued on LIC9099] Regarding the allegation, it was alleged that resident (R1) was not getting their medication due resident spitting medication out when being administered and staff not trying to dispense medication again at a later time. Interview with outside source (OS) revealed that they have witnessed staff dispense medication to R1, R1 spit medication out and staff wrote down that R1 refused medication. OS reported that staff stated they could not dispense the medication again due to R1 refusing medicine. Interviews with facility staff revealed that staff are aware that residents have the right to refuse medication and are not to be forced to take medication. Facility staff reported that when a resident spits medication out staff dispose of the medication and note it in Quick MAR. Records review revealed that the facility had documentation of incident where R1 spit medicine out. Records review revealed that none of R1’s medication orders state that the medication is to be administered multiple times in the event that R1 spits medication out. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Executive Director Jessica Zepeda. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Zepeda whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, May 21, 2024 · control 08-AS-20240122152834

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) conducted an unannounced Case Management visit. LPA disclosed the purpose the visit to Mainentance Director George Hayes and was allowed entry into the facility. Executive Director Jessica Zepeda met with LPA shortly after. The facility presently uses delayed-egress doors in its secured memory care area and requested the local fire authority to grant approval in writing for the use of the delayed-egress doors. The Fire Safety Inspection Request (STD850) was completed by the local fire authority and received in the RO on May 9, 2024. The requested fire clearance has been approved by the local fire marshal, which includes the facility's updated floor plan and the use of delayed egress. LPA reviewed the facility’s updated floor plan, which matches the STD850. LPA also observed that the new floor plan was posted in a visible area. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Jessica Zepda, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, May 15, 2024

Allegation investigated: Staff did not meet resident's incontinence care needs.

Licensing Program Analyst Becky Kennedy concluded the investigation which began on 7/29/21. LPA Kennedy made an unannounced visit to the above facility today and met with Jessica Zepeda, Executive Director. LPA advised Ms.Zepeda that the reason for today's visit is to deliver the investigation findings on the above allegation. The investigation consisted of interviews with internal sources, a review of reports and records, and a tour of the facility. It was alleged that Resident 1 (R1) (see LIC 811 for confidential names) requested incontinence care from facility staff and the care was not provided for approximately six hours when R1 called again to request care. Substantiated The investigation revealed that R1 activated their call button at 9:17 PM to request care as they had defecated and needed to be cleaned. Staff 1 (S1) responded to the resident and informed them that they could not provide the care at that time as S1 was the only caregiver on duty at that time. S1 was near the end of their shift. S1 reported that they informed the relieving caregiver about R1’s need for care. The care need was not transferred to the next shift in writing violating facility policy. The relieving caregiver did not provide care to R1. R1 fell asleep without receiving care. R1 woke up about and called for care at 3:26 AM and the care staff provided the required care. R1 received care over six hours after their first request for assistance. R1 was left in soiled clothing for an excessive period of time. The preponderance of evidence standard has been met and this allegation is substantiated. A deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6 Chapter 8, and is listed on the 9099D. An exit interview was conducted with Jessica Zepeda, Executive Director and a copy of this report, LIC 811, LIC 9099 D and Licensee/Appeals Rights (LIC 9058 01/16) was provided.the state’s words, verbatim · CDSS document, Apr 26, 2024 · control 08-AS-20210726092242

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(4) · Plan of correction due date: Apr 26, 2024

87464 Basic Services(to include) (4) Personal assistance and care as needed by the resident …with those activities of daily living ... Based on interviews and record review 1 of 63 residents did not receive basic services when care was not delivered to R1 for six hours which posed a potential risk to the health of persons in care.the state’s words, verbatim · CDSS document, Apr 26, 2024

Plan of correction: Facility will coach S1 regarding edorsing care needs to other staff if unable to provide care, endorse in writing from shift to shift, and to elivate issues with specific residents to supervisor.

Allegation investigated: Staff did not communicate with responsible party of fee increases for resident's care plan.

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Resident Services Director Eva Amorim and discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside agency. It was reported to CCL that staff did not communicate with responsible party of fee increases for resident’s care plan. [Continued on 9099-C] Unsubstantiated [Continued from 9099] Regarding allegation, “staff did not communicate with responsible party of fee increases for resident’s care plan”, it was alleged that the facility increased cost in care level for R1 without having a meeting with responsible party. Interviews with facility staff revealed that they do not schedule a meeting every time there is a change in care level pricing. Review of admission’s agreement had no mention of required meetings when changes in care level costs. Admission’s agreement section “Change in Services” states “If Westmont at San Miguel Ranch determines through an assessment, that you require additional services or a different care program than the one in which you are participating , you agree to the new additional services or care program appropriate to your needs. The rate for the new service or care program shall apply immediately. The community will give you written notice of a care change and corresponding rate increase within two (2) business days after providing newly assessed services.” Interview’s with outside sources revealed that R1’s responsible party did not receive notification of increase in care level cost. Facility provided LPA documentation showing that changes to service plan was emailed to R1’s responsible party on 12/20/2023. Review of records revealed that R1 required more assistance with ADL’s on updated assessment dated 12/20/2023. Interview’s with outside sources revealed that R1 did require more assistance with ADL’s since the last assessment that was conducted in 6/9/2023. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Resident Services Director Eva Amorim . A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Resident Services Director Eva Amorim whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Mar 27, 2024 · control 08-AS-20240112134103

Allegation investigated: Staff are not providing residents with food Staff did not meet the needs of incontinent resident (s) Staff did not administer medications as prescribed Facility staff falsified a document Staff are not following residents care plan Facility did not ensure that hazardous items were inaccessible to residents Facility did not maintain comfortable temperature for residents Facility staff failed to follow reporting requirements

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Michael Sokolowski. Throughout the investigation, the Department requested pertinent records and conducted interviews with external and internal sources, including staff and residents. It was alleged staff did not provide residents food. It reported to the Department staff would not assist residents with feeding, and often food trays were witnessed to be untouched. Interviews with internal and external sources revealed the facility used food trays to deliver food to residents during the COVID-19 Pandemic. These sources did not corroborate witnessing lack of assistance with feeding, nor witnessing undelivered food trays. It was also revealed staff had provided the resident in question with different options, including cultural food choices. (See LIC 9099-C for continuation of report.) Unsubstantiated It was alleged staff did not meet the needs of an incontinent resident. It was reported to the Department residents were found with soiled incontinence briefs. Interviews with internal and external sources did not reveal any concerns regarding staff not providing incontinence care. Interviews did reveal some of the residents may have experienced an increase in bowel movements and this may have contributed to staff encountering residents with soiled briefs, but there were no concerns with lack of care. Additionally, there were no concerns with skin irritation, nor breakage due to lack of incontinence care. It was alleged staff did not assist residents with prescribed medication and that staff falsified documents. It was reported to the Department facility staff had witnessed medications had been dispensed, documented as taken by resident, but instead placed in a medication cart. Interviews with internal sources did not recall witnessing any similar incidents, nor the staff not assisting residents with medication. External sources did not have any concerns with lack of medication assistance. The facility did not produce the records requested by the Department, as they were not readily available. It was alleged Staff were not following a resident's care plan. It was reported to the Department staff had not assisted residents with showers. Interviews with internal and external sources did not corroborate staff were not assisting residents with showers, nor did they reveal any concerns with lack of assistance from staff. Interviews did reveal that during the time period in question, there were staff disagreements that had led to staff blaming each other. Records requested from the facility were not readily available for review. It was alleged staff did not ensure hazardous items were inaccessible to residents. It was reported to the Department that a Salon in the Memory Care unit was not secured; therefore, chemicals and sharp items were accessible to residents. An interview with the Executive Director at the revealed the facility had addressed the concern about the door not locking properly. Interviews with internal and external sources did not corroborate chemicals, nor sharp items being accessible to residents. During a visit to the facility, the LPA witnessed the salon to be locked and used for Personal Protective Equipment storage. Additionally, the Reporting Party disclosed having photographs corroborating the door was unlocked. These photographs were not provided to the Department. (See additional LIC 9099-C for continuation of report.) It was alleged staff did not maintain a comfortable temperature for residents. It was reported to the Department staff left residents windows open at night. Interviews with internal and external sources did not reveal any concerns regarding staff leaving residents windows open. Staff would close windows at the residents’ requests. Additional interviews revealed residents had reported rooms may have been warm and management addressed this with the facility maintenance personnel. There was no evidence to corroborate windows were left open, nor that this resulted in residents having cold like symptoms. It was alleged facility staff failed to follow reporting requirements. It was reported to the Department facility staff did not follow the facility's internal process of reporting concerns. External sources revealed some staff would report concerns to management team and would expect management to follow up with them when follow up was not required, or necessary.. Interviews with internal and external sources, including third party providers, did not reveal any concerns with lack of communication from staff. Based on the evidenced obtained throughout the investigation, there was not a preponderance of evidenced to prove the alleged violations occurred, therefore, the allegations were unsubstantiated. An exit interview was conducted with Michael Sokoloswky, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Jan 30, 2024 · control 08-AS-20200713094709

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPAs) Liliana Silveira and Dang Nguyen conducted an unannounced visit to continue a Required Annual Inspection which began on 01/16/2024. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Michael Sokolowski. According to the facility’s license, the facility has a maximum capacity of 105 residents, all which will be non-ambulatory and seven may be bedridden (and the bedridden residents may only reside on the ground floor). During today’s inspection, according to records, there were a total of 71 residents in care, of which 43 were non-ambulatory and none were bedridden. During today’s visit, LPAs, accompanied by licensee’s staff, toured the interior and exterior of the facility and inspected common areas and a sampling of resident bedrooms. LPAs privately interviewed multiple staff and residents. LPAs also reviewed multiple staff and resident records/files. The files which were reviewed contained the required documents. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained required furniture. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Confidential records and centrally stored medications were kept in locked areas. The facility had at least two days of perishable food and seven days of non-perishable food present. The facility had cooking and dining utensils to facilitate resident meal service. The Walk-In Refrigerator’s temperature was compliant at 40 F, and the Walk-In Freezer’s temperature was complaint at 0 F. The facility’s ambient internal temperature was compliant at 74 F. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Where tested, hot water temperature at taps (which were used by residents for personal care) were compliant: Bedroom #107 sink was 116.1 F, Bedroom #131 sink was 115.5 F, Bedroom #214 sink was 109.7 F, Bedroom #229 sink was 114.5 F, Bedroom #246 sink was 112.4 F. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents diagnosed with Dementia. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke and fire alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were serviced within the last 12 months. A complete first aid kit was present and readily accessible. Licensee's staff also presented proof of current/active business liability insurance. Required licensing postings were observed in visible areas of the facility. Based on LPAs’ observation and confirmed by manager interviews: The facility presently uses delayed-egress doors in its secured memory care area. However, Licensee did not ensure that the facility’s local fire authority granted approval in writing for use of delayed-egress doors, as was required before their use. Per the facility license which CCLD issued to Licensee, approval for use of delayed-egress doors was also not expressly approved. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with Licensee. LPAs also issued Technical Assistance (TA) regarding Infection Control (see the LIC 9172-TA). An exit interview was conducted with Sokolowski, to whom a copy of this report, the LIC 809-D, the LIC9172-TA, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jan 19, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Dang Nguyen and Liliana Silveira conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by and identified themselves to Executive Director Michael Sokolowski. LPA discussed the purpose of the visit with Executive Director Michael Sokolowski and Resident Services Director Eva Amorim. During today’s visit, LPAs briefly toured the facility, reviewed staff and resident records, and interviewed staff and residents. No deficiencies were cited during today’s visit. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection. An exit interview was conducted with Michael Sokolowski, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jan 16, 2024

Allegation investigated: - Insufficient staff to respond to residents' call buttons timely

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver investigative findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by Alyssa Antolin, concierge. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director Michael Sokolowski. The Department’s investigation consisted of interviews with residents and staff, and records review of relevant documents pertinent to this investigation. On September 20, 2023, it was alleged that there were insufficient staff to respond to residents’ call button timely resulting in injuries. Interview with residents did not coincide. Upon interviews, most residents did say that the staff response time once their call buttons were pushed were timely. One resident reported staff responding to call buttons untimely of about 20 minutes or not at all. None of the residents reported being injured in the process of staff response to their call buttons. Unsubstantiated Staff interviews said that there are times when the residents accidentally take their devices with them out into the community which staff are unable to answer. A review of the facility’s activity records for the months of August 2023 and September 2023, there were five residents whose call button were over the time frame of 30 minutes. Submission of incident reports (IR) were reviewed for the months of August 2023 and September 2023. Upon review of the IR’s, there was only one incident report on file submitted to the San Diego Regional Office that reported resident sustaining an injury due to a fall, but according to the Device Activity Report, there was no call to the room. According to that IR the staff responded accordingly by contacting emergency response. In review of additional submitted reports, residents who sustained falls were taken to the hospital for further evaluation and treatment. None of the IR’s displayed major injuries due to staff untimely response of call devices. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside source interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Executive Director Michael Sokolowski. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Sokolowski at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Dec 5, 2023 · control 08-AS-20230920152253

Allegation investigated: - Staff did not meet training requirements

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings of a complaint investigation regarding the above-mentioned allegation. LPA identified herself and was granted entry by Alyssa Antolin, concierge. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director Michael Sokolowski. The Department’s investigation consisted of interviews with residents and staff, and records review of relevant documents pertinent to this investigation. On October 2, 2023, it was alleged that staff did not meet training requirements. It was specifically alleged that staff #1 (S1) was inappropriately trained to provide medications to residents. Interview with S1 confirmed that they assisted with passing out medications, but there was always an assigned Medication Technician (Med Tech) dispensing the medications into a cup for the residents. Unsubstantiated S1 confirmed that they did not dispense the medications. The assigned Med Tech dispensed the medication into assigned cups that displayed the room number on the cup and onto a clipboard that had the same room number that matched the cup. There were no more than approximately 5 cups on the clipboard which S1 passed out along with the assigned Med Tech. Interview with staff #2 (S2) confirmed S1’s interview. LPA Lopez reviewed staff job descriptions, medication administration records (MAR’s), training logs, and Provider Information Notice (PIN). Records revealed that S1 did not have medication training, but the Med Tech who S1 assisted had records that showed they had medication training. S1’s job description say’s that S1 should have the ability to make independent decisions when circumstances warrant such action and to remain calm during emergency situations. A review of medication logs revealed that a Med Tech provided residents with their medications on 10/01/2023. There was no indication that S1 dispensed residents’ medications. S1’s training log showed active action towards their training for the months of June, July and September. In review of Med Tech's training log, it revealed that they were properly trained to dispense medications. In review of PIN 23-16-ASC, Residential Care Facilities for the Elderly Reference Guide to Administrator, Staff and Volunteer Training Requirements, the requirements that all staff require were fulfilled by S1 and S2 according to their training logs. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside source interviews, and records reviewed, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Executive Director Michael Sokolowski. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Sokolowski at the conclusion of the visit. The signature below confirms the receipt of these documents. Although residents confirmed their medications were provided late, they did not confirm that the medications were incorrect. Staff interviews confirmed that medications were formerly provided to residents late due to agency staff cancelling their shifts on their assigned shift date. Staff said that they were redirected to fill-in the vacant areas to ensure residents had their morning medications dispensed. They confirmed that due to a late start in passing medications, some of the medications were dispensed late. Interview with the Executive Director confirmed that they worked with an agency to fill the vacant positions as needed. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during resident and staff interviews, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Executive Director Michael Sokolowski. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Sokolowski at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Dec 5, 2023 · control 08-AS-20231002095754

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(C)(2) · Plan of correction due date: Dec 22, 2023

87465 (C)(2) Incidental Medical and Dental Care … Once ordered by the physician the medication is given according to the physician's directions… this requirement was not met as evidence by: Based on staff and resident interviews, facility did not provide the residents their medications as prescribed, at the appropriate timeframe. This posed a potential health risk to 4 of 71 [R1, R2, R3, & R4] residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2023

Plan of correction: Facility will assign a lead staff to ensure agency staff are trained and there is an assigned staff who are responsible for proper medication distribution. Facility will submit a month's calendar of the assigned leads by POC due date, 12/22/23.