Whitten Heights Assisted Living and Memory Care

Allegation investigated: Staff are not providing medication as prescribed. Staff are falsifying medication records.

On August 10, 2026, at 10:30 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced initial complaint visit and delivered findings at the facility. LPA Kim met with Chief Operating Officer Faye Shen and explained the purpose of the visit. During today's visit, LPA Kim conducted a physical tour of the facility. LPA Kim reviewed and obtained copies of resident roster, staff roster, and one resident’s records, which include: Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans/Reappraisal, Medication Administration Record, and other pertinent records. LPA conducted interviews with one residents and four staff. The investigation revealed the following: Continued on LIC9099C Unsubstantiated Allegation: Staff are not providing medication as prescribed. It is alleged Resident #1 (R1) is experiencing pain and is not receiving their medications when requested. Based on interviews conducted, four out of four staff and one out of one resident denied the allegation. One of two witnesses confirmed the allegation. One out of two witnesses could not confirm or deny the allegation. R1 stated that the facility provides all medication as prescribed and that if R1 requested pain medication, the staff would provide all the necessary pain medication. Four staff stated that although R1 can communicate verbally, but R1 is soft-spoken and is hard to understand. Through physical cues all staff stated they can understand if R1 is in pain. Whenever R1 was in pain, all staff stated they would provide the correct PRN as needed if requested. Based on record review, Medication Administration Record dated July 2026 show that R1 was given their PRNs on July 1, 2026, to July 30, 2026. R1 did not make any PRN requests for August 2026, and LPA verified this by reviewing the Medication with the Medication Administration Record which matched. Based on the information gathered, there is no sufficient evidence to corroborate the above allegation. Based on interviews conducted and records reviewed, when R1 requested PRN pain medication, then it was given. If R1 didn’t request, then R1 did not receive. R1 verified the facility provides all medication prescribed and through PRN as requests in a timely manner and when requested. Allegation: Staff are falsifying medication records. It is alleged on July 6, 2026, that a medication technician was filling out the requested Medication Administration Record (MAR) and was not maintained accurately. It is alleged a more precise and fixed MAR would be sent later in email. Based on information gathered four out of four staff denied the allegation. One out of two witnesses confirmed the allegation. One out two witnesses could not confirm or deny the allegation. S3 stated that they filled out the MAR in person from the electronic MAR on July 6, 2026, when it was requested. They stated they had made mistakes because they were copying from the electronic MAR to a physical copy. S2 stated that they sent and updated MAR with the correct information from the Electronic MAR to the requested representative. Based on record review, the MAR dated July 2026, the Electronic MAR and PRN MAR was filled accurately for R1 when administered. LPA observed the MAR provided on July 6, 2026, and July 10, 2026, through an email correspondence from the staff and representative. All the documents provided verified the interviews of S2 and S3 about the errors on the MARs provided to the representative. Continued on LIC9099C Based on the information gathered, there is no sufficient evidence to corroborate the above allegation. Based on the record review and interviews, the facility staff did not falsify medication records. There was an error from S3 transcribing from the Electronic MAR to the physical MAR provided to the representative requesting the MAR on July 6, 2026. S2 sent an accurate MAR because they were notified of the concerns and provided the accurate MAR on July 10, 2026. Based on observations, interviews, and records review, LPA did not find sufficient evidence to support the above allegations Staff are not providing medication as prescribed and Staff are falsifying medication records. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Exit interview was conducted and a copy of the report was provided to Chief Operating Officer Faye Shen.the state’s words, verbatim · CDSS document, Aug 10, 2026 · control 22-AS-20260803160824

Allegation investigated: Staff allow residents to smoke in non-smoking areas

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Chief Operating Officer (COO) Faye Shen, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that staff allow residents to smoke in non-smoking areas revealed the following: During the course of the investigation, LPA inspected the facility, interviewed COO and residents, and obtained and reviewed copies of the resident roster, staff roster, and Resident #1’s (R1) facility progress notes. CONTINUED Substantiated It was alleged that the facility is allowing residents to smoke in their rooms. LPA interviewed COO who stated that the designated smoking area is the central courtyard and smoking is not allowed anywhere else. LPA inspected the facility and noted the smell of smoke around stairway 3 in the first floor hallway when no smoke could be smelled in the central courtyard. COO was unable to explain the smell of smoke in the first floor hallway, stating no nearby residents are known to smoke. LPA inspected five occupied rooms on the second floor and noted that R1’s room smelled like smoke and ash, indicating R1 has smoked in their room often and for a long time. COO stated that R1 has smoked in their room in the past because they are far from the designated smoking area, R1 has been given warnings, R1 has stopped smoking in their room in response to these warnings, but R1 has also resumed smoking in their room necessitating additional warnings. Per R1’s facility progress notes, R1 was given a warning on July 19, 2026, about smoking in their room. This is the only documented warning R1 received. COO stated that R1 is currently in the process of being relocated to the first floor, closer to the central courtyard, to encourage them to smoke in the designated smoking area. LPA also observed that rooms close to R1’s room contained oxygen, which increases the safety risk of R1 smoking in their room. When interviewed, R1 denied smoking in their room, stating they smoke two cigarettes a day only in the courtyard since moving in. However, residents nearby corroborated smelling smoke, that the smell bothered them, and that this is not a recent issue. The information obtained corroborated that the facility did not timely and sufficiently address R1 smoking in their room, which is not a recent issue and creates a risk due to oxygen being nearby. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 22-AS-20260721085252

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jul 25, 2026

87468.1 Personal Rights… (a) … (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on observations and interviews, the licensee did not ensure a safe and healthful environment by allowing R1 to smoke in their room near rooms with oxygen, which poses an immediate safety and personal rights risk to persons in care.CIVIL PENALTY ASSESSEDthe state’s words, verbatim · CDSS document, Jul 24, 2026

Plan of correction: The licensee stated that R1 is already being moved closer to the designated smoking area and they will submit proof to LPA by 07/31/26. Licensee stated they will investigate the smoke smell near stairway 3 and provide a plan to address it to LPA by POC due date.

Allegation investigated: Due to staff neglect, resident sustained multiple falls resulting in injuries Staff verbally abused resident Staff did not meet resident's needs

This report is being amended for signature. On 05/10/2026, Licensing Program Analyst (LPA) Arielle Pascua delivered complaint findings. LPA Pascua informed Facility Designated Administrator (FDA), Faye Shen the purpose of the call. Current Census 118. Allegation: Due to staff neglect, resident sustained multiple falls resulting in injuries. It was alleged that due to staff neglect, resident sustained multiple falls resulting in injuries. During the course of this investigation, LPA Pascua conducted interviews and reviewed facility records. Based on interviews conducted with Facility staff it was denied that the facility staff neglected the resident which lead to falls resulting in injuries. It was stated that this resident was placed on hospice services during their stay at the facility due to their progressive diagnosis. A review of the resident's care plan revealed that this resident's condition may have contributed to the resident falling due to leg weakness however due to conflicting information gathered from interviews, it was unclear id due to staff neglect the resident sustained multiple falls resulting in injuries. Unsubstantiated Allegation: Staff verbally abused residents It was alleged that staff verbally abused residents. During the course of this investigation, LPA Pascua conducted interviews. Based on interviews conducted, it was denied by facility management that staff verbally abused residents in care. LPA Pascua was unable to reach facility staff who may have worked during the time of the allegation, therefore, LPA Pascua was unable to corroborate that the facility staff verbally abused residents in care. Allegation: Staff did not meet resident's needs It was alleged that staff did not meet resident's needs. During the course of this investigation, LPA Pascua conducted interviews. Based on interviews conducted, it was denied by facility management that staff did not meet resident's needs. LPA Pascua was unable to reach facility staff who may have worked during the time of the allegation, there, LPA Pascua was unable to corroborate that the facility staff verbally abused residents in care. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. Exit Interview, a copy of this report will be mailed to the facility licensee address as well as via email.the state’s words, verbatim · CDSS document, May 10, 2026 · control 22-AS-20240722164910

Allegation investigated: Neglect resulted in a resident aspirating

This report is being amended for signatures. On 05/09/2026, Licensing Program Analyst (LPA) Arielle Pascua delivered complaint findings via telephone with Facility Licensee, Faye Shen and explained the purpose of the visit. The purpose of the visit was to deliver complaint findings for the allegation above. Current census was 118. A brief interview with Licensee Shen was conducted. It was alleged that due to staff neglect the resident aspirated. Based on information gathered, it was learned that during the time when the resident aspirated, the resident was not at the facility at the time. This agency has investigated the complaint allegation(s). This agency has found that the complaint was UNFOUNDED, meaning that the allegation(s) were false, could not have happened and/or was without a reasonable basis. This agency has therefore dismissed the complaint. There were no deficiencies observed or cited during today’s complaint visit. Exit Interview and a copy of this report will be sent to the facility mailing address. An email copy was also provided for signature. Unfoundedthe state’s words, verbatim · CDSS document, May 9, 2026 · control 22-AS-20240710140223

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Activity Coordinator (AC) Clara Ramirez and discussed the purpose of the inspection. Chief Operating Officer (COO) Faye Shen arrived during the inspection. LPA reviewed Infection Control requirements. At about 1:00PM, LPA and AC conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following: Structure: this is a large commercial facility. Facility is composed of a single, three-story building with an outdoor courtyard in the center, a commercial kitchen and large dining room on the first floor, a medication room on the second floor, multiple laundry rooms, a memory care unit on the second floor, a memory care unit on the third floor, resident rooms on all floors, along with multiple common areas and storage rooms. There is a total of 135 resident rooms. Resident Bedrooms: the 12 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 12 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 113 and 125 degrees F, before corrections, in the 12 resident bathrooms tested. Call system tested in multiple resident bedrooms with prompt responses from staff. LPA tested the delayed egress systems in both memory care units and noted they functioned properly. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the housekeeping closets and laundry rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing paid. At about 8:00AM, LPA reviewed 10 resident files and 10 staff files, interviewed 5 residents and 5 staff, and inspected medications for 10 residents. Facility does not handle resident money. LPA provided California Department of Public Health informational material on Legionnaires’ Disease during the inspection. During the inspection, LPA and AD observed the following: based on observations, there were multiple areas in the facility's two memory care units, especially Room 259, which smelled strongly of urine; based on observation, the water temperature tested at 122 degrees F in Room 122, 125 degrees in Room 347, and 124 degrees in room 341; based on documents, the physician's reports for R1, R6, and R9 are on the old form and do not contain required information, including behavioral expressions; and based on documents, the facility has been conducting emergency disaster drills annually, and not quarterly as required. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Apr 21, 2026

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Licensee did not ensure that resident's responsible party was notified of resident's change in condition in a timely manner. Licensee does not ensure that resident is adequately fed while in care. Licensee did not ensure that staff addressed resident's change in condition in a timely manner.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegations. LPA arrived at the facility and was greeted and granted entry. LPA spoke with Steven Shen, Administrator, and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, resident file review, facility file review, and interviews conducted. It is alleged licensee did not ensure that resident's responsible party was notified of resident's (R1) change in condition in a timely manner. Record review LPA obtained copies of text message exchange between staff (S1) and R1’s responsible parties where they are notifying of behavior episodes, behaviors Continued on LIC9099-C Unsubstantiated worsening progressively, refusing to eat and discarding the meals. Progress report for R1 reflects that move in was January 1, 2024, and it was noted on May 11, 2024, resident had a behavior episode and responsible parties were notified. This reflects timeline of text messages. Interview with 2 of 2 staff stated that they would communicate with R1’s responsible parties since they were out of state. Staff stated that only change was with R1’s behavior episodes in which the nurse practitioner was notified, and changes were made with R1’s medication in aiding with resolving the behavior change. Staff stated that when responsible parties were notified their solution was to keep resident in their room to avoid interaction with others. It is alleged licensee does not ensure that resident (R1) is adequately fed while in care. Record review LIC602 physicians report reflect able to feed self as marked yes. Admission agreement reflects the basic services for R1, and no additional services were required. Services included memory care basic services include incontinence care, medication management, providing meals, bathing & dressing, escorting to and from activities and laundry service. Interview with 2 of 2 staff stated that R1 was able to feed themselves and did not require feeding. However, when R1 was noted to not want to eat staff would encourage R1 to eat and/or attempt to feed them. Staff would make various attempt to get R1 to eat but at times it was hard because they would refuse. R1’s responsible party would provide meals and/or groceries to help with R1 having food that they liked available in hopes that R1 would eat. Staff noticed that regardless of what food it was,when R1 did not want to eat they would refuse and flush food down the toilet causing the toilet to clog daily. It is alleged licensee did not ensure that staff addressed resident's (R1) change in condition in a timely manner. Record review progress report on May 11, 2024, is when it was first observed that R1’s behavior had changed. Text message to responsible party reflects that on May 11, 2024, staff S1 notified both responsible parties for R1 of the episode. Both records show timeline coincides with each other and reflect staff addressing the changes for R1. Progress notes reflect medication was changed on October of 2024 and R1’s appraisal and needs/services plan were updated for changes in November of 2024 which reflect the changes Continued on LIC9099-C in needs. Interview with 2 of 2 staff stated that once the behavior episodes became more frequent and more aggressive, they addressed the changes by notifying the nurse practitioner and medication was adjusted. Staff stated that once behavior became more frequent and unable to control medication was adjusted and R1 was reappraised for the changes. Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted with the facility representative and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Apr 7, 2026 · control 22-AS-20241216152259

Allegation investigated: Unlawful eviction

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Chief Operating Officer (COO) Faye Shen and explained the reason for today’s inspection. The investigation into the allegation of unlawful eviction revealed the following: During the course of the investigation, LPA inspected the facility, interviewed COO and residents, and obtained and reviewed copies of the resident roster, staff roster, a 3-Day Eviction Notice dated June 16, 2022, a 30-Day Eviction Notice dated June 17, 2022, Resident #1’s (R1) Admission Agreement, R1’s Written Statement to the Facility dated June 21, 2022, and R1’s Billing Statement. CONTINUED Substantiated It was alleged that R1, who was back on their rent because they could not afford the full amount, was advised that they needed to leave the facility immediately on June 20, 2022, as part of a 3-Day Eviction, and told they owed an incorrect amount. On June 17, 2022, LPA received a 3-Day Eviction Notice dated June 16, 2022, from COO for R1 on the basis of non-payment of rent, which COO withdrew that same day and later issued a 30-Day Eviction Notice dated June 17, 2022. While COO claimed the 3-Day Eviction Notice dated June 16, 2022 was not served on R1, R1 confirmed they were told by COO that their eviction was a 3-Day Eviction and they would have to leave on June 20, 2022, which corroborates that R1 was unlawfully evicted verbally as R1 otherwise would not have known about the 3-Day Eviction or the end date of the notice period. Regarding the back owed rent, R1’s Admission Agreement indicates R1’s monthly rent was $2,700. Per R1’s Written Statement to the Facility dated June 21, 2022, R1 and COO agreed that “[R1] could ‘not’ pay more than $1,400 per month.” However, COO denied that R1’s rent was reduced from $2,700 to $1,400 per month and there is no written documentation of this modification to R1’s Admission Agreement. R1’s Billing Statement indicates that R1 was indeed given a discount from $2,700 to $2,000 per month, but that this amount was not fully paid and as of June 16, 2022, R1’s outstanding balance was $8,735. LPA interviewed COO who stated that the $2,700 monthly rent was already discounted from $4,000, COO worked with R1’s family to obtain financial support for R1, R1 could only pay $1,400 per month but also made no payments for multiple months, and the facility never agreed to accept $1,400 as total payment for R1’s rent. Per COO, there were no irregularities with R1’s billing and the total amount owed is correct. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. Regarding the allegation that staff did not prevent residents from engaging in inappropriate behaviors: it was alleged that Resident #2 (R2) was observed using the common bathroom on the first with the door open, Resident #3 (R3) was observed urinating in a public area, and R3 was observed walking around the facility with their pants down. LPA interviewed COO who confirmed that the incident with R3 urinating in a public area was reported to them, but stated that the issue was addressed with R3 and R3 has not engaged in any similar behavior for a long time since. COO was unable to provide information about the other two alleged incidents, but stated that staff address all inappropriate behavior with residents when they observe it or learn of it from other residents and if residents continue to engage in inappropriate behavior after being warned the facility will begin the eviction process. LPA interviewed 12 residents who did not corroborate that staff are not addressing inappropriate behavior. Regarding the allegation that staff did not prevent resident from making inappropriate comments towards another resident: it was alleged that R1 observed R2 using the shared bathroom with the door open, R1 advised R2 to close the door, and R2 responded with an expletive. Per R1’s Written Statement to the Facility dated June 3, 2022, in response to R2’s expletive, R1 responded with the same expletive. LPA interviewed COO who was unable to provide information about this particular incident, but stated that staff address all inappropriate comments with residents when they observe it or learn of it from other residents and if residents continue to make inappropriate comments after being warned the facility will begin the eviction process. LPA interviewed 12 residents who did not corroborate that staff are not addressing inappropriate comments. Regarding that allegation that a resident is not awarded privacy: it was alleged that, despite R1 advising staff to knock before entering their room, staff enter their room without knocking and in one instance a medication technician entered R1’s room without knocking in order to ask R1 if they needed assistance. Per COO, staff are trained to knock before entering a resident’s room, R1 never reported any concerns on this topic to the facility, and it is possible that hearing issues may have prevented R1 from hearing the staff knock. LPA interviewed 12 residents who did not corroborate any concerns with privacy or the way staff enter residents’ rooms. Regarding the allegation that residents toilet is in disrepair: it was alleged that R1’s toilet does not always work and that they sometimes have to use the common bathroom on the first floor. When interviewed, R1 stated their toilet had been fixed on or before June 21, 2022, did not report any concerns with the facility’s efforts to fix their toilet, and noted their main concern was something they observed in the common bathroom on the first floor. LPA interviewed COO who was unable to provide specific information regarding R1’s toilet but stated that broken items are addressed as quickly as possible by maintenance. LPA inspected the toilets in 11 rooms and observed them to be working properly. LPA interviewed 12 residents who did not corroborate any concerns about the fixtures in their room or the facility’s efforts to repair items when they break. Regarding the allegation that staff are not providing adequate food service to resident: it was alleged that R1 cannot have sugar, beef, shellfish, or pork and the facility’s menu has limited options to accommodate their diet. When interviewed, R1 stated they did not have a doctor’s order for this diet. LPA reviewed R1’s Physician’s Report that indicates R1 is allergic to shellfish and should avoid red meat. LPA interviewed COO who stated that the facility has special diets for residents with low sugar or low salt needs, as well as multiple options for residents who have personal preferences. Per COO, most of the facility’s menu avoids shellfish and beef, so it is always possible to get food without these ingredients, and the facility’s menu has not substantially changed since 2022. LPA interviewed 12 residents who did not corroborate any concerns about the quality of food or their ability to choose what items they want. LPA reviewed the facility’s menu for March 2026 and noted there are options that do not include sugar, beef, shellfish, or pork on almost all days and per COO and residents interviewed, the facility will make residents’ requested items if they do not want what is on the menu. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Apr 3, 2026 · control 22-AS-20220620112925

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(b) · Plan of correction due date: Apr 4, 2026

87224 Eviction Procedures (b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit… This requirement was not met as evidenced by: Based on interviews, the licensee told R1 they would be evicted via 3-Day Eviction when the 3-Day Eviction was withdrawn by the licensee and not approved, which poses an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: Licensee stated that R1 is no longer a resident of the facility. Licensee stated they will review 87224 and submit a statement of understanding to LPA by POC due date.

Allegation investigated: Staff do not ensure the facility is clean and sanitary

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Chief Operating Officer (COO) Faye Shen and explained the reason for today’s inspection. The investigation into the allegation that staff do not ensure the facility is clean and sanitary revealed the following: During the course of the investigation, LPA inspected the facility, interviewed residents, and obtained and reviewed copies of the resident roster, staff roster, and photographs of the central outdoor courtyard. CONTINUED Substantiated It was alleged that residents with dogs are leaving dog feces in the central outdoor courtyard, both on the cement and grass, and the dog feces are not being cleaned up by the residents with dogs or staff. LPA inspected the facility and observed multiple areas with dog feces in the central outdoor courtyard, both on the grass and cement, with some feces appearing dry and old and some feces appearing flat from being stepped on. LPA reviewed photographs of the central outdoor courtyard showing similar dog feces from days prior. Out of seven residents interviewed, four residents corroborated that dog feces are not being cleaned up timely and that it negatively affects them, with one resident reporting that some residents stopped using the central outdoor courtyard because they could not handle the smell and the flies. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Apr 3, 2026 · control 22-AS-20260402130307

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Apr 4, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times.... This requirement was not met as evidenced by: Based on photographs, observations, and interviews, the licensee did not ensure dog feces are timely cleaned up in the central outdoor courtyard resulting in residents not being able to enjoy their outdoor space, which poses an immediate personal rights risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: During the inspection, the licensee had the dog feces cleaned up. Licensee stated they will submit a plan to ensure that residents with dogs clean up after their pets or, if they do not, that staff will make sure it is done by April 6, 2026.

Allegation investigated: Staff did not ensure residents personal property was safely secured Staff do not ensure residents receive personal mail correspondance Staff does not ensure residents room has required bedroom furniture Staff do not ensure reporting requirements are followed Staff do not ensure transportation arrangements are made for residents Staff don't ensure residents rooms are cleaned in a timely manner Staff do not ensure facility has hot water for residents in care Staff speak inappropriately to residents in care Staff pushed resident in care Staff do not ensure residents are kept free from humiliation, intimidation, ridicule, coercion, threat and mental abuse while in care

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegations. LPA arrived at the facility and was greeted and granted entry. LPA spoke with Clara Ramirez, Activities Director and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, resident file review, facility file review, and interviews conducted. It is alleged that facility did not ensure residents personal property was safely secured, specifically items in an resident (R1) bedroom. Interview with 2 of 2 staff stated that when residents move in the facility the inventory sheets is completed when residents bring their own belongings. Residents have the right to go out Continueed on LIC9099-C Unsubstantiated into the community and purchase items or family brings them items. If a resident doesn’t notify the facility staff of they new items then facility is not aware of the items. Residents’ bedrooms have a door that can be locked when they leave out of the community. Staff have not received any complaints or information that any residents had any missing items and were not aware of it. Interview with 10 of 10 residents stated that they have not had any items missing from their bedroom. When they leave to the community they lock their doors. It is alleged that staff do not ensure residents received personal mail correspondence. Interview with 2 of 2 staffed stated that when facility received resident mail they place it in residents inbox, take it to their room if residents request it or leave at the front desk so residents can pick it up. Interview with 10 of 10 residents stated that they get their mail when it gets to the facility. They normally pick it up from the front of the facility where their mailbox is. It is alleged that staff does not ensure residents room has required bedroom furniture. LPA Tirre on May 2, 2024, while conducting the facility visit toured the physical pant of the facility and observed various rooms throughout the facility. LPA observed that resident bedrooms had required furnishings per required regulations. Interview with 10 of 10 residents stated that they have always had furnishing in their bedrooms to beds, closet, chairs and dressers. They stated that they had no any issues with not having furnishing in their bedroom. It is alleged that staff do not ensure reporting requirements are followed, specifically to reporting incidents involving residents. Interview with 2 of 2 staff stated that when an incident happens at the facility staff report it to management and management fills out the LIC624 unusual incident report and send it to the Department. Complaint details does not state a specific date or incident to verify is such was reported. However, LPA Martinez verified through our reporting system that there are records of the Department receiving incident report from the facility. It is alleged that staff do not ensure that transportation arrangements are made for residents. Record review revealed that page 37 of the admissions agreements states the following for transportation: The van schedule will be posted at the front office on a daily basis. Transportation will be provided to medical appointments within a five (5) mile radius, and must be scheduled by front office personnel. Transportation to non-medical Continued on LIC9099-C appointments or events may be provided at the discretion of front office personnel. Participation in generally scheduled transportation to events such as shopping and banking is on a first come basis and will be provided as posted. Extra fees may be charged for van transportation for (I) personal nonmedical appointments, (2) if the van is required to wait longer than fifteen (15) minutes at he destination for the resident, (3) if a community caregiver is required to escort a resident, or (4) for personal medical or non-medical transportation outside a five (5) mile radius. Should you require special transportation, other than the scheduled runs, please contact the front desk. It is requested that the facility have at least 24 hours advance notice of special transportation arrangements. Facility may coordinate transportation with other services such as senior transportation services, local transit services, ambulances, etc. Interview with 10 of 10 residents stated that when they needs transportation they look at the schedule and let the front office know that they need a ride and to where they are going. They have always been able to get transportation for their needs and never had an issue with doing so. It is alleged that staff don’t ensure residents rooms are cleaned in a timely manner. Record review revealed that facility has a deep cleaning schedule and a housekeeping schedule. The deep cleaning schedule has each floor listed and divided by days which rooms will be cleaned throughout the week. The housekeeping schedule has what staff is assigned on what day and time. Admissions agreement page 32 states the following: Your room will be cleaned on a weekly basis. Housekeeping staff will inform you of the day that your room will be cleaned. Weekly cleaning service is complimentary for all residents and includes: making of bed, emptying trash, tidying up room and fresh towels, dusting, vacuuming, cleaning bathrooms and kitchenettes, (if you have valuable "breakables" you are asked to take them off of your furniture tops before housekeeping staff begins to dust. Special arrangements are made for cleaning carpets, walls, etc. Should you have special concerns, please feel free to contact housekeeping. Interview with 10 of 10 residents stated that their room gets cleaned all the time when it suppose to get cleaned and if they require additional services or for trash to be taken out then they call the front desk or let staff know. Then staff come to take our trash or clean room. It is alleged that staff do not ensure facility has hot water for residents in care. LPA Tirre on May 2, 2024, conducted a tour of the physical plant of the facility and measure the hot water temperature throughout the facility. Various resident bathrooms were tested for hot water temperature and water temperature measured Continued on LIC9099-C between 118.2 -119.8 Fahrenheit degrees. Interview with 10 0f 10 residents stated that they have not had issues with not having hot water in the bathrooms. It is alleged that staff speak inappropriately to residents in care. Interview with 10 of 10 residents stated that they have never seen staff be rude or threaten any other resident. They have seen residents being rude and disrespectful to staff. Staff is nice and speak to them with care. Interview with 2 of 2 staff stated that they have not gotten any complaints of staff observed that they were threatening or speaking inappropriate to residents. It is alleged that staff pushed resident in care. Records review staff roster for all employees of the facility do not reflect staff (S1) in question. However, roster reflects staff (S2) in question. Interview with S2 stated that they did not have any problem with any residents and that there are times that residents are difficult with staff. S2 stated that she doesn’t know recall any staff by the name of S1. Interview with 10 of 10 residents stated that they have no seen any staff push or treat any resident badly but that they have seen residents being difficult with staff often. It is alleged that staff do not ensure residents are kept free from humiliation, intimidation, ridicule, coercion, threat and mental abuse while in care. Interview with 2 of 2 staff stated that residents tend to have behavior when they don’t get things as they want them or how they want them. Staff try hard to keep residents happy all the time despite the challenges. Staff have not seen other staff treating residents badly or speaking to them bad. Staff stated that the required dress code at work is scrubs at all times. Interview with 10 of 10 residents have not seen staff yelling at anyone and there is residents that gets upset and yells all the time and is disruptive. Resident stated they like the staff, and they have a good relationship with them. They have not seen any of the staff be abusive to anyone, talk badly or make fun of anyone and they treat them very well. Residents stated that staff were hospital looking for clothes to work all the time. Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted with the facility representative and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Feb 3, 2026 · control 22-AS-20240425142757

Allegation investigated: Staff did not prevent a resident from engaging in inappropriate behaviors

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Chief Operating Officer (COO) Faye Shen, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that staff did not prevent a resident from engaging in inappropriate behaviors revealed the following: During the course of the investigation, LPA inspected the facility, interviewed COO, residents, witnesses, and staff, and obtained and reviewed copies of the resident roster, staff roster, a facility incident report dated January 19, 2026, Resident #2’s (R2) Physician’s Report dated April 1, 2024, Resident #1’s (R1) Physician’s Report dated August 15, 2025, and R1’s Eviction Notice dated January 20, 2026. It was alleged that on January 17, 2026, R1 touched R2 inappropriately and made inappropriate comments. LPA reviewed a facility incident report dated January 19, 2026, which states that on January 17, 2026, around 6:30PM, R1 was seen on the facility’s surveillance video entering the elevator with R2 and that R2 reported that R1 touched them inappropriately, made a sexual comment, then touched them inappropriately again while in the elevator. Unsubstantiated Per the facility incident report dated January 19, 2026, R2 initially reported the incident to their family member who notified the facility, R1 denies the incident occurred as reported, and, although the incident itself was not witnessed or recorded, R1 will be evicted as they make other residents uncomfortable and facility staff will conduct additional checks on R2 in the meantime. LPA interviewed COO who confirmed the information provided on the incident report. LPA interviewed R2 who confirmed that R1 touched and spoke to them inappropriately as reported, stated they did not consent to R1’s behavior, and reported that R1’s behavior had made them uncomfortable. Per COO and R2’s Physician’s Report dated April 1, 2024, R2 does not have confusion. LPA interviewed R1 who admitted to touching R2 inappropriately, but claimed they did it in an innocent manner. Per COO and R1’s Physician’s Report dated August 15, 2025, R1 has mild cognitive impairment. When interviewed, COO stated that no one else saw the incident and it was not captured on camera, but the facility believed R2’s allegation and is evicting R1 in response. LPA reviewed R1’s Eviction Notice dated January 20, 2026, which confirms R1 is being evicted. Per COO, although R1 does have a history of making inappropriate comments to other residents, the other residents never requested action be taken against R1, and previous reports of inappropriate touching were not substantiated. LPA interviewed witnesses, staff, and other residents and was unable to obtain information confirming that R1 has previously engaged in behavior as inappropriate as their behavior on January 17, 2026. COO stated that on January 18, 2026, when the facility was notified of the incident by R1’s responsible party, the facility investigated the situation and notified local law enforcement, local law enforcement investigated the situation, stated they would review the matter to determine if additional action is warranted, and have not returned to the facility to provide an outcome. R2’s consistent statement of events, video footage seen by R2’s responsible party and facility staff confirming R2’s timeline of events, and R1’s admission of inappropriate behavior corroborate R2’s allegations against R1. However, the facility took proper action after the incident was discovered and information was not obtained showing that the facility should have taken action against R1 prior to this incident, as R1 had no confirmed history of inappropriate touching prior to this incident. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. Per the facility incident report dated January 19, 2026, R2 initially reported the incident to their family member who notified the facility, R1 denies the incident occurred as reported, and, although the incident itself was not witnessed or recorded, R1 will be evicted as they make other residents uncomfortable and facility staff will conduct additional checks on R2 in the meantime. LPA interviewed COO who confirmed the information provided in the incident report. LPA interviewed R2 who confirmed the details of R1 entering their room and engaging in appropriate behavior as reported, stated they did not consent to R1’s behavior, and reported that R1’s behavior had made them uncomfortable. Per COO and R2’s Physician’s Report dated April 1, 2024, R2 does not have confusion. LPA interviewed R1 who admitted entering R2’s room and asking R2 for a kiss, but appeared confused and gave conflicting information about what else took place during this incident. Per COO and R1’s Physician’s Report dated August 15, 2025, R1 has mild cognitive impairment. When interviewed, COO stated that no one else saw the incident and it was not captured on camera, but the facility believed R2’s allegation and is evicting R1 in response. LPA reviewed R1’s Eviction Notice dated January 20, 2026, which confirms R1 is being evicted. Per COO, although R1 does have a history of making inappropriate comments to other residents, the other residents never requested action be taken against R1, and previous reports of inappropriate touching were not substantiated. LPA interviewed witnesses, staff, and other residents and was unable to obtain information confirming that R1 has previously engaged in behavior as inappropriate as their behavior on January 17, 2026. COO stated that on January 18, 2026, when the facility was notified of the incident by R1’s responsible party, the facility investigated the situation and notified local law enforcement, local law enforcement investigated the situation, stated they would review the matter to determine if additional action is warranted, and have not returned to the facility to provide an outcome. When interviewed, R1 and R2 both confirmed that R2’s door was not locked when R1 entered. COO stated that the facility has previously offered to help R2 lock their door, but that both R2 and their responsible party refused, stating R2 does not want their door locked. R2’s responsible party corroborated that R2 does not like locking their door. The information obtained did not corroborate that the facility could have prevented R1 from entering R2’s unlocked room and showed that the facility responded properly after the incident was discovered. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 22-AS-20260123160115

Allegation investigated: Unlawful eviction

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Chief Operating Officer (COO) Faye Shen, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation of unlawful eviction revealed the following: During the course of the investigation, LPA inspected the facility, interviewed COO, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Eviction Notice dated January 20, 2026, a facility incident report dated January 19, 2026, Resident #2’s (R2) Physician’s Report dated April 1, 2024, and R1’s Physician’s Report dated August 15, 2025. Unfounded It was alleged that R1 is being evicted unlawfully. LPA reviewed R1’s Eviction Notice dated January 20, 2026, which states that R1 is being evicted for violating house rules when they inappropriately touched and spoke to R2 and entered R2’s room without permission. LPA reviewed a facility incident report dated January 19, 2026, which states that on January 17, 2026, around 6:30PM, R1 was seen on the facility’s surveillance video entering the elevator with R2 and that R2 reported that R1 touched them inappropriately, made a sexual comment, then touched them inappropriately again while in the elevator. The incident report also states that on January 17, 2026, around 11:15PM, R1 was seen on the facility’s surveillance video entering R2’s room, R2 reported that R1 entered their room uninvited and asked for a kiss, R2 stated they gave R1 a kiss because they were flustered, and the surveillance video showed R1 leaving R2’s room at around 11:30PM. LPA interviewed R2 who confirmed that R1 engaged in these behaviors, that R2 did not consent to R1’s actions, and that R2 was made uncomfortable by these actions. Per COO and R2’s Physician’s Report dated April 1, 2024, R1 does not have confusion. LPA interviewed R1 who admitted to touching R2 inappropriately, but claimed they did it in an innocent manner, and also admitted to entering R2’s room and speaking inappropriately to R2. Per COO and R1’s Physician’s Report dated August 15, 2025, R1 has mild cognitive impairment. COO also stated that although surveillance footage did not capture R1’s behavior, as they took place in an elevator and R2’s room, the footage placed R1 at those locations at the times that R2 alleged the incidents took place. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 22-AS-20260123125748

Allegation investigated: Facility is unable to meet resident's needs. Resident sustained multiple falls due to neglect.

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Chief Operating Officer (COO) Faye Shen and Administrator Steve Shen arrived at 11:00 am The Department recieved a complaint on 12/08/2023 and LPA Mendivil conducted the initial 10 day visit on 12/15/2023. LPA Mendivil obtained copies of pertinent documents such as physician report and admission agreement and interviewed staff and residents. Regarding the allegation facility is unable to meet residents' needs and Resident sustained multiple falls due to neglect., the investigation revealed the following: It was reported faciltiy is unable to meet residents needs for Resident 1 (R1), per review of R1's file there is no care plan or needs/services plan on record. It was reported that R1 had mutliple falls in the six weeks they were at the facility. Based on interviews with staff it was reported that R1 was a fall risk, per reivew no documented care plans on record to mitagate falls. Substantiated Therefore based on records reviewed the allegation facility is unable to meet resident's needs and resident sustained multiple falls due to neglect is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative. Per interviews with 3 out of 3 residents stated no one has been rough or mean to them while at the facility. Residents stated they have no been injured while in care. Therefore based on the preponderance of evidence through records reviewed and interviews the allegation resident sustained unexplained injuries due to staff being rough is determined to be UNSUBSTANTIATED, meaning athough the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 22-AS-20231208162507

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a) · Plan of correction due date: Nov 21, 2025

(a) The pre-admission appraisal, as specified in Section 87457.., shall be updated, in writing as frequently as necessary... This requirement was not met as evidence by there was no appraisal conducted for R1 and therefore facility cannot meet needs that are not identified. This poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Nov 18, 2025

Plan of correction: Adminstrator stated will conduct in service on appraisals and when to update based on change of condition.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Nov 19, 2025

(f) Basic services shall at a minimum include:(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications... This requirement was not met as evidence by R1 did not have a care plan for fall mitagation which resulted in resident sustaining multiple falls due to neglect. This poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Nov 18, 2025

Plan of correction: Administrator to conduct in service regarding fall risk/mitagation of falls and provide to LPA by POC due date.

Allegation investigated: Staff are not responding to resident's requests in a timely manner Staff used offensive language in the presence of resident and resident's family.

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Chief Operating Officer (COO) Faye Shen and Administrator Steve Shen arrived at 11:00 am The Department recieved a complaint on 12/11/2023 and LPA Mendivil conducted the initial 10 day visit on 12/15/2023. LPA Mendivil obtained copies of pertinent documents such as physician report, needs and services plan and admission agreement and interviewed staff and residents. Regarding the allegations staff are not responding to resident's request in a timely manner, staff used offensive language in the presence of resident and resident's family, the investigation revealed the following: It was reported that Resident 1 (R1) request are not answered in a timely manner. Per review R1 was diagnosed with Mild Cognitive Impairment based on physician's report dated 03/28/2023. Unsubstantiated It was also noted that R1 was confused but was able to follow directions and was able to communicate their needs.Per interviews with 2 out of 2 residents stated that staff are responding to their request for assistance. 3 out of 3 staff stated the calls from pendants are received at the front desk, then the front desk will notify staff of the request for assistance. Based on interviews with staff they indicated the response time is within 5 minutes or less. It was reported on or around 12/08/2023 a staff member used profanity in front of R1 and their family. Per interviews with 2 out of 2 staff denied using profanity, Interviews with COO Faye Shen stated that staff denied using profanity but may have been loud. LPA was unable to interview R1 as they are not currently oriented to time and space as they could not answer LPA's questions. Therefore based on the records reviewed and interviews the allegations Staff are not responding to resident's requests in a timely manner and Staff used offensive language in the presence of resident and resident's family are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiencies cited. An exit interview was conducted and a copy of this report and confidential names list was provided. Per interviews with staff R1 was sent out to the hospital on 12/10/2023 due to difficulty breathing and weakness and R1 was admitted back to the facility on 12/15/2023 with updated medication. Based on interview with COO Faye stated they never denied R1 back into the facility. Per review no incident report was sent for R1's hospitalization, issue will be cited via case management dated 11/18/2025. Per review of R1's file and based on interviews R1's care plan has not been updated on paper in the 10 years that R1 has resided in the facility. Per review of current rates and the amount R1 is paying for care at a level lower than his stated care needed. Therefore based on records reviewed and interviews the allegations Facility is refusing to take resident back Facility is overcharging resident are determined to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report and LIC 811 was provided.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 22-AS-20231211105431

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit in conjuction with complaint control 22-AS-20231211105431. LPA was greeted and granted entry and explained the reason for the visit. During the course of the complaint investigation it was revealed Resident 1 (R1) had to be admitted to the hospital due to shortness of breath and feeling weak. Per review of Progress Report for Resident dated 12/10/2023 R1 was seen via Facetime by their Nurse Practitioner and staff was advised to send R1 to the hospital. Per review of Community Care Licensing Division's records there is not an incident report for R1's visit to the hospital. Therefore the following is being cited per Title 22. An exit interview was conducted and a copy of this report, appeal rights, LIC 809-D, and LIC 811 confidential names were provided.the state’s words, verbatim · CDSS document, Nov 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 28, 2025

(a) Each licensee shall furnish to the licensing agency ...:(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. (D) Any incident which theatens... the welfare, safety or health of any resident... This requirement was not met as evidence by there was no incident report for R1's hospitalization in December 2023. This poses a potential health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Nov 18, 2025

Plan of correction: Administrator agrees to conduct in service regarding reporting requirements and provide proof to LPA by POC due date.

Allegation investigated: Staff do not ensure recliners and chairs are in good condition Staff did not ensure elevators are functional and accessible Staff do not ensure urine and feces on floors and furniture is cleaned with appropriate chemicals

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegations. LPA met with Staff #1 (S1) Clara Ramirez, discussed the purpose of the inspection, and explained the allegations. The investigation into the allegation that staff do not ensure recliners and chairs are in good condition, staff did not ensure elevators are functional and accessible, and staff do not ensure urine and feces on floors and furniture is cleaned with appropriate chemicals revealed the following: During the course of the investigation, LPA inspected the facility, interviewed residents and staff, and obtained and reviewed copies of the resident roster, staff roster, and the facility sketch. CONTINUED Substantiated Regarding the allegation that staff do not ensure recliners and chairs are in good condition: it was alleged that the chairs in the memory care are falling apart and the recliners are broken. LPA inspected the facility and observed multiple chairs, couches, and recliners not in good repair, including the cloth recliners in the second-floor memory care that were heavily stained and are unsanitary, and the leather recliners in the second-floor memory care where the leather was torn or flaking off. The information obtained corroborated the allegation. Regarding the allegation that staff did not ensure elevators are functional and accessible: it was alleged that one of the facility’s elevators has been broken for over a year and the elevator that is used for emergencies is covered with clutter which is dangerous in the case of an emergency. LPA reviewed the facility sketch which indicates the facility has three elevators: one on the north side near the dining room; one on the southeast side near the laundry room; and one on the southwest side. LPA inspected the facility and confirmed the elevator on the north side near the dining room is operational. Per facility staff, this elevator is the only one used by residents. LPA observed that the elevator on the southeast side near the laundry room is non-operational. Per facility staff, this elevator was used by memory care staff to enter and leave the memory care units, it has not been working for some time, efforts to repair it have been unsuccessful, and the facility has decided to decommission this elevator. LPA observed that the elevator on the southwest side is operational, but the entrance on the first floor is obstructed by furniture. Per facility staff, this elevator is used for emergencies, is not generally used, and the entrance should not be blocked by furniture. The information obtained corroborated that one of the facility’s three elevators is non-functional and that a second elevator is inaccessible due to being obstructed by furniture. Regarding the allegation that staff do not ensure urine and feces on floors and furniture is cleaned with appropriate chemicals: it was alleged that the third-floor memory care common area is covered in urine and feces and staff do not have proper cleaning supplies and have to clean with water and hand soap from time to time. LPA inspected the facility and observed the facility to be generally clean and free from foul odors. LPA observed multiple housekeepers cleaning the facility with appropriate chemicals. However, LPA inspected the third-floor memory care and noted there is no cleaning closet or access to appropriate chemicals. Per facility staff, if the caregivers on the third-floor memory care needed to clean a mess, they can call the front desk and have cleaning supplies delivered to them. However, facility staff also stated that there are no housekeepers at the facility between 4:00PM and 6:00AM and that sometimes the caregivers will leave a mess for the housekeepers to clean when they arrive because that is the job of the housekeepers. Based on the information obtained, the caregivers in the third-floor memory care do not have immediate access to appropriate cleaning chemicals to clean messes as they arise and also have a practice of leaving messes for the housekeepers to clean up possibly much later as the facility does not have housekeepers available for 14 hours each day. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. LPA reviewed the facility’s pest control records which show that the exterminator comes to address pests at the facility regularly. LPA interviewed 10 residents and did not obtain information corroborating the allegation. The information obtained did not corroborate the allegation. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 22-AS-20250812102106

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Aug 19, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times…. This requirement was not met as evidenced by: Based on admission and observations, the licensee did not ensure two out of three elevators were functional and accessible, with one elevator being non-functional for over a year and another elevator being obstructed, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Aug 18, 2025

Plan of correction: During the inspection, the licensee cleared the obstructed elevator and LPA confirmed. Licensee stated they will repair the broken elevator or request approval to decommission it by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 15, 2025

87468.1(a)(2) – 87468.1 Personal Rights… (a) … (2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by: Based on observations, the licensee did not ensure residents were able to enjoy healthful and comfortable accommodations by not cleaning, repairing, or replacing multiple stained and torn furniture items, which poses a potential personal rights risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Aug 18, 2025

Plan of correction: Licensee stated that they will clean, repair, or replace the stained and torn furniture items and submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Sep 15, 2025

87307 Personal Accommodations and Services (d) … (2) The premises... shall provide a safe and healthful environment. This requirement was not met as evidenced by: Based on admission and observations, the licensee did not ensure messes in the third-floor memory care are cleaned appropriately and timely by not providing immediate access to appropriate cleaning chemicals to caregivers and allowing caregivers to leave messes for the housekeepers to clean up hours later, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Aug 18, 2025

Plan of correction: Licensee stated that they will create a protocol to ensure messes are addressed timely and properly, train staff on the protocol, and submit proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20250416094856. LPA met with Chief Operating Officer (COO) Faye Shen and explained the reason for today’s inspection. During the course of the investigation, Licensing Program Analyst (LPA) Sean Haddad inspected the facility, interviewed COO, witnesses, and staff, and obtained and reviewed copies of the resident roster, staff roster, and a staff statement. Per an interview with Witness #1 (W1), on May 12, 2025, at around 8:00PM, W1 was visiting Resident #1 (R1) at the facility, Staff #1 (S1) advised W1 that visiting hours were over, W1 called Regional Manager (RM) Stanic who spoke with S1 and confirmed W1 could visit longer, but then at around 9:00PM S1 called the police on W1. LPA reviewed a staff statement from S1 indicating they received RM’s guidance that family members are able to visit at any time, but ignored that guidance and chose to call the police because W1 stayed past visiting hours. LPA interviewed COO who stated that the facility generally has no issue with allowing visitors to stay past visiting hours, but that W1 is abusive to staff when they visit, the facility has had to call the police on W1 multiple times in the past, R1’s other responsible parties have warned the facility about W1, that the police were called because W1 was speaking angrily to staff, and that it was the police who arrested W1 based on W1’s behavior. . COO also stated that facility staff felt scared and thought W1 could become violent, but it appears from the timeline that W1’s behavior towards the staff was a reaction to the staff trying to kick them out of the facility and there was no evidence that W1 has ever been violent at the facility in the past. While W1 may have a history of being disruptive, W1 was not committing a crime and R1 had the right for their visitor to remain as there was no negative impact to other residents. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representativethe state’s words, verbatim · CDSS document, Aug 6, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Aug 7, 2025

87468.1 Personal Rights … (a) … (11) To have their visitors… permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidenced by: Based on documents and admission, the licensee did not ensure R1 was able to enjoy the right of visitation by calling the police on W1 for staying past visiting hours, which poses an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Licensee stated they will retrain staff on visitation rights and submit proof to LPA by POC due date.

Allegation investigated: Facility staff do not treat resident with dignity or respect. Facility staff yells at residents in care.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Chief Operating Officer (COO) Faye Shen and explained the reason for today’s inspection. The investigation into the allegations that facility staff do not treat resident with dignity or respect and facility staff yells at residents in care revealed the following: During the course of the investigation, Licensing Program Analysts (LPAs) Sean Haddad and William Vanegas inspected the facility, interviewed COO, residents, and staff, and obtained and reviewed copies of the resident roster and staff roster. CONTINUED Substantiated Regarding the allegation that facility staff do not treat resident with dignity or respect: it was alleged that Staff #1 (S1) treats residents with disrespect. When interviewed, COO who stated that S1 was liked by some residents but unliked by other residents and that S1 no longer works at the facility. When interviewed, S1 stated they have a friendly, respectful, and jovial relationship with residents. One staff stated that S1 had a lot of issues with residents. Out of 12 residents interviewed, four residents corroborated the allegation and identified instances of rudeness, mockery, and ignoring resident inquiries by S1, Staff #2 (S2), Staff #3 (S3), and Staff #4 (S4). The information obtained corroborated the allegation. Regarding the allegation that facility staff yells at residents in care: it was alleged that S1 yells at residents. When interviewed, COO who stated that S1 was liked by some residents but unliked by other residents and that S1 no longer works at the facility. When interviewed, S1 denied yelling at residents. One staff stated they have observed yelling between residents and staff and that S1 had a lot of issues with residents. Another staff stated that the PM shift has less positive interactions with residents because they are lower staffed. Out of 13 residents interviewed, two residents corroborated that S1 yelled at residents and in at least once instance got into a shouting match with a resident. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. Regarding the allegation that facility staff are not ensuring that the facility is being adequately cleaned and sanitized: it was alleged that a mess was observed, staff did not respond to clean it up timely, and when staff did respond they cleaned it improperly. LPA Haddad inspected the entire facility, including hallways, common bathrooms, 10 resident rooms, and 10 private resident bathrooms, and did not obtain information corroborating the allegation. When interviewed, COO denied the allegation, stating that the facility is cleaned and sanitized. Three housekeeping staff interviewed denied the allegation and stated that the facility is regularly cleaned and when a mess is reported they will respond quickly to properly clean it up. Out of 12 residents interviewed, eight stated the facility was clean enough. Four of the residents interviewed stated the facility could be cleaner, but did not corroborate that cleanliness is a major concern for residents. One resident stated that when they identify a mess, they bring it up and staff will address it quickly. Although messes may occur within the facility, the information obtained did not corroborate that the facility is not regularly cleaning the facility and addressing messes in a reasonable time when they occur. Regarding the allegation that facility staff are not ensuring that restrooms are with toiletry supplies: it was alleged that resident bathrooms frequently lack basic supplies such as soap, toilet paper, and paper towels. LPA Haddad inspected the facility, including the common bathrooms and 10 private resident bathrooms, and did not obtain information corroborating the allegation. When interviewed, COO denied the allegation, stating that each resident receives two rolls of toilet paper every day, residents are welcome to ask for more, and that sometimes residents take toiletry supplies from the common bathrooms, but these are checked multiple times a day to ensure they are always stocked. Three housekeeping staff interviewed denied the allegation, stating that the common bathrooms are regularly restocked and that individual resident bathrooms are stocked based on the needs of the residents. For example, toiletry supplies may be given to the resident themselves instead of being stocked in their bathroom if there is a risk another resident may take the supplies or the supplies pose a risk to nearby residents. However, one staff did note that residents have been complaining about low stock of toiletry supplies in the common bathrooms recently. Out of 13 residents interviewed, 11 residents identified no issues with toiletries at the facility. Two residents stated that the common restrooms lack toiletry items once in a while. While some residents may have seen the common restrooms lacking toiletry items on occasion between restocking, LPA observed the facility has a sufficient supply of toiletries and no information was obtained that the facility is not regularly restocking toiletry supplies or that the facility is refusing to restock the bathrooms if notified of a shortage. The information obtained is conflicting. Regarding the allegation that facility staff are not adequately assisting residents with their needs: it was alleged that a resident was not properly assisted by S1 when S1 was pushing the resident in a wheelchair in the dining room and the resident’s foot became stuck but no injuries were sustained. LPA Haddad inspected the facility and observed multiple residents being transported in wheelchairs to and from the dining room by staff with no issues. The residents appeared comfortable in their wheelchairs, both during transport and while enjoying their meals, and the staff were attentive. When interviewed, COO stated that S1 no longer works at the facility and that the alleged incident, if it occurred, did not result in injuries. When interviewed, S1 was unable to provide information regarding the alleged incident, but stated they provide care to residents and have good relationships with residents. The resident at issue could not be interviewed because they have since passed away. Out of 13 residents interviewed, no residents reported issues with the care they received, staff responsiveness to their needs, or the quality of care. LPA reviewed S1’s staff training and noted it to be up to date for 2025. While S1 may have improperly transported a resident in a wheelchair during this instance, the information obtained did not corroborate any systematic issues with the care provided to residents in wheelchairs. Regarding the allegation that facility staff did not provide adequate food service to residents in care: it was alleged that S1 brings a resident late to meals, leaves the resident unattended despite the resident needing help with eating, and in one instance this resident was not served food timely. LPA Haddad inspected the facility and observed during meal times that residents in the dining room promptly received their meals and were eating without issue, there were three care staff as well as multiple kitchen staff serving food and assisting residents, and the residents were timely returned to their rooms after finishing their meals. LPA Haddad’s observations did not corroborate the allegation. When interviewed, COO stated that S1 no longer works at the facility. When interviewed, S1 was unable to provide information regarding the alleged incident, but stated they provide care to residents and have good relationships with residents. The resident at issue could not be interviewed because they have since passed away. Out of 10 residents interviewed, eight reported no issues with food service. However, two residents reported that they are sometimes late to meals because they are sleeping and staff do not wake them up. When interviewed, COO stated that as a general rule, staff do not wake sleeping residents because that is what most residents want and that residents who show up to the dining room late will still receive food, but stated that residents who communicate with the facility that they would like to be woken up for meals will be woken up. Per COO, a resident recently advised the facility they would like to be woken up for meals and now care staff are waking them up. The information obtained did not corroborate the allegation. Regarding the allegation that residents are not provided activities: it was alleged that the facility is not providing activities. Per the facility’s activity schedule, the facility has activities every day except Sunday. LPA Haddad inspected the facility and observed that activities are taking place at the facility with six to twelve residents participating in any given activity. Out of 10 residents interviewed, eight confirmed that the facility provides activities and some of these residents take great enjoyment from these activities, one resident was unaware whether there were activities, and one confirmed there were activities but stated there are fewer than there used to be. While the facility is providing activities, the information is conflicting regarding the quality and quantity of the activities. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegation are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. Regarding the allegation that facility staff are not assisting residents when soiled in a timely manner: it was alleged that some residents are frequently left in soiled diapers or clothing for over 30 minutes. When interviewed, COO and two staff denied the allegation, stating that residents are changed when they are soiled and are checked on every two hours. Out of 10 residents interviewed, none reported any issues with personal care, staff responsiveness to their care needs, or the quality of care. No information was obtained corroborating the allegation. Regarding the allegation that facility staff do not provide enough food to residents: it was alleged that the meals are too small and that residents who request more are often told there is none available and provided a snack to tide them over. LPA Haddad reviewed the facility’s menu and noted a proper variety of foods offered. LPA Haddad inspected the facility and observed that residents received generous portions of food, residents left food on their plates that they did not finish, the facility had sufficient food supplies, and there were at least 15 extra plates of food that were not served and were extra available to residents who wanted more. LPA Haddad also noted that residents received food that they requested, for example one resident had five English muffins during breakfast. When interviewed, COO and one kitchen staff denied the allegation, stating that residents are given a sufficient portion, residents can request more food if they finished their first serving, and residents have access to snacks between and after meals. 13 out of 13 residents interviewed stated they get enough food at the facility. No information was obtained corroborating the allegation. Regarding the allegation that staff do not provide snacks to residents: it was alleged that staff are not serving snacks to residents anymore. Three staff interviewed denied the allegation, stating that snacks are available at all times and include apple sauce, yogurt, fruit, and peanut butter and jelly sandwiches. LPA Haddad inspected the kitchen and observed sufficient quantities of all of these items. Out of 10 residents interviewed, eight confirmed that snacks are available and two indicated they did not know whether snacks were available. No information was obtained corroborating that the facility is not offering snacks to residents. The Department has investigated the above allegations and found them to be Unfounded, meaning the allegations were false, could not have happened, or are without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 31, 2025 · control 22-AS-20250416094856

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 1, 2025

87468.1 Personal Rights… (a) … (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure residents were accorded dignity when multiple staff engaged in rudeness, mockery, and ignoring resident inquiries, which poses an immediate personal rights risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: Licensee stated that they will retrain staff on personal rights, create a system for identifying future instances of staff misconduct, and submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Aug 1, 2025

87468.2 … Personal Rights … (a) … (8) To be free from …mental … abuse. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure residents were free from mental abuse when S1 yelled at them, which poses an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: Licensee stated that they will retrain staff on personal rights, create a system for identifying future instances of staff misconduct, and submit proof to LPA by POC due date.

Allegation investigated: Facility staff allow residents to smoke in non-smoking areas

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Chief Operating Officer (COO) Faye Shen, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that facility staff allow residents to smoke in non-smoking areas revealed the following: During the course of the investigation, LPA inspected the facility, interviewed COO and staff, and obtained and reviewed copies of the resident roster, staff roster, a photograph of Resident #1 (R1), the facility’s house rules, and R1’s eviction notice. CONTINUED Substantiated It was alleged that R1 smokes in the patio in front of the building, which is not a designated smoking area, right in front of the facility’s entrance, subjecting residents and visitors to the smell of smoke when entering the building and leaving cigarette butts in the front patio. LPA reviewed a photograph of R1 smoking in the front patio. LPA inspected the facility and observed R1 smoking in the front patio about five feet from the front door, with cigarette butts on the floor and a strong smell of smoke present at the front entrance. LPA reviewed the facility’s house rules which state that smoking is only allowed in the designated smoking area and smoking is prohibited inside the building and where there are “no smoking” signs. LPA interviewed COO and a staff knowledgeable about R1 who admitted the allegation, stating that the only designated smoking area is the central courtyard and residents are not allowed to smoke in their rooms or anywhere else. Both COO and the staff stated that R1 smokes in the front patio near the front door regularly, the facility has warned R1 and worked with their social worker multiple times but has been unsuccessful in stopping R1’s behavior, and residents and visitors complain about R1 and have engaged in verbal altercations with R1 due to their smoking at the front door. The facility was previously cited for R1 smoking outside near the front door in connection with Complaint Control No. 22-AS-20250106112758. Since then, in addition to continuing to give R1 warnings and working with R1’s social worker, COO stated they served an eviction notice. LPA reviewed R1’s eviction notice which indicates the 30-day notice period ended on June 6, 2025, almost two months ago. Per COO, the facility has not proceeded with the next steps in the eviction process as required to protect the personal rights of other residents because they are still trying to work with R1’s social worker. By not proceeding with the next steps of the eviction process, the facility is not properly addressing R1’s continuing violations of the house rules which is causing residents and visitors to engage in verbal altercations with R1. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 31, 2025 · control 22-AS-20250729083734

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Aug 1, 2025

87468.1 Personal Rights… (a) … (2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by: Based on admission and observations, the licensee did not ensure residents can safely and comfortably enjoy the facility by not properly enforcing the facility’s smoking rules resulting in verbal altercations between residents and visitors and R1, which poses an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: Licensee stated that they will take all measures to address R1’s violations of the house rules, including by moving forward with the eviction process, and submit proof to LPA by POC due date.

Allegation investigated: Facility failed to report power outage. Facility did not ensure doors were free of obstruction.

Licensing Program Analyst (LPA) Celine Rodriguez conducted a continuation visit to the facility for the complaint and to deliver the findings. LPA Rodriguez explained the purpose of today's visit and met with Chief Operating Officer (COO) Faye Shen. During the investigation, LPA Rodriguez toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that facility failed to report power outage. LPA Rodriguez conducted 5 resident interviews, of which all 5 interviews did not corroborate with the allegation. LPA Rodriguez conducted 2 staff interviews, and 2 out of 2 staff interviews stated that there was a power outage due to the Edison Electric company working throughout the city, and the power briefly went out, but was resolved. Per record review, on 7/11/23, facility staff spoke to assigned LPA who was informed that the fire alarm system burned out and needed to be replaced, but verified that there was no power outage. Unsubstantiated It was alleged that facility did not ensure doors were free of obstruction. LPA Rodriguez conducted 5 resident interviews, of which all 5 interviews did not corroborate with the allegation. LPA Rodriguez conducted 2 staff interviews, who stated that there was a time when the door alarms in the memory care unit were not working for a few hours, therefore, staff placed furniture in front of the doors to prevent residents from wandering out of the unit. During the tour of the facility, it was observed that the alarms were working and that the doors were hazard and obstruction free. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with COO Shen. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 22-AS-20230711163355

Allegation investigated: Staff failed to intervene in verbal altercation between resident and visitor Staff failed to meet residents hygienic needs Facility allowing resident to smoke in non designated areas

Licensing Program Analyst (LPA) Celine Rodriguez conducted a continuation visit to the facility for the complaint and to deliver the findings. LPA Rodriguez explained the purpose of today's visit and met with Chief Operating Officer (COO) Faye Shen. During the investigation, LPA Rodriguez toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that staff failed to intervene in verbal altercation between resident and visitor. LPA Rodriguez conducted 5 out of 5 resident interviews of which all 5 interviews did not corroborate with the allegation. 2 out of 2 staff interviews did not corroborate with the allegation. Per record review, there was no documentation regarding this incident. During the tour of the facility, LPA Rodriguez observed visitors entering the facility, and did not witness any verbal altercations among residents and visitors. Unsubstantiated It was alleged that staff failed to meet residents hygienic needs.LPA Rodriguez conducted 5 out of 5 resident interviews of which all 5 interviews did not corroborate with the allegation. 2 out of 2 staff interviews did not corroborate with the allegation by stating that staff will assist residents with meeting their hygienic needs at least twice a week. 2 out of the 2 staff interviews also stated that often times, prior to admission to the facility, residents are homeless, which is why they make appear unhygienic, but that staff are present to assist. Per record review of the facility bathing log, it was observed that residents were bathed between 2 to 3 times a week. During the tour of the facility, LPA Rodriguez observed that residents were clean and no odor was observed. It was alleged that facility allowing resident to smoke in non-designated areas. LPA Rodriguez conducted 5 out of 5 resident interviews of which all 5 interviews did not corroborate with the allegation. 5 out of 5 resident interviews verified that the designated smoking area at the facility is located outside, in the patio area on the first floor. 2 out of the 2 staff interviews conducted did not corroborate with the allegation by stating that residents know the designated smoking areas, however stated that resident 1 (R1) used to have a habit of smoking in their room but ever since R1 was informed of needing to smoke outside, R1 does so. During the tour of the facility, LPA Rodriguez observed R1 smoking in the designated facility smoking area four times. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with COO Shen. A copy of this report was explained and provided during the visit.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 22-AS-20230426155348

Allegation investigated: Facility staff slapped resident. Facility staff handled resident(s) in a rough manner. Facility staff spoke inappropriately to resident(s). Facility staff did not treat resident(s) with respect. Facility staff did not prevent resident from hitting another resident.

Licensing Program Analyst (LPA) Celine Rodriguez conducted a continuation visit to the facility for the complaint and to deliver the findings. LPA Rodriguez explained the purpose of today's visit and met with Chief Operating Officer (COO) Shen. During the investigation, LPA Rodriguez toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that facility staff slapped resident. LPA Rodriguez conducted 5 resident interviews, of which all 5 interviews did not corroborate with the allegation. Interviews with the residents, denied of being slapped by staff 1 (S1), and also denied of witnessing S1 slap a resident. LPA Rodriguez conducted 2 staff interviews, of which both interviews also did not corroborate with the allegation by verifying that there was never an instance where a resident has complained about being slapped by staff. Unsubstantiated Per record review, LPA Rodriguez observed that there was no documentation regarding this incident with (S1) and that S1 was trained on how to care for residents and resident rights. During the tour of the facility, LPA Rodriguez observed S1 on the Memory Care unit cleaning the hallway. It was alleged that facility staff handled resident(s) in a rough manner. LPA Rodriguez conducted 5 resident interviews, of which all 5 interviews did not corroborate with the allegation. 2 out of the 2 staff interviews did not corroborate with the allegation by verifying that there has not been an instance where staff handled resident(s) in a rough manner. Per record review, LPA Rodriguez observed that there was no documentation regarding this incident and that staff are trained on how to care for residents. During the tour of the facility, LPA Rodriguez observed that staff were assisting residents, and both staff and resident(s) were calm and not being handled roughly. It was alleged that facility staff spoke inappropriately to resident(s). LPA Rodriguez conducted 5 resident interviews, of which all 5 interviews did not corroborate with the allegation. 2 out of the 2 staff interviews did not corroborate with the allegation by stating that if a resident complained about staff, then management will meet with that staff member, and will also conduct a corrective action plan. Per record review, LPA Rodriguez observed that there was no documentation regarding this incident and that the corrective action plan taken with staff 1 (S1) was due to an unrelated issue (S1 excessive absenteeism) from the allegation. It was alleged that facility staff did not treat resident(s) with respect. LPA Rodriguez conducted 5 resident interviews, of which 3 out of the 5 interviews did not corroborate with the allegation, however 2 out of the 5 resident interviews corroborated with the allegation by stating that staff do not treat resident(s) with respect due to staff implementing “too many rules” (such as having to be respectful to one another, no smoking in room, no foul language). 2 out of the 2 staff interviews did not corroborate with the allegation by stating that there have not been complaints about staff being disrespectful to residents, however there have been complaints about between staff and staff regarding staff 1 (S1) being lazy, but not regarding how staff treats residents. It was alleged that facility staff did not prevent resident from hitting another resident. LPA Rodriguez conducted 5 resident interviews, of which all 5 interviews did not corroborate with the allegation. However, 3 resident interviews stated that they would hit another resident as self-defense if they felt like they were being disrespected but verified that they have not done so. 2 out of the 2 staff interviews conducted did not corroborate with the allegation, however 1 out of the 2 staff interviews specified that there was an instance in the past where resident 1 (R1) and resident 2 (R2) were out in the community without staff, and R1 hit R2, to which upon their return to the facility, that was when staff were notified. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with COO Shen. A copy of this report was explained and provided during the visit.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 22-AS-20230109163057

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced case management visit in conjunction to complaints: 22-AS-20230109163057, 22-AS-20230426155348 and 22-AS-20230711163355. LPA Rodriguez explained the purpose of visit, and met with Chief Operating Officer (COO) Faye Shen. On 7/24/25, LPA Rodriguez conducted a continuation investigation visit for the complaints listed, and during the course of the investigation, LPA Rodriguez observed that 4 out of the 5 resident physician reports reviewed, were incomplete, outdated and not renewed. For today's visit citations were issued per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with COO Shen. A copy of this report was explained, and appeal rights were provided during the visit.the state’s words, verbatim · CDSS document, Jul 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87458(a) · Plan of correction due date: Jul 23, 2025

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed... and made within the last year. This requirement is not met as evidence by: Based on interviews, record review and observations, R1, R2, R3, R4 have not recieved an updated medical evaluation. R1's physican report is dated for 5/18/22, R2's physican report is dated for 3/28/23, R3's physican report is dated for 3/24/23 and R4's physican report is dated for 3/28/23. This poses an immediate Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: As a plan of correction (POC) facility agrees to schedule R1, R2, R3, and R4 appointments with their physican and will obtain an updated physican report and submit proof to assigned LPA on or by 7/25/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87458(c)(1)(A) · Plan of correction due date: Jul 24, 2025

87458 Medical Assessment (c) The medical assessment shall include... (1) ...results of an examination for... (A) Communicable tuberculosis. This requirement is not met as evidence by: Based on interviews, record review and observations, R2 and R3 did not complete a tuberculosis screening. This poses an immediate Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: As a plan of correction (POC) facility agrees to schedule R2 and R3 appointments to complete a TB exam and submit proof to assigned LPA on or by 7/25/24.

Type of visit: Case Management - Other

On this day, Licensing Program Analyst (LPA) Samer Haddadin made an unannounced visit to amend a complaint report. The control number is 22-AS-20250521095845. LPA Haddadin was greeted and granted entry into the facility by Administrator (AD) Angle Renture . A copy of this report and a copy of the amended report was provided to AD.the state’s words, verbatim · CDSS document, Jul 24, 2025

Allegation investigated: Staff are taking unauthorized photos of resident. Staff are bullying resident and calling the resident names.

On the above noted date and time, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility to investigate two allegations. Upon stating the purpose of the visit, LPA Haddadin was greeted by Administrator (AD) Angie Rentutar and granted entry. During the investigation, LPA Haddadin toured the facility, interviewed staff members and residents, and reviewed facility records. The allegations under review were that "Staff are taking unauthorized photos of resident" and "Staff are bullying resident and calling the resident names." LPA Haddadin interviewed four staff members, four other residents, and the resident in question (R1). All individuals interviewed denied the allegations. Staff members stated that R1 is verbally aggressive towards facility personnel. A review of staff records confirmed that all personnel received appropriate training on residents' personal rights, as documented on form SOC 341. LPA Haddadin also interviewed R1, who denied that the alleged incidents occurred. *****THIS IS AN AMENDED REPORT***** Unsubstantiated Based on the preponderance of evidence gathered through multiple interviews and a review of records, the allegations that staff took unauthorized photos of a resident and bullied a resident were found to be UNSUBSTANTIATED. This determination signifies that while the alleged incidents may have occurred or the concerns might be valid, there is insufficient evidence to prove that a violation took place. An exit interview was conducted with the Administrator, and a copy of this report was provided to AD, Angie Rentutarthe state’s words, verbatim · CDSS document, Jul 15, 2025 · control 22-AS-20250521095845

Allegation investigated: . Facility accepted resident with a higher level of needs. 2. Incident(s) involving resident were not reported to their Resident Representative.

Licensing Program Analyst (LPA) Hiratsuka conducted this visit to deliver the results of the allegation above. This incident occurred in May 2022. 1. Title 22 Regulations requires a facility to keep a resident's records for three years after moving out or upon passing away. A partial portion of the file was found. The resident in question was at this facility for only three days. The physician's report listed the diagnoses does meet Title 22 Regulations. However, due to only being able to review a partial file it cannot be determined if the facility did a thorough pre-appraisal of the resident. 2. It cannot be proved or disproved who was the responsible party of the resident because only a partial copy of the file was found. Interviews indicate there was possible personal issues with the resident that made it difficult to determine who was allowed to be the responsible party. Unsubstantiated Therefore, LPA finds the allegation to be "unsubstantiated." A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the violation occurred.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 22-AS-20220517105925

Allegation investigated: Staff did not safeguard resident's personal property

Licensing Program Analyst (LPA) Hiratsuka conducted this visit to deliver the results of the allegation above. This incident occurred in September 2021 to June 2022. A former resident stated many of their personal items were stolen. Chief Operating Officer Faye Shen stated she was not made aware of any items missing from the resident. The resident's file did not have a personal property inventory list. LPA unable to interview resident. Based on the information, the allegation cannot be proved or disproved. Therefore, LPA finds the allegation to be "unsubstantiated." A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the violation occurred. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 11, 2025 · control 22-AS-20220616111042

Allegation investigated: . Resident behavior poses as a risk to other residents while in care 2. Resident is entering another resident's room while in care

Licensing Program Analyst (LPA) Hiratsuka conducted this visit to deliver the results of the allegation above. This incident occurred in December 2021. 1. The facility submitted an incident report regarding the allegation. One resident walked around and did walk into another resident's room. The resident who walked into the room did not injure the resident who resided in the room. Per record review there was no history of violent behavior of the resident who walked into the room. Witness stated they felt threatened by the resident who walked into the other's room. Staff interiews stated the one resident who was walking around did not attempt to harm anyone and walked quickly out of the room. Because each side has their version of events the allegation cannot be proved or disproved. Unsubstantiated 2. Title 22 Regulations does not require staff to have residents in line of sight or within earshot 24 hours a day, seven days a week. Title 22 Regulations require facilities to assess residents and determine how much supervision and care a resident requires. Residents are allowed to walk freely around the facility. The resident rooms are not locked to prevent people from entering the rooms unless requested by the resident. Also, some residents do not close their doors. It cannot be determined if the resident in question wandered into the room due to lack of supervision. Therefore, LPA finds the allegation to be "unsubstantiated." A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the violation occurred.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 22-AS-20220106152835

Allegation investigated: Lack of supervision resulting in resident sustaining injury from fall

The department conducted the investigation into the allegations above. The department reviewed medical records, facility records, and conducted interviews. This complaint came in March 2021. Title 22 Regulations does not require staff to have residents in line of sight or within earshot 24 hours a day, seven days a week. Title 22 Regulations require facilities to assess residents and determine how much supervision and care a resident requires. Records and interviews do state one resident was found on the floor in front a a recliner face down. Interviews with staff stated they check on residents a minimum of every two hours and the checks are adjusted according to a resident’s needs. Interviews indicate the resident possibly fell out of the recliner in between the checks. Based on the interviews the allegation cannot be proved or disproved because it cannot be determined what time the resident feel. Resident was not able to be interviewed. Therefore, LPA finds the allegation to be "unsubstantiated." A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the violation occurred. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 11, 2025 · control 22-AS-20210324094334

Allegation investigated: Staff did not prevent a resident from wandering

Licensing Program Analyst (LPA) Hiratsuka conducted this visit to deliver the results of the allegation above. This incident occurred in May 2021. A review of the resident's physician's report was done. There were two and both stated the resident may leave the facility unassisted. Per interviews the resident did leave the facility at any time day or night. The facility staff are not allowed to restrain or prevent a resident from leaving the facility. The one incident in question the resident had a fall while out of the facility during the evening hours and brought back by good samaritans. The resident did not suffer any ill effects. Based on the evidence gathered, the Department finds that the allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Unfoundedthe state’s words, verbatim · CDSS document, Jul 11, 2025 · control 22-AS-20210521161415

Allegation investigated: Facility staff did not prevent residents from engaging in a physical altercation resulting in a major injury

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Chief Operating Officer (COO) Faye Shen and explained the reason for today’s inspection. The investigation into the allegation that facility staff did not prevent residents from engaging in a physical altercation resulting in a major injury revealed the following: During the course of the investigation, LPA inspected the facility, interviewed residents, witnesses, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) medical records dated April 20, 2025, R1’s medical records dated April 30, 2025, and R1’s progress notes. CONTINUED Unsubstantiated It was alleged that, due to lack of care and supervision, R1 was pushed by another resident and fell, resulting in a head injury that progressed R1’s Dementia and caused R1 to be placed on hospice with a short time left to live. LPA inspected the facility, conducted health and safety checks on residents, including R1, and observed no health and safety issues. LPA attempted to interview R1, but R1 was unable to communicate. LPA interviewed the facility’s medication technician supervisor who stated that, on April 20, 2025, R1 was not pushed by another resident, but instead fell on their own, hit their head, went to the hospital, and came back that same day with stitches. LPA interviewed the three staff present during the incident, one of whom confirmed seeing R1 fall by themselves and stated they attempted to catch R1 but were unable to reach R1 in time. LPA reviewed R1’s medical records dated April 20, 2025, which confirm that R1 received treatment for a head laceration, was diagnosed with a urinary tract infection, and was released back to the facility the same day. The information obtained did not corroborate that R1’s fall was caused by an altercation with another resident. Per the facility’s medication technician supervisor, three caregivers are assigned to the second-floor memory care and the facility’s resident roster indicates there are 22 residents in the second-floor memory care. Interviews with the three staff present during the incident confirmed that the second-floor memory care was fully staffed at the time of the incident. Per the facility’s medication technician supervisor, R1 has a history of falls and has a fall prevention plan which includes encouraging R1 to sit in their favorite recliner in the common area where they can be frequently checked on by staff. LPA interviewed the three staff who were present during the incident who confirmed that R1 was a known fall risk, staff know to check on R1 frequently, that the fall prevention plan for R1 included encouraging R1 to sit in their favorite couch in the common area close to staff and frequent checks. The information obtained did not corroborate that R1’s fall was caused by lack of care and supervision as the second-floor memory care was fully staffed and R1 was in the line of sight of one of the staff who saw R1 fall but was unable to catch R1 in time. CONTINUED Per the facility’s medication technician supervisor, R1 had a change of condition relating to a urinary tract infection before the fall on April 20, 2025, facility staff communicated almost daily with R1’s doctor regarding R1’s condition, R1’s condition got worse days after their fall due to their urinary tract infection which resulted in their hospitalization on April 23, 2025 and return to the facility on hospice on April 30, 2025. LPA reviewed R1’s medical records dated April 30, 2025, which indicate that R1’s fall did not result in any serious injuries, R1 had an acute urinary tract infection and electrolyte imbalances due to dehydration, R1 refused to eat at the hospital, R1’s family discussed the possibility of hospice, and R1 was discharged back to the facility on hospice. LPA reviewed R1’s progress notes which document that facility staff noticed R1’s change of condition and suspected a urinary tract infection as early as April 14, 2025, and coordinated with R1’s doctor almost daily to ensure R1’s medical needs were met. LPA interviewed R1’s family who had no concerns about the care R1 received at the facility. The information obtained did not corroborate that R1’s fall led to their decline and placement on hospice or that the facility failed to meet R1’s medical needs. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jun 13, 2025 · control 22-AS-20250506124029

Allegation investigated: Staff did not provide resident with a safe environment.

Regarding the allegation: Staff did not provide resident with a safe environment. During the complaint investigation it was discovered, accusations of unwanted and inappropriate attention was being showed to resident 1 (R1). According to S1, no one witnessed any of the alleged incidents. S1 explained, they encouraged the family member of one of the accusers (R1) to call the police and file a report since there are no witness and there was no camera footage of the alleged incident that took place. According to S1, there’s a former resident (FR1) who had a tendency of being inappropriate with women. After FR1 admitted to groping R1, it was immediately explained to FR1 that is grounds to be removed and FR1 was served with an eviction notice. Eventually, FR1 moved out prior to the eviction date on their own accord. Further, prior to the groping incident, FR1 was being monitored by staff because FR1 had a reputation for being inappropriate with women. Document review revealed that staff provided a copy of the house rules to the residents, and Continued on LIC9099C Unsubstantiated the resident were informed the consequences for violating facility rules "will include eviction." Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegation is deemed Unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 20, 2025 · control 22-AS-20250514151355

Allegation investigated: Lack of supervision resulting in resident being sexually abused by another resident while in care.

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to begin the investigation into the complaint received May 14, 2025. LPA Haley was greeted by staff and explained the reason for the visit upon entry. During the visit, LPA Haley conducted a staff interview collected relevant documents, interviewed a witness, and requested additional documents to be provided via email. Regarding the allegation: A lack of supervision resulted in a resident being sexually abused by another resident while in care. During the investigation it was discovered R1 was groped by another resident who moved out and is now a former resident (FR1). R1 reported the groping incident to a family member and the family member reported the incident to facility staff. At that time, R1’s family member was encouraged by the staff member to call the police and file a report since there were no witnesses. Continued on LIC9099C Substantiated When confronted by staff, the resident (FR1) accused of the groping, FR1 stated, they "did not remember" doing the act. FR1 was served with an eviction notice. According to S1, FR1 had a tendency to be inappropriate with women in the facility, however, no of the alleged victims/accusers ever wanted to pursue any actions against FR1. After being served with an eviction notice, FR1 moved out. After the incident took place, the facility took immediate action and served FR1 with an eviction notice. Document review revealed the eviction notice provided FR1 two examples of inappropriate behavior that contributed to the eviction: 1: An Aggressive Sexual Act against another resident 2: Foul language towards female residents. Female residents of Whitten Heights Assisted Living do not feel safe with your presence / behavior and are worried about their well being. Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 20, 2025 · control 22-AS-20250514151355

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(A)(1) · Plan of correction due date: May 23, 2025

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not being met as evidenced by: FR1 was evicted for being inappropriate with women after being accused of groping R1.the state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: Plan of Correction: The resident was served with an eviction notice and FR1 moved out of the facility. FR1 voluntarily moved out on November 29, 2024. Eviction notice provide. No further action required.

Allegation investigated: Facility is not reporting incidents

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Administrator (AD) Steve Shen, discussed the purpose of the inspection, and explained the allegation. Chief Operating Officer (COO) Faye Shen appeared via telephone. The investigation into the allegation that facility is not reporting incidents revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD and COO, and obtained and reviewed copies of the resident roster and staff roster. CONTINUED Substantiated It was alleged that the facility is not properly reporting incidents, including incidents involving Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5). LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA reviewed the incident reports received in the Orange County Regional Office (OCRO) and noted that the incident involving R4 was properly reported, but the incidents involving the other four residents were not reported to the OCRO. LPA interviewed AD and COO who admitted the allegation, confirming that the incidents involving R1, R2, R3, and R5 occurred more than seven days ago and the facility has not reported them yet, but is planning to report them. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, May 16, 2025 · control 22-AS-20250513084011

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 30, 2025

87211 Reporting Requirements (a) … (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below… This requirement was not met as evidenced by: Based on documents and admission, the licensee did not ensure multiple reportable incidents were reported as required, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: The licensee stated they will create a plan to ensure incidents are properly reported and will submit proof to LPA by POC due date.

Allegation investigated: Due to lack of supervision, resident was physically assaulted by another resident causing a bruise

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Chief Operating Officer (COO) Faye Shen and explained the reason for today’s inspection. The investigation into the allegation that due to lack of supervision, resident was physically assaulted by another resident causing a bruise revealed the following: During the course of the investigation, LPA inspected the facility, interviewed residents and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #2’s (R2) Physician’s Report dated January 1, 2025, and R2’s Appraisal/Needs and Services Plan dated February 1, 2024. CONTINUED Substantiated It was alleged that, due to staff’s lack of care and supervision of residents in the memory care unit, on May 3, 2025, Resident #1 (R1) was attacked by R2, who has a history of aggressive behavior, resulting in a bruise. LPA inspected the facility, conducted health and safety checks on residents, including R1 and R2, noted that R1 has a small bruise on their cheek and that R1 has been relocated to another floor in the memory care unit, and observed no health and safety issues. LPA interviewed R1 and R2 who denied engaging in any fights or sustaining any injuries, stated they receive good care at the facility, and denied having any problems at the facility. LPA interviewed the facility’s medication technician supervisor who stated that on May 3, 2025, staff in the third-floor memory care heard a fall, observed R1’s door open with R1 on the floor inside and R2 standing outside the room, noted no serious injuries on R1, offered R1 first aid and reported the fall to R1’s doctor, but did not observe whether R1 fell or was pushed by R2. Per the facility’s medication technician supervisor, three caregivers are assigned to the third-floor memory care and the facility’s resident roster indicates there are 35 residents in the third-floor memory care. Interviews with staff confirmed that three caregivers were working on the third-floor memory care at the time of the incident. LPA interviewed three staff who were witnesses to the incident, and one confirmed seeing R2 push R1 causing R1’s fall. All four staff interviewed also confirmed that R2 has a history of aggression. LPA reviewed R2’s Physician’s Report dated January 1, 2025, which indicates R2 has Dementia, and R2’s Appraisal/Needs and Services Plan dated February 1, 2024, which was not updated as required due to R2’s Dementia diagnosis, does not indicate R2 has a history of aggressive behavior as confirmed by facility staff, or provide a care plan to address R2’s aggressive behavior. Interviews with three staff confirmed that the incident was caused when R2 was left to wander around the memory care, confirming that no special care was provided to address R2’s aggressive behavior. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, May 8, 2025 · control 22-AS-20250507114305

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: May 9, 2025

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure R2 received care and supervision for their aggressive behavior resulting in R1’s injury, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSEDthe state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: The licensee stated they reassess R2 and create a care plan for their aggression and will review their roster, identify residents with aggressive behavior, and create care plans to address those aggressive behaviors, and submit proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20250507114305. LPA met with Chief Operating Officer (COO) Faye Shen and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, interviewed staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #2’s (R2) Physician’s Report dated January 1, 2025, and R2’s Appraisal/Needs and Services Plan dated February 1, 2024. LPA interviewed the facility’s medication technician supervisor who stated that on May 3, 2025, staff in the third-floor memory care heard a fall, observed Resident #1’s (R1) door open with R1 on the floor inside and R2 standing outside the room, noted no serious injuries on R1, offered R1 first aid and reported the fall to R1’s doctor, but did not observe whether R1 fell or was pushed by R2. LPA interviewed three staff who were witnesses to the incident, and one confirmed seeing R2 push R1 causing R1’s fall. All four staff interviewed also confirmed that R2 has a history of aggression. LPA reviewed R2’s Physician’s Report dated January 1, 2025, which indicates R2 has Dementia, and R2’s Appraisal/Needs and Services Plan dated February 1, 2024, which was not updated as required due to R2’s Dementia diagnosis. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, May 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: May 22, 2025

87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first…This requirement was not met as evidenced by: Based on documents, the licensee did not ensure R2 was reappraised at least yearly, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: Licensee stated they will submit a plan to ensure all residents are reassessed at least yearly to LPA by POC due date.

Allegation investigated: Staff are not serving residents food free from contamination Due to lack of training, staff did not ensure that residents' dietary needs are met

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced inspection visit to deliver findings for complaint investigation LPA explained the reason for the visit with Executive Director Steve Shen. During the course of the investigation LPA toured facility, reviewed records, conducted staff and resident interviews, made visual observations and requested pertinent documentation such as Physician’s reports, Admission Agreements, weekly menu, alternative menu, special orders list, Resident alert record and menu needs list. During investigation LPA reviewed facility records for Resident 1 (R1). Record reviews revealed the following: Special orders list states that R1 is lactose intolerant and R1 is not to have: Pork/ processed food or spicy food. This special order was provided to kitchen staff and listed in both English and Spanish for staff reference. Resident Alert Record which is discussed upon move in to facility also states that R1 is lactose intolerant (no milk, almond milk only), no pork or processed meat and no spicy foods. The Menu Needs List which was CONTINUED ON 9099C Unsubstantiated provided by R1’s family states that R1 can have the following: Beverages- 1/2/cup coke, coffee, cranberry juice or water. Menu needs list states that for Breakfast- wheat toast, scrambled egg/ Omelets with potatoes or French toast and for Lunch/Dinner-1/2 bowl of soup, tender chicken beef or fish. Pasta with meat sauce. Sandwich with wheat bread with tuna, turkey or chicken salad. Rice, mashed potatoes, tater tots, peas and carrots. On menu needs list it states No pork, sausage, hot dogs or string beans. No ice cream, milk, pudding, yogurt or tapioca. R1’s physician’s report dated 9/2/2022, is not marked on special diet section. Staff records revealed that cooks at facility all have to maintain a strict “clean as you go” policy, utilize sound food handling practices for the storage and preparation for each menu item and coordinate in checking the next day food production needs, pull and thawing frozen items in a timely manner. Based off interviews with staff, seven of seven staff stated that facility has a Special Diet Needs list posted inside kitchen area for kitchen staff to review while prepping and serving meals to residents. Interviews with staff state that Special Diet needs list get updated whenever a resident is new to facility or if there is a change noted by doctors order. Interviews with Facility cooks state that two of two cooks stated that food is prepped fresh same day, facility rarely uses frozen foods, food and supplies are washed prior to cooks preparing meals for residents. Seven of Seven staff interviewed stated that no residents have gotten sick or had food poisoning due to meals at facility. Interviews with residents stated that five of five residents stated they liked the food served to them at facility, states that they get the option to pick their breakfast and can exercise changes in meals. All resident interviews were conducted with residents who have special diet needs and all residents interviewed stated they have never gotten sick as a result of the food they have eaten at facility. During investigation, LPA Tirre made the following observations: Kitchen staff were wearing gloves while handling food. Floors & tables were cleaned during visit. During tour of kitchen LPA Tirre observed special diet needs list posted inside kitchen area near tray service for staff. LPA observed R1 listed on Special Diets list. LPA observed perishable and nonperishable foods. Foods were observed to be fresh in nature, no mold or expired dates. Food was plastic wrapped and sealed inside kitchen fridges. LPA did not observe any cross contamination or seen any “rotten” foods being served. Based off records review, interviews and observations LPA Tirre is unable to corroborate allegations made that Staff are not serving residents food free from contamination and Due to lack of training staff did not ensure that residents' dietary needs are met therefore although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Steve Shen and a copy of this report was provided during this visit.the state’s words, verbatim · CDSS document, May 1, 2025 · control 22-AS-20250424102452

Allegation investigated: Staff did not respond to resident’s requests for assistance in a timely manner.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Chief Operating Officer (COO) Faye Shen and explained the reason for today’s inspection. The investigation into the allegation that staff did not respond to resident’s requests for assistance in a timely manner revealed the following: During the course of the investigation, LPA inspected the facility, interviewed COO, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, the facility’s staff schedule, the facility’s payroll records, and the facility’s call system logs. CONTINUED Substantiated It was alleged that on February 3, 2025, a resident called for assistance with using the restroom, had to wait an hour because there was only staff to assist all three floors of assisted living due to another staff calling out, and there have been multiple instances where wait times for assistance were up to 30 minutes. LPA inspected the facility, conducted health and safety checks on residents present, and observed no health and safety issues. LPA tested the call system in three separate resident rooms and observed that a caregiver responded each time in less than five minutes. LPA reviewed the facility’s staff schedule and noted that on February 3, 2025, there were two caregivers for the morning shift, three caregivers for the afternoon shift, and two caregivers for the overnight shift scheduled for all three floors of the assisted living section. Per the facility’s resident roster, the facility had 70 residents in assisted living on February 3, 2025. LPA interviewed COO, who denied that any staff called out on February 3, 2025. LPA reviewed the facility’s payroll records and confirmed that all staff scheduled to work on February 3, 2025, signed in to work that day. LPA interviewed two staff, one of whom admitted that on February 3, 2025, a caregiver was running an hour late so there was only one caregiver for all of assisted living, a resident called for assistance and was advised to wait because there is only one caregiver for assisted living, the caregiver went to the resident’s room and advised the resident they were the only caregiver and they had to assist other residents who had called first but that they would be back, and it is unknown how long the resident had to wait in total. LPA reviewed the facility’s call system logs which do not properly document this incident, as the response time indicated does not specify if it is for the time the phone call was answered, the caregiver was first sent to the resident’s room but did not provide the requested care, or the resident finally received care, meaning the facility does not have any documentation of how long the resident had to wait for care. LPA interviewed 12 residents, 11 of whom stated that response times are generally 10 minutes or less. However, one resident corroborated that wait times for care can be up to 45 minutes. LPA reviewed the facility’s call system logs which do corroborate that wait times can be up to an hour on occasion. The information obtained corroborated the allegation, as the facility was unable to provide timely care to a resident because of short staffing. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. It was alleged that the facility’s call system was not functioning. LPA reviewed a facility incident report dated February 6, 2025, which states that on February 2, 2025 at 11:00AM, it was discovered that some of the call buttons had stopped working, troubleshooting of the system began, in the meantime regular checks were conducted on residents and residents were provided with the receptionist’s phone number as an alternative to the call system, troubleshooting of the system was completed on February 4, 2025 and new parts for the call system were ordered, and the call system was fixed a little over three days later on February 5, 2025 at 8PM. LPA interviewed COO and one staff who corroborated the information in the incident report and stated that the issue with the call system did not affect memory care and only affected the second-floor assisted living section. LPA reviewed a call system parts invoice dated February 4, 2025, which shows that the parts to fix the call system were ordered after the troubleshooting was completed. LPA inspected the facility, conducted health and safety checks on residents present, and observed no health and safety issues. LPA tested the call system in three rooms and observed the call system to be working properly. LPA interviewed COO and one staff who stated that after the issue with the call system was discovered, regular checks were conducted on residents, a notice was posted informing residents of the situation, residents were advised of the situation in-person and were provided with the receptionist’s phone number to call for assistance, and these measures mitigated the effect of the call system being non-functional for a few days. LPA reviewed a facility notice regarding the call system which states that the call system is out of order and advises residents to call the receptionist for assistance. LPA reviewed facility phone number cards showing the receptionist’s phone number which facility staff stated they handed out to all affected residents. LPA interviewed 12 residents and did not obtain any information that the call system being down affected their ability to call for assistance. LPA also noted that all residents interviewed had phones they are able to use and that many residents use their phones to call for assistance generally instead of using the call system. The information showed that although a portion of the call system did not function for a few days, the facility quickly repaired the call system and created an alternative system which mitigated any effects of the outage. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 22-AS-20250203163717

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 4, 2025

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure one resident received care and supervision by having to wait approximately one hour for assistance with using the bathroom due to short staffing, which poses an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: The licensee stated they will create a plan to ensure staff call-outs are properly covered and submit proof to LPA by POC due date.

Allegation investigated: Licensee did not provide a healthful environment by allowing resident to smoke at the facility entranceway.

Licensing Program Analyst (LPA) arrived at the facility unannounced for the purpose of initiating the complaint investigation into the above allegation. LPA was greeted and granted entry by the receptionist. Chief Operating Officer (COO) Faye Shen arrived approximately 10:18am and was informed the reason for the visit. During the course of the investigation, LPA interviewed ten residents and three staff and obtained pertinent documentation which includes the resident/staff rosters, staff contacts, face sheets, physician's reports, admission agreement, resident code of conduct, and smoking log from January 16, 2025 to today's date. LPA is unable to qualify three resident interviews due to their medical condition or language barriers. Regarding the allegation, Licensee did not provide a healthful environment by allowing resident to smoke at the facility entranceway, the investigation revealed the following: Approximately 8:30am, LPA smelled cigarette odor from the entrance area and observed Resident #1(R1) smoking in the front patio. LPA observed cigarette buds on the ground and R1 smoking throughout the day at 9:39am, 10:05am, and 1:56pm. Substantiated The three staff also indicated R1 expressing anger only when told not to smoke in the front patio. Due to conflicting information, 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 following allegation: Licensee did not provide a safe environment is deemed Unsubstantiated. An exit interview was conducted with Chief Operating Officer Faye Shen, and a copy of this report was provided at exit. Six out of the seven residents and three out of the three staff interviews acknowledged R1 smoking in the front patio which is a no smoking zone evidenced by the two no smoking signs and one personal sign posted for R1. Three out of the three staff indicated reminding R1 not to smoke, however R1 would not adhere to the house rules. Based on the review of the resident code of conduct, facility enforces a strict zero-tolerance policy and permits smoking "exclusively in designated areas" and prohibits in areas marked with no smoking signs. Per review of the the resident's smoking log, which was part of the Plan Correction (POC) issued on January 15, 2025, the log reveals R1 smoking at the front entrance. Based on the observations made, interviews which were conducted, and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Licensee did not provide a healthful environment by allowing resident to smoke at the facility entranceway is deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. See the attached LIC9099D. A civil penalty for a repeat violation is being assessed on the LIC421FC. An exit interview was conducted with Chief Operating Officer Faye Shen, and a copy of this report including the LIC811 and the appeal rights were provided at exit.the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 22-AS-20250327111846

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Apr 11, 2025

87468.1 Personal Rights… (a) … (2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by: Based on observations and interviews, the licensee did not ensure residents are able to safely and comfortably enjoy the facility by not properly enforcing the facility’s smoking rules, which poses a potential personal rights risk to persons in care. CIVIL PENALTY ASSESSED for repeated violation.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: Administrator stated that the facility will move forward with the eviction of R1 and will provide the eviction notice to LPAs Cho and Haddad via email by POC due date.

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809 D on 02/14/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87303(a) regarding Maintenance and Operation has been cleared. Licensee corrected noted items. Licensee has complied with the POC. Licensee has been advised to remain in compliance with items previously cited at the facility. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 2, 2025

Allegation investigated: Facility staff are not dispensing medications as prescribed

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Chief Operating Officer (COO) Faye Shen and explained the reason for today’s inspection. The investigation into the allegation that facility staff are not dispensing medications as prescribed revealed the following: During the course of the investigation, LPA inspected the facility, interviewed residents and staff, and obtained and reviewed copies of the resident roster, staff roster, the facility’s Medication Administration Records (MAR), the facility’s as-needed medication logs, and resident medication lists. It was alleged that instead of giving residents their prescribed pain medications, facility staff are giving alternate medications, smaller doses, or skipping medications altogether, and there is concern about theft of these medications. Substantiated LPA interviewed the facility’s medication technician supervisor who reported there were issues in December 2024 with residents on controlled pain medications but denied that any of these medications have been stolen. LPA reviewed the facility’s MAR for December 2024 for the five residents on controlled pain medications and noted the MARs are incomplete and do not properly document the medications dispensed. Per the facility’s medication technician supervisor, the facility is using a new electronic MAR system which does not always record the information that is entered, but the facility’s as-needed medication logs are still handwritten and properly document medications dispensed. LPA inspected the controlled pain medications for the five residents, all of which were in bubble packs, and observed no errors. LPA reviewed the January 2025 as-needed medication logs for the three residents who take controlled pain medications on an as-needed basis and confirmed the logs matched the medications administered and that there were no missing or extra pills. The facility’s medication technician supervisor denied that residents were ever given smaller doses than prescribed, but revealed that in December 2024 one of these residents missed one or two doses and was offered an alternate medication (Tylenol) because the facility ran out of supply of the resident’s controlled pain medication. LPA reviewed this resident’s medication list and confirmed Tylenol is one of their prescribed medications. Per the facility’s medication technician supervisor, this resident requests and takes this controlled pain medication four times a day. LPA reviewed this resident’s as-needed medication logs and noted approximately six days in November and December 2024 when the resident missed at least one dose of their controlled pain medication. LPA also noted that these logs did not document the facility’s attempts to refill the medication, which dates and times the medication could not be provided as requested, and the reason the medication could not be provided as requested. LPA inspected the medications for an additional 10 residents and did not observe any additional medication issues. LPA interviewed two additional medication technicians and did not obtain additional information regarding the allegation. LPA interviewed the four residents on controlled pain medications who were present at the facility and did not obtain additional information regarding the allegation. The information obtained corroborated that the facility did not dispense one resident’s medications as prescribed by running out of one of supply and that the facility instead dispensed an approved alternate medication. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Mar 27, 2025 · control 22-AS-20250113112051

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 10, 2025

87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure one resident received assistance with medications when the facility ran out of supply and provided a doctor-prescribed alternative, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: The licensee stated they will submit a plan to ensure residents’ medications are refilled timely to LPA by POC due date. CIVIL PENALTIES ASSESSED

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Clara Ramirez and discussed the purpose of the inspection. Chief Operating Officer (COO) Faye Shen arrived during the inspection. LPA reviewed Infection Control requirements. At about 8:45AM, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following: Structure: this is a large commercial facility. Facility is a 180-bedroom, 100-bathroom, 3 story building. There is 1 large central patio with patio covers for the residents. Resident Bedrooms: the 18 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 18 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 105 degrees F and 120 degrees in the 18 resident bathrooms inspected. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees are paid. At about 11:00AM, LPA reviewed 10 resident files and 10 staff files, interviewed 5 residents and 5 staff, and inspected medications for 10 residents. Facility does not handle resident money. During the inspection, LPA and AD observed the following: based on documents and admission, the current administrator's administrator certificate lapsed on February 5, 2025; based on documents, the staff files for 5 out of 10 staff did not have health screenings; based on Guardian records and admission, the licensee did not ensure staff VERONICA DIAZ VILLEGAS was background cleared prior to working at the facility for multiple years and that staff Dolores L Gonzalez was associated prior to working at the facility for multiple months; based on documents, the licensee did not maintain complete records for annual training requirements for 10 out of 10 staff; and based on documents, it has been more than three months since the facility's last emergency disaster drill. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421BG. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Mar 25, 2025

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Facility is in disrepair

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the visit, LPAs interviewed staff and toured the facility. Regarding the allegation that facility is in disrepair, the investigation revealed the following: LPAs toured the facility and observed the following: The back elevator is inoperable. Interview with staff indicated the elevator has been down for about 6 months. LPAs observed multiple holes in the memory care unit sitting area with buckets for leaking water and an air conditioning unit in memory care unit is in disrepair. Electrical socket in common area of memory care unit is in need of repair. The flooring inside room 247 appeared to be buckling. Based on observation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report, LIC9099D, and appeal rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Feb 14, 2025 · control 22-AS-20250210083250

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 28, 2025

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This req is not being met as evidenced by: Based on observation, Licensee failed to ensure facility is in good repair. LPA observed noted items on LIC 9099. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 14, 2025

Plan of correction: Licensee to repair/ replace noted items and forward proof to LPA by POC due date.

Allegation investigated: Facility is in disrepair

On this day, Licensing Program Analysts (LPAs) Andrea Mendivil and Kimberly Lyman made an unannounced visit to deliver complaint findings. LPAs were greeted and granted entry to the facility and explained the reason for the visit. The Department received a complaint on 12/21/2023 and an initial 10 day visit on 12/29/2023. LPA Mendivil obtained copies of activities and LPA interviewed staff and residents. LPA Mendivil toured the facility with staff. Regarding the allegation facility is in disrepair, the investigation revealed the following: LPA Mendivil toured the facility with staff, during the tour LPA Mendivil observed an air conditioning unit to be in disrepair on the 3rd floor TV room. Based on interviews with 2 out of 2 staff indicated the floor on 3rd floor needed to be replaced and it was as of 12/21/2023. Substantiated Therefore, based on the preponderance of evidence through observations and interviews the allegation that facility is in disrepair the allegation is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative. Per interviews with 3 out of 3 staff stated they contract out activities’ services from Lifeskills Education Advancement Program at least 3 times a week. The classes range from music to exercise, in addition to facility activities of arts and crafts. Based on interviews with staff, staff will assist residents from 2nd and 3rd floor to the 1st floor to participate in activities daily. Based on LPA Mendivil’s observations on 12/15/2023 and 12/29/2023 residents were participating in activities such as exercise. Therefore based on the preponderance of evidence through interviews, records reviewed and observations the allegations staff do not keep the facility clean or sanitary and staff do not provide daily activities for residents in care are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 14, 2025 · control 22-AS-20231221162726

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 20, 2025

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by facility had an AC unit on the 3rd floor that is still in disrepair as of 2/14/2025. Civil Penalty assessedthe state’s words, verbatim · CDSS document, Feb 14, 2025

Plan of correction: Administrator agrees to remove AC unit in 3rd floor tv room and provide proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

On this day Licensing Program Analysts (LPAs) Andrea Mendivil and Kimberly Lyman made an unannounced visit in conjuction with complaint control #22-AS-20241219124149. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the investigation for complaint control 22-AS-20241219124149 it was revealed that Resident 1 (R1) hospice records were not available. It was also reported by 2 out of 2 staff that R1's hospice does not provide updates or care plans to the facility. Based on observations made during today's visit a deficiency is being cited per Title 22 An exit interview was conducted and a copy of this report was provided along with appeal rights.the state’s words, verbatim · CDSS document, Feb 14, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87632(a)(4) · Plan of correction due date: Feb 26, 2025

a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency....(4) A statement by the licensee that an agreement with the hospice agency will be entered into regarding the care plan for the terminally ill resident... ... to be accepted and/or retained in the facility. (4)The agreement with hospice shall design and provide for the care, services, and necessary medical intervention related to the terminal illness.. This requirement was not met as evidence by R1's hospice records were not available.the state’s words, verbatim · CDSS document, Feb 14, 2025

Plan of correction: COO agrees to retain all hospice records and to hold a meeting with hospice for R1

Allegation investigated: Facility does not have hot water

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the investigation. LPA was greeted and granted entry into the facility and met with Activities Director Clara Ramirez. LPA explained the reason for the visit. Chief Operating Officer (COO) Faye Shen arrived during the visit. This agency has investigated the complaint alleging that facility does not have hot water. Regarding the allegation, the following was revealed: During the initial visit on February 13, 2025, LPA Ramirez tested the hot water in the following bedrooms: #114, #116, #217, #222, #226, #323 and #328. The hot water tested between 107.9 to 116.7 degrees Fahrenheit. During the course of the interviews with Residents, Resident 1 (R1) reported that a couple of days ago there was not hot water for two days. Per R1 she has hot water now. Per R2 the hot water was off for a little while and reported that there was a sign by the elevator which notified Residents. CONTINUED ON LIC9099-C... Unsubstantiated During the course of the interviews with staff, Staff 1 (S1) reported that management tried their best to replace the boiler and stated that the boiler got replaced within two days. During the investigation LPA reviewed documents including the Hot Water Temperature Check dated January 2025. Per Hot Water Temperature Check notes on January 22 and 23 it states boiler rebuilt/replaced heat exchanger, new burners and two new blower pressure switch. LPA reviewed documents including the Etna Heat Transfer Products invoice dated January 22, 2025. Per Etna Heat Transfer Products invoice, the Licensee ordered a tube bundle-kit copper. Per Etna Heat Transfer Products invoice dated January 23, 2025, the Licensee ordered a burner kit, an ignitor kit and a flame sensor kit. Per Etna Heat Transfer Products invoice dated January 24, 2025, the Licensee ordered an air pressure switch kit. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with facility representative, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Feb 13, 2025 · control 22-AS-20250206141343

Allegation investigated: Staff are not ensuring that residents have hot water

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced inspection visit to deliver findings for complaint investigation into the above allegations. LPA explained the reason for the visit with Wellness Director Angie Rentutar and Chief Operating Officer (COO) Faye Shen. During the course of the investigation LPA toured facility, reviewed records, conducted interviews with residents & staff, made observations and requested pertinent documentation such as Notification Memos, Hot Water Temperature log, utilities log, Repair Invoice, Resident Physician’s reports, Unusual Incident Report dated 1/22/2025, Resident and Staff Rosters. During investigation LPA conducted interviews with staff, residents and Family Member. Interviews conducted with staff revealed the following: Seven of Nine staff interviewed stated that hot water was temporarily out. Four of Nine staff confirmed that water boiler was broken and that Maintenance Director had to order parts in order to repair boiler. Staff Interviews revealed that staff notified residents of hot water being out via signs posted throughout facility common areas and elevator as well as staff making update announcements on facility PA system and front desk notifying residents that parts needed were on order. CONTINUED 9099-C Unsubstantiated Interviews conducted with residents revealed that seven out of fourteen residents stated that facility was out of hot water last week beginning January 22, 2025. Resident interviews revealed that remaining seven of fourteen residents stated they did not have any issues with water in their apartments. Seven of fourteen residents stated they were made aware of hot water issue via posted signs inside facility as well as information provided by front desk. Interview with family member revealed that facility was out of hot water for three days. Interviews with nine staff members and seven of fourteen residents have confirmed that hot water was restored as of Friday January 24, 2025. During investigation, LPA conducted water temperature checks on each three floors and observed water temperature measured between 114.6 to 117.5 degrees Fahrenheit inside resident restrooms. Common area restrooms water temperature measured at 114.6 degrees Fahrenheit. Water Temperatures observed today are within Title 22 Regulations. Records reviewed revealed that facility has a Hot Water Temperature Check log and notates when facility has Hot water issues. Temperature Check log revealed that on January 22, 2025 facility boiler needed to be rebuilt. Temperature Check log notated that on the following day January 23, 2025 the following was replaced: Heat exchanger, new burners, and two new blower pressure switch. An invoice reviewed from Etna Heat Transfer Products revealed that a tube bundle kit was ordered on January 22, 2025. On January 23, 2025 an additional invoice reviewed, revealed that facility replaced a burner kit, Ignitor kit and flame sensor probe kit. On January 24, 2025 an additional invoice reviewed, confirms facility ordered a Air pressure switch. Facility provided copies of posted signs notifying residents that Hot water is currently off and maintenance is addressing problem and that parts on order from January 22, 2025 1:00PM to January 23, 2025 11:28AM. Based on Interviews conducted, and records reviewed the timeline of events of hot water temperature out due to facility ordering replacement parts for water boiler and invoices of parts ordered varies from one to three days. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the following allegations: Staff are not ensuring that residents have hot water is deemed UNSUBSTANTIATED. An exit interview was conducted with Chief Operating Officer Faye Shen and a copy of this report was reviewed and provided to facility.the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 22-AS-20250124104826

Allegation investigated: Staff do not treat residents with dignity or respect Staff allow residents to smoke in areas not designated for smoking

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Chief Operating Officer (COO) Faye Shen and explained the reason for today’s inspection. The investigation into the allegations that staff do not treat residents with dignity or respect and staff allow residents to smoke in areas not designated for smoking revealed the following: During the course of the investigation, LPA inspected the facility, interviewed COO and residents, and obtained and reviewed copies of the resident roster, staff roster, the facility’s shower log for December 2024, and the facility’s house rules. CONTINUED Substantiated Regarding the allegation that staff do not treat residents with dignity or respect: it was alleged that residents go to dinner without shoes and without showering for days, facility staff argue with and intimidate residents who bring up concerns at resident council meetings, and facility staff stand around gossiping about residents and disclosing their confidential information. LPA observed one resident walking around the facility barefoot on January 10, 2025, and the same resident walking around the facility wearing only socks on January 13, 2025. Per COO, the facility has not received complaints about residents going without shoes and has not addressed this issue with any residents. LPA did not observe any residents with offensive odors throughout the facility and out of 13 residents interviewed, none had offensive odors and none reported concerns regarding showers or the hygiene of other residents when asked if they were experiencing any problems at the facility. Per COO, residents receive showers twice a week, some residents refuse but facility staff can usually work with them and convince them to shower. LPA reviewed the facility’s shower log for December 2024 which shows only four shower refusals for the month. LPA interviewed 13 residents, none of whom corroborated that staff argue with or intimidate residents at the facility. However, two residents reported witnessing staff making fun of a resident who has issues with speech by mimicking them and one resident reported that staff shared personal information about how this resident developed their issues with speech. The information obtained corroborated the allegation. Regarding the allegation that staff allow residents to smoke in areas not designated for smoking: it was alleged that residents are allowed to smoke in their rooms leaving the building smelling like smoke. LPA inspected the facility and noted a strong smell of cigarette smoke coming out of one room and Resident #1 (R1) smoking in the front courtyard of the facility where there are multiple “no smoking” signs with dozens of used cigarettes and a lighter on the ground near R1. LPA reviewed the facility’s house rules which state that smoking is only allowed in the designated smoking area and smoking is prohibited inside the building and where there are “no smoking” signs. When interviewed, COO stated the only designated smoking areas are in the central courtyard and residents are not allowed to smoke in their rooms or anywhere else. COO could not provide information about the resident whose room smelled like smoke, but stated that R1 has been at the facility for about six months, facility staff tell R1 they can only smoke in the designated smoking areas but R1 does not listen, the facility is working with R1’s responsible party regarding this issue, and the facility has issued one written warning to R1 but has not issued an eviction notice. LPA interviewed 13 residents, five of whom corroborated that the facility is not doing enough to enforce the house rules and ensure the inside of the facility is smoke-free, including one resident who asked R1 to stop smoking in non-smoking areas and was yelled at by R1. The information obtained corroborated the allegation as the facility is not properly identifying and addressing rooms that smell like smoke and has not moved quickly enough to address R1’s constant violation of the house rules. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. Regarding the allegation that staff do not keep the facility clean or sanitary: it was alleged that common areas are cluttered with trash preventing residents from enjoying these areas of the facility, residents on the second floor have pets they cannot properly care for or clean up after leaving the facility malodorous, and staff hours were cut resulting in the facility floors not being mopped. LPA inspected the facility and did not observe any clutter, trash, or unclean floors. LPA interviewed COO, who denied the allegation and stated that the housekeeping staffing levels have actually increased. LPA reviewed the facility’s housekeeping schedule for September 2024 through January 2025, which shows that the number of housekeeping staff has increased slightly. LPA noted mild, but not unpleasant, pet odors in the room of R2. LPA reviewed a photograph of R2’s dog which shows that it urinated in a common area, however it is unclear how much time elapsed before R2 or facility staff cleaned up after the dog. Per COO, R2 is a good resident, their dog is friendly and other residents like this dog, the dog generally stays outside, and R2 cleans up after their dog and facility staff will clean up after the dog if R2 does not. LPA noted strong and unpleasant pet odors in the room of R3. Per COO, R3’s dog is a problem, R3 did not move in with the dog, the facility has tried multiple times to get R3 to get rid of the dog, and the facility is in the process of evicting R3 due to the dog and other issues. LPA reviewed R3’s 30-day Eviction Notice dated September 19, 2024 and the facility’s Unlawful Detainer Complaint against R3 filed November 12, 2024, which show that the facility is taking proper measures to address R3’s violation of the house rules. Out of 13 residents interviewed, 12 reported no concerns with cleanliness or pets at the facility. The information obtained did not corroborate the allegation and shows that the facility is addressing the issues raised by R3’s dog through the eviction process. Regarding the allegation that staff do not provide a safe environment for residents: it was alleged that some residents are involved in illegal activities, treat other residents and staff in a rude manner, and argue, do illegal drugs, and drink late into the night in common areas. LPA interviewed COO who denied the allegation. However, per COO, R3 violates the house rules and when the facility tried to enforce the house rules on R3, R3 became angry and shouted profanities in the past. One witness interviewed stated they saw R3 threaten staff. LPA reviewed a video showing R3 yelling at another resident. COO stated that the facility is in the process of evicting R3 due to their violation of the house rules. LPA reviewed R3’s 30-day Eviction Notice dated September 19, 2024 and the facility’s Unlawful Detainer Complaint against R3 filed November 12, 2024, which show that the facility is taking proper measures to address R3’s behavior. LPA interviewed 13 residents, 12 of whom stated they feel safe at the facility, well-treated by other residents, and have not seen any drugs at the facility, while one resident stated that other residents sometimes curse at them and they saw drug use once at the facility but the facility addressed it. LPA did not obtain information that R3 or any other resident is engaging in violence. COO stated that R3 has not engaged in violence and staff know to call police if R3 places other residents in danger pending their eviction. The information obtained did not corroborate the allegation and shows that the facility is addressing R3’s behavior through the eviction process. Regarding the allegation that staff do not keep the facility free of illegal drugs: it was alleged that some residents bring illegal drugs into the facility and do illegal drugs late into the night in common areas. LPA interviewed COO who stated that some residents claim other residents are doing drugs, facility staff have never found any proof of illegal drug use at the facility, and most of the allegations of illegal drug use have been made against R3 who the facility is in the process of evicting. LPA reviewed R3’s 30-day Eviction Notice dated September 19, 2024 and the facility’s Unlawful Detainer Complaint against R3 filed November 12, 2024, which show that the facility is in the process of evicting R3. LPA interviewed 13 residents,12 of whom stated they have not seen any drugs at the facility, while one resident stated they saw drug use once at the facility but the facility immediately put a stop to it. The information obtained did not corroborate the allegation. Regarding the allegation that staff do not safeguard resident's personal items: it was alleged that residents’ personal items are being stolen while in the facility. LPA interviewed COO who denied receiving any recent reports of lost property and stated they advise residents to lock their doors and take care of their property. Out of 13 residents interviewed, only one resident reported a theft at the facility. However, per the facility’s Admission Agreement, residents are responsible for securing their personal property and per COO, this resident did not entrust any property to the facility to safeguard so it was the resident’s responsibility to safeguard their property. In addition, COO stated that this alleged theft was not reported to the facility. It is also possible the resident misplaced their property and it was not stolen. Based on the information obtained, there is not a widespread issue of theft at the facility and the facility did not fail to safeguard any property that was entrusted to it. The information obtained did not corroborate the allegation. Regarding the allegation that facility staff violated resident’s personal rights: it was alleged that Staff #1 (S1) took an inappropriate photograph of Resident #4 (R4) and shared it with other residents. LPA interviewed 13 residents and did not obtain information corroborating this type of inappropriate behavior by staff. LPA interviewed the facility’s medication technician supervisor who confirmed that R4 has issues with taking off their clothes due to their mental condition, R4 has been observed naked outside their room and redirected back to their room, photographs of R4’s behaviors were taken and shared only with R4’s family to coordinate R4’s care, but could not provide information regarding whether any of these photographs were shared with other residents. LPA interviewed S1 who denied taking or sharing any photographs of R4 and stated that R4 is often observed naked outside their room, other residents commonly complaint about this behavior, whenever S1 sees R4 engaging in this behavior they redirect R4, and that at some point in the past photographs of R4’s behaviors were taken and shared only with R4’s family to coordinate R4’s care. LPA interviewed COO who stated R4’s behavior is the result of a recent decline, the facility has attempted to address R4’s behavior with R4’s family but R4’s family has not cooperated, and R4 is currently out of the facility and will be reassessed if they are to return to ensure their behaviors will be addressed by their care plan. LPA interviewed one additional staff who could not provide information regarding this allegation. During the course of the investigation, LPA did not obtain or see the alleged photograph. LPA attempted to interview R4, but R4 is not on the facility and R4’s family refused the interview. The information obtained did not corroborate that any inappropriate photographs of R4 were shared with anyone other than R4’s family and any alleged photographs could have been taken by other residents who saw R4. The information obtained did not corroborate the allegation. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. It was alleged that the facility van is not working which prevents residents from being taken on outings because only one or two residents can be taken out at a time and a resident was showered and there was no hot water. LPA interviewed COO who stated the facility has a small bus and a sedan, the bus is used for residents in wheelchairs and it works. LPA inspected the facility bus and observed the bus and its lift used to allow residents in wheelchairs access worked properly. LPA interviewed 13 residents, none of whom reported issues with being transported to where they need to go. Per COO, the facility recently had to shut the water off for two hours to fix a pipe. LPA inspected the water and hot water for 13 residents and observed the water and hot water to be working properly. Out of 13 residents interviewed, five residents noticed this recent water outage and two of these residents had prior notice of the outage and knew that it was a planned outage to fix a pipe. Per COO, the facility provides notice of planned water outages by posting a notice by the activity wall and making an announcement over the intercom. LPA reviewed the facility’s water shut off notice for January 3, 2025, which warns residents that there will be no water from 6PM to 8PM for pipe maintenance. LPA reviewed the facility’s water maintenance logs which show the January 3, 2025, two-hour water outage was planned in order to allow maintenance staff to fix a pipe. The facility’s water maintenance logs also show multiple other repairs made to the water system, most of which did not require that the water be turned off. COO stated they will take additional measures in the future, including posting notices in additional locations and making multiple intercom announcements, to ensure all residents are aware of water outages. Based on the information obtained, the facility’s vehicle works properly and the facility is consistently maintaining its water system. This allegation is unfounded. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jan 15, 2025 · control 22-AS-20250106112758

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jan 16, 2025

87468.1 Personal Rights… (a) … (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews and observation, the licensee did not ensure residents are encouraged to wear shoes and that staff do not make fun of residents, which poses an immediate personal rights risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Jan 15, 2025

Plan of correction: Licensee stated that they will address the facility’s dress code with residents in violation, retrain staff on treating residents with dignity and respect, and submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jan 16, 2025

87468.1 Personal Rights… (a) … (2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by: Based on interviews and observations, the licensee did not ensure residents are able to safety and comfortably enjoy their rooms and interior spaces of the facility by not properly enforcing the facility’s smoking rules, which poses an immediate personal rights risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Jan 15, 2025

Plan of correction: Licensee stated that they will create a list of residents violating the facility’s smoking rules, take action against these residents, document the actions taken on the list, and submit proof to LPA by POC due date.

Allegation investigated: Facility staff are not meeting resident’s hygiene needs

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unnanounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by Administrator Steve Shen and explained the reason for the visit. The Department received a complaint on 12/19/2024 and the initial 10 day visit was conducted on 12/26/2024. LPA Mendivil interviewed staff and obtained copies of pertinent documents such as physicians report LIC 602 for Resident 1 (R1) and shower schedule. Regarding the allegation facility staff are not meeting resident's hygiene needs, the investigation revealed the following: Per interview with Administrator Steve Shen and Angie Rentutar Care Coordinator R1 is on hospice. Angie stated that hospice is responsible for R1's showering needs. Angie stated that R1 is very oriented and is able to communicate their own needs and has not asked to be put on the shower schedule. Unfounded Per review of R1's LIC 602 Physician's Report dated 04/28/2024 R1 is able to groom themselves, able to follow instructions and able to communicate needs. It is also listed that R1 needs assistance with bathing. Per interview with hospice staff R1 refused bath services on 5/31/2024 verbally for indefinite services. Per LIC 602 R1 is parapalegic. Based on interviews with staff it was stated that R1 receives bed baths from hospice staff and is able to wash their own face in bathroom sink. 4 out of 4 staff indicated that R1 has not requested to be placed on the shower schedule. 3 out of 4 residents on the shower schedule indicated they receive their showers on their scheduled dates and times without issue. The fourth resident does not receive baths from facility staff but felt they would be able to ask staff if needed. During the visit LPA observed residents throughout the facility, residents appeared to be clean and well groomed. LPA did not observe or encounter any odors emitting from residents. Therefore based on the preponderance of evidence through records reviewed and interviews the allegation that facility staff are not meeting resident's hygiene needs is determined to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report and confidential names list was provided.the state’s words, verbatim · CDSS document, Dec 26, 2024 · control 22-AS-20241219124149

Allegation investigated: Facility staff are not properly addressing roaches in the facility

This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and Edward Kim for the purpose of investigating the above-mentioned complaint allegation. LPAs met with Chief Operating Officer (COO) Faye Shen, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that facility staff are not properly addressing roaches in the facility revealed the following: During the course of the investigation, LPAs inspected the facility, interviewed COO and residents, and obtained and reviewed copies of the resident roster, staff roster, and the facility’s recent pest control records. CONTINUED Substantiated It was alleged that multiple large roaches were observed in Resident #1’s (R1) room, that R1’s room has had roaches for about a year, and that facility staff have not properly addressed the roach infestation. LPAs inspected 13 resident rooms and observed no roaches or insects, but LPAs did observe cat food left out in R1’s new room. LPAs interviewed 13 residents, two of whom reported seeing roaches at the facility. LPAs interviewed COO who admitted that R1’s room did have multiple roaches and that after learning of the roaches on December 4, 2024, the facility relocated R1 to another room on December 6, 2024, in order to address the infestation. COO stated that the facility’s measures to address insects in the facility include caregivers checking for food left out in residents’ rooms during their twice daily checks, a deep cleaning of residents’ rooms weekly, and regular pest control inspections and spraying approximately every 21 days by a professional exterminator. LPAs reviewed the facility’s recent pest control records which show that R1 refused the professional exterminator’s services on July 10, 2024 and September 13, 2024. Per COO, R1 sometimes refused pest control services in their room because they have a cat in their room and it is possible the infestation in R1’s room may have been caused by cat food in R1’s room. However, COO stated that the facility did not issue R1 notices of violation of the house rules for refusing pest control services and for leaving cat food out in their rooms and the information obtained corroborated that the facility’s current measures are not properly addressing roaches in the facility. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Dec 9, 2024 · control 22-AS-20241204160626

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Dec 10, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure the facility was safe and sanitary when R1’s room was infested with roaches, which poses an immediate health risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Dec 9, 2024

Plan of correction: Licensee stated that they relocated R1 and are addressing the infestation in R1’s room with a professional exterminator. Licensee stated they will create a plan to address future infestations and submit proof to LPA by POC due date.

Allegation investigated: Facility does not have a full-time activity director Facility is in disrepair

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegations and to deliver the findings of the investigation. LPA was greeted and granted entry into the facility and met with Receptionist Gerardo Reyes. LPA explained the reason for the visit. Chief Operating Officer (COO) Faye Shen arrived during the visit. This agency has investigated the complaint alleging that facility does not have a full-time activity director and facility is in disrepair. Regarding the allegations, the following was revealed: During the course of the investigation LPA reviewed documents including the October 2024 Activities Schedule. Per Activities schedule Staff 1 (S1) is schedule to work from 6:00am-4:00pm, Monday through Friday. During the course of the interviews with staff, Staff 1 (S1) reported that from 6:00am-9:00am she does housekeeping duties. Per S1 from 09:00am-4:00pm she does the activities as she is also the Activities Director. Regarding the allegation that facility is in disrepair, the following was revealed: CONTINUED ON LIC9099-C... Substantiated During the initial visit on October 31, 2024 LPA tour the facility and observed that on the second and third floors there are couches with brown and black discoloration. LPA observed that the couches' leather and/or cloth is ripped or cracked. On the Memory Care units located on the second and third floors LPA observed that the wood floor is broken and missing parts of the tiles. LPA observed that some of the disrepair tiles can be a hazard trip for residents in care. On the Memory Care units LPA observed chipped tables, tables missing paint and chairs with ripped plastic covers. During the tour LPA observed that the baseboards throughout the facility are chipped and have brown and/or black discoloration. On the first floor LPA observed that the dryer is missing the top cover which exposes the flame. On the first floor LPA also observed that one of two washing machines is missing the front cover exposing the washing machine's cables. LPA also observed that the elevator by the first floor laundry room is out of service. Two of three elevators are operating properly. Based on observations and the interviews which were conducted, the preponderance of evidence standard has been met, therefore the following allegations: facility does not have a full-time activity director and facility is in disrepair are deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with facility representative and a copy of this report along with the Appeal Rights were provided at the time of this visit. Regarding the allegation that facility is not maintaining a comfortable temperature for residents, the following was revealed: Eight of eleven individuals interviewed denied the allegation. During the initial visit LPA tested the temperature throughout the facility and it tested between 72.5 and 77.3 Degrees Fahrenheit. During the course of the interviews with residents, R1 reported that the temperature is comfortable and stated that he can adjust the temperature. Per R3 the temperature is comfortable and reported that she can adjust the air conditioning and heater. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, this allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with facility representative, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 31, 2024 · control 22-AS-20241022080554

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(f) · Plan of correction due date: Nov 7, 2024

87219 Planned Activities(f)In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities,...The program of activities shall be written, planned in advance, kept up-to-date, and made available to all residents. This requirement was not met as evidence by: Based on interviews and records reviewed the facility does not have a full-time Activities Director. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2024

Plan of correction: Per Licensee a Plan of Action to have a full-time Activities Director will be develop. Licensee to email proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 14, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: LPA observed ripped couches with brown and black discoloration, LPA observed that the wood floor is broken and missing parts of the tiles, LPA observed chipped tables, tables missing paint and chairs with ripped plastic covers, LPA observed that the baseboards throughout the facility are chipped and have brown and/or black discoloration and on the first floor LPA observed that the dryer is missing the top cover which exposes the flame. This poses a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Oct 31, 2024

Plan of correction: Licensee to repair the floor, tables, chairs, couches, baseboards, dryer, washer and elevator. Licensee to email LPA proof by POC due date.

Allegation investigated: Facility staff did not ensure hallways are free from obstruction.

Licensing Program Analysts (LPAs) Jessica Cho and William Vanega arrived at the facility unannounced for the purpose of conducting the 10-day complaint investigation into the above allegation. LPAs were greeted and granted entry by Receptionist Gerardo Reyes and Activity/Housekeeping Supervisor Clara Ramirez after explaining the purpose of the visit. During the course of the investigation, LPAs inspected the indoor passageways and conducted four staff interviews and two out of the six resident interviews. LPAs did not take statements of the remaining four residents as they were either occupied or refused the interview. LPAs obtained pertinent documentation which includes the Resident/Staff Roster, Face Sheets, Physician's Report, an Admission Agreement, Care Note, and Pet Addendum. The investigation revealed the following: It is alleged that the facility did not ensure hallways are free from obstruction. Based on LPAs' observations of the hallways of the the three levels approximately 8:25am, LPAs observed the indoor passageways were clear of tripping hazards. LPAs observed the black dog named Karma present in the resident's room at the time of inspection. Substantiated However, based on the interviews with one out of the two residents, one witness resident confirmed Resident #1 (R1) falling on October 6, 2024 as a result of a black dog running in the hallway of the 1st floor. The second resident stated that they did not observe or have knowledge of the fall. Additionally, four out of the four staff confirmed R1 falling. Based on the review of the Care Note dated October 6, 2024, R1 did in fact sustain a fall because of the dog. Therefore, based on LPA's observations, interviews which were conducted, and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility did not ensure hallways are free from obstruction is deemed SUBSTANTIATED. A deficiency is being cited as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations is being cited on the attached LIC 9099D. An exit interview was conducted with Chief Operating Officer Faye Shen, and a copy of this report including the appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Oct 15, 2024 · control 22-AS-20241009123331

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: Oct 22, 2024

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by: Based on interviews and record review, the black dog became a tripping harzard for R1 causing R1 to trip and fall on 10/06/24 which poses a potential Safety Risk to persons in care.the state’s words, verbatim · CDSS document, Oct 15, 2024

Plan of correction: Administrator stated that the facility will post signs requiring all pets to be leashed or in a carrier at all times and will submit proof of the signs and an Acknowledgement of Understanding of the said regulation to LPA via email by POC due date.

Allegation investigated: Residents are smoking in their room

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to begin the investigation into the complaint allegation above. LPA was greeted by staff and explained the reason for the visit upon entry. The complaint investigation consisted of interviews with facility staff, residents, and LPA observations. Regarding the complaint allegation: Residents are smoking in their room During the investigation 3 of 5 individuals interviewed, confirmed the allegation above. During an interview with Staff 1 (S1) it was discovered, R1 was moved from the second floor due to smoking inside their room. R1 was moved to a first floor room with a patio to prevent R1 from smoking inside the room. During the visit, observations were made that confirmed the complaint allegation. Photos were taken. Based on the evidence gathered through interviews and observations, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22. An exit interview was conducted, and a copy of this report, and appeal rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Oct 2, 2024 · control 22-AS-20240926084612

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Oct 8, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not being met as evidenced by: Interview confirmation and observation that revealed Resident 1 smokes cigarettes inside their room. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: The licensee stated a formal meeting will be conducted with Resident 1. The house rules will be presented for R1 to sign and acknowledge, and R1 will be given a final warning regarding smoking inside the room. Licensee will email LPA Haley the copy of the House Rules signed by R1, and a copy of the Final Warning Notice presented to R1 with the residents signature by 1:00PM on the POC due date.

Allegation investigated: Staff do not provide adequate care and supervision to a resident Staff do not have adequate record keeping for a resident

This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by Receptionist. LPA met with Faye Shen, Chief Operating Officer and explained the nature of the inspection. The department received a complaint on 7/24/2024 stating staff do not provide adequate care and supervision to a resident and that staff do not have adequate record keeping for a resident. During the investigation, the department interviewed the Chief Operating Officer (COO), staff and residents in care. (continued on LIC9099-C) Unsubstantiated (continued from LIC9099) On 8/2/2024 LPA conducted a visit to the facility. LPA obtained copies of the staff schedule for the month of August 2024, staff contact information and resident census for 8/2/2024. LPA toured the facility and interviewed staff and residents in care. In regards to the allegation of staff do not provide adequate care and supervision to a resident, LPA conducted interviews with five residents who indicated being able to recall R1 when they resided at the facility. Of the five residents interviewed, four stated they do not believe the staff neglected R1 based on their observations. LPA conducted interviews with COO and three staff (S1, S2, S3). Of the four staff interviewed, four stated they do not believe the staff neglected R1. In regards to the allegation of staff do not have adequate record keeping for a resident, LPA returned to the facility on 8/15/2024. LPA reviewed R1's file. LPA obtained copies of all of the documentation in the resident's (R1's) file. These files include: copy of state identification card, copy of health insurance card, copy of benefits identification card, admission record from previous facility, physician's report, admission agreement dated 5/17/2024, Assisted Living Waiver Informing Notice, Reassessment checklist, Medi-Cal Eligibility printout, signed Service Plan Agreement, completed assessment tool dated 3/14/2024, Individual Service Plan, physician's orders and medication administration record. LPA conducted interviews with COO and Staff (S1, S2, S3). COO stated no documents were removed from or added to R1's records after they moved out of the facility. S1, S2, S3 made no disclosures regarding the allegation. Based on Title 22 Regulations, R1's file contains all the required documentation. Based on interviews conducted, LPA was unable to determine if R1's file did or did not have the same documentation in it while R1 resided at the facility. Based on interviews conducted and records reviewed there is insufficient evidence to support the allegation(s). Although the allegation(s) may have happened or is valid; there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and this report was reviewed with Faye Shen, Chief Operating Officer (COO). A copy of this LIC-9099 was provided to the facility.the state’s words, verbatim · CDSS document, Sep 10, 2024 · control 22-AS-20240724140359

Allegation investigated: Resident's incontinent needs are not being met.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) Allen Nishikawa and explained the reason for today’s inspection. The investigation into the allegation that a resident's incontinent needs are not being met revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, Chief Operating Officer (COO) Faye Shen, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Resident Appraisal dated June 22, 2018, R1’s Physician’s Report dated September 9, 2019, R1’s Physician’s Report dated October 8, 2019, and R1’s Admission Agreement dated June 22, 2018. CONTINUED Unfounded Regarding the allegation that a resident's incontinent needs are not being met: it was alleged that facility staff were repeatedly notified that R1 was running low on incontinence supplies, did not order incontinence supplies for R1, and R1 had to purchase incontinence supplies from another resident. When interviewed, R1 stated that they had been receiving incontinence supplies for free from the facility for the last two years, but that recently facility staff claimed that they had spoken to R1’s doctor and R1’s doctor and medical records indicated that R1 does not need incontinence supplies and R1 was told by facility staff that if they wanted incontinence supplies, they would have to pay an extra charge. LPA interviewed AD who was unable to provide information regarding this allegation. LPA interviewed COO and one facility staff who stated that residents like R1 who were placed by Los Angeles County were provided incontinence supplies by the facility at no extra charge if their physician’s report indicated they needed incontinence supplies, that they are unaware of any issues with R1 and incontinence supplies, that R1 did not need incontinence supplies because they were able to use the restroom and were not incontinent, and that the facility did not regularly supply R1 with incontinence supplies. LPA reviewed R1’s Resident Appraisal dated June 22, 2018, which indicates R1 does not need help with toileting or incontinence. LPA reviewed R1’s Physician’s Report dated September 9, 2019, and Physician’s Report dated October 8, 2019, which indicate R1 is not able to care for their own toileting needs but does not have incontinence. LPA reviewed R1’s Admission Agreement dated June 22, 2018, which indicates that the facility is not responsible for providing or paying for incontinence supplies, that R1 is responsible for paying for incontinence supplies, and that R1 was not paying for incontinence supplies. LPA interviewed eight additional residents and did not obtain information corroborating this allegation. No information was obtained corroborating the allegation because the information obtained showed that R1 did not have incontinence needs. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. Regarding the allegation that facility staff did not treat resident with respect: it was alleged that facility staff spoke disrespectfully to R1. When interviewed, R1 stated that they had previously received the wrong medications which caused a severe reaction, so they double-check the medications they receive from the medication technician and on one occasion a medication technician responded to the resident’s request to double-check the medications by stating that even if the resident received the wrong medication and passed away, the medication technician’s job would be safe. Regarding the alleged past medication error, R1 did not specify if it occurred at this facility or another location. LPA reviewed R1’s Resident File and interviewed the staff in charge of medications and did not obtain information corroborating a medication error. LPA reviewed the MAR for R1 and four other residents and observed no medication errors of the severity described by R1. LPA interviewed AD who was unable to provide information regarding this allegation. LPA interviewed COO and two facility staff who denied this allegation and one staff reported that R1 verbally abused and threatened them. LPA interviewed eight additional residents and did not obtain information corroborating this allegation. The information obtained is conflicting. Regarding the allegation that facility staff did not ensure resident received speech therapy: it was alleged that R1 missed two appointments of speech therapy that is conducted using the facility’s phone because the phone was purportedly not working at the time of the appointment, but another resident was observed using the phone that same day. When interviewed, R1 stated that during this incident a facility staff told R1 that “this phone will work for who we want it to work for, but it won’t work for you.” LPA interviewed AD who was unable to provide information regarding this allegation. LPA interviewed COO and one facility staff who denied the allegation and stated that R1 had their own phone and that R1 was not denied from using the facility’s phone for medical appointments. LPA interviewed eight additional residents and did not obtain information corroborating this allegation. The information obtained is conflicting. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 22-AS-20201221092131

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20201221092131. LPA met with Administrator (AD) Allen Nishikawa and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, interviewed AD, Chief Operating Officer (COO) Faye Shen, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Resident File, and Medication Administration Records (MAR) for multiple residents. When interviewed, R1 stated that they had previously received the wrong medications which caused a severe reaction, so they double-check the medications they receive from the medication technician. Regarding the alleged past medication error, R1 did not specify if it occurred at this facility or another location. LPA reviewed R1’s Resident File and interviewed the staff in charge of medications and did not obtain information corroborating a medication error. LPA reviewed the MAR for R1 and noted dozens of instances of medications not being signed off as being given to R1 with no documented explanation, although LPA obtained no evidence of R1 suffering a severe reaction. The MAR for four other residents also showed similar blanks where the medications were not signed off, but the pills were no longer in the bubble packs. Per the staff in charge of medications, the reason the doses were not signed off by the medication technician is because the medication technician forgot or did not have time to sign off on the dose and this does not indicate that the medications were not given. However, the doses were still not properly documented as required to ensure residents were receiving their medications as required. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 29, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 26, 2024

87465 Incidental Medical and Dental Care (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure the medications for 5 out of 5 residents were documented on the MAR as being given as prescribed, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Aug 29, 2024

Plan of correction: Licensee stated that they will create a procedure for ensuring the MAR is completed properly and will train medication technicians on the procedure and submit proof to LPA by POC due date.

Allegation investigated: Staff enters room without knocking on the door Staff turns off lights without consent

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate n investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and resident. Regarding the allegations that staff turns off lights without consent and staff enters room without knocking on the door, the investigation revealed the following: Resident 1's (R1) room has signage posted on the door requesting staff to ring doorbell which has been installed. Posted signage states "Do not enter" without the resident's approval and following certain steps. Three out of three staff interviewed state ringing the doorbell before entering the room but indicate the resident does not always hear the doorbell. Resident indicates no staff should ever enter without the resident's approval. Staff 1 (S1) states entering the resident's room with approval and accidentally turning the light on. The staff immediately turned the light back off once it was realized that the resident did not want the lights on. Three out of three staff state making an effort to comply with the resident's wishes however the facility is CONTINUED ON LIC 9099C DATED 07/10/2024 Unsubstantiated mandated to check on resident to provide care and supervision. Based on the information gathered during the investigation, the Department is unable to ascertain if the above allegations occurred. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation occurred; therefore, the allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 10, 2024 · control 22-AS-20240702095631

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809 D on 06/18/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87303(a) regarding Maintenance and Operation has been cleared. Licensee provided proof of extermination. Licensee has complied with the POC. Licensee has been advised to remain in compliance with items previously cited at the facility. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 10, 2024

Allegation investigated: Licensee failed to eradicate insect infestation

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Chief Operating Officer (COO) Faye Shen, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that the licensee failed to eradicate insect infestation revealed the following: During the course of the investigation, LPA inspected the facility, interviewed COO and residents, and obtained and reviewed copies of the resident roster, staff roster, and the facility’s recent pest control invoices. CONTINUED Unsubstantiated Regarding the allegation that the licensee failed to eradicate insect infestation: it was alleged that the facility was recently investigated for an insect infestation, the facility did not correct the issue, and the insect infestation is getting worse. LPA reviewed the facility’s compliance history and noted the facility was issued a deficiency for an insect infestation on June 18, 2024 in connection with Complaint Control No. 22-AS-20240617103710. LPA inspected six resident rooms and observed no evidence of insects or an insect infestation. LPA interviewed six residents, five or whom reported no issues with insects in their rooms. One resident reported that they previously had insects in their room, the facility had addressed the issue, but that the insects had returned, and the facility is not taking adequate steps to address the issue. LPA interviewed COO who stated that the facility was aware of insects in this resident’s room, the exterminator had sprayed this resident’s room on June 19, 2024, facility staff have been spraying this resident’s room on an as-needed basis, facility staff clean this resident’s room regularly to prevent insects from returning, the exterminator is scheduled to spray this resident’s room again three weeks from June 19, 2024, and the facility is able to call the exterminator in at any time for additional spraying, but this resident’s room does not need it because no insects have been observed and the facility does not want to unnecessarily expose the resident to pesticide as they spend most of their time in their room. LPA reviewed the facility’s recent pest control invoices corroborating that this resident’s room was recently sprayed on June 19, 2024. The information obtained did not corroborate that the facility was not taking adequate steps to address the infestation. LPA observed the resident in question likes to keep food in their room and eat in their bed and COO stated they will move the resident’s mini-fridge and microwave closer to their bed to allow them to store food and eat in bed while minimizing crumbs that would attract insects. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 2, 2024 · control 22-AS-20240628153302

Allegation investigated: Staff handled resident in a rough manner.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with staff Kate Bernal, discussed the purpose of the inspection, and explained the allegation. Administrator (AD) Allen Nishikawa was not present during the inspection. The investigation into the allegation that staff handled resident in a rough manner revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, an Unusual Incident Report received May 17, 2024, Resident #1’s (R1) Physician’s Report dated November 2, 2023, R1’s Monthly Case Manager Visit Summary dated April 18, 2024, and R1’s Assisted Living Waiver Assessment dated November 22, 2023. Unsubstantiated Regarding the allegation that staff handled resident in a rough manner: it was alleged that staff are handling residents in a rough manner resulting in injuries. LPA interviewed AD who was unable to provide information about the allegation. LPA reviewed the facility’s recently reported incidents and noted an Unusual Incident Report received May 17, 2024, which states that on May 16, 2024, R1, a memory care resident with Dementia, was agitated and angry with Staff #1 (S1) for telling R1 to return to their room because it was time to go to sleep, R1 knocked over a trash can, taunted S1, followed S1 into another resident’s room, knocked off S1’s hat and hit S1 on the back, then S1 turned quickly to face R1, R1 was startled and fell backwards, hitting their arm against a nearby chair and receiving a cut and bruise on their arm. LPA conducted a health and safety check on and interviewed R1 who reported that R1 and S1 “hate each other,” during this incident R1 knocked S1’s hat off and then S1 pushed R1 from behind which caused R1 to hit a railing and cut their arm, no one else was present during the incident, R1 has never seen S1 engage in similar behavior with other residents, and this was the only incident between R1 and S1. LPA reviewed R1’s Physician’s Report dated November 2, 2023 which states R1 has Dementia and is frequently confused, R1’s Monthly Case Manager Visit Summary dated April 18, 2024 which states R1 had been more angry lately and fixated on one resident and got into an altercation with that resident, and R1’s Assisted Living Waiver Assessment dated November 22, 2023 which states R1 has multiple cognitive impairments, is sometimes agitated, disruptive, and/or aggressive, and states R1 lacks awareness of their limitations and often tries to exceed what is safely achievable and given their history of falls there is a heightened risk of injury due to lack of safety awareness. LPA interviewed S1 who stated that during this incident, R1 was fixated on S1, followed S1, and knocked S1’s hat off as reported, but denied that S1 pushed R1 and stated that R1 fell on their own. S1 also stated that this is not the first time R1 has attacked S1. LPA interviewed four other residents, none of whom corroborated the allegation. LPA interviewed three other staff, none of whom corroborated the allegation. The information obtained regarding whether R1’s fall was caused by S1 or whether R1 fell on their own is conflicting. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jun 24, 2024 · control 22-AS-20240520140910

Allegation investigated: Staff are not properly addressing pest infestation in facility

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as extermination records. Regarding the allegation that staff are not properly addressing pest infestation in facility, the investigation revealed the following: Facility staff indicate spraying resident rooms once advised of pests infestation and obtaining outside extermination. Rooms 135R, 105R and 230 were exterminated by Outstanding Pest Solutions on 06/10/2024. Facility indicates rooms 137L, 121, and 210 refused extermination. Two out of three residents of noted rooms deny refusing extermination. During the visit, LPA observed ants in room 137L and cockroaches on bed and table in room 210. Based on interviews conducted and observations made, The preponderance of evidence standard has been met; therefore, CONTINUED ON LIC 9099C DATED 06/18/2024 Substantiated the above allegation is deemed Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jun 18, 2024 · control 22-AS-20240617103710

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jun 19, 2024

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision ... for the safety and well-being of residents, employees and visitors. This req is not being met as evidenced by: Based on observation and interviews conducted, the Licensee failed to ensure facility is clean and sanitary. LPA observed cockroaches and ants in resident rooms. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2024

Plan of correction: Licensee to exterminate noted resident rooms and forward proof to LPA by POC due date.

Allegation investigated: Residents smoke in the facility

Licensing Program Analyst (LPA) Jerome Haley made an unannounced follow up visit to the facility to complete additional interviews and deliver the findings on the complaint allegations made January 18, 2024. LPA Haley was greeted by staff and explained the reason for the visit. The complaint investigation consisted of interviews with facility staff, residents, a witness, document review, and observations. A total of 9 individuals were interviewed during the investigation and observations were made by LPA Haley during both visits to the facility. Regarding the complaint allegation: Residents smoke in the facility During the investigation, 4 of 5 staff members confirmed residents smoke in their room or have smelled smoke inside the facility. Staff 1 (S1) and Staff 2 (2) both acknowledged Resident 1 (R1) has a history of smoking inside R1's room. S1 and S2 both acknowledged they try to monitor the resident and make sure R1 goes to the designated smoking area. Continued on LIC9099C Substantiated During the initial complaint visit January 23, 2024, LPA Haley observed burn marks in R1's bathroom and smelled the odor of cigarette smoke upon entering the resident’s room. The smell of smoke was not fresh smoke, but you could tell that smoking takes place inside the room. Photos were taken in R1's room of several cigarette burn marks. Based on the evidence gathered through interviews and observations, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6. An exit interview was conducted, and a copy of this report, and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 12, 2024 · control 22-AS-20240118101539

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Apr 19, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not being met as evidenced by: Interview confirmation and observation that confirm Resident 1 smokes cigarettes in their room. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2024

Plan of correction: Chief Operating Officer (COO) Faye Shen agrees to develop and implement a plan to address residents who fail to follow facility rules and continue to smoke in their room and other areas of the facility where smoking is prohibited. COO Shen will email LPA Haley a copy of the plan by the POC due date, April 19, 2024 at 1:00PM.

Allegation investigated: Staff drink alcohol in the facility Facility room is malodorous Facility is not kept free of pests

Regarding the complaint allegation: Staff drink alcohol in the facility During the investigation 8 of 9 individuals interviewed either denied or were unable to support the complaint allegation above. Staff 1 (S1) denied the complaint allegation and stated staff are not allowed to consume alcohol on their shift or work while intoxicated. Resident's are allowed to drink alcohol, as it's their personal right, as long as they drink responsibly and are not intoxicated. Staff 2 (S2) denied drinking while on duty and denied ever being intoxicated while on duty. Regarding the complaint allegation: Facility room is malodorous. During the investigation 5 of 5 staff denied the allegation above. Staff 5 (S5) stated some rooms have an odor because they have pets, but they clean up and after the room is clean the odor is not that strong. Continued on LIC9099C Unfounded During the initial visit January 23, 2024, and the follow up visit made to complete interviews and deliver findings, LPA Haley walked through the facility to make observations. During both brief tours of the facility, no foul odors were smelled coming from any resident rooms during the initial visit in January, or the follow up visit made to deliver the findings. Regarding the complaint allegation: Facility is not kept free of pests. 8 of 8 resident's and staff denied the presence of any rodents. Staff 1 (S1) stated there was a problem over the summer and the issue may be seasonal, but pest control came and eradicated the problem. S1 says pest control still make regular monthly visits to the facility. Pest control invoices were provided after the interview. One staff member did mention they have saw an occasional cockroach, but said as soon as you spray them, they’re gone. No rodents or cockroaches were observed during the initial visit made in January or during the follow up visit made to deliver the findings. Based on the information gathered through interviews and observations, the following allegations: Staff drink alcohol in the facility, Facility room is malodorous, and Facility is not kept free of pests, are UNFOUNDED, meaning the allegations are false, could not have happened and/or are without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 12, 2024 · control 22-AS-20240118101539

Allegation investigated: Staff did not ensure hot water heater works properly

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Chief Operations Officer (COO) Faye Shen and explained the reason for today’s inspection. The investigation into the allegation that staff did not ensure hot water heater works properly revealed the following: During the course of the investigation, LPA inspected the facility, interviewed Administrator (AD) Allen Nishikawa, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, and a water shut-off notice dated April 5, 2024. Regarding the allegation that the staff did not ensure hot water heater works properly: it was alleged that the facility’s hot water goes out regularly, the longest outage lasted three days, and the most recent outage was during the week of March 25, 2024. Unsubstantiated LPA reviewed the facility’s compliance history and noted no complaints regarding hot water outages in the past year. LPA inspected 8 resident rooms and observed the hot water to be working. Per AD, the water at the facility was shut off on April 5, 2024 from 7PM to 11PM for maintenance and residents were warned via a flier that was circulated. AD is unaware of any other water issues in the last year. LPA reviewed a water shut-off notice dated April 5, 2024 which was used to notify residents of the recent water shut off. LPA interviewed eight residents. Three of these residents did not notice the water being shut off and five of these residents were aware of the water shut off on April 5, 2024 and reported the maintenance was completed timely and did not impact them. However, four of the residents reported additional hot water outages in the past year or two that affected their ability to care for their hygiene needs, with some outages lasting for days, but four residents reported that the April 5, 2024 maintenance outage was the only hot water outage in the past year or two. LPA interviewed the facility’s maintenance director who reported that the April 5, 2024 shut off was due to maintenance and that it was the only shut off in the last year. The maintenance director stated that the hot water went out three months ago for one and half hours, but that they fixed it quickly. In addition, the electricity for the entire city went out for a few hours sometime in the last year, but the maintenance director does not believe that should have affected the hot water at the facility due to the size of the storage tank. Per the maintenance director, these are the only two water issues in the past year and that if there are ever any issues with the water boiler they are notified immediately and will fix the issue as quickly as possible. When interviewed, the maintenance director stated that it is not possible for some rooms to lose hot water individually while the water boiler is still working because the water system does not have internal shut offs. Based on the information obtained, the water was shut down for maintenance with proper notice to residents and minimal impact and when the hot water went out three months ago it was addressed by the facility in less than two hours with minimal impact to residents. The information obtained regarding whether there have been frequent hot water outages that lasted for days in the past two years is conflicting. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Apr 9, 2024 · control 22-AS-20240402152116

Allegation investigated: Facility did not ensure that resident's personal rights were respected Facility staff are not properly trained Facility staff did not ensure that resident's relationships with staff were accorded dignity

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, and was greeted by Chief Operating Officer- Faye Shen. It was alleged that facility did not ensure that resident's personal rights were respected. 4 out of the 5 resident interviews conducted did not corroborate with the allegation by stating that staff are respectful. 1 out of the 5 resident interviews stated that resident 1 (R1) does not like when staff enter their room, and added that only certain staff are allowed in their room due to personal preference. 3 out of the 3 staff interviews conducted did not corroborate with the allegation by stating that upon hire, staff are required to complete training regarding personal rights. LPA De Perio conducted a record review and observed that 3 out of the 3 staff had completed training regarding personal rights. It was alleged that facility staff are not properly trained. 5 out of the 5 resident interviews conducted did not corroborate with the allegation by stating that staff are trained. Unsubstantiated 1 out of the 5 resident interviews specified that the staff who are not trained properly, are the ones who are unable to speak English. 3 out of the 3 staff interviews stated that not only do staff undergoing training, but staff will also complete orientation and shadowing prior to taking care of residents. LPA De Perio conducted documentation review, and it was observed that upon hire, training such as, but not limited to, regarding personal rights, resident rights, care and supervision, and adult abuse are completed and that facility stores the completed trainings in each individualized staff folder. It was alleged that facility staff did not ensure that resident's relationships with staff were accorded dignity. 4 out of the 5 resident interviews conducted did not corroborate with the allegation by stating that staff do accord residents with dignity. 1 out of the 5 resident interviews stated that there are some good and some bad staff, but provided no further details about the bad staff. 3 out of the 3 interviews conducted with staff stated that if there was an issue regarding not according relationships with residents with dignity, that staff would be given a warning via documentation. LPA De Perio conducted record reviews and observed that there were no documented issues regarding staff not according residents with dignity. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Chief Operating Officer- Faye Shen. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Mar 19, 2024 · control 22-AS-20240102113340

Allegation investigated: Facility did not provide adequate notice of rate change to residents and/or POA/responsible party

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Administrator (AD) Allen Nishikawa and explained the reason for today’s inspection. The investigation into the allegation that the facility did not provide adequate notice of rate change to residents and/or POA/responsible party revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, and obtained and reviewed copies of the resident roster, staff roster, and a rent increase notice dated 02/26/24. Regarding the allegation that the facility did not provide adequate notice of rate change to residents and/or POA/responsible party: it was alleged that the facility did not provide proper notice of a rate change to residents. LPA requested and reviewed a rent increase notice dated 02/26/24 which indicates a rate increase will be effective on 03/31/24. Substantiated LPA interviewed AD who stated this notice was used by the facility to provide notice of a rate change to residents, was posted at the front of the facility and distributed at a resident council meeting where 12 residents were present, and was placed in the mailbox of each resident at the facility. However, because the notice does not provide at least 60 day’s notice of a rate increase as required, the facility did not provide adequate notice of the rate change to residents. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. LPA inspected the kitchen and observed it to be clean and organized, the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations, the refrigerator and freezer were at proper temperatures, there were no spoiled or expired foods, and the perishable food appeared fresh and included fresh fruit and vegetables. LPA observed lunch being served in the dining room and via room service in resident rooms on 03/12/24 and LPA’s observations did not corroborate the allegation. The meals were generous in size and included a quesadilla with a side of rice, beans, salad and salsa, a soup with meat and vegetables, a salad, and a cookie. LPA interviewed 10 residents, including both residents who eat in the dining room and residents who receive their meals in their rooms. Of the 10 residents interviewed, none had any complaints about the quality of the food. 4 residents reported that portions are sometimes smaller, but all residents that responded confirmed they are getting enough to eat and that they are able to ask for more and always receive more food if they request it. None of the residents interviewed had any complaints about the quantity of food provided. LPA reviewed facility menus for the last three months and noted a proper variety of meat and vegetables in the meals. Residents interviewed corroborated that the meals balance meat, vegetables, and other items. LPA interviewed AD who did not corroborate the allegation and reported the facility orders its food from Sysco, US Foods, and Dairy King. LPA reviewed Sysco, US Foods, and Dairy King invoices for the month of February 2024 and those from approximately a year prior and noted the facility spent approximately 13.5% more on food in February 2024 than a year previous. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Mar 12, 2024 · control 22-AS-20240306120233

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(4) · Plan of correction due date: Apr 9, 2024

87507 Admission Agreements … (g) Admission agreements shall specify the following: (4) Modification conditions, including the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change... This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not provide at least 60 days’ notice of a rate change to residents, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: Licensee stated they will create a new notice of rate change specifying the amount of the increase, the reason, and a general description of the additional costs, and will give the notice to each resident and mail it to each responsible party at least 60 days prior to the effective date and will provide proof to LPA by POC due date.

Allegation investigated: Resident sustained a bruise to the left arm while being assisted. Facility did not accommodate a new caregiver per the family's request.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the investigation into the allegations listed above. LPA met with Administrator Steve Shen and explained the reason for the visit. The investigation into the allegation, resident sustained a bruise to the left arm while being assisted revealed the following. Resident 1 (R1) reported that they bruised their arm because of the bed rail on their bed. R1 reported that sometimes they put their arm over the bed rail and it causes bruising. Staff reported they do not handle R1 in a rough manner and did not do anything to cause R1 to be bruised. R1 verified this report. Resident did get bruised while at the facility but it was not caused by staff. None of the evidence gathered supports the allegation, therefore the allegation is unfounded, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. The investigation into the allegation, facility did not accommodate a new caregiver per the family's request, revealed the following. It was alleged that family of R1 requested a new caregiver that could better meet the needs of R1 but the facility refused to accommodate this request. Unfounded Regarding the allegation, resident's representative was not informed of the bruise, the investigation revealed the following. It was reported that R1 sustained a bruise sometime in November or December 2023. 5 out of 5 staff interviewed reported seeing R1 with a bruise on their left arm but do not know when R1 got the bruise. 5 out of 5 staff reported that they remember seeing R1 with a bruise on their left arm in December 2023. 5 out of 5 staff reported that they did not report the bruise to anyone. R1 reported they did not remember when they sustained the bruise but reported they got it from the bed rail. A review of facility records and Agency records shows no incident report was sent regarding R1’s bruise. R1's responsible party reported they saw the bruise in December and it was not reported to them by facility staff. The facility could not provide any documentation that the bruise was reported to the responsible party. The preponderance of evidence standard has been met, therefore, the allegation, is found to be SUBSTANTIATED Violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report along with citation and Appeal Rights was provided. Regarding the allegation, facility staff does not communicate properly with resident due to language barriers, the investigation revealed the following. It was reported that on December 3, 2023, staff ignored resident’s request to have the TV turned off because of a language barrier between the staff and residents. 5 out of 5 staff interviewed denied this report. None of the staff interviewed recall being asked to turn of a TV on December 3, 2023. R1 reported they do not remember the incident. 4 out of 4 residents interviewed reported they had no language issues with staff. Based on the information gathered through interviews the allegation is unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided. The Administrator and staff interviewed reported that after the request was made Staff 1 (S1) was assigned to a different area and Staff 2 (S2) replaced S1 in assisting R1. Both S1 and S2 verified this report. R1 verified this report. None of the evidence gathered supports the allegation, therefore the allegation is unfounded, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Mar 4, 2024 · control 22-AS-20231205121033

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Mar 14, 2024

To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by; On December 3, 2023 facility staff wore a sweatshirt "hoodie" that said, "F - U" on it. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 4, 2024

Plan of correction: Licensee agrees to train staff on personal rights of all residents CCR 87468.1 and to instruct all staff not to wear offensive clothing while working. Licensee to submit proof of training to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Mar 14, 2024

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes... or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by, the facility did not notify R1's responsible party of the bruise on their right arm. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 4, 2024

Plan of correction: Licensee agrees to train facility staff on all reporting requirements CCR 87211 and the proper observation of residents CCR 87466 and to submit proof of training to LPA by POC due date.

Allegation investigated: Resident was injured by a resident in care.

Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit for the purpose of continuing the investigation and delivering the findings into the above allegation. LPA met with Chief Operating Officer (COO) Faye Shen and General Manager (GM) Allen Nishikawa and explained the reason for the visit. On July 13, 2023, LPA initiated the complaint investigation. A subsequent visit was conducted on October 19, 2023. During the course of the investigation, LPA interviewed four residents and eight staff and obtained the following documentation: resident/staff rosters, June 2023 staff schedule, Incident Report dated July 6, 2023, Communication Logs from June 6, 2023, to June 29, 2023, floor plan, and four resident records which includes the face sheet and physician’s report. During today’s visit, LPA reviewed the records received. The investigation revealed the following: It is alleged that a resident was injured by a resident in care. [Continued on LIC9099-C] Unsubstantiated On June 24, 2023, Resident #1 (R1) and Resident #2 (R2) were involved in an altercation as documented on the Incident Report dated July 7, 2023. It was also noted that R2 pushed R1 off their wheelchair. Per review of the incident report, R1 was assessed, and no injuries were sustained. Interviews revealed that four out of the four residents and seven out of the seven staff were aware of the altercation between R1 and R2. However, only one out of the four residents and one out of the seven staff indicated that R1 suffered bruising related to the fall. Therefore, based on the interviews and the records that were reviewed, 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 following allegation: Resident was injured by a resident in care is deemed UNSUBSTANTIATED. An exit interview was conducted with Chief Operating Officer Faye Shen, and a copy of this report including the LIC9099C, and the LIC811 were provided at the end of the visit.the state’s words, verbatim · CDSS document, Feb 27, 2024 · control 22-AS-20230707101643

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jessica Cho continued the visit after delivering the findings in connection to Complaint Control Number: 22-AS-20230707101643. LPA stated the purpose of the Case Management visit to Chief Operating Officer Faye Shen. During the course of the complaint investigation mentioned above, LPA discovered that the Department received a written report on July 7, 2023, pertaining to an altercation exchanged between Resident #1 (R1) and Resident #2 (R2) that occurred on June 24, 2023. The incident report was received 13 days after the occurrence. Per Reporting Requirements 87211, a written report shall be submitted to the licensing agency seven days of the occurrence. Therefore, as a result of today’s Case-Management visit, a Technical Advisory Note (LIC9102) will be issued. An exit interview was conducted with Chief Operating Officer Faye Shen, and a copy of this report including the LIC9102 and the LIC811 were provided at the end of the visit.the state’s words, verbatim · CDSS document, Feb 27, 2024

Allegation investigated: Facility is not maintaining a comfortable temperature in the dining room and resident are too cold.

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility and to deliver the findings. LPA De Perio explained the purpose of today's visit, and was greeted by Chief Operating Officer - Faye Shen. During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that the facility is not maintaining a comfortable temperature in the dining room and residents are too cold. During the tour of the physical plant of the facility, LPA observed that the temperature at the entrance of the dining room was observed to be at 76 degrees Fahrenheit, and the temperature in the central part of the dining room was measured to be at 75.0 degrees Fahrenheit. Unsubstantiated 2 out of the 2 staff interviews conducted did not corroborate with the allegation by stating that if there were any complaints about the temperature of the dining room, then staff will adjust it accordingly. Per staff interview, the temperature throughout the facility is kept between 74 to 80 degrees Fahrenheit. 4 out of the 4 resident interviews conducted, did not corroborate with the allegation by stating that the temperature in the dining room was comfortable and that if it either gets too warm or too cold, they inform staff, and that staff will adjust the temperature, however all 4 residents expressed no concerns regarding the temperature in the dining room. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Chief Operating Officer Shen. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Jan 18, 2024 · control 22-AS-20240111151910

Allegation investigated: Staff do not assist resident with medication management. Resident did not receive medication as prescribed.

On this Day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry by Steve Shen, Administrator and explained the reason for the visit. The Department received a complaint on 12/08/2023 and the initial 10-day visit on 12/15/2023. During the visit LPA Mendivil interviewed staff and residents. LPA Mendivil obtained copies of physician reports, admission agreement and appraisal. Regarding the allegations staff do not assist resident with medication management and resident did not receive medication as prescribed, the investigation revealed the following: Per review of Resident 1 (R1) physician report dated 04/26/2023 it is reported that R1 is able to administer their own medications and R1 is able to administer their PRN medications.Based on an interview with Chief Operating Officer Faye Shen, R1 is independent and does not want assistance from the Med-Techs for medication management. Unfounded Therefore based on preponderance of evidence through records reviewed and interviews the allegations that staff do not assist resident with medication management and resident did not receive medication as prescribed are determined to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report and confidential names list was provided.the state’s words, verbatim · CDSS document, Dec 29, 2023 · control 22-AS-20231208160644

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced case management visit. LPA observed during the required 10-day visit for complaint number 22-AS-20231205121033, that none of the 4 stairwells at the facility had an emergency evacuation chair. LPA informed the Administrator and the Chief Operating Officer (COO) that all stairwells must have an emergency evacuation chair. The Administrator and COO stated they understood. Violations are being cited per California Code of Regulations, Title 22 division 6. An exit interview was conducted and a copy of the report and appeals rights was provided.the state’s words, verbatim · CDSS document, Dec 11, 2023

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.695(f)(1) · Plan of correction due date: Dec 12, 2023

(f) A facility shall have both of the following in place:(1) An evacuation chair at each stairwell, on or before July 1, 2019. This requirement is not being met as evidenced by... LPA observed that none of the 4 stairwells in the facility had an evacuation chair. This poses an immediate Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 11, 2023

Plan of correction: Licensee states that the facility will order and install an evacuation chair at each stairwell in the facility. LIcensee to forward proof to LPA by POC due date.