Whittier Glen Assisted Living

Allegation investigated: Staff did not ensure communication was maintained with residents authorized representatives. Staff did not maintain residents admission retention requirements in a timely manner.

Licensing Program Analyst (LPA) Tao conducted an unannounced subsequent complaint investigation visit for the allegations listed above. LPA met with Administrator Itzayana Barba Aguirre and explained the reason for the visit. LPA Tao conducted investigation visits on 05/05/2026, 06/16/2026 and 08/11/2026 (today). The investigation consists of the following: LPA toured the facility, interviewed eight (8) residents, attempted to interview resident#1 (R1) but the resident declined to be interviewed, interviewed four (4) staff, interviewed three (3) visitors, interviewed one (1) responsible party, and obtained the following documents: copies of the staff and resident rosters, In-service training related to scabies, resident#1 (R1)’s files including: (-Continued on LIC 9099C-) Substantiated Admission Agreement, Admission Record, Progress notes, Physician’s Reports, Medical Assessment for Residential Care Facilities for the Elderly, Preplacement Appraisal, Assisted Living Waiver Patient’s Rights (or ALW agreement), lab result of scabies examination (specimen collection date 04/07/2026), hospital report dated 05/05/2026 and 06/10/2026, Assisted Living Program’s communication log from 03/11/2026 to 06/02/2026, and progress note dated 04/21/2026. During today’s visit LPA conducted interviews with visitors and family member, reviewed hospital reports and toured the physical plant. There were no immediate health and safety concerns observed. The investigation revealed the following: Regarding allegation: Staff did not ensure communication was maintained with resident’s authorized representatives - It is alleged that the administrator did not respond to resident#1 (R1)’s responsible party's communication regarding resident’s Assisted Living Waiver Program (ALWP) placement. Per resident interviews, eight (8) out of eight (8) residents interviewed could not corroborate the allegation. Four (4) out of four (4) staff interviewed denied the allegation. Three (3) out of three (3) visitors and one (1) out of one (1) family member interviewed stated the facility did not ensure communication with resident’s authorized representatives. Per record review of call logs, the hospital’s social worker and ALWP representatives had made multiple contacts via phone calls and emails with the facility regarding R1’s medical updates and ALWP retention requirement follow ups. The facility did not respond to their communication timely which resulted in passing the 60-day ALWP placement requirement. Regarding allegation: Staff did not maintain resident’s admission retention requirements in a timely manner - It is alleged that the administrator did not accept resident#1(R1) back to the facility from hospital after R1 was cleared which missed resident’s ALWP 60-day retention requirement due to resident had scabies. Per resident interviews, eight (8) out of eight (8) residents interviewed could not corroborate the allegation. (-Continued on LIC 9099C-) copies of the staff and resident rosters, In-service training related to scabies, resident#1 (R1)’s files including Admission Agreement, Admission Record, Progress notes, Physician’s Reports, Medical Assessment for Residential Care Facilities for the Elderly, Preplacement Appraisal, Assisted Living Waiver Patient’s Rights (or ALW agreement), lab result of scabies examination (specimen collection date 04/07/2026), hospital report dated 05/05/2026 and 06/10/2026, Assisted Living Program’s communication log from 03/11/2026 to 06/02/2026, and progress note dated 04/21/2026. During today’s visit LPA conducted interviews with visitors and family member, reviewed hospital reports and toured the physical plant. There were no immediate health and safety concerns observed. The investigation revealed the following: Regarding allegation: Staff did not meet resident’s care obligations - It is alleged that staff did not provide care to resident resulted in body rash. Per resident interviews, eight (8) out of eight (8) residents interviewed could not corroborate the allegation. Residents stated their care needs were being met. Four (4) out of four (4) staff interviewed denied the allegation. Three (3) out of three (3) visitors could not corroborate the allegation. One (1) out of one (1) family member interviewed stated the facility did not meet resident’s care needs. Per record review, staff had training regarding providing proper cares to residents such checking on residents’ for body rash and scabies. Proper pre-cautious protocol was in place when body rash was observed. Per observation, residents observed to be clean and look fine. Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator Itzayana Barba Aguirre. The findings were discussed and a copy this report was provided. Four (4) out of four (4) staff interviewed denied the allegation. Three (3) out of three (3) visitors and one (1) out of one (1) family member interviewed revealed that R1 was cleared for return to the facility on 04/10/2026. Per the hospital report, R1’s medical clearance was on 04/10/2026. Per the lab result, R1 did not have scabies. R1’s ALWP’s 60 day return window ended on 04/13/2026. As mentioned above, the responsible party and ALWP representative made multiple attempts to communicate with the facility as well as notified the administrator that R1 did not have scabies on 04/10/2026, but the administrator did not respond until 04/15/2026, which had passed the 60-day deadline required to maintain the R1’s ALWP admission retention requirements. Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Administrator Itzayana Barba Aguirre. Copies of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 11, 2026 · control 28-AS-20260501141051

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(9) · Plan of correction due date: Aug 14, 2026

Personal Rights of Residents in All Facilities (a)(9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement is not met as evidenced by: Administrator did not respond to resident#1 (R1)’s responsible party's communication and failed to follow up with resident’s Assisted Living Waiver Program (ALWP). Based on observation and record review, the licensee did not comply with the section cited above which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: Licensee agreed to provide (1) a statement according to 87468.1(a)(9) that indicate how to prevent future occurrence. (2) in-service training regarding responding to residents’ authorized presentative timely by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Aug 14, 2026

To have their representatives regularly informed by the licensee of activities related to care or services,...as appropriate to their needs. This requirement is not met as evidenced by: Administrator did not assist R1 to maintain in ALWP 60-day retention requirement to meet R1's cares and service needs. Based on observation and record review, the licensee did not comply with the section cited above which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: Licensee agreed to provide (1) a statement according to 87468.1(a)(8) that indicate how to prevent future occurrence. (2) in-service training regarding responding to residents’ authorized presentative timely by POC due date.

Allegation investigated: Staff did not address a resident's change in medical condition in a timely manner Staff did not notify authorized representative of incident

Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent unannounced complaint visit to investigate the allegations listed above. LPA met with Itzayana Barba Aguirre, administrator for the facility, and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 5/28/2026, LPA Zaragoza interviewed Staff #1 - 2 (S1 - S2), obtained the staff resident roster, and also obtained the physician's report, service plan, reappraisals, FACE Sheet, and hospice care plan and visit logs for Resident #1 (R1). During today's visit, LPA interviewed Staff # 3 - 5 (S3 - S5), and Residents #2 - 7 (R2 - R7), and reviewed the Serious Incident Reports (SIRs) that were sent by the facility to Community Care Licensing Division (CCLD). LPA was unable to interview R1 because they passed away on 5/19/2026. Unsubstantiated The investigation revealed the following: In regards to the allegation that "Staff did not address a resident's change in medical condition in a timely manner," it is alleged that R1's health condition was declining prior to their hospitalization on 5/14/2026, which included sustaining falls, severe dehydration, and wounds on R1's heels and sacrum, and that this change in condition was not addressed by staff prior to R1's hospitalization. During interviews with the residents, none of them corroborated the allegation. LPA interviewed R2 who is the former roommate of R1, and they stated from their observations staff did address R1's change of condition in a timely manner. Other residents interviewed stated that from their experience, staff do assist residents who have a declining medical condition in a timely manner. During interviews with the staff, none of them corroborated the allegation. One staff interviewed stated that they did not observe R1 having a drastic change of condition prior to their hospitalization, nor did they have any record of R1 sustaining any falls or having wounds or pressure injuries. Another staff interviewed also stated that they did not observe R1 have a decline in condition prior to hospitalization, and also was on hospice who checked on the condition of his skin for any wounds or injuries. Based on hospice visit notes obtained from Quality Hospice on 5/6/2026 and 5/13/2026, it notes that R1's skin was intact and did not receive wound care respectively. In regards to the allegation that "Staff did not notify authorized representative of incident," it is alleged that R1 sustained falls at the facility, and that R1's family was not notified of these incident or their change of condition. During interviews with the residents, none of them corroborated the allegation. One resident stated that the facility has contacted their family in the past and stays in touch with them. Another resident interviewed stated they are unsure if staff contact authorized representatives of serious incidents. During interviews with staff, none of them corroborated the allegation. One staff interviewed stated that R1 did not sustain any falls while living at the facility, and therefore no falls were reported. Another staff interviewed also stated they had no record or recollection of R1 falling, however they did notify the family and the licensing agency of R1's hospitalization when it occurred. During review of the SIRs, LPA confirmed the facility did notify CCLD of R1's hospitalization and deaths as required per reporting requirements. Based on statements and interviews conducted with staff, residents, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 7, 2026 · control 28-AS-20260518150011

Allegation investigated: Resident developed multiple pressure injuries in care due to staff neglect.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation on the allegation listed above. LPA met with Administrator Itzayana Barba Aguirre and explained the purpose of the visit. The investigation consisted of the following: On 4/9/26, LPA E. Mallett conducted the initial visit. Mallett toured the facility, obtained copies of the staff and resident rosters, and pertinent files for Resident #1. There were no immediate health and safety concerns noted. It was determined that the allegation requires further investigation. During the course of the investigation, a total of seven (7) Staff and eight (8) Residents were interviewed. The investigation revealed the following: Allegation - Resident developed multiple pressure injuries in care due to staff neglect. It is alleged that Resident #1 (R1) did not receive the appropriate level of care and supervision, resulting in R1 developing multiple pressure injuries. Unsubstantiated The Department investigated the allegation and collected hospital medical records, interviewed staff and residents to determine the findings. The hospital medical records obtained indicated that R1 was admitted to the hospital on 4/7/26 due to chronic diarrhea and was diagnosed with stage II pressure injury on the sacral area with redness on the heels and a scrape on the right shoulder. R1 was discharged back to the facility on 4/14/26. R1 returned to the hospital on 4/24/26 for back pain and vertigo. The pressure injury on his sacrum was still noted as a stage II. The redness on the bi-lateral heels was noted as stage I. R1’s medical concerns were addressed, and returned to the facility on 4/26/26. Interviews with Staff revealed that R1, who moved in on 3/26/26, was observed with a pressure injury or redness on the sacral area and a scrape on the shoulder. Staff acknowledged that R1 had lots of back pain and assisted the resident with transferring and repositioning regularly. Staff often checked R1 during bed baths and changes and did not observe the redness in the sacral area getting worse while R1 was residing at the facility. Staff noted that R1 was in and out of the hospital multiple times and discharge paperwork did not indicate any pressure injuries. Caregivers and Med Techs are instructed to document and report to the Wellness Coordinator(s) if they observe any changes to the residents and/or their wounds. According to R1’s care plan and progress notes, there were no indications of pressure injuries nor wound care being provided by a home health agency. R1’s physician’s report dated 3/20/2026 also did not note any pressure injuries. Interview with R1 revealed that the resident moved into the facility with an existing pressure injury on the sacral area and an abrasion on the shoulder. R1 stated that the staff regularly assisted the resident with repositioning while in bed since R1 was unable to move onto the side due to back pain. R1 did not believe the wounds got worse or developed any new pressure injuries since living at the facility. R1 believed that the needs are being met. The additional seven (7) residents interviewed indicated that staff check on them and assist them with their needs. One of the residents who developed a pressure injury was being treated by a home health agency. Staff were also monitoring to ensure that the wounds did not worsen. Based on the information gathered, staff repositioned R1 regularly and conducted body checks. The facility documents did not note or confirm any areas with pressure injuries. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with the administrator. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Jul 30, 2026 · control 28-AS-20260408143644

Allegation investigated: Staff neglect resulted in resident eloping and sustaining a fracture.

Licensing Program Analyst (LPA), Mayra Cota, conducted subsequent visit to deliver findings regarding the above-mentioned allegation. LPA met with Brianna Fierra, Med-Tech, and the reason for the visit was explained. The investigation consisted of the following: LPA Irra, conducted initial visit on 11/3/2025 and reviewed files for Resident#1 (R-1) through Resident #8 (R-8) and obtained relevant documentation. Additionally, LPA obtained a copy of the staff schedule and resident roster. During the span of the investigation, the department conducted interviews with Staff 1 – Staff 4 (S1-S4) and Resident 1 – Resident 2 (R1-R2) and reviewed and obtained copies of R1’s medical records and police report. The investigation revealed the following: ***Continues on LIC 9099-C*** Substantiated Regarding: Staff neglect resulted in resident eloping and sustaining a fracture. It is alleged that resident hit their head and sustained a fracture during a fall after resident left the facility premises unsupervised. It is also alleged that staff were not aware that the resident had eloped from the facility and that there were prior concerns regarding safety due to resident having wandering behavior and staff being insufficient in numbers to provide supervision. Interviews with S1-S4 revealed that R1 eloped from the facility during the overnight (NOC) shift on 10/30/2025. Staff indicated that R1 was discovered to be missing from their room during morning medication pass at around 7:00 a.m. S2 noticed that R1 was not in their room, which was unusual because R1 is always in their room waiting for their morning medication. S2 informed management regarding R1 not being in their room, and after confirming that R1 was not signed out of the facility for an outing and after looking for R1 throughout the facility, staff realized that R1 left the facility without anyone noticing. A missing person report was filed; however, it was done until 9:00 a.m. according to police report. Staff could not precisely indicate when R1 walked out of the facility nor how many hours passed before staff realized R1 had eloped; however, staff acknowledged that it took staff long to notice that R1 was missing because a proper check was not conducted in R1’s room on the night R1 left the facility. Staff stated that R1 should have received a “bed check” in their room, but staff did not properly check on R1. Staff indicated that there were only two staff on shift and staff probably became distracted due to responding to an incident involving another resident which activated a call to 911. Staff indicated that R1 was never heard saying they wanted to leave nor showed signs of being an elopement risk; however, staff stated that R1 was known to wander in the hallways of the facility and needed constant re-direction. Review of R1’s Physician Report indicated that R1 could leave the facility but only with a “responsible party.” R1’s Resident Appraisal indicated that R1 tends to wander and needs to be re-directed. Furthermore, R1’s Service Plan indicated that R1’s mobility is limited and needs to be escorted to activities in the facility and in the community. Service Plan states that R1 has to get a one-time bed check at night to ensure wellness and safety. It is also stated on the plan, that R1 is not able to leave the facility unassisted and that R1 has specified Dementia. ***Continues on LIC 9099-C page 2*** R1’s medical report indicated that R1 was admitted to the hospital on 10/30/2025 at around 2:30 a.m. Report indicated that on the day R1 left the facility, R1 arrived at the hospital via ambulance with pain and swelling in the right elbow. Report states that R1 was able to recall experiencing a fall and hitting their head on a tree. The medical report states that R1 was diagnosed with a right humeral fracture per x-ray impressions conducted when admitted to the hospital on 10/30/2025. Police interrogation of the nurse on shift during R1’s hospital care stated that R1 sustained the humeral fracture after falling when walking in the community. Information also provided by the police indicated that facility filed a missing person report at 9:00 a.m. Based on interviews, facility staff did not conduct proper checks on R1 which resulted in R1 eloping and walking outside of the facility unassisted and without anyone noticing. Records also show that R1 fell and sustained a fracture during the time they were missing from the facility. The elements reviewed during the investigation, corroborate the allegation that staff neglect resulted in resident eloping and sustaining a fracture. The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided. ***Immediate Civil Penalties are issued today in the amount of $500 due to neglect/lack of supervision that resulted in resident sustaining a fracture and for Repeat Violation of Section 87468.2(a)(4). At this time, an Enhanced Civil Penalty (ECP) determination in reference to Health and Safety Code 1569.49(f) is pending and may be assessed at a later date.***the state’s words, verbatim · CDSS document, Jul 23, 2026 · control 28-AS-20251030164022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 24, 2026

Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews, facility staff did not conduct proper checks on R1 which resulted in R1 eloping and walking outside of the facility unassisted and without anyone noticing. Records also show that R1 fell and sustained a fracture during the time they R1 was missing from the facility.the state’s words, verbatim · CDSS document, Jul 23, 2026

Plan of correction: Licensee/Administrator shall ensure to comply with Title 22 Section 87468.2 at all times. Additionally, Licensee/Administrator shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 87468.2(a)(4). Written POC must be submitted to CCL/LPA by POC due date. An immediate Civil Penalty of $500.00 is being issued today, due to a resident sustaining injury while in care. Refer to LIC 421IM.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Mayra Cota, conducted a Case Management – Deficiencies visit today. LPA met with Brianna Fierro, Med-Tech and the purpose of the visit was explained. During today’s visit, a deficiency was noted during complaint investigation and cited under the following section: CCR 87457(c)(3) – Pre-Admission Appraisal. During record review it was noted that there is no indication that Resident 1’s Preplacement Appraisal was completed appropriately because the appraisal the facility provided to the department for review is missing a signature from Resident 1 and/or authorized representative. Exit interview was conducted and a copy of the report, LIC 809-D and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Jul 23, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c)(3) · Plan of correction due date: Aug 11, 2026

Pre-Admission Appraisal (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.(3) The prospective resident, or his/her responsible person, if any, shall be involved in the development of the appraisal. This requirement is not met as evidenced by: during record review it was noted that there is no indication that Resident 1’s Preplacement Appraisal was completed appropriately because the appraisal the facility provided to the department for review is missing a signature from Resident 1 and/or authorized representative.the state’s words, verbatim · CDSS document, Jul 23, 2026

Plan of correction: Licensee will ensure that this form is thoroughly completed as a part of the admissions process/intake assessment for all future residents. Licensee will email LPA confirmation that the regulation was reviewed and a plan on how appropriate monitoring for accurary and completion of residents' documents will take place by POC due date.

Allegation investigated: Facility staff are not meeting residents’ needs in a timely manner. Facility staff are not providing the resident medications as prescribed.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegations listed above. LPA met with the administrator Itzayana Aguirre and informed the purpose of the visit. LPA obtained copies of the staff and resident rosters, facility’s call history reports, and documents for Resident #1. LPA also reviewed medications and interviewed staff and residents. The investigation revealed the following: Allegation – Facility staff are not meeting residents’ needs in a timely manner. It is alleged that the residents’ needs are not adequately met and the staff response time is too long. LPA interviewed five (5) Staff. Staff indicated that they would try to tend to residents as soon as they can when they press the pendant for assistance. The med tech would also assist the residents when care staff cannot get to the residents right away. Substantiated LPA interviewed eight (8) residents. Four (4) out of the eight (8) residents stated that the staff could take as long as 15 minutes to 1 hour before they respond to their calls. Residents feel that the facility could use more caregivers since there are many residents at the facility. LPA obtained a copy of the facility’s call history from 5/1/26 – 5/5/26, and the reports show that the residents’ calls were acknowledged within a few seconds to over an hour. Based on the information gathered, this allegation is substantiated. Allegation - Facility staff are not providing the resident medications as prescribed. LPA interviewed the administrator and medication aides regarding this allegation. Staff stated that they are administering medication within the time frame for the morning, noon, evening, and bedtime. Staff refill the medications before they run out. Staff will use the electronic medication administration record (MAR) when the medication is given to the resident. LPA reviewed nine (9) residents’ medications. LPA observed a discrepancy for Resident #1, whose medication (Baclofen 20mg) was not given today. Staff provided an order for the medication to be prescribed for 10 days. The order began on 4/26/26 and the last pill should have been given this morning on 5/5/26. However, the medication was not marked as given today. Although residents interviewed stated that they are being given their medications as prescribed, an error was found during the review. Therefore, this allegation is deemed substantiated. Based on LPA observations, interviews conducted, and record review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Corrections were reviewed and developed with the administrator. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 5, 2026 · control 28-AS-20260427140812

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 6, 2026

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation and record review, the medication for Resident #1 was not administered today which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 5, 2026

Plan of correction: The licensee shall submit a plan to ensure that all the residents' medications are present and refills are obtained. The plan is due by 5/6/26.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: May 12, 2026

87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interview and record review, the facility did not employ sufficient caregivers to assist residents with their needs timely which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 5, 2026

Plan of correction: The licensee shall develop a plan to provide sufficient staffing to ensure residents' needs are met in a timely manner. The plan is due to LPA by 5/12/26.

Allegation investigated: Questionable death Staff abandoned resident

Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent complaint visit to deliver the findings of the investigation. LPA met with Itzayana Barba-Aguirre, administrator for the facility, and explained the purpose of the visit. The complaint consisted of the following: On the initial visit condcuted on 7/18/2025 conducted by Tena Herrera, LPA obtained copies of Staff/Resident Roster, and toured facility. On a subsequent visit conducted on 8/4/2026, LPA Zaragoza interviewed Residents #2 - 9 (R2 - R9), Staff #1 - 4 (S1 - S4), and obtained the admissions agreement, FACE Sheet, facility discharge paperwork, physician's report, appraisals, and service plan for Resident #1 (R1). Since the visit LPA Zaragoza attempted to gain physician orders for R1, obtained a physical report from R1's previous placement to the facility and also the transportation policy for the facility. . Since the visit on 8/4/2025, LPA Zaragoza also interviewed Staff #5 and Staff #6 (S5 - S6). Between the dates of 7/18/2025 - 11/5/2025, Investigations Branch (IB) investigator Real interviewed S6, Witnesses #1 - 2 (W1 - W2), and also obtained the death certificate for R1. [CONT. on LIC9099-C page.] Unsubstantiated IB investigator Real attempted to interview R1 and Staff #7 (S7), however was unable to because they are both deceased. During today's visit, LPA Zaragoza will be delivering the findings of the investigation. The investigation revealed the following: In regards to the allegation of "Questionable death," it is alleged that R1 passed away on 4/18/2022 due to staff neglect, because R1 had been dropped off at a bus station by S7, and ultimately did not get on the bus which led to their passing. During interviews conducted by IB, it was revealed that a plan was put in place for R1 to travel to Iowa to live with W1, however R1 never got on the bus to arrive at their destination. During interview with S6, they stated that a plan was put in place for R1 to travel by bus to Iowa to live with W1, and all parties agreed to the plan. S6 stated that R1 was to travel by Greyhound bus with R1's trip beginning in California on 3/21/2022, and arriving on 3/23/2022. During interview with W1, they stated went to the Iowa bus station on 3/23/2022 to pick up R1 but they never arrived. W1 stated that about a month later they were notified that R1 was found deceased in Los Angeles. It was determined that R1 did not notify any party of their change in plan to not board the bus. During interview with W2, housing coordinator for R1, they stated that Whittier Glen Assisted Living did notify them of R1's discharge from the facility as required. During record review of R1's death certificate, the cause of death is listed as an accidental drug overdose. In regards to the allegation that "Staff abandoned resident," it is alleged that R1 was abandoned at the bus station because R7 did not ensure that R1 had boarded the bus to travel to Iowa. During interviews conducted by IB, it was revealed that S7 did transport R1 to the bus station for their planned travel to Iowa. During interview with S6, they stated that after S7 did drive R1 to the bus station and made sure that R1 had their tickets to make the travel. S6 stated that S7 left the victim waiting for the bus at the station and returned to the facility. During interview with W1, they stated that they were not comfortable with R1 travelling by themselves to Iowa, but they plan was made anyway, and R1 never arrived at the bus station in Iowa as planned on 3/23/2022. During record review of the facility's transportation policy for scheduled transportation that "unfortunately, the driver may not wait for the resident." Therefore it was determined the facility did not deviate from their plan of operation. Based on statements and interviews conducted with staff, residents, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided. for the allegation "Staff did not ensure residents plan of care was followed." IB investigator Real attempted to interview R1 and Staff #7 (S7), however was unable to because they are both deceased. During today's visit, LPA Zaragoza will be delivering the findings of the investigation. In regards to the allegation that "Staff did not ensure residents plan of care was followed," it was alleged that R1 had lacked capacity and not allowed to leave the facility without assistance according to their physician report, however the facility proceeded with allowing R1 to travel three (3) days by bus to Iowa on their own to live with W1 in March of 2022. During interviews conducted by IB, it was determined that R1 was allowed to travel by themselves to Iowa. During interviews with S6, they stated that according to their appraisal of R1, they displayed a high cognitive level, and did not display any memory related issues during his assessment. S6 stated that R1 was able to communicate their own needs, ambulate on their own with assistant at times, however they were “pretty independent while walking.” During interview with W1, they stated that R1 lost the use of is hand or arm and would forget who they were talking to occasionally. During record review of R1's physician's report, it does indicate that they were unable to leave the facility unsupervised and required supervision. In regards to the allegation that "Staff did not ensure resident was provided medications," it is alleged that R1 was a diabetic who required insulin medication, however they were not provided any of their medications when they were taken to the bus station to relocate to live with W1. During interviews with residents conducted by LPA Zaragoza on 8/4/2025, three (3) out of eight (8) corroborated the allegation. One resident stated that they do not receive their medications on time by staff. Another resident interviewed stated that they need to ask staff for their medications during medication passes or else don't receive them. During interviews with staff, none of them corroborated the allegation. S6 stated that R1 never required insulin or had a physician's order for it, and that is why they were not provided insulin as part of their travel to Iowa. Another staff interviewed stated that they also did not work at the time R1 lived in the facility, however when residents are going out or discharged, they do provide medications to the residents and also document the medications that were provided on a medication release form as proof. During record review of R1's physician report dated 1/27/2022, it describes that R1 was not able to administer their own medications or injections, and that they had a diabetes diagnosis with two (2) different types of insulin listed for their medication/treatment of their diabetes. LPA requested medication records for R1 from the facility, however there is nothing on record. In regards to the allegation that "Staff did not ensure reporting requirements were followed," it is alleged that following R1 did not arrive at their planned destination in Iowa to live with W1 on 3/23/2022 and their passing on 4/18/2022, the facility did not notify Community Care Licensing Division (CCLD) or the law enforcement of these incidents. During interviews with staff, one (1) out of six (6) corroborated the allegation. During interview with S6 who was the administrator of the time, they admitted that they were aware that R1 did not arrive at their destination in Iowa as planned, because they did remain in communication with W1 during this time. Another staff member interviewed who presently works at the facility stated that whenever a resident has an absence or passes away, they always report it to the licensing agency. During record review of incident reports for the facility in 2022, LPA did not discover any incident reports related to the missing status or death for R1. Based on LPA interviews conducted with the residents and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 is being cited on the attached LIC9099-D page. Exit interview was held and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 1, 2026 · control 28-AS-20250717142605

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 2, 2026

(a) In addition to (...) residents (...) shall have the following personal rights. (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This regulation is not met as evidenced by: Based on record review and interview, the facility did not meet the above requirement in one (1) out of nine (9) residents, because R1 was unable to leave the facility unassisted and was allowed to travel on ther own by bus without a responsible adult to assist them, which posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, May 1, 2026

Plan of correction: Licensee/Administrator is to ensure that all residents are provided care and supervision to meet their individual need at all times. Administrator shall submit the facility's plan on how all residents care plans will be adhered to by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 2, 2026

(a) A plan for the indicental medical and dental care shall be developed (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This regulation is not met as evidenced by: Based on interview and record review, the facility did not meet the above requirement in four (4) out of nine (9) residents, because R1 required insulin based on available documentation and no evidence was provided that they were provided it, along with corroborations from R2 - R4. Which poses/posed an immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, May 1, 2026

Plan of correction: Licensee/Administrator is to ensure that all residents are assisted with self-administered medications as needed at all times. Administrator shall submit a plan to ensure that all the residents' are assisted with their self-administered medications and injections to LPA by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: May 22, 2026

(a) Each licensee shall furnish to the licensing agency such reports (...) including (...) the following. (1) A written report (...) within seven days of the occurrence (...) and disposition of the case. (D) Any incident which threatens the welfare, safety (...) or unexplained absence of the resident. This regulation is not met as evidenced by: Based on interview and record review, the facility did not meet the above requirement in 1 out of 9 residents. Because an incident report was not submitted following R1's absence and death, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 1, 2026

Plan of correction: Licensee/Administrator is to ensure that all incident and death reports are to be submitted to the licensing agency within the appropriate timeframe at all times. Administrator shall submit a plan on how the facility will ensure all incident reports are reported timely to LPA by the POC due date.

Allegation investigated: Staff did not provide activities to residents in care

Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent unannounced complaint visit to investigate the allegations listed above. LPA met with Itzayana Barab-Aguirre, administrator for the facility, and explained the purpose of the visit. The investigation consisted of the following: On the initial visit conducted on 1/28/2026, LPA conducted a tour of the facility, obtained a copy of the activities calendar, and interviewed Staff #1 - 2 (S1 - S2). During today's visit, LPA interviewed resident's #1 - 10 (R1 - R10), and also interviewed Staff #3 - 5 (S3 - S5). The investigation revealed the following: In regards to the allegation that "Staff did not provide activities to residents in care," it is alleged that facility staff have not been offering activities to the residents for the month of January 2026. Unsubstantiated During interviews with the residents, nine (9) out of ten (10) did not corroborate the allegation. One resident interviewed stated that that they are offered activities including music therapy to stir memories for residents, along with humor classes as well that they like to participate in. Another resident interviewed stated that activities are offered for any resident to participate in if they want to, and that they enjoy participating in the arts and crafts classes. During interviews with the staff members, none of them corroborated the allegation. One staff interviewed that as the activity director they do hold activities for the residents including classes on history and comedy, physical stretching activities, board games, and outings including shopping activities. Another staff member interviewed stated that activities are offered to residents, and that residents are encouraged to participate in activities at breakfast when they make announcements on which activities are offered, and also through verbal reminders with residents. During a tour of the facility, LPA observed that the facility does have an activities calendar in place offering activities every day of the week, and observed the facility transportation vehicle taking the residents on an outing during today's visit on 2/10/2026. Based on statements and interviews conducted with staff, residents, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 10, 2026 · control 28-AS-20260128085216

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Erik Zaragoza conducted a case management visit in conjunction with a complaint that has the control #28-AS-20251210115908. During the course of the investigation, a total of five (5) residents and one (1) staff member corroborated that a staff member has handled residents in a rough manner in the past. Therefore a resulting deficiency is being cited on the LIC809D page. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 10, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Feb 11, 2026

(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 regulation is not met as evidenced by: Based on resident interviews and a observation, LPA determined that 5 out of 10 residents had either been handled roughly or pushed by staff while being assisted with transfers or care, which poses a potential health and safety threat to clients in care.the state’s words, verbatim · CDSS document, Feb 10, 2026

Plan of correction: Administrator is to ensure residents are assisted with care needs and bed transfers without being handled in a rough manner or leading to injury. Administrator to provide a staff training on proper procedures for bed transfers and to submit proof of training including the (...) sign-in sheet with staff signatures, date of training, duration of training and curriculum used for training to LPA by POC due date.

Allegation investigated: Staff pushed resident in care Staff yelled at resident in care

Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent unannounced complaint visit to address the allegations listed above. LPA met with Itzayana Barba Aguirre, administrator for the facility, and explained the purpose of the visit. The investigation consisted of the following: During the first visit conducted on 12/12/2025, LPA interviewed Staff #1 - 3 (S1 - S3), Resident #2 (R2), and also obtainted staff rosters, resident rosters, and also the FACE Sheet, Physician's Report, and Appraisals for Resident #1 (R1). During the second visit conducted on 1/6/2026, LPA interviewed Residents #4 - 9 (R4 - R9), and also interviewed Staff #4 (S4). LPA interviewed R1 regarding the above allegation on a previous visit on 11/24/2025. During today's visit, LPA is delivering the findings of the allegation. Unsubstantiated In regards to the allegation that "Staff pushed resident in care," it is alleged that on 11/20/2025, R1 was pushed into a wall by S4 when they were being assisted with being transferred out of bed which caused a skin tear on R1's arm. During interviews with the residents, eight (8) out of nine (9) did not corroborate the allegation. One resident interviewed stated that they have not been pushed by any of the staff members in the facility. Another resident interviewed stated that while they have also not been pushed by any staff member in the past. During interviews with the staff, none of them corroborated the allegation. S4 stated that they are utilizing a buddy stem with fellow caregivers to avoid the rough handling of residents when transferring them out of bed. Other staff denied that R1 was handled roughly and noted that they have thin fragile skin which led to the tear during transferring R1 to a hoyer lift. In regards to the allegation that "Staff yelled at resident in care," it is alleged that R1 had been yelled at by staff members in the facility. During interviews with the residents, seven (7) out of nine (9) interviewed did not corroborate the allegation. One of that staff have never yelled at them or said anything inappropriate to them. During interview with another resident, they stated that they also have never been yelled at in the facility by any of the staff members. During interviews with staff members, none of them corroborated the allegation. One staff member stated that they never yell at residents and treat all of them respectfully. All other staff members stated that they have never witnessed any staff yelling at residents in the facility. During tour of the facility, LPA did not observe any staff members yelling at residents in the facility. Based on statements and interviews conducted with staff, residents, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 28-AS-20251210115908

Allegation investigated: Staff did not assist resident in a timely manner resulting in resident sustaining a fracture. Staff did not seek medical attention in a timely manner. Staff yell at resident.

Licensing Program Analysts (LPAs) Erik Zaragoza and Gabriela Castro conducted a subsequent unannounced complaint visit to address the allegations listed above. LPAs met with Lindsey Stallings, Clinical Director for the facility, and explained the purpose of the visit. The investigation consisted of the following: During the inital visit conducted on interviewed Residents #1 - 8 (R1 - R8), Staff #1 - 4 (S1 - S4), obtained the staff and resident rosters, hospital discharge paperwork for R1, incident reports for R1, and the medication and Medications Administration Records (MARs). Since the initial visit, LPA Zaragoza interviewed Staff #6 (S6), and attempted to interview Staff #5 (S5) however they no longer work at the facility. LPA Zaragoza also obtained incident reports, X-rays, and doctor's note regarding R1. During today's visit, LPAs will be delivering the findings for the investigation. Unsubstantiated In regards to the allegation that "Staff did not assist resident in a timely manner resulting in resident sustaining a fracture," it is alleged that R1 sustained a fall on 7/5/2025 and fractured their wrist, and that staff did not assist them in a timely manner. During interviews with residents, seven (7) out of eight (8) did not corroborate this allegation. Some residents indicated that they have not been assisted in a timely manner by the staff at the facility, however they explained that they did not sustain any fracture in any of these incidents. During interviews with staff, none of them corroborated the allegation. One staff member explained that they were aware that R1 had fallen, and that they offered to take them to the hospital however they refused. Another staff member also indicated that R1 refused to be taken to the hospital, and therefore facility staff scheduled an appointment for R1 to be see their doctor on 7/9/2025. Records reviewed shows that on 7/11/2025 R1 was referred for an x-ray which revealed the fracture and was then ordered to be placed in a splint for the healing of the broken bone. In regards to the allegation that "Staff did not seek medical attention in a timely manner," it is alleged that R1 reported that they had fallen on 7/5/2025 to S5, however they never reported the injury to the administrator or any other staff. During interviews with the residents, six (6) out of eight (8) did not corroborate the allegation. One resident stated that they have not had issues with obtaining timely medical care while living in the facility. Another resident also stated that they haven't had problems obtaining medical care when they need it. During interviews with staff, none of them corroborated the allegation. The administrator stated that they became aware of the incident on the day that it occurred by other staff, and offered medical assistance to R1. Another staff interviewed stated that all staff were aware of the fall and did seek medical attention for R1. An SIR dated 7/5/2025 indicated that administrator and staff were aware of the fall and attempted to obtain medical assistance for R1 however they refused. In regards to the allegation that "Staff yell at resident," it is alleged that S5 has screamed at R1 in the facility in the past. During interviews with residents, six (6) out of eight (8) residents did not corroborate the allegation. One of the residents interviewed stated that they believe that S5 is a fair caregiver and is nice. Another resident stated that they have never witnessed staff yell at the residents in the past. During interviews with the staff, none of them corroborated the allegation. One staff interviewed stated that they have never heard S5 or any other staff raised their voice at residents in the facility. LPA attempted to interview S5, however they have since stopped working at the facility. Based on statements and interviews conducted with staff, residents, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided. In regards to the allegation that there is "Insufficient Staffing," it is alleged that residents have waited for over an hour to be assisted by caregivers in the facility. During interviews with the residents, six (6) out of eight (8) corroborated the allegation. One of the residents interviewed stated that they have had to wait half an hour or more to be assisted by staff members at the facility after requesting assistance through their call light. Another resident interviewed stated that it has taken a long time to be assisted by staff particularly in the night shift. During interviews with staff, none of them corroborated the allegation. One staff member stated that during the morning shift they have two (2) caregivers and two (2) med techs on schedule, in the afternoon it is two (2) caregivers and one (1) med tech, and at night it is one (1) caregiver and one (1) med tech. Another staff member stated that they are not short staffed and that they have caregivers and med techs fill positions as needed if a staff were to call out. Based on LPA interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 is being cited on the attached LIC9099D page. Exit interview was held and a copy of the report along with the appeal rights were provided and will be emailed to the administrator.the state’s words, verbatim · CDSS document, Dec 12, 2025 · control 28-AS-20250728095405

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Dec 26, 2025

(a) Facility personnel shall at all times be sufficient in numbers (...) to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed (...) for the provision of adequate services. This regulation is not met as evidenced by: Based on interviews, LPA determined that several residents have experienced delays in received care when requesting assistance through their call button, which poses a potential health and safety concern at the facility.the state’s words, verbatim · CDSS document, Dec 12, 2025

Plan of correction: Licensee/Administrator is to ensure that all residents are assisted in a timely manner by staff at all times. Administrator will email LPA a plan on how the facility will ensure that there is sufficient staff to assist residents in a timely manner by the POC due date.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Erik Zaragoza and Gabriela Castro conducted an unannounced case management visit in response to an incident report received 12/9/2025. LPAs met with Lindsey Stallings, Clinical Director, and explained the purpose of the visit. LPAs interviewed Staff #1 - 4 (S1 - S4), Resident #2 (R2), and obtained the FACE Sheet, Physician's Report, and Admissions Agreement for Resident #1 (R1). In the incident report dated 12/9/2025, it was detailed that R1's wheelchair had caught on fire after R1 placed a burning cigarette in a pouch in the back of their wheelchair, which caused R1 to sustain third degree burns on their body. S3 explained that staff was notified of R1's wheelchair becoming engulfed in flames in the front patio of the facility, and that staff had rushed over and extinguished the fire with a blanket and the trousers of the resident. R2 witnessed the incident and described that R1's wheelchair became engulfed in flames in a very short period of time, and that R1 was caught on fire for around two (2) minutes. At this time, R1 is still currently hospitalized. Following the conclusion of the visit, no deficiencies were observed. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 12, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPA) Erik Zaragoza conducted a a subsequent unannounced Annual Continuation visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The initial visit was conducted on 11/24/2025. LPA met with Monica Guardian, and explained the purpose of the visit. There are eighty-eight (88) residents currently living in the facility. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control plan is on file. Physical Plant/Environment Safety: · The facility is a two-story building that contains the following: First floor consists of resident rooms with individual bathrooms, 1 living room, Dining Rooms, courtyard, office rooms, medication room, kitchen, and laundry area. The second floor of the facility consists of the following: resident bedrooms with individual bathrooms, laundry room, outdoor porch seating area, and Activity room. LPA toured eight (8) resident bedrooms, and all of them had hot water temperatures that measured within the required 105 – 120 Degrees Fahrenheit range. The facility was observed to be in good repair. Carbon Monoxide detector is operational. · The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has multiple fully charged fire extinguishers throughout the facility. Operational Requirements: · Fire clearance was approved by LA County Fire Department for a capacity of ninety-three (93) non-ambulatory clients, and a hospice waiver approved for fifteen (15) residents. · Care and supervision to meet the clients’ needs was observed. Staffing: · There are a sufficient amount of full-time staff members that provide care and supervision to the residents. Personnel Records/Staff Training: · Seven (7) staff files were reviewed for criminal background clearance and training. · All Seven (7) staff records reviewed have a health screening with a Tuberculosis clearance, and seven (7) staff have First Aid/CPR trainings that are active. · The administrator’s certificate expires in January of 2027. Resident Rights/Information: · Physician orders were reviewed for Seven (7) resident files. · Medications were also reviewed for Seven (7) residents. Resident Records/Incident Reports: · Seven (7) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have an Appraisal/Needs and Services Plan on file. · Staff training was on file. Disaster Preparedness: · Emergency and Disaster Plan (LIC610E) was posted in the facility. · The last emergency and disaster drill was conducted on 10/7/2025. Planned Activities: · Sufficient Space is provided to accommodate both indoor and outdoor activities. · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed. Exit interview held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 25, 2025

Allegation investigated: Staff handled resident in a rough manner

Licensing Program Analysts (LPAs) Erik Zaragoza and Gabriela Castro conducted an unannounced complaint visit to address the allegation listed above. LPAs met with Lindsey Stallings and Lizbeth Acuna, Clinical Director and Business Office Manager for the facility, and explained the purpose of the facility. The investigation consisted of the following: During today's visit LPAs interviewed Residents #1 - 9 (R1 - R9), Staff #1 - 4 (S1 - S4), and obtained the physician's report, appriasal, and FACE Sheet for R1. The investigation revealed the following: In regards to the allegation that "Staff handled resident in a rough manner," it is alleged that staff handled R1 in a rough manner in their bed. Unsubstantiated Based on interviews with the residents, seven (7) out of nine (9) did not corroborate the allegation. One of the residents interviewed explained that none of the staff have ever handled them in a rough manner in the past. Another resident stated that they have not witnessed staff pushing or handling residents roughly, and that staff treat them with dignity and respect. During interviews with the staff, four (4) out of four (4) did not corroborate the allegation. One staff member who was present during the incident explained that they had been assisting R1 with transferring to their wheelchair in the morning, and did not observe or notice any injury to R1 while they were assisting R1. Another staff who was present at the time of the incident stated that they did assist another staff with assisting R1 into a hoyer lift, but did not directly observe any staff handling R1 in a rough manner. Based on statements and interviews conducted with staff, residents, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 24, 2025 · control 28-AS-20251120155712

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Erik Zaragoza and Gabriela Castro conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Lindsey Director for the facility, and explained the purpose of the visit. There are eighty-eight (88) residents currently living in the facility. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Physical Plant/Environment Safety: · The facility is a two-story building that contains the following: First floor consists of resident rooms with individual bathrooms, 1 living room, Dining Rooms, courtyard, 3 offices, medication room, kitchen, and laundry area. The second floor of the facility consists of the following: resident bedrooms with individual bathrooms, laundry room, outdoor porch seating area, and Activity room. LPA toured eight (8) resident bedrooms, and all of them had hot water temperatures that measured within the required 105 – 120 Degrees Fahrenheit range. The facility was observed to be in good repair. · The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has multiple fully charged fire extinguishers throughout the facility. Due to time constraints, the annual will be completed at a later date. Exit interview held and a copy of the report will be emailed to the Clinical Director and Wellness Coordinator as LPAs printer is non-operable.the state’s words, verbatim · CDSS document, Nov 24, 2025

Allegation investigated: Staff do not ensure facility elevator is maintained in good repair.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to address the allegations listed above. LPA met with Monica Guardian and explained the purpose of the visit. The investigation consisted of the following: On 10/30/25 LPA Daniel Konishi conducted a unannounced initial 10-day complaint visit obtained a copy of the staff/resident roster and interviewed 1 Staff. Further investigation was needed. During todays visit 11/17/25 LPA Herrera conducted a subsequent visit, LPA toured facility, obtained copies of the following Physician Reports for R1 and R2, Food Menu, House Rules, Showering Schedule, Elevator Repair Invoices and Staff/Resident Rosters. Continued on LIC9099-C Substantiated The investigation revealed the following: Allegation: Staff do not ensure facility elevator is maintained in good repair. It is alleged that the elevator went out on 10/13/25 and R1 who utilizes a wheelchair to ambulate, had no way of getting downstairs during this time. LPA interviewed 4 staff and each confirmed the allegation, stating that the elevator was down for a few weeks. Interview with S1 and review of Invoices, confirmed that the elevator was in disrepair from 10/13/2025 – 10/31/2025. LPA tested the elevator, and it was in operating condition. LPA interviewed 8 residents, and each confirmed the above allegation and stated that although the elevator was in disrepair they were not affected by the outage. Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview held, and a copy of this report and appeal rights were provided. The investigation revealed the following: Allegation: Staff do not ensure food is of good quality and quantity. It is alleged that the food served at the facility are in small portions and cold. LPA interviewed 4 staff and each denied the allegation and stated that although some residents may consider portions to be small, they are provided with second servings if requested, staff also stated that if the temperature is too cold for the residents staff will reheat the food for them. LPA interviewed 8 residents and 7 out of 8 residents denied the allegation and stated that the portions are sometimes small but they can ask for a second serving once everyone has been served and that if the food is cold staff will reheat it for them with no issues. Based on statements and interviews conducted with staff/residents, and review of client files, and LPA observations, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held and a copy of report was provided.the state’s words, verbatim · CDSS document, Nov 17, 2025 · control 28-AS-20251028084138

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 18, 2025

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 standard was not met as evidence by: Per Interviews with 4 staff and 8 residents each confirmed the above allegation stating that the elevator was in disrepair for weeks during the month of October 2025. Invoices for repairs were also provided.the state’s words, verbatim · CDSS document, Nov 17, 2025

Plan of correction: Durining visit LPA tested the elevator and it was in operating condition. LPA reviewed Invoices for the repairs made and due to facility already addressing the issue and making needed repairs there is no POC needed and POC will be cleared and emailed to Administrator by end of day tomorrow 11/18/25.

Allegation investigated: Staff did provide adequate care and supervision to a resident. Staff denied a resident entry to the facility. Staff did not properly maintain a resident's room. Staff exposed a resident to harmful material. Staff did not ensure a resident attended scheduled appointments. Staff did not meet a resident's bathing needs.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to address the allegations listed above. LPA met with Monica Guardian and explained the purpose of the visit. The investigation consisted of the following: On 10/14/25 LPA Erik Zaragoza conducted an unannounced initial complaint visit and obtained copies of the staff/resident rosters, obtained the appraisal, physician's report, FACE sheet, and transportation records for Resident #1 (R1), and also interviewed 2 Staff. During todays visit 11/17/25 LPA Herrera conducted a subsequent visit, LPA toured facility, obtained copies of the following Physician Reports for R1 and R2, Food Menu, House Rules, Showering Schedule, Elevator Repair Invoices and Staff/Resident Rosters. Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not provide adequate care and supervision to a resident. It is alleged that R1 had consumed alcohol and was intoxicated, and staff did nothing to prevent this from happening. LPA reviewed facility House Rules and it is written that residents are allowed to have alcoholic beverages in moderation, within resident rooms, not allowed in common areas. LPA interviewed 4 staff and each denied the above allegation, staff stated that per the house rules residents are allowed to consume alcohol as long as it is in their rooms and in moderation and not taken to the common areas, when residents exhibit chronic issues with alcohol this right may be revoked. LPA interviewed 8 residents and each denied the above allegation and stated they are provided with adequate care and super vision. R1 stated they are able to consume alcohol, drank it in their room and did not take the alcohol out in common areas. Allegation: Staff denied a resident entry to the facility. It is alleged that staff refused to answer the phone or door when R1 was ready to return from the hospital. LPA interviewed 4 staff and each denied the above allegation. Interview with S4 revealed that R1 had been admitted to the hospital during the day and later that evening past 10pm resident was brought back via non-emergency transportation, however, the front door is locked (from exterior coming in only) at 9pm for safety of staff and residents and during that time staff were conducting rounds, S2 observed the non-emergency transportation vehicle and instructed other staff to allow entrance. LPA interviewed 8 residents and each denied the above allegation and stated they have never been denied re-entry to facility after being hospitalized. Per interview with R1 resident stated that they were never denied re-entry but did have to wait maybe 5-10 minutes for staff to open the door as it was after hours and the door was locked. Allegation: Staff did not properly maintain a resident's room. It is alleged that R1’s room has a foul odor and R1’s clothes, bedding and floor was observed to be covered in throw up, urine and feces for over 6 hours as this was observed upon returning from the hospital. LPA interviewed 4 staff and each denied the allegation and stated that rooms are cleaned regularly with a weekly bedding change and deep cleaning, however, if bedding or floors have urine or feces they tend to it right away. LPA interviewed 8 residents and each denied the allegation and stated that staff clean their rooms and bedding is changed weekly. Interview with R1 revealed that upon returning from the hospital the room was clean and bedding was not soiled. (Continued on LIC9099-C) Allegation: Staff exposed a resident to harmful material. It is alleged that when R1 returned to the facility from the hospital R1’s wheelchair still had the bottle of alcohol in it. LPA interviewed 4 staff and each denied the above allegation and stated that although alcohol is permitted at the facility if there is negligent use the alcohol is confiscated. Interview with S4 revealed that although they did not remove the bottle of alcohol from the room, as they were helping with getting the resident care and to the hospital, another staff confiscated the alcohol and this was noticed during a round they made that evening. LPA interviewed 8 residents and each denied the above allegation and stated they have never been exposed to any harmful materials at the facility. Interview with R1 revealed that once they returned to the facility the room was cleaned and alcohol was removed. Allegation: Staff did not ensure a resident attended scheduled appointments. It is alleged that staff are not assisting R1 to their appointments. LPA interviewed 4 staff and each denied the above allegation stating that residents are provided with the proper assistance (if needed) with scheduling appointments. LPA interviewed 8 residents and 5 out of 8 residents denied the allegation and stated that they are assisted with appointments and have not had any issues with this. R1 stated that staff do not provide transportation to their appointments and refused to take them to an appointment, after interview with Staff it was revealed that R1 did not notify staff of the need for transportation to their appointment (which is asked for a 24hr notice), R1 is not able to leave facility unattended and special scheduling was needed as a caregiver would need to accompany R1 and transportation would need to be scheduled, the appointment has been rescheduled and R1’s daughter confirmed that they will be transporting R1 to the appointment. Allegation: Staff did not meet a resident's bathing needs. It is alleged that R1 has gone 3 days without being assisted with showers. LPA interviewed 4 staff and each denied the allegation, stating that residents have a shower schedule and if they are needed with an additional shower one will be provided when as long as a caregiver has the availability. LPA interviewed 8 residents and 6 out of 8 residents denied the allegation and stated they have never been refused assistance with showers by staff. R1 stated that they don’t need assistance with showering/bathing and can do this on their own, they further stated that staff have never refused to assist them with their showers as they have never needed to ask. Based on statements and interviews conducted with staff/residents, and review of client files, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED.Exit interview held, a copy of report was provided.the state’s words, verbatim · CDSS document, Nov 17, 2025 · control 28-AS-20251006120341

Allegation investigated: Staff did not ensure resident's showering needs were met. Staff threatened resident. Staff retaliated against resident for reporting. Staff wrongfully evicted resident.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to address the allegations listed above. LPA met with Monica Guardian and explained the purpose of the visit. The investigation consisted of: On 10/30/25 LPA Daniel Konishi conducted a unannounced initial 10-day complaint visit and obtained a copy of the staff/resident rosters. Further investigation was needed. During todays visit 11/17/25 LPA Herrera conducted a subsequent visit, LPA toured facility, obtained copies of the following Physician Reports for R1 and R2, Food Menu, House Rules, Showering Schedule, Elevator Repair Invoices and Staff/Resident Rosters. Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not ensure resident's showering needs were met. It is alleged that staff refused to assist R1 with a shower as R1 could not shower during scheduled time due to a family visit, staff also allegedly refused to assist with shower the following day as well. LPA interviewed 4 staff and each denied the allegation, stating that residents have a shower schedule and if they are needed with an additional shower one will be provided when as long as a caregiver has the availability. LPA interviewed 8 residents and 6 out of 8 residents denied the allegation and stated they have never been refused assistance with showers by staff. Allegation: Staff threatened resident. It is alleged that that 2 residents were informed of R1’s allegations against staff and threatened R1 and stated to keep S2’s name out of R1’s mouth. LPA interviewed 4 staff and each denied the above allegation, S2 stated that they never speak with residents regarding other residents issues and believe that residents overheard R1 when R1 was shouting at S2 about their showering. Interviews with staff also revealed that R1 was verbally aggressive towards staff and residents which made staff uncomfortable when left unattended with R1 and R1 was then placed on a two person assist when bathing. LPA interviewed 8 residents and 7 out of 8 residents denied the allegation, and stated they have never felt threatened by staff. Allegation: Staff retaliated against resident for reporting. It is alleged that R1 is being retaliated against as they have reported to upper management their concerns and feel staff (S2) are now refusing to assist with showers. LPA interviewed 4 staff and each denied the allegation, S2 stated there was not a refusal however since R1 had been aggressive towards staff there was an adjustment made to R1’s showering where R1 will need a 2 person assist. LPA interviewed 8 residents and 7 out of 8 residents denied the allegation and stated that they have never felt retaliated against by staff. Allegation: Staff wrongfully evicted resident. It is alleged that R1 is being evicted as S3 has asked R1’s sister to remove belongings and R1 has no where else to go. LPA interviewed 4 staff and each denied the above allegation, interviews with S1-S3 reveled that R1 was never evicted and had voluntarily discharged from the facility and was placed in a board and care of their preference. LPA interviewed 8 residents and each denied the allegation and stated they have never been evicted or issued an eviction noticed. R1 stated that while hospitalized they asked to be sent to a board and care and they voluntarily left the facility and are now at a now facility of their liking. Continued on LIC9099-C Based on statements and interviews conducted with staff/residents, and review of client files, and LPA observations, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED. Exit interview held and a copy of report was provided.the state’s words, verbatim · CDSS document, Nov 17, 2025 · control 28-AS-20251021104817

Allegation investigated: Staff did not address a change in resident’s condition in a timely manner.

Licensing Program Analyst (LPA) Alberto Lopez conducted subsequent unannounced complaint visit to deliver fidnings for the above allegation. LPA met with Maddison Guardian, Medical Technician and discussed the purpose of the visit. 11/10/2025 - The investigation consisted of LPA interviewing five (5) (staff S#1 - S#5), nine (9) residents (R#1 - R#9), one witness, LPA obtained copies of the following documents: staff roster, resident roster, R1 ‘s physicians report, and appraisal needs and service plan, doctor’s order for R1, MAR for 11/2025 and other medical records. LPA also took tour of facility common areas. The investigation revealed regarding allegation: Staff did not address a change in resident’s condition in a timely manner. It is alleged that staff are not addressing resident’s change of condition on a timely basis. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. LPA interviewed eight (8) residents and all eight (8) could not corroborate the allegation. (continued on 9099C) Unsubstantiated (continued from 9099) R1 was sent to hospital on 11/05/2025 and it was of concern that that facility did not notice change of condition because resident arrived to the hospital in an altered and confused state and had elevated glucose levels when admitted. LPA spoke with resident’s doctor’s office and learned that resident has no standing order for glucose testing and there was no way facility staff would know it was elevated. Resident was sent to hospital in prompt manner right after resident had an un-witnessed fall in R1 restroom. It was discovered at hospital that resident had a urinary tract infection. There is not enough evidence to support this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Maddison Guardian, Medical Technician, A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Nov 15, 2025 · control 28-AS-20251105142214

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alberto Lopez conducted subsequent unannounced complaint visit to deliver findings for an allegation addressed on 9099. LPA met with Maddison Guardian, Medical Technician and discussed the purpose of the visit. During record review of R1 records, LPA observed that R1 LIC602A dated 08/29/2025 did not clearly indicate if resident can administer own injections and test glucose levels as it was marked N/A on page 8 , #6 under Medication Management b. and c. Deficiency cited and citation issued on 809D Exit interview conducted and copy of report, 809D and appeal rights provided.the state’s words, verbatim · CDSS document, Nov 15, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Nov 25, 2025

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Based on record reviewed, R1 LIC602A dated 08/29/2025 did not clearly indicate if resident can administer injections and test glucose levels as it was marked N/A on page 8 , #6 under Medication Management b. and c.the state’s words, verbatim · CDSS document, Nov 15, 2025

Plan of correction: Administrator will obtained up to date LIC602A from RI Physician and sent it to LPA as proof by POC date which is 11/21/2025

Allegation investigated: Staff does not ensure residents care needs are being met. Staff handled resident in a rough manner. Staff speak to residents in an inappropriate manner.

Licensing Program Analysts (LPAs) Cynthia Chan and Elena Mallett conducted the initial complaint investigation regarding the allegations listed above. LPAs arrived unannounced and met with the interim Administrator, Monica Guardian. The purpose of the visit was explained. LPAs obtained copies of the staff roster, resident roster, and documents regarding Resident #1. Interviews were held with the administrator, seven (7) staff, and ten (10) residents. LPA attempted to interview Staff #1 but was unsuccessful. The investigation revealed the following: Allegation - Staff does not ensure resident's care needs are being met. It is alleged that on 10/29/25, Staff #1 (S1) did not assist with changing Resident #1’s (R1) soiled diaper because R1 was changed not that long ago. LPAs interviewed the interim administrator and seven (7) staff. The administrator was aware of the incident, and an internal investigation was conducted. Unsubstantiated Per the administrator and staff, S1 denied not assisting R1 in changing the adult brief. S1 acknowledged R1’s call button and checked the diaper but it was not soiled. Staff told the resident that the adult brief was not soiled but eventually fulfilled the request. Other staff interviewed have not heard or witnessed any staff not assisting residents when needed. Staff stated they check on the residents at least every 2 hours to ensure their adult briefs are not soiled. LPAs obtained a copy of the “Alarm History” for R1 on 10/28/25 through 10/30/25. The log shows that R1 had requested assistance during the overnight hours and S1 responded to the calls. Ten (10) residents were interviewed during the visit. One out of the ten residents stated that S1 refused to change the resident because the resident did not need a diaper change or was not changed too long ago. The rest of the residents did not have any concerns regarding S1 and that staff assist them with their needs when needed. Based on the information gathered, there is insufficient information to corroborate this allegation. Allegation - Staff handled the resident in a rough manner. It is alleged that Staff #1 (S1) pulled the pendant off of Resident #1 (R1) and shoved the resident. Seven (7) of the Staff interviewed today stated they do not handle residents in a rough manner. Staff have not observed other staff shoving or pushing a resident or handling residents roughly. Nine (9) out of ten (10) residents do not feel that staff handle them in a rough manner. One of the residents stated that S1 was shoved as staff was grabbing the resident’s pendant and the string came apart. There were no witnesses to support this allegation, therefore, the allegation is unsubstantiated. Allegation - Staff speak to residents in an inappropriate manner. It is alleged that Staff #1 (S1) engaged in an altercation because the resident kept pressing the call pendant. Staff interviewed have not witnessed other staff arguing with a resident. Staff stated they received training in communication with residents. Staff do not yell or talk back to residents inappropriately. Eight (8) out of the ten (10) residents stated that staff are respectful and do not engage in any altercations. Two (2) of the residents stated that staff have yelled at them when they needed assistance. The witness to this allegation stated that S1 did not exchange any inappropriate words with R1. S1 explained to R1 that resident was not wet and did not need to be changed. Based on interviews, there is insufficient evidence to corroborate this allegation. 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 allegations are UNSUBSTANTIATED. An exit interview was conducted with administrator M. Guardian. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 28-AS-20251029101156

Allegation investigated: Staff do not ensure medications are dispensed as prescribed. Staff does not ensure medications are properly managed. Staff do not ensure call buttons are answered in a timely manner.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation for the allegations listed above. LPA arrived unannounced and met with Administrator, Itzayana Barba. The purpose of the visit was explained. The investigation consisted of the following: On 7/10/25, LPA toured the physical plant, random rooms, and reviewed medications. Interviews were held with the Administrator, Staff #1 - #9, and a resident. During the visit today, LPA continued interviews with two Staff and seven Residents. The investigation revealed the following: Allegations - Staff do not ensure medications are dispensed as prescribed, and Staff do not ensure medications are properly managed. Substantiated It is alleged that staff often miss dispensing several residents’ medications daily. In addition, it is alleged that residents’ medications are not being managed properly, and Staff do not re-order medications timely when they see they are getting low. LPA reviewed medications for seven (7) residents on 7/10/25. There were discrepancies found in two (2) of the residents’ medications. Resident #2 did not have the Ascorbic Acid tablet available as indicated on the medication log. Resident #3 did not have the Multiple Vitamin tablet available as prescribed, but was marked as given, and Trazodone 50 MG was discontinued on 7/7/25. However, the medication was still being given to the resident until 7/10/25. Based on observation and review, the medications were not properly dispensed and/or missed. It could not be determined whether the medications unavailable for the residents were due to misplacement or not being refilled timely. Staff interviewed stated they would refill a few days before the meds ran low. Seven (7) out of eight (8) residents interviewed stated that their medications are given by the staff and have not missed any. One (1) stated that the staff had missed giving some of their medications. Allegation - Staff do not ensure call buttons are answered in a timely manner. LPA interviewed a total of 12 staff. The administrator stated the average time that staff should respond to a call button is between 5-10 minutes. She stated sometimes it could take a little longer due to staff assisting another resident. She stated there are 2 caregivers and 2 Med Techs for the morning and afternoon shifts. There is 1 caregiver and 1 Med Tech in the overnight shift. The caregivers and med techs have phones with an app that alerts them when a resident presses the pendant or pulls the cord for assistance. Staff stated that they will acknowledge the resident’s call and then clear it after they finish assisting the resident. LPA reviewed the facility’s Alarm history, which indicates the times and dates when residents call for assistance. LPA pulled the history from 7/6/25 – 7/11/25, and the reports showed that the residents’ calls were acknowledged within a few seconds to as long as 59m 16s. Five (5) of the staff feel that there are not enough caregivers to assist the residents. Sometimes, there is one caregiver on shift if the other calls out. Two (2) out of the eight (8) residents interviewed stated they waited a long time before staff assist, and half of them feel there is a shortage of caregivers. Based on LPA observations, interviews conducted, and record review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Corrections were reviewed and developed with the administrator. A copy of this report and appeal rights were provided. Staff interviewed stated the residents have a day of the week when the housekeepers do their laundry. They normally get their clean clothing back the same day or the next. If the residents have soiled clothing, staff will do an extra load. LPA interviewed eight (8) residents, and seven (7) of them receive their clean clothes back the same day or the next day. They do not have any issues regarding their clothes not being returned timely or not being cleaned properly. Allegation - Staff allow resident to be in soiled clothing for an extended period of time. It is alleged that residents who are incontinent get left in their soiled clothing for a long time. LPA interviewed Staff regarding this allegation. All the staff stated they do not allow residents to sit in soiled diapers or clothing for a long time. Once they observe their diapers soiled, staff will change them right away to prevent getting into their clothing. However, some residents refuse to be changed, but the staff would try to convince them. Residents interviewed have observed staff immediately tend to residents if they notice a smell or if their clothing is soiled. Allegation - Staff do not ensure facility is kept free of malodors. It is alleged that the facility smells of feces and urine in certain hallways and the elevator. Staff interviewed stated that when they smell any unpleasant odor, they will immediately check to see where it is coming from. If the resident has an accident, the staff will call for a caregiver to assist with changing the resident. If the odor is coming from a certain area, they will request a housekeeper to clean and sanitize the area, or they will do it themselves. LPA interviewed eight (8) residents. Seven (7) out of the eight (8) stated that the staff do a good job in keeping the facility clean. They do not allow any smells to linger in the facility. During LPA visits, there were no malodorous smells at the facility. Allegation - Staff do not ensure floors in residents’ rooms are kept clean. LPA interviewed housekeepers and caregivers who stated they clean the residents’ floors when they see any dirt or if there are any spills. Housekeepers clean the residents’ rooms, which include sweeping and mopping the floors and taking out the trash. Each resident gets their room cleaned once a week and upon request. Care staff stated that if they see the floor wet or dirty, they will help clean it up. LPA interviewed eight (8) residents, and seven (7) of them stated that staff clean their rooms and will clean the floor if they see it dirty. LPA selected a few rooms to inspect, and the floors did not appear to have any stains. Allegation - Staff did not ensure resident phone conversation was kept private. It is alleged that the resident’s personal information was heard by others in the activity room when a staff was helping the resident on the speaker phone. None of the staff interviewed has heard or observed any staff sharing personal information of a resident in the activity room. The family advisor coordinators who assist residents with medical or social security calls are done privately in their office. LPA interviewed eight (8) residents, and none have had their personal information heard by others at the facility. 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 allegations are UNSUBSTANTIATED. An exit interview was conducted with the administrator. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Aug 5, 2025 · control 28-AS-20250701090048

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 6, 2025

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation and record review, the medication for Resident #3 was not administered as prescribed by the physician which poses an immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: The licensee shall submit a plan to ensure that all the residents' medications are present, obtaining refills, and staff training. The plan is due by 8/6/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Aug 12, 2025

87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interview and record review, the facility did not employ sufficient caregivers to assist residents with their needs which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: The licensee shall develop a plan to provide sufficient staffing to ensure residents are assisted in a timely manner and that their needs are met. Plan due to LPA by 8/12/25.

Allegation investigated: Staff not meeting resident’s grooming needs. Staff not emptying resident’s commode. Staff not administering resident’s medication as prescribed.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 06/03/2025, regarding the above allegations. LPA Ramirez identified herself to Receptionist- Michelle Bascom and was granted entry into the facility. Business Office Manager- Lizbeth Acuna and Wellness Director- Kathleen McDonald greeted LPA and assisted with facility tour. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster, Staff#1 - 6 interviews (S1 – S6), Resident#2 - 6 interviews (R2-R6), Attempted Interview of Resident#1 (R1), Copies of Residents# 1-6 (R1 – R6) Physician’s Report and Physician’s orders, Copies of Documentation Survey Report on bathing/showering, dressing, and housekeeping for Resident#1 (R1) for May 2025, Unusual Incident/Injury Report (LIC624) for Resident#1 (R1), Medication Administration Record (MAR) for May 2025 for Resident#1 (R1), and physical plant tour. SEE 9099 for continued report. Unsubstantiated The investigation revealed the following: regarding the allegation “Staff not meeting resident’s grooming needs.” It is alleged facility staff do not assist R1 with grooming needs. Review of R1’s physician’s report revealed R1 can bathe and dress/groom themselves with staff assistance. Review of R1’s Documentation Survey Report for May 2025, did not corroborate this allegation. Staff interviews conducted did not corroborate this allegation. Resident interviews conducted did not corroborate this allegation. R1 was not present at the facility during LPA Ramirez’s visit and therefore was not interviewed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. “Staff not emptying resident’s commode.” It is alleged facility staff are not emptying R1’s commode. Review of R1’s physician’s report revealed R1 can tend to their own toiletry needs with staff assistance. Review of R1’s Documentation Survey Report for May 2025, did not corroborate this allegation. Staff interviews conducted did not corroborate this allegation. Resident interviews conducted did not corroborate this allegation. R1 was not present at the facility during LPA Ramirez’s visit and therefore was not interviewed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. “Staff not administering resident’s medication as prescribed.” It is alleged facility staff are not administering R1’s fungal medication. Review of R1’s Physician’s Report revealed R1 is unable to administer their own medication and store their own medication. Review of R1’s Physician’s Order revealed, on 05/12/2025, R1’s primary physician ordered Nystatin Powder 100000 UNIT/GM to be applied to affected areas two times a day. Review of R1’s MAR for May 2025 revealed, facility staff began administering Nystatin Powder on 05/13/2025, according to R1’s physician’s order. Staff interviews conducted did not corroborate this allegation. R1 was not present at the facility during LPA Ramirez’s visit and therefore was not interviewed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited for this investigation. Exit interview was conducted. A copy of this report was provided via email.the state’s words, verbatim · CDSS document, Jun 3, 2025 · control 28-AS-20250529130258

Allegation investigated: Staff are not ensuring residents are provided a safe environment

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced complaint visit to investigate the allegation listed above. LPA met with Kathleen Mcdonald, Wellness Director for the facility, and explained the purpose of the visit. Executive Director Itzayan Barba Aguirre arrived shortly thereafter. The investigation consisted of the following: LPA Erik Zaragoza toured the facility, obtained copies of the staff and resident roster, obtained the Physician's Report and Pre-Placement Appraisals for Residents #1 - 2 (R1 - R2), interviewed Staff #1 - 5 (S1 - S5), and also interviewed R1, along with Residents #3 - 10 (R3 - R10). LPA attempted to interview R2, however they are currently hospitalized as of the time of this visit. The investigation revealed the following: In regards to the allegation that "Staff are not ensuring residents are provided a safe environment," it is alleged that roommates R1 and R2 had gotten into a physical altercation with each other amidst growing tensions with each other, which was causing the facility to not provide a safe environment for either of them. Unsubstantiated During interviews with the residents, eight (8) out of ten (10) did not corroborate the allegation. During an interview with R1, they explained that the staff have taken appropriate action towards addressing the issues between themselves and R2 by moving them into separate rooms, and that besides this R1 had no safety concerns regarding the facility. Other residents interviewed during the visit also stated that from their experience the staff have been providing them and everyone else a safe environment at the facility. During interviews with the staff members, none of them corroborated the allegation. One of the staff members explained that after becoming aware of the incident that occurred between R1 and R2 they took the next steps of separating the two residents to ensure that further escalations between the them are prevented. Another staff member interviewed stated that they have also moved their assigned seats in the dining room to separate areas in order to avoid future potential conflicts. During the tour of the facility, LPA did not observe any potential hazards or threats to the residents and determined the facility to be safe. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 8, 2025 · control 28-AS-20250404091749

Allegation investigated: Staff did not meet resident's needs

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced complaint visit to investigate the allegation listed above. LPA met with Kathleen McDonald and Itzayana Barba, Wellness Director and Executive Director for the facility, and explained the purpose of the visit. The investigation consisted of the following: During today's visit, LPA interviewed Residents #1 - 7 (R1 - R7), Staff #1 - 4 (S1 - S4), toured six (6) resident bedrooms, obtained a copy of the Staff and Resident Rosters, a copy of the facility sketch, along with copies of the Physician's Report, Pre-Placement Appraisal, and Move In Record for R1. The investigation revealed the following: In regards to the allegation that "Staff did not meet resident's needs," it is alleged that residents needs are not being met becauuse they have significant diffculty entering the restroom in their bedroom because the door is too narrow and does not accomodate their wheelchair, and that staff are not available to assist them when they do need help using the restroom. Unsubstantiated During interviews with the residents, five (5) out of seven (7) interviewed did not corroborate the allegation. One of the residents stated that they had no issues passing in and out of their restrooms with their wheelchair. Another resident stated that the doorway to their restroom is an appropriate size and is not too narrow. During interviews with staff, none of them corroborated the allegation. One staff interviewed stated that the doorframe of the resident restrooms can be a tight fit when using a wheelchair, however all residents are able to pass into the restroom using a wheelchair. Another staff member interviewed that all residents can pass through their doorframe to enter their restrooms when using a wheelchair, and that all residents are able to request assistance entering their bathroom from caregivers by using their call pendant if they do require assistance, and that caregivers do not refuse assistance. During tours of the resident rooms, LPA observed that although some wheelchairs narrowly fit through the restroom doors in the resident bedrooms, the wheelchairs were ultimately able to pass into the restroom so that residents are able to use them. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 27, 2025 · control 28-AS-20250321105924

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent case management visit in response to an initial case management dated 1/24/2025 following the death of Resident #1 (R1) that occurred at the facility after R1 choked during their meal on 12/31/2024. During the initial visit, LPA obtained R1's FACE Sheet, Most Recent Physician's Report, a meal menu for the week of 12-29/2024 - 1/4/2025, their medication orders, and also interviewed Staff #1 (S1). Since the initial case management visit was conducted, Investigations Branch (IB) investigator Christine Ferris conducted her own investigation including a visit to the facility on 2/3/2025 which involved interviewing residents, staff, and obtaining the death certificate of R1. During today's visit, LPA will deliver the findings of the investigation. During IB's investigation, IB interviewed the staff and residents who were present at the time that R1 passed away. R1 had a mechanical soft or "chopped" diet as ordered by their physician, which they received for lunch on 12/31/2024. When R1 began to choke, all residents and staff interviewed explained that staff responded quickly and appropriately to the incident, including initiating CPR and calling emergency services. Residents who witnessed the incident said R1's meal was indeed "chopped." Neither staff nor residents shared any information to indicate the incident could have been prevented. The Death Certificate of R1 states that the cause of death was "Upper Airway Obstruction - Food Bolus Complicating Neurological Impairment." Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 27, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced case management visit in response to Serious Incident Report (SIR) dated 1/2/2025 that describes the passing of Client #1 (C1). LPA met with Kathleen McDonald, Wellness Director for the facility, and explained the purpose of the visit. LPA Interviewed Staff #1 (S1) during the visit. LPA attempted to interview Staff #2 (S2), however they were not available. S1 explained on the day of the incident they were notified by other residents that C1 was choking and needed medical assistance. S1 observed that C1 could not speak and was struggling to breathe, and therefore began performing sets of Heimlich Maneuvers before beginning cardiopulmonary resuscitation (CPR). S1 stated that they began performing chest compressions on C1 as directed by the 911 operator, and S1 stated that they could not see any food in C1's throat when asked by the operator. Emergency Medical Technicians (EMT) arrived on the scene and took over chest compressions along with administering an Automatic External Defibrillator (AED) for 10 - 15 minutes until C1 was declared deceased. LPA obtained C1's FACE Sheet, Most Recent Physician's Report, a meal menu for the week of 12-29/2024 - 1/4/2025, and their medication orders. LPA attempted to obtain the resident's most recent appraisal, however there was none available on record. Deficiency was issue per Title 22, Division 6, Chapter 8, Article 8 and is cited on the LIC809D page. Exit interview was conducted and a copy of the appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 24, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c) · Plan of correction due date: Feb 14, 2025

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This regulation is not met as evidence by: Based on record review, it was determined that there was no available pre-admission appraisal or recent appraisal available for C1, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 24, 2025

Plan of correction: Administrator is to ensure that appraisals for all residents are available at all times. Administrator is to create a plan explaining how the facility will ensure that appraisal are conducted, documented, and available at all times in the facility and submit this plan to the LPA by the POC due date.

Allegation investigated: Staff do not distribute resident's medications as prescribed

Licensing Program Analyst (LPA) Erik Zaragoza conducted an initial complaint visit to address the allegation listed above. LPA with Kathleen McDonald, Wellness Director for the facility, and explained the purpose of the visit. The investigation consisted of the following: LPA obtained the staff rosters, resident rosters, facility house rules, interviewed Residents #1 - 8 (R1 - R8), Witness #1 (W1), Staff #1 - 5 (S1 - S5), and also obtained documentation including R1's Physician's Report, Resident Appraisal, FACE Sheet, land also reviewed the Medication Administration Records (MARs) and medications for eight (8) residents. The investigation revealed the following: In regards to the allegation that "Staff do not distribute resident's medications as prescribed," it is alleged that on the dates of 12/3/2024 and 12/4/2024, R1 was not provided their required medication as prescribed by the staff, which resulted in R1's hospitalization. Unsubstantiated During interviews with the residents, six (6) out of eight (8) did not corroborate the allegation. During an interview with R1, they stated that they were not being provided their medications by staff in the days leading up to their medical emergency, and they have since had their significant other assisting them with medication management. Other residents interviewed stated that they have not had issues with receiving their medications from staff as prescribed by their physicians. During interviews with the staff, five (5) out of five (5) did not corroborate the allegation. One of the staff interviewed stated that they were not aware of any instances in which medications were not passed to R1, and that the significant other of R1 now handles their medications so the facility only has the MAR for R1. During review of the MAR, LPA observed that it was documented that on 12/3/2024 and 12/4/2024, it was logged that S2 had distributed R1 their medications. During an interview with S2, they stated that on these dates that they had given R1 their required medications and observed R1 taking the medications. LPA was not able to inspect the medication for R1 because their medications are with their significant other. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 13, 2024 · control 28-AS-20241209093245

Allegation investigated: Facility not assisting residents in obtaining medical care Facility is malodorous and dirty Facility does not dispense resident medications as prescribed Facility did not notify resident's responsible party regarding missed medical appointments Facility did not meet resident's dietary needs Facility did not meet residents showering needs

Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent complaint visit to address the allegations listed above. LPA with Kathleen McDonald, Wellness Director for the facility, and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 11/21/2024, LPA obtained the staff rosters, resident rosters, facility house rules, toured the kitchen and one (1) resident bedroom, interviewed Residents #1 - 7 (R1 - R7), Staff #1 - 2 (S1 - S2), and also obtained documentation including R1's Physician's Report, Resident Appraisal, FACE Sheet, log of R1's transportation for their medical appointments, and also a progress note for R1. During Today's visit, LPA toured seven (7) additional bedrooms, checked the Medication Administration Records (MARs) and medications for eight (8) residents, interviewed Staff #3 - 5 (S3 - S5), and interviewed Resident #8 (R8). Unsubstantiated The investigation revealed the following: In regards to the allegation that "Residents are drinking alcohol on premises," it is alleged that residents drink beet outside in the front porch area of the facility. During interviews with the residents, three (3) out of eight (8) corroborated the allegation. One of the residents stated that they have witnessed other residents drinking alcohol on the front porch area of the facility. Another resident also stated that some residents drink on the front porch of the facility and they sometimes drink heavily. LPA observed during the initial visit that one of the residents interviewed was drinking alcohol in front of the facility and was also displaying symptoms of heavy drinking. During interviews with the staff, three (3) out of five (5) corroborated the allegation. One of the staff witnessed the resident drinking in front of the facility along with the LPA and stated that the resident typically only drinks in their room. Another staff member stated that they have also observed residents drinking in front of the facility before as well. While reviewing the house rules for the facility, it states that "Alcoholic beverages are allowed in our community, in moderation. Alcoholic beverages must be enjoyed in resident rooms and are not permitted in our common areas." Based on LPA interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 is being cited on the attached LIC9099D. Exit interview was held and a copy of the report along with the appeal rights were provided. The investigation revealed the following: In regards to the allegation that "Facility not assisting residents in obtaining medical care," it was alleged that R1 was not obtaining assistance in coordinating and scheduling transportation to their medical appointments from the facility staff members, and that staff had no notes of R1's required appointments. During interviews with the residents, seven (7) out of eight (8) interviewed did not corroborate the allegation. One of the residents stated this allegation is simply not true and that the facility assists all residents with coordinating transportation to their medical appointments. Another resident interviewed stated that they have never had any problems getting assistance from staff in obtaining transportation to their medical appointments. During interviews with the staff, five (5) out of five (5) did not corroborate the allegation. One staff member stated that R1 has been obtaining transportation to their medical appointments, and that they missed one appointment due to a scheduling problem with the facility bus, however since then there had been no issues. Another staff member stated that they do assist residents with coordinating transportation to their medical appointments, and when the facility bus is not available then they will order an Uber for the resident and have a caregiver be transported with them. During record review of the facility transportation log LPA observed that R1 obtained transportation to multiple appointments in the months of November, October, September, and July of 2024. In regards to the allegation that "Facility is malodorous and dirty," it is alleged that there are resident rooms that smell of mildew and urine and that they are dirty as well. During interviews with the residents, eight (8) out of either (8) interviewed did not corroborate the allegation. One resident interviewed stated that they believe the housekeepers of the facility do a good job of helping clean their room on a consistent basis. Another resident similarly stated that they believed their rooms are cleaned adequately. During interviews with the staff, five (5) out of five (5) interviewed did not corroborate the allegation. One housekeeper stated that they clean up to six (6) different resident rooms once to twice per day, and that other housekeepers cover the remaining rooms of the facility. Another staff member stated that they were not aware of any resident bedrooms that were malodorous or not being cleaned. During the tour of the eight (8) resident rooms and common areas, LPA did not observe any room that was dirty, in disrepair, or malodorous. In regards to the allegation that "Facility does not dispense resident medications as prescribed," it is alleged that R1 had not been receiving their medications from the facility staff in over a year. During interviews with the residents, six (6) out of eight (8) stated that they were not getting their medications as prescribed. One resident stated that they have had no issues in obtaining the medications that they need. Another resident stated that they did have one issue obtaining their medications when they arrived at the facility, however it has since been resolved and there have been no additional issues. During interviews with the staff, five (5) out of five (5) did not corroborate the allegation. One staff member interviewed stated that R1 has always received their medications, and there has never been an issue in distributing medications to them. Another staff member similarly stated that there have not been any issues in providing R1 their medications. During record review of the MARs and medications for the eight (8) residents, LPA observed that R1 had all of their required medications based on their physician's orders. In regards to the allegation that "Facility did not notify resident's responsible party regarding missed medical appointments," it is alleged that R1 had missed several doctor's appointments and that their responsible party was never informed of these missed appointments, the most recent one being for a 9/3/2024 appointment. During interviews with the residents, eight (8) out of eight (8) interviewed did not corroborate the allegation. One of the residents stated that as far as they understand the facility has been notifying their families and responsible parties of all significant and important events that occur in the facility. Another resident interviewed stated that they believe the facility staff keep their families updated with all significant information related to the facility and themselves. During interviews with the staff, five (5) out of five (5) did not corroborate the allegation. One staff member indicated that they did not have a family contact on file for R1 before 9/3/2024, and that they had added the contact on this date. According to a progress note recorded on 9/3/2024, R1 provided confirmation that they were adding the family member to their profile so that the facility can provide information to them. In regards to the allegation that "Facility did not meet resident's dietary needs," it is alleged that the facility is not following a health-appropriate diet for R1 based on their medical history. During interviews with the residents, eight (8) out of eight (8) did not corroborate the allegation. One of the residents interviewed stated that they do not have a specialized diet that the facility needs to meet and therefore did not corroborate the allegation. Another resident interviewed stated that the facility is meeting all of their dietary needs. During interviews with the staff, five (5) out of five (5) did not corroborate the allegation. One of the staff interviewed stated that they provide the kitchen staff the physician's orders for clients that have specialized diets to ensure that they are all receiving health-appropriate diets. A kitchen staff interviewed stated that they follow the list of orders for all residents when preparing food for the day to ensure that they meet the dietary needs of residents. LPA reviewed the list of specialized diets located in the kitchen of the facility and observed R1's physician's order for his specialized diet located on the list. In regards to the allegation that "Facility did not meet residents showering needs," it is alleged that staff have not assisted R1 with bathing in over a week. During interviews with the residents, eight (8) out of eight (8) did not corroborate the allegation. One of the residents interviewed stated that all of their activities of daily living (ADL) needs are being met by the facility. Another resident similarly stated that all of their needs are being met by the facility. During interviews with the staff, (5) out of five (5) did not corroborate the allegation. One of the staff interviewed that R1 does not in fact require assistance with showering. Another staff interviewed stated that R1 showers themselves, and that staff only have staff on standby in case R1 slips and falls while showering. During record review of R1's physician's report and appraisal, it states that R1 does not require assistance with bathing or showering. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 13, 2024 · control 28-AS-20241118145129

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jan 10, 2025

(a) In addition to the rights listed in Section 87468.1 (...) residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This regulation is not met as evidenced by: Based on observation, record review, and interview, LPA determined that at least one resident had been drinking heavily in a common area in the facility, which poses a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Dec 13, 2024

Plan of correction: Administrator is to ensure that the house rules are enforced by the facility staff at all times to ensure proper supervision. Administrator is to submit a written plan to LPA explaining how the facility will ensure that they will ensure the house rules related to drinking alcohol will be enforced by the POC due date.

Allegation investigated: Staff mismanaged resident's medication Staff did not provide adequate transportation services to resident in care Staff did not prevent resident from harming another resident in care

Licensing Program Analyst (LPA) Tena Herrera conducted the initial visit to investigate the above allegations. LPA met with Lizbeth Acuna – Business Office Manager and explained the purpose of today's visit. The investigation consisted of the following: LPA obtained copies of Resident and Staff Rosters, Reviewed Medications, Reviewed Tansportation Logs and obtained relevant copies, interviewed 5 Staff (S1-S5) and 10 Residents (R1-R10). (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff mismanaged resident's medication. It is alleged that several medications have gone missing from R1’s prescribed medication supply at the facility. LPA reviewed 6 residents medications (including R1’s) and there were no missing medications nor any issues with medication observed. LPA interviewed 5 staff and 5 out of 5 staff denied the allegation. S2-S4 work with medications and stated that there hasn’t been a time where medication went missing for R1, however, R1 has mentioned their fear of medication running out or not being provided but there has not been a time where that happens. Staff further stated to accommodate R1 and their concerns they now administer medications individually and have R1 sign for anti-psychiatric medication since that is the medication they have been most concerned about. R1 confirmed that the medication was of concern for them, yet they have never missed a dose and medications now are being given individually with R1 signing for their anti-psychiatric medication. LPA interviewed 10 residents and 10 out of 10 residents denied the above allegation and stated they have never had any medications gone missing and have no concerns when it comes to medication. Allegation: Staff did not provide adequate transportation services to resident in care. It is alleged that on Nov 24, 2024 at 9am the facility transportation vehicle left R1 behind, resulting in R1 nearly missing a doctors appointment and being late. LPA reviewed transportation log for week of November 25-29, 2024 (Nov 24th was a Saturday, the transportation bus is not available weekends), and there was no log for R1 during that week. R1 confirmed that the date was for Nov 25th, and although they were not able to utilize the transportation bus (because the schedule was full) they were accommodated with an alternate source of transportation (uber) and were able to make their appointment. LPA interviewed 5 staff and 5 out of staff denied the above allegation and stated that the transportation bus is available to residents on Mon & Tues (sometimes Fridays, if needed) and if for whatever reason the bus is full or residents have appointments on a different day, residents are provided with alternate transportation services. LPA interviewed 10 residents and 10 out of 10 residents denied the above allegation and stated that the facility offers a transportation bus for them at least 2 days out of the week and they are also offered uber in the case that the bus is not available, each resident also denied being left behind without any transportation for appointments. (continued on LIC9099-C) Allegation: Staff did not prevent resident from harming another resident in care. It is alleged that R2 harmed another resident and staff did not prevent the altercation and that R2 and R3 have threatened R1. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation. Staff stated although there have been altercations between residents in the past, staff do their best to intervene and redirect residents when there is a dispute, if needed residents are offered a relocation of room or new seating in dining. Staff further stated that there have never been altercations between R1 and R3, however, disagreements have happened between R1 and R2. Staff stated that both residents keep their distance from each other and are located on opposite sides of the facility to avoid crossing paths. Both R2 and R3 denied the above allegation and stated they have never threatened R1 and deny wanting to cause any harm to R1. During interview with R1, resident stated that they have never been threatened nor assaulted by R3 but feel that because R3 is friendly with R2 something may happen. R1 stated that they have had arguments with R2 in the past over previous issues but have never been physically harmed by R2. Staff are aware of the differences between R1 and R2 and they monitor both residents when they are in the same common areas to prevent any potential altercations. LPA interviewed 10 residents and 9 out of 10 residents denied the above allegation and stated that staff do their best to intervene when there are altercations between residents and separate residents when these situations arise. Based on statements and interviews conducted with Staff and Residents, review of transportation log and medication, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Lizbeth Acuna.the state’s words, verbatim · CDSS document, Dec 5, 2024 · control 28-AS-20241202095328

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Itzayana Barba Aguirre, Executive Director for the facility, and explained the purpose of the visit. Seventy-nine (79) residents that are currently living in the facility. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control practices were observed. · Infection control plan is on file. Physical Plant/Environment Safety: · The facility is a two-story building that contains the following: First floor consists of resident rooms with individual bathrooms, 1 living room, Dining Rooms, courtyard, 3 offices, medication room, kitchen, and laundry area. The second floor of the facility consists of the following: resident bedrooms with individual bathrooms, laundry room, outdoor porch seating area, and Activity room. LPA toured eleven (11) resident bedrooms, and all of them had hot water temperatures that measured within the required 105 – 120 Degrees Fahrenheit range. The facility was observed to be in good repair. · The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has multiple fully charged fire extinguishers throughout the facility. Operational Requirements: · The Program Design was reviewed. · Fire clearance was approved by LA County Fire Department for a ninety-three (93) non-ambulatory residents, and a hospice waiver approved for fifteen (15) residents. · Care and supervision to meet the clients’ needs was observed. Personnel Records/Staff Training: · Seven (7) staff files were reviewed for criminal background clearance and training. · All staff records reviewed have health a health screening with a Tuberculosis clearance, and all staff have First Aid/CPR trainings that are active. · The administrator’s certificate expires on 1/23/2025. Resident Rights/Information: · Physician orders were reviewed for seven (7) resident files. · Medications were also reviewed for seven (7) residents. Resident Records/Incident Reports: · Seven (7) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have an Appraisal/Needs and Services Plan on file. · Staff training was on file. Disaster Preparedness: · Emergency and Disaster Plan was publicly posted within the facility. · The last emergency and disaster drill was conducted on 10/5/2024. Planned Activities: · Sufficient Space is provided to accommodate both indoor and outdoor activities. · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs: · There are six (6) residents who are currently receiving hospice services. · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 15, 2024

Allegation investigated: Facility staff not ensuring kitchen is free of cockroaches. Facility staff not following proper infection control practices. Facility staff served resident food from the floor. Facility staff not maintaining kitchen equipment in a clean condition. Facility staff not serving meals with adequate portion sizes. Facility staff not ensuring kitchen is clean.

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced initial complaint investigation for the allegations listed above. LPA met with Welness Coordinator Citlali Galeana and explained the purpose of vist. On today's visit LPA toured the facility including kitchen and dinning room. LPA interviewed Welness Coordinator, Staff 1- Staff 3 (S1-S3) and Residents 1- Resident 8 (R1-R8) and collected the following documents: Staff and Resident Roster, copy of the food menu for the weeks of 07/21/24 - 07/27/24, 07/28/24 - 08/03/24,08/04/24 - 08/10/24, 08/11/24 - 08/17/24, reviewed documentation of pest control services for the months of June and July and Juice machine service work orders for the month of August 2024. Continue 9099C Unsubstantiated In regards to the allegations "Facility staff not ensuring kitchen is clean and facility staff not ensuring dining room / kitchen is free of cockroaches". It was alleged that kitchen is not clean and there are cockroaches. LPA toured the kitchen and dining room and observed lunch being served. The kitchen and dining room were clean. LPA didn't observe any evidence of cockroaches in the kitchen or in the dining room. Interviewed Wellness Coordinator (WC) and staff denied the allegations. Interviews with staff show that the kitchen and dining room are cleaned before and after each mealtime. During the investigation LPA observed staff are cleaning tables and mopping dining area after lunch. Interviewed WC stated that pest control comes every month as a preventative measure. LPA reviewed facility pest control invoices (service dates: 06/10/24, 07/08/24, 07/22/24) and no cockroach activity was noted during the inspections and / or services. Residents interviewed could not corroborate the allegations. Interviewed residents stated that they have not seen any cockroaches in the kitchen / dining area. In regards to the allegation "Facility staff not following proper infection control practices". It was alleged that kitchen staff is coughing and not covering his/her mouth and not wearing gloves. Interviewed staff denied the allegations. WC stated that not witnessed any kitchen staff coughing without covering their mouth. If the staff member is sick, they are advised to call out sick or wear a mask. All kitchen staff are aware that they need to wear gloves when handling food. All interviewed staff stated that they are not coughing without covering their mouth. They were not witnessed that kitchen staff coughing and not covering their mouth. They stated they always wearing gloves in the kitchen. LPA observed kitchen staff serving lunch at the time of visit. Kitchen staff were observed to be wearing gloves while working in the kitchen and serving the meals to the residents. Continue 9099C In regards to the allegations "Facility staff not serving meals with adequate portion size and facility staff served resident food from the floor". It was alleged that residents are complaining that portions are small and kitchen staff served resident food from the floor". LPA observed the dining area during lunch time. LPA observed the meal that was served to the residents. They were served carnitas with beans and rice and vegetable. As a desert they had vanilla pudding. LPA noted that residents were served with variety of juices, milk, and coffee. The portions of the meals were appropriate. LPA reviewed the approved menu that facility was currently using. Facility had five week cycle. Interviews with Staff indicated that the facility does provide residents with adequate meals, of good quality and sufficient portions. Interviews with Residents 1- 8 indicated that the facility serves adequate meals, and the portion size is also adequate. Interviewed staff stated that kitchen staff will never serve residents food from the floor. S1 and S2 stated that they cook quite a lot of food and If food falls on the floor, they throw it away. Residents interviewed could not corroborate the allegations. Interviewed residents stated that they never witnessed that staff serve food from the floor. In regards to the allegation "Facility staff not maintaining kitchen equipment in a clean condition". It was alleged that the juice machines tubes are moldy, they haven’t been changed. LPA tour the kitchen and did not observe juice machines tubes are moldy. Interviewed kitchen staff denied the allegation that juice machine tubes or any kitchen equipment are moldy. S1 stated that staff clean / sanitize juice machine tubs constantly with hot water, when changing the juice BiBs ( Bag-in-Box). Also Juice machine is maintenance from "Quick Dispense" company and last service done in August 2024. Interviewed WC didn't hear complain from staff that any kitchen equipment are moldy. Although the allegation(s) 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 allegations are Unsubstantiated. Exit interview was conducted with Wellness Coordinator. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 5, 2024 · control 28-AS-20240801160346

Allegation investigated: Staff did not accept resident back into care following hospitalization.

Licensing Program Analyst (LPA) Nune Margaryan conducted unannounced initial visit to facility to investigate the above allegation. LPA met with Lizbeth Acuna. Welness Director Kathleen McDonald, arrived shortly after and LPA discussed the purpose of the visit. During today's visit LPA obtained copies of staff and residents roster. Interviews conducted with Welness Director Kathleen McDonald and Staff #1 - Staff #3 (S#1 - S#3). LPA also obtained copies of the following documents in reference to Resident #1:Admission Agreement, Face Sheet, Physician report, Preplacemen Appraisal Information,Hospice documents, SIRs dated 3/27/24 and 5/12/24, Individual Service Plan. Continue 9099C Substantiated Regarding allegation: "Staff did not accept resident back into care following hospitalization". It was alleged that R1 was ready to be discharged from the hospital, however when Hospital Social worker / Case Manager contacted the facility to coordinate the discharge, Facility staff refused to accept R1 back due to R1 "high levels." On 05/12/24, Resident #1 was admitted to Whittier Hospital Medical Center. Interviewed Case Manager from the Hospital stated that Resident #1 was ready to return to the facility on 05/15/24, but Facility refused to accept Resident #1 back to facility. Interviewed S#1 and S#3 stated that they aware of R1's hospitalization, but don't have any discharge information or not accepting back to the facility. Interviewed S#2 stated that he/she spoke with discharged nurse from the hospital and was notify that R1 was ready to discharge on 05/12/24. S#2 ask the nurse for R#1 discharge documents and medications and discharge nurse said everything is ready and they will arrange the transportation for R1. The information that R1 cannot be back to the facility, S#2 get from R1's POA when POA came to the facility to find out the reason that R1 cannot be accepted back to the facility. Interviewed Wellness Director denied the allegation. Facility did not refuse to accept R1 back from the hospital. Stated that he/she spoke to the hospital staff and told them that they will accept R1 back, after R1's behavior will be stabilized. Wellness Director indicated that R1 was hospitalized because of R1's behavior. Due to the fact the staff refused to accept Resident #1 back to the facility after being discharge on 05/15/2024 is considered an unlawful eviction. A review of the R1's file revealed no indication that R1 required a higher level of care. LPA did not observe any documentation of giving residents a 30 day notice of removal from the facility. Based on LPA interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. See LIC 9099D. An exit interview was conducted, and a copy of this report was provided along with the Appeals Rights.the state’s words, verbatim · CDSS document, May 23, 2024 · control 28-AS-20240515115023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: May 30, 2024

87224 Eviction Procedures (a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph... This requirement is not met as evidenced by: Based on LPA interviews and record review, Facility / administrator refusal to accept R1 back to the facility upon discharge from hospital and not providing R1 with the 30 day eviction notice which poses a potential health, safety or personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, May 23, 2024

Plan of correction: Administrator will review Title 22 Regulations, Section 87224 on Eviction Procedures, and submit a written statement to CCL ensuring that he/she understands and will comply with Title 22 Regulations pursuant to this section by the POC due date.

Allegation investigated: Staff are not ensuring that resident in care is provided their medication(s) as necessary. Staff did not assist resident to perform their glucose testing

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced initial visit to facility to investigate the above allegation(s). LPA met with Kathleen McDonald, Wellness Director and LPA discussed the purpose of the visit. The investigation consisted of the following: LPA interviewed Five (5) staff (S#1-S#5), Eight (8)Residents R#1-R#8. LPA reviewed and obtained Staff and resident rosters, R1 MAR, R1 list of medications, R1 Physician's Report for Residential Care Facilities for the Elderly (RCFE), R1 Resident Admission Agreement, R1 bed rail order and facility food menu for the week. LPA also took tour of facility and random rooms. The investigation revealed: Allegation: Staff are not ensuring that resident in care is provided their medication(s) as necessary. (Continue on 9099C) Substantiated It is alleged that R1 was admitted to facility on 4/19/2024 and required insulin and that it was not ordered by facility until 05/14/2024. LPA interviewed eight (8) residents and seven (7) of (8) residents could not collaborate the allegation. LPA interviewed five (5) staff and three (3) of five (5) staff stated they did not know because medications are not within their scope of work. S1 stated the medication was ordered on 4/19/2024 and they were waiting on doctors orders. No documentation was provide to support statement. One (1) staff stated that R1 medication was not ordered until 05/14/2024 and could not explain why. LPA reviewed R1 doctor's orders and the order form shows that the medication was ordered on 05/14/24 with a start date of 05/15/2024. The resident went with out medication for 25 days. Allegation: Staff did not assist resident to perform their glucose testing. It is alleged that facility did not provide resident with glucose meter until 25 days from admission. The investigation revealed: Review of documentation and medical records indicate that resident was admitted to facility on 04/19/2024 and resident arrived without a glucose meter. Resident's glucose meter arrived the same day (05/15/2024) as the medication according to S1. Facility failed to assist resident in testing R1 glucose for 25 days. Based on record review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is cited according to California Code of Regulations, Title 22. See LIC 9099D. Exit interview was conducted with Kathleen McDonald, Wellness Director A copy of the report and appeal rights were issued. The investigation revealed: LPA interviewed five (5) staff and five (5) of five (5) staff denied the allegation. LPA interviewed eight (8) residents and seven (7) of eight (8)residents could not collaborate the allegations. One resident stated that he is not aware he could ask for more food. LPA interviewed five (5) staff and five (5) of (5) staff denied the allegation. All staff stated that residents can eat as much as they like and just have to ask for more food if they desire more. LPA was present during the lunch hour and observed the food served to be plentiful and nutritious. Plates were removed after residents had finished their meals and many if not most plates had uneaten food. There is not enough evidence to substantiate this allegation. Allegation: Staff are not meeting resident’s bathing needs. It is alleged that residents are not assisted with bathing needs. LPA interviewed eight (8) residents and seven (7) of eight (8) residents could not collaborate the allegations. R1 stated R1 had sponge bath 3 days ago. LPA interviewed five (5) staff and five (5) of (5) staff denied the allegation. Staff stated that residents are assisted with bathing 2 times per week. There is not enough evidence to substantiate this allegation. Allegation: Staff made inappropriate comment to resident. It is alleged that unknown staff told resident "you're nasty" LPA interviewed eight (8) residents and eight (8) of eight (8) residents could not collaborate the allegations. All residents stated staff are respectful and considerate towards them. LPA interviewed five (5) staff and five (5) of (5) staff denied the allegation. Staff stated they are always respectful towards residents. There is not enough evidence to substantiate this allegation. Based on interviews, and observations conducted, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED. Exit interview conducted and copy of report provided to Wellness Director, Kathleen McDonaldthe state’s words, verbatim · CDSS document, May 20, 2024 · control 28-AS-20240514095705

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a)(b)(2) · Plan of correction due date: May 21, 2024

(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (2) Ensuring that sufficient amounts of medicines, testing equipment, syringes, needles and other supplies are maintained and stored in the facility as specified in Section 87465(c). This requirement was not met as evidence by: Medication records were reviewed for R1. R1 was admitted to facility on 04/19/2024 and facility did not received the resident's insulin and glucose meter until 05/14/2024. R1 went 25 days without glucose testing and insulin which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 20, 2024

Plan of correction: Licensee will send a written plan to LPA on how facility will avoid residents from going without medication and send it to LPA by POC date which is 05/21/2024

Allegation investigated: Staff are not logging incidents with residents

Licensing Program Analyst(LPAs) Jose Villalobos conducted a subsequent complaint investigation visit for the allegation(s) listed above. LPA met with Business Office Manager Lizbeth Acuna and the purpose of the visit was discussed. Previous visits consisted of the following: LPA Villalobos toured the physical plant, interviewed Staff #1-#5 (S1-S5) and collected copies of the resident and staff rosters. LPA also reviewed facility notes regarding resident falls and collected incident reports and notes. LPA has also collected list of residents who receive staff assistance with showering and toileting needs. LPA interviewed residents #1-#2 (R1-R2) and toured the physical plant. On todays visit, LPA has interviewed Residents #3-10 (R3-R10) and Staff #6-7 (S6 and S7). The investigation revealed the following: Continued on LIC 9099-C Substantiated In regards to the allegation "Residents have fallen multiple times due to staff neglect" it was alleged that residents were falling in the facility due to staff not addressing issues with cracks on the sidewalks. (7) of (7) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Interviews with residents and staff noted that residents fall due to other reasons not related to the cracks on the concrete sidewalks. LPA received photos of cracks on sidewalks around the facility. Residents interviewed stated to have no issues with the cracks as they are not large or they can go around them if needed. LPA observed the cracks around the facility. One crack was large but was in an area used for the facilities dumpsters and not a resident walkway. No documentation or interviews showed that residents fell due to the this crack. Based on interviews, file review, and observations; although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. In regards to the allegation "Staff are not meeting residents needs" it is alleged that there is not a sufficient amount of staff to meet resident needs. (7) of (7) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Staff interviewed stated they are able to meet the residents needs everyday. Residents interviewed stated they have their needs met and are not aware of which other residents may not be having their needs met. LPA observed sufficient staffing during the 3 separate visits conducted. Based on interviews, file review, and observations; although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. In regards to the allegation "Staff left residents in soiled diapers for an extended period of time" it is alleged that residents are left in wet and soiled diapers for hours. (7) of (7) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Residents interviewed who receive assistance with diaper changes stated that staff check in and change them regularly. The residents are also able to contact staff with the call system to request to be changed when needed. LPA was not provided with specific names or times when a resident was left in soiled diapers for extended periods of time. Staff stated to work together to make sure residents are changed and checked on regularly throughout the day. There is a caregiver assigned to each floor throughout the day as med tech staff also assist the residents. LPA observed staff throughout the visit to be assisting residents in need. Based on interviews, file review, and observations; although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Continued on LIC 9099-C In regards to the allegation "Staff are not meeting residents showering needs" it is alleged that staff are conducting showers timely for residents who need that assistance. (7) of (7) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Staff interviewed detailed that there is a computer/phone application system that provides the daily assignments on residents who needs showering assistance. Staff interviewed stated they complete the assignments without missing and have not missed any residents showers. Residents interviewed who receive assistance in showers from staff did not have any complaints. There were no specific resident names or times about a resident not being given a shower when needed. Based on interviews, file review, and observations; although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. In regards to the allegation "Staff are not providing a secure way to pay rent" it is alleged that the facility does not provide the residents a secure way to pay their rent. (7) of (7) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Interviews with staff stated that residents are able to pay their rent via direct deposits, cash or checks. Whichever method is most comfortable to them. There is also a locked safe area where residents may deposit their payment if they do not want to hand it personally which is always in sight of staff. Interviews stated no one uses it as most people pay direct deposit or hand the administrator or business office manager the check in hand. Many residents will have their responsible parties, usually a family member, make the payments for them as well. Interviews with residents does not show that there is an issue with the methods in which they can pay their rent. Residents interviewed did not express any issue in the security of making their payments. Based on interviews, file review, and observations; although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted and a copy of this report was provided. In regards to the allegation "Staff are not logging incidents with residents" it is alleged that the facility does not properly record incidents involving resident incidents and hospitalization's. (7) of (7) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Interviews with staff shows that there is a incident/accident report that is filled out by staff whenever an incident occurs in the facility involving the residents. Depending on the situation, the incident is then reported to Licensing , a residents physician, and the residents responsible party. LPA reviewed the facilities internal incident reports and attempted to match them with the incident reports received by Licensing. LPA observed that there are facility incident reports that fall under the reporting requirements set by the department that were not followed. There is an facility incident report dated 6/1/23 of a resident being hospitalized that was not submitted to licensing. There is another facility incident report of a resident threatening another resident dated 12/6/22 not reported to Licensing. This shows the facility failed to properly record incidents in the facility by not following reporting requirements. Based on LPAs interviews conducted, files reviewed, and observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted and a copy of this report was provided. Appeal rights provided and discussedthe state’s words, verbatim · CDSS document, Apr 30, 2024 · control 28-AS-20230814092308

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: May 14, 2024

87211(a)(1) 87211 Reporting Requirements: (a) Each licensee shall furnish..: (1)A written report shall be submitted to the licensing agency... within seven days of the occurrence...(D)Any incident which threatens the welfare, safety or health of any resident.. This requirement is not met as evidence by: LPA observed facility reports dated 6/1/23 and 12/6/22 met the above requirement but were not reported to licensing which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2024

Plan of correction: Facility will conduct in-service training for staff and create incident reports to file from the previous mentioned dates. Administrator will provide a copy of in-service training along with names of participants to the department by POC due date provided.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the purpose of citing deficiencies. LPA Met with staff Lizbeth Acuna, and explained the purpose for the visit. During an investigation conducted for a complaint dated: 3/18/22, it was discovered that Resident#1 (R1) sustained several documented falls at the facility during March 2022. Per hospice records, R1 fell at the facility on 3/01/22 and 3/20/22. Per facility incident reports obtained dated 3/03/22 and 3/20/22, facility reported to the Licensing agency that R1 sustained falls. Per R1's Physician's Report, Pre-Placement Appraisal, Needs and Services plan, and Current Appraisal, R1 was non-ambulatory and required two-person assist for transferring, but was able to propel self on her wheelchair. There was no indication that R1 was a fall risk. In the incident report and hospice notes dated 3/20/22, it was documented that R1 fell and sustained a laceration to the head that resulted in bleeding. Upon facility notifying hospice, the hospice physician ordered for R1 to be discharge from hospice and be sent to the hospital. After review of R1's records obtained, it was discovered that the facility failed to update the service plan for change of condition of R1, and not implementing interventions that led to additional falls resulting in the R1 sustaining a head laceration that required hospitalization. There was no recorded documentation from the facility or hospice indicating that the R1's Assessment/Needs and Services Plan was ever updated to reflect R1's fall risk/plan of care. Per California Code of Regulations, Title 22, deficiencies were observed and cited during today's visit. Exit interview was conducted and copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 19, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Apr 24, 2024

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement was not met as evidenced by: Baased on records review, Licensee failed to update R1's appraisal/plan of care to implement fall interventions due to R1's fall history that led to R1 sustaining a head laceration, which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 19, 2024

Plan of correction: Licensee will submit a written plan indicating how facility will ensure to document and update resident's plan of care any time a change in condition is observed. POC to be emailed to LPA by POC due date.

Allegation investigated: Staff did not post CCL signs in an accessible area for residents

Licensing Program Analyst(s) (LPAs) Jose Villalobos and Tyler Reyes conducted a subsequent complaint investigation visit for the allegation(s) listed above. LPAs met with Business Office Manager Lizbeth Acuna and the purpose of the visit was discussed. Initial visit conducted on 8/16/23 consisted of the following: LPA Villalobos toured the physical plant, interviewed Staff #1-#5 (S1-S5) and collected copies of the resident and staff rosters. LPA also reviewed facility notes regarding resident falls and collected incident reports and notes. On todays visit, LPA's interviewed residents #1-#2 (R1-R2) and toured the physical plant. The investigation revealed the following: continued on Lic 9099-C Unsubstantiated In regards to the allegation "Staff did not post CCL signs in an accessible area for residents" it was alleged that the facility does not post required postings from licensing and the administrators certificate. (5) of (5) Staff interviewed denied the allegation. (2) of (2) Residents interviewed could not corroborate the allegation. LPAs observed the facility to have required posting located in the hallway accessible to all residents in care. The posting observed included the personal rights form, resident council form, emergency disaster plan, CCL let us know poster, local ombudsman, facility license, and designation of facility responsibility amongst others. LPA's observed current administrator's certificate posted as well. The certificate is active. Based on interviews, file review, and observations; although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 18, 2024 · control 28-AS-20230814092308

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff does not provide a care plan for residents during pre-admissions. Staff has forged resident's signatures. Staff has overchaged residents in care.

Licensing Program Analyst (LPA) Jose Villalobos and Tyler Reyes conducted a subsequent complaint investigation visit for the allegation(s) listed above. LPA met with Business Office Manager Lizbeth Acuna and the purpose of the visit was discussed. The following was conducted on initial visit on 4/11/23: LPA interviewed Staff #1-#2 (S1-S2). LPA toured the physical plant of the facility. LPA collected a copy of the staff and resident roster. LPA collected documents related Resident #1-6 (R1-R6) File such as the facesheet, needs and services plan, physicians report, admissions agreements and current ledgers. As of todays visit, LPAs have interviewed R1-R5 and Resident #7 (R7). Resident #6 is no longer in the facility and unavailable for interview. LPA also collected related documents from R7's file. The investigation revealed the following: Continued on LIC 9099-C Unsubstantiated In regards to the allegation "Staff does not provide a care plan for residents during pre-admissions" it is alleged that resident care plans are not created or provided for admitted residents. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. The files for seven (7) residents in care were reviewed and the needs and services plans for each file was observed. LPA's observed the pre admission appraisals on file. Interviews show that staff will create the care plans with the residents and keep it on file upon admission. Staff interviewed explained that residents and their responsible parties are allowed to participate in creating the care plan and receive a copy if they choose too. The care plans are kept on file for each resident. The documents initially provided to residents and their responsible parties is the admissions agreement and all its attachments. The care plans are not part of the admissions agreement as they are a separate document, but is available upon request. There is no regulation requiring the facility to provide a care plan during the pre-admission of a resident. Based on interviews, file review, and observations; although the allegation 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. In regards to the allegation "Staff has overcharged residents in care" it was alleged that the facility overcharged residents in millions of dollars with their level of care charges. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Residents interviewed were aware of the amount they pay the facility monthly. No residents interviews stated to be overcharged for services provided and are informed with a notice when rent increases. Interviews show that the facility is a private pay facility that calculates each persons total monthly fee by adding the cost of room and board plus level of care (service). The level of care charge is discussed prior to admission with the resident and/or their responsible party prior to any contract agreements being signed. There are no changes done or charges made without notifying the residents or their responsible parties. File review shows that residents are provided notices of price increases throughout the years. Review of most recent ledgers for the residents matches with the most recent notices on file for the total monthly fees which includes the service level they are provided. Based on interviews, file review, and observations; although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Continued on LIC 9099-C In regards to the allegation "Staff has forged resident's signatures" it was alleged that resident signatures and initials were being forged by the staff. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. LPAs showed residents their signatures from documents on file and they confirmed to believe it their own signatures. LPA was not provided with proof that signatures were being forged in facility documentation. Based on interviews, file review, and observations; although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit Interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 18, 2024 · control 28-AS-20230406103046

Allegation investigated: Resident possibly has possession of a firearm. Resident verbally attacked another resident in care.

Licensing Program Analyst (LPA) Wong conducted an initial "10 days" complaint visit and ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1 Michelle Bascom (Receptionist) who allowed entry into the facility and was later met by Wellness Director Kathleen McDonald (Katie) who assisted with the visit. The investigation consisted of the following: On today's date, LPA interviewed eight (8) staff (S1-S8) in the facility and sevevn residents (R2-R8) in the facility and administartor via telephone. LPA obtained the copy of the resident and staff roster and R1 and R2 face sheet, physician report and needs and service plan and the copy of the staff in serve training about de-escalation. See LIC 9099C for continuation Unsubstantiated The investigation revealed of the following: Allegation#1 "Resident possibly has possession of a firearm." It's alleged that a man went into R2's room for less than a minute and left the building and possibly dropped off a gun in R2's room as R2 was asking for a gun a couple weeks ago in the facility. LPA interviewed seven (7) residents and five out of seven residents denied the allegation. They never heard and seen any resident has possession of a firearm. LPA interviewed staff and all denied the allegation. They never heard and see any resident has possession of a firearm. LPA also toured the room of R2 and did not observe any possession of a firearm. Allegation#2 "Resident verbally attacked another resident in care. " It's alleged that R2 was verbally attacked R1 and threatened R1 and yelled at R1. LPA interviewed residents and reported R1 and R2 always argued in the facility for unknown reason but four out of seven residents denied seeing them hitting each other. Residents indicated staff interfered immediately and separated both residents and asked residents to calm down when two residents started arguing or verbally attacking each other. LPA interviewed staff and reported R1 and R2 do not like each other for some reasons. Staff always kept an eye on them. Staff stated that they usually ensure R1 and R2 were not in the same location or area. Regarding the altercation between R1 and R2 few weeks ago, the staff were in the kitchen prepared and served food and it was happened so fast, therefore no staff was not around while incident happened. Both R1 and R2 resolved themselves at the end and no one was getting hurt. Once the staff found out, staff immediately evacuated the dining area to prevent any other residents were involved in the incident. The administrator reported usually if something happened between two residents, staff would always de-escalate the situation and separate the residents immediately. They would also call police or paramedic if needed. Based on the interviews were conducted with staff and residents, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview was conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 28-AS-20240315094335

Allegation investigated: Staff did not prevent residents from engaging in inappropriate behaviors.

Licensing Program Analyst(LPA) Nicol Wesley conducted an unannounced 10 day complaint visit at the facility and met with Business Office Manager Lizbeth Acuna to discuss the purpose for todays visit. Investigation consisted of: LPA requested a copy of the resident roster, staff roster, interviewed staff, interviewed residents, requested a copy of the incident report for altercation in dinning room, house rules, eviction notices, and notice of court hearing. The investigation revealed:Staff did not prevent residents form engaging inappropiate behaviors. R2 and R3 were in the dinning room and began an exchange of words. R2 hit R3 in the upper head area and R7 and R8 witnessed the incident. Staff called the police and the police suggested that R3 get a restraining order. R3 has a temporary restraining order and has to go to court on 03/26/24. LPA conducted interviews with other residents who says R2 starts problems with them all the time, and two of the residents were Unsubstantiated interviewed and said R2 doesn't start any mess with them at all. R1 and R2 refused to be interviewed. The Business Office Manager said they are aware and cant share information about one resident with another. They have a legal team that will be handling the situation. The staff are trained in de escalating a situation, but the staff was not present during this argument. When staff found out about it, they intervened and that's when the police were called. LPA Wesley spoke to 3 other residents who have had altercations with R2 and and seems to think that he has a drinking problem due to him being a Veteran, which is causing his aggression. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. A copy of this report was given to the Business Office Manager.the state’s words, verbatim · CDSS document, Mar 7, 2024 · control 28-AS-20240227155221

Allegation investigated: Staff left resident in soiled diapers for extended period of time

** This report supercedes report dated 8/15/2023. Further inofrmation was aquired resulting in changes to the findings and details on 9099's** Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit for the allegation(s) listed above. LPA met with Wellness Director Kathleen McDonald and the purpose of the visit was discussed. Visits conducted on 2/16/22 and 8/15/23 consisted of the following: LPA Villalobos interviewed Staff #1-#8 (S1-S8). LPA toured the facility and observed the food supply. LPA reviewed resident #1 (R1) and resident #2's (R2) file. LPA collected copies of R1 and R2's file. LPA also received a copy of the staff and resident roster. LPA interviewed Residents #1-6 (R1-R6), and Hospice agency for R1. LPA collected hospice agency documents for regarding R1. The Investigation revealed the following: Continued on LIC 9099-C Substantiated In regards to the allegation "Resident fell while in care" it was alleged that R2 fell in the facility resulting in head wound and staff did not assist them. (8) of (8) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews do not show that R2 has fallen and needed to shout for help. Staff denied that they would refuse to assist any resident in care. Interviews did show R2 having an unwitnessed fall on 2/2/22 in their room and staff assessed R2 and assisted them back to their bed. No head injuries were noted during file review. R2 did not state they had a fall and needed to scream for help. Interviews with residents state that staff assist residents when they are in need. Based on interviews, file review, and observation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated In regards to the allegation "Resident's sustained injuries while in care" it was alleged that facility staff scratched R1 leaving wounds on their arm. (8) of (8) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews with staff deny having scratched R1 while assisted them in and out of bed or when assisting them with their grooming needs. LPA was not provided with proof that any staff had scratched R1. Files reviewed by LPA do not show that staff had scratched R1 as there are no notes documented regarding injuries while assisting resident. Based on interviews, file review, and observation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated In regards to the allegation "Staff are not meeting resident's hygiene needs" it was alleged that R1 was not given showers as needed. (8) of (8) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. It was alleged that during a covid outbreak in the facility staff was not able to meet R1's showering needs. File review shows the facility had a covid outbreak from December 2021 - End of January 2022. During this time many staff and residents had covid. Staff interviewed stated that scheduling and assisting residents with their needs was still conducted and that R1 did receive the amount of showers as needed each week. R1's Service Plan states that R1 should get 1-5 showers as needed. LPA was not provided proof that R1 was not being showered by staff. File review shows shower notes for R1 being completed 2 times a week. Based on interviews, file review, and observation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated Continued on LIC 9099-C In regards to the allegation "Resident rooms are unsanitary" it was alleged that R3's room was malodorous and R1's bathroom was dirty. (8) of (8) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews stated that R3 is a resident who refuses to shower for extended periods of time and it is not the room the smells. Rooms are cleaned daily and R3 is also reminded daily to take a shower but they refuse. R3 confirmed to LPA that they do not like to shower and did not want to shower. R3 did not need assistance with showering and was independent. LPA observed R3 refusing to shower or wanting assistance with showers during the initial visit. LPA did not observe the hallways to be malodorous during the initial and subsequent visit as the smell was coming from a resident and not the facility. LPA observed R1 to have a private bedroom with a private bathroom in the facility. LPA observed the bathroom to be clean and appear unused. LPA was not provided with proof of the resident rooms being unsanitary. Based on interviews, file review, and observation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated In regards to the allegation "Staff are using resident's bathroom" it was alleged that staff were using R1's private bathroom. (8) of (8) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews with staff deny using R1s room for their own personal break time. Staff denied using any residents bathrooms for their own personal use. Staff have a designated restroom on each floor which they can use when needed and should not be using a residents bathroom. R1 was unable to confirm whether any staff were using their restroom. Based on interviews, file review, and observation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated In regards to the allegation "Staff did not notify resident's authorized representative of incidents" it was alleged that R1 had scratches on their arm that were not reported to R1's authorized representative. (8) of (8) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews state that R1 did have a scratch on her arm at one point and it was initially observed by R1s family member. The exact date is not known. Interviews state that R1's family member observed the scratch prior to any staff being aware of it. Since the family member was the first to observe it, the staff could not have known and notified them prior. Interview with R1's hospice agency also was not aware of scratches on R1 until they were notified by R1s family member. Based on interviews, file review, and observation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Continued on LIC 9099-C In regards to the allegation "Residents room is in disrepair" it was alleged that R1's blinds, sliding door, and emergency call button were broken or missing. (8) of (8) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews show that rooms are checked often for damages and residents can also report damaged to staff so things can be fixed in timely manner. Interviews do not show that there were any issues with the blinds or sliding door in R1's room not working. There were also no known issues with the emergency button in R1's room. According to interviews, sometimes the moving blinds will have a part that falls off but they just clip back on and does not mean they are broken. During the initial visit LPA observed the blinds and sliding door in R1's room to be working and in good condition. As for the call button, LPA observed it to be present in the room during the initial visit. There was one in the room and another in the bathroom. During the initial visit, LPA pressed the emergency button in R1's room and observed staff arriving to assist within 2 minutes. LPA did not observe the buttons to be in disrepair or to be missing. There were no signs of items or things in disrepair in R1's room during the initial visit. Based on interviews, file review, and observation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. In regards to the allegation "Staff are not ensuring resident has call bracelet on as required by admissions agreement" it was alleged that the facility staff did not ensure that R1 had their emergency pendant on at all times. (8) of (8) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews state that R1 was provided an emergency pendent and that R1 would not like to have it on. Staff interviews explained R1 would have issues with the pendant around their neck and so it was removed and placed on the dresser at times. R1 was not able to communicate with LPA to confirm. LPA reviewed R1's file and observed that the pendant was purchased as a one time cost and that it would be provided to R1. Review of the admissions agreement and service plan does not state that staff would manage the pendant or make sure R1 had it on at all times. Based on interviews, file review, and observation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated Continued on LIC 9099-C In regards to the allegation "Staff are not providing adequate food service to resident's" it was alleged that R1 was not getting sufficient food and that it was not good enough. (8) of (8) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. LPA observed the food supply during the initial and subsequent visit. There was no spoiled or expired food present. LPA reviewed the food menus and nutritionist notes and did not observe issues with the quality of the food provided by the facility. Interviews with staff stated R1 was assisted daily into the dining room for all meals and was observed to finish their plate during meals. Based on interviews, file review, and observation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated In regards to the allegation "Staff are not providing adequate laundry service to resident" it was alleged that R1 would soil their clothes and the staff would not wash it. (8) of (8) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews with staff show that R1's clothes were washed in the same consistency as every other resident. There is a schedule for washing clothes and is done that way so that no residents clothes get mixed up with one another. Staff denied refusing to wash and clean R1's clothes and stated that R1's clothing was always washed. LPA was not provided proof that R1's clothing was not washed. Based on interviews, file review, and observation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated Exit interview conducted and copy of the report with appeal rights were provided and discussed. In regards to the allegation "Staff left resident in soiled diapers for extended period of time" it was alleged that Staff were not changing R1 frequently as needed. (8) of (8) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews with staff state they would attempt to change R1 each shift. File review shows that R1's service plan stated R1 was at risk of incontinence and required regular assistance with toileting needs to avoid skin breakdown. Interviews with staff show that there were moments where R1 was having incontinence issues but due to workload, staff was not always able to immediately assist R1 with diaper changes. File review further shows that R1's hospice agency observed R1 to have rash issues around their genital area on 2/5/22. It was noted that a correction was needed and that diaper changes were to be done frequently. This shows that the facility failed to change R1's soiled diapers in a timely manner. Based on LPA interviews, record review, and observations the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Deficiencies cited under California Code of Regulations Title 22. See 9099D. Exit interview conducted and copy of the report with appeal rights were provided and discussed.the state’s words, verbatim · CDSS document, Feb 22, 2024 · control 28-AS-20220207115219

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Mar 7, 2024

87625.Managed Incontinence(b)In addition to Section 87611... the licensee shall be responsible for the following:(3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This was not met as evidenced by: R1 was left unchanged for prolonged times resulting in rashes. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Facility to provide in service training to staff in regarding information on providing residents assistance with toileting needs. Letter of completion signed by staff attending to be provided to Licensing by POC due date.

Allegation investigated: Staff member is verbally abusive to resident(s) in care. Staff member threatens resident(s) in care. Staff member yells at resident(s) in care.

On 01/16/2024 at 8:50 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted a subsequent complaint investigation regarding the above listed allegations. Upon arrival LPA met with Business Office Manager Lizbeth Acuna and LPA explained the reason for the visit. During the initial visit on 12/18/2023, LPA Baptiste toured the facility with Wellness Director and Business Office Manager. LPA interviewed Wellness Director and a total of two (2) staff who shall be referred to as S2, and S3. LPA attempted to call S1 and left a voice mail. LPA interviewed a total eight (8) residents who shall be referred as R1 through R8. During the visit LPA obtained the staff roster, resident roster and R1’s physicians report. File review for S1 was also conducted. Prior to the visit LPA contacted S1 via phone and conducted an interview. Report continued on 9099c Unsubstantiated The investigation reveals the following: Regarding “Staff member is verbally abusive to resident(s) in care”. It is alleged that S1 is verbally abusive to R1. The wellness director confirmed that R1 complained about S1. They further stated they have never witnessed S1 being verbally abusive but still addressed the situation by speaking to S1 about R1. 3 out of 3 staff denied the allegation stating they have never witnessed staff verbally abusing residents, nor have they ever treated the residents in that manner. 2 out of 8 residents stated a staff member has been verbally abusive. 6 out of 8 residents stated they have never seen staff verbally abuse residents and the residents are the one’s verbally abusing staff. LPA reviewed S1’s file and did not observe any disciplinary actions. The investigation reveals the following: Regarding “Staff member threatens resident(s) in care”. It is alleged that S1 threatens R1. The wellness director confirmed that R1 complained about S1. They further stated they have never witnessed S1 threatening R1, but still addressed the situation by speaking to S1 about R1. 3 out of 3 staff denied the allegation stating they have never witness staff threatening the residents nor have they ever treated the residents in that manner. 1 out of 8 residents stated they were threatened by S1’s tone of voice. 7 out of 8 residents stated they have never seen staff threaten residents. LPA reviewed S1’s file and did not observe any disciplinary actions. The investigation reveals the following: Regarding “Staff member yells at resident(s) in care”. It is alleged that S1 yelled at R1. The wellness director confirmed that R1 complained about S1. They further stated they have never witnessed S1 yelling at R1, but still addressed the situation by speaking to S1 about R1. 3 out of 3 staff denied the allegation stating they have never witness staff yelling at the residents nor have they ever treated the residents in that manner. 2 out of 8 residents stated a staff member has yelled at them. 6 out of 8 residents stated they have never seen staff yelling at the residents and the residents are the one’s yelling at the staff. LPA reviewed S1’s file and did not observe any disciplinary actions. Based on LPA's interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Wellness Director Kathleen McDonald and Business Office Manager Lizbeth Acuna and a copy of this record provided.the state’s words, verbatim · CDSS document, Jan 16, 2024 · control 28-AS-20231211153326

Allegation investigated: Staff is denying resident's representative the right to represent resident in matters pertaining to the resident's residency at the facility.

Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit regarding the above allegation. LPA met with Busniess/ HR Manager Lizbeth Acuna and the purpose of the visit was discussed. Initial visit on 7/28/23 consisted of the following: LPA requested a copy of staff/resident roster. Conducted interview with Staff #1-#4 (S1-S4) and Resident #2. LPA reviewed and collected documents related to Resident #1's file such as documentation of power of attorney, identificaiton and emergency sheet, physician's report, and, admission agreement. As of todays visit, LPA has interviewed staff #5-#6 (S5-S6) and residents #3-#6 (R3-R6). R1 was not available for interview. Staff #7 (S7) no longer works in the facility and was unavailable for interview. The investigation revealed the following: Continued on LIC 9099-C Unsubstantiated In regards to the allegation "Staff is denying resident's representative the right to represent resident in matters pertaining to the resident's residency at the facility." it was alleged that the facility did not allow R1's representative to represent R1 regarding their needs and services received at the facility. (6) of (6) Staff interviewed denied the allegations. (5) of (5) residents interviewed could not corroborate the allegation. Interviews with staff show that R1 had their needs met for their duration of their stay in the facility. R1 left the facility in July 2023. Interviews show that there had been an ongoing dispute that started in November 2021 between R1's relative and the facility regarding a rent increase. R1's relative became R1's responsible party and Power of Attorney on 9/10/2022. R1 was self responsible up until that point. Interviews conducted also show that administrators of the facility and representatives of the corporation were in contact with R1's relative from the start of the dispute up until the day that R1 left the facility. LPA was not provided proof that the facility did not allow R1's power of attorney to represent them during the time they were R1's representative. Based on observation, interviews and file review; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. Exit Interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 11, 2024 · control 28-AS-20230721141211

Allegation investigated: Facility does not have a full time Activity Director

Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit for the allegation(s) above. LPA met with Busniess/ HR Manager Lizbeth Acuna and the purpose of the visit was discussed. Initial visit conducted on 9/7/22 consisted of the following: LPA toured the physcial plant. LPA requested a copy of the resident/staff roster. LPA interviewed Staff #1-#5 (S1-S5), LPA collected the following documents from Resident #1's (R1) file; physicians report, identification and emergency information, needs and services plan and Medication record for July/August 2022. LPA also collected documents from S2's staff file. Subsequent visit conducted on 12/12/23 consisted of the following: LPA interviewed Staff #6-#7 (S6-S7). As of todays visit. LPA has also interviewed Staff #8 (S8). Staff #9 (S9) was unavailable for interview LPA reviewed and collected documents from S1,S3-S5's files. The investigation revealed the following: Continued on LIC 9099-C Substantiated In regards to the allegation "Staff left resident unsupervised after fall" it is alleged that R1 had a fall on 7/24/22 and staff did not stay with R1 until paramedics arrived. (8) of (8) Staff interviewed denied the allegation. (4) of (5) Residents interviewed could not corroborate the allegation. Staff interviews state that staff are to assess to residents when there are any falls and based on the situation, call paramedics when necessary. Interviews show that it was staff S9 who assisted R1 when they fell and called the paramedics after assessing R1. LPA was unable to interview S9 to determine whether they had left R1 unsupervised. Based on observation, interviews and file review; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. In regards to the allegation "Facility is not adequately staffed" it is alleged that there are not enough staff at the facility to meet the residents needs. (8) of (8) Staff interviewed denied the allegation. (4) of (5) Residents interviewed could not corroborate the allegation. Interviews show that all residents are having their needs met in the facility. There is a phone application used by the facility caregivers that notes which residents in the facility need assistance based on their needs and services plan throughout each day. The staff will check off each task completed for each resident and no one is left unattended. Interviews state that medication aide staff and administration staff will assist when necessary to complete all tasks for the residents. Based on observation, interviews and file review; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. In regards to the allegation "Staff are not qualified to perform duties" is is alleged facility staff do not have basic required training's for their positions regarding medical issues. (8) of (8) Staff interviewed denied the allegation. (4) of (5) Residents interviewed could not corroborate the allegation. Interviews state that not all staff handle resident medications. That duty is assigned to trained medication aides and the Wellness Director. File review for medication aides show that staff have completed medication management training's as well as first aid /cpr trainings required of the position. All staff providing direct care to residents are also trained in resident wellness and recognizing signs of dementia. Based on observation, interviews and file review; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Continued on LIC 9099-C In regards to the allegation "Staff mismanaged residents medications" it is alleged that staff provided R1 the improper combination of medication. (8) of (8) Staff interviewed denied the allegation. (4) of (5) Residents interviewed could not corroborate the allegation. LPA reviewed R1s medication records and did not observe errors. Interviews with staff state that doctors or psychiatrists will review resident medications and make the orders for any adjustments. The staff will collect the medication from the pharmacies and administer medications as prescribed to residents in care. LPA also observed doctor orders on file for medications observed. Based on observation, interviews and file review; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit Interview conducted and a copy of this report was provided In regards to the allegation "Facility does not have a full time Activity Director" it is alleged the facility went months without a full time staff running the activities and social gathering. Interviews show that between the months of March 2022-July 2022 there was no full time activity director and the facility activities and social gatherings were being conducted by S2 whos position was not as a full time activity director. File review shows the S2 was given the title and hired as the full time Activities Coordinator on 7/5/2022 while the previous staff had left the facility in March 2022. This shows that as a facility, licensed for 50+ residents, failed to have a full-time staff who's responsibility is to organize, conduct and evaluate planned activities. Based on LPA interviews conducted and record review, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Deficiencies cited under California Code of Regulations Title 22. See 9099D. Exit interview conducted and copy of the report with appeal rights was provided.the state’s words, verbatim · CDSS document, Jan 11, 2024 · control 28-AS-20220830111314

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(f) · Plan of correction due date: Jan 12, 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... This was not met as evidenced by Facility went about 4 months without a full time activity coordinator for the residents, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: Facility currently has a qualified full time activity coordinator. Deficiency cleared at the time of this visit.

Allegation investigated: Facility did not accept resident's prescribed medication. Staff locked resident's wheelchair. Facility did not ensure that resident was properly dressed. Resident was left in dirty clothing. Facility did not safeguard resident's personal belongings.

Licensing Program Analyst (LPA) Tao conducted a subsequent unannounced complaint investigation for the allegations listed above today. LPA met with Kathleen McDonald, Wellness Director, and explained the purpose of today's visit. On 03/24/22, LPA Tao conducted the initial investigation visit. LPA obtained staff/resident roster, and resident #1’s (R1) facility files. LPA Tao interviewed the former administrator and residents. Due to insufficient information, it needed a further investigation. Investigation consisted of the following: interviews of staff from Staff #1 (S1) through Staff #5 (S5); attempted to interview resident#1 (R1) but R1 was deceased; interviews of residents from Resident#2 (R2) through Resident #8 (R8); reviewed resident#1’s record reviews, and a facility tour. (-continued in LIC 9099 C-) Unsubstantiated LPA obtained copies of the staff/ resident rosters; and resident files for Resident #1 (R1) with relevant information. The investigation revealed the following: In regard to: facility did not accept resident's prescribed medication, it was alleged that staff did not take a glucose meter from resident's responsible party. Seven (7) out of eight (8) residents interviewed could not corroborate the allegation. Resident interviews revealed that staff administer residents’ medication as prescribed including their diabetic care needs. All staff interviewed denied the allegation. Staff interviews revealed only LVNs or medical professionals were allowed to administer glucose check using glucose meter if it was prescribed by physician orders. Per record reviews, the resident was on hospice care. There was no prescription or doctor's order to instruct the facility to conduct glucose test or use glucose meter on the resident. As a result, facility did not have physician order on administering glucose test or accepting glucose meter. In regard to: staff locked resident's wheelchair, it was alleged that the wheels on the resident’s wheelchair were locked while resident was in resident's room. Seven (7) out of eight (8) residents interviewed could not corroborate the allegation. Resident interviews revealed that their wheelchairs were locked for safety purposes, such as dining in dining room. Staff would unlock residents' wheelchairs after meals. All staff interviewed denied the allegation. Per staff interviews, it stated staff were not allowed to lock the wheels of residents' wheelchairs, unless for safety reasons. Per record reviews, it indicated that resident was able to unlock the wheels. Per LPA's observation, the residents in wheelchairs were able to move around and staff would assist residents if their wheelchairs got stuck. Thus, there was not preponderance of evidence to show staff locked resident's wheelchair. In regard to: facility did not ensure that resident was properly dressed, it was alleged that staff did not check on resident#1 (R1) to ensure resident was clothed appropriately. Seven (7) out of eight (8) residents interviewed could not corroborate the allegation. Resident interviews revealed that staff dressed residents every morning and clothed them properly. All staff interviewed denied the allegation. Staff was instructed to check and change R1’s diaper every two (2) hours which staff would clean and dress R1 every two (2) hours. Per LPA’s observation, residents were dressed properly. Therefore, staff dressed residents decently. (-continued in LIC 9099 C-) In regard to: resident was left in dirty clothing, it was alleged that resident’s clothes was full of food. Seven (7) out of eight (8) residents interviewed could not corroborate the allegation. Resident interviews revealed that staff would clean them after meals if their clothes had food on. All staff interviewed denied the allegation. Staff interviews revealed staff would change residents’ clothes if they got food on their clothes. Some residents may have bibs on while eating. As mentioned above, staff was instructed to check on R1 every two (2) hours which staff would clean and dress R1 every two (2) hours. Per LPA’s observation, residents looked clean. Therefore, staff did not leave residents in dirty clothing. In regard to: facility did not safeguard resident's personal belongings, it was alleged that the facility stole resident#1 (R1)’s diapers. Seven (7) out of eight (8) residents interviewed could not corroborate the allegation. Resident interviews revealed that staff did not steal residents’ diapers supplies. All staff interviewed denied the allegation. Staff interviews revealed staff was instructed to change R1’s diaper every two (2) hours. By comparing the diaper supplies to the diaper usages, R1’s diaper’s usage matched with diaper supplies. Therefore, R1’s diaper supplies were used up by R1, not stolen by staff. Although the allegations may have happened or is valid, there is not preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted with Kathleen McDonald, Wellness Director. A hard copy of this reports was provided.the state’s words, verbatim · CDSS document, Jan 10, 2024 · control 28-AS-20220317104159

Allegation investigated: Resident sustained an injury from a fall while in care. Staff did not address a resident's diabetic needs while in care. Staff are using a resident's room for work breaks.

Licensing Program Analyst (LPA) Tao conducted a subsequent unannounced complaint investigation for the allegations listed above today. LPA met Itzayana Barba Aguirre, Administrator, and explained the purpose of today's visit. On 03/30/22, LPA Tao conducted the initial investigation visit. LPA obtained staff/resident roster, and resident #1’s (R1) facility files. LPA Tao interviewed staff and residents. Due to insufficient information, it needed a further investigation. Investigation consisted of the following: interviews of staff from Staff #1 (S1) through Staff #5 (S5); attempted to interview resident#1 (R1) but R1 was deceased on 4/22/23; interviews of residents from Resident#2 (R2) through Resident #8 (R8); reviewed resident#1’s record reviews, and a facility tour. LPA obtained copies of the staff/ resident Rosters; and resident files for Resident #1 (R1) with relevant information. (-continued in LIC 9099 C-) Unsubstantiated The investigation revealed the following: In regards to the allegation of: resident sustained an injury from a fall while in care, it was alleged that the resident fell and injured when getting up from resident’s own wheelchair at the facility. Seven (7) out of eight (8) residents interviewed could not corroborate the allegation. One (1) out of eight (8) residents was deceased and unable to be interviewed. Resident interviews revealed that they did not fall from their wheelchair or staff would assist them right away when they fell. All staff interviewed denied the allegation. Per staff interviews, staff stated the resident got agitated and fell off from resident’s own wheelchair when resident tried to get up by oneself. Per record reviews, it indicated that staff was trained to provide care to resident who had fall risk. Staff assisted resident and provided care after the fall occurred. Resident had plan of care in place. Thus, there was not preponderance of evidence to show resident sustained an injury from a fall due to lack of care. In regards to the allegation of: staff did not address a resident's diabetic needs while in care, it was alleged that staff failed to check resident's glucose by using Glucose meter. Seven (7) out of eight (8) residents interviewed could not corroborate the allegation. Resident interviews revealed that staff provided residents with diabetic medication and had the LVNs or their own health care nurses monitored their glucose level. Meals were modified per doctors' prescription for diabetic residents. All staff interviewed denied the allegation. Per staff interviews, staff stated only LVNs allowed to administer glucose check using glucose meter. Other staff were not qualified to administer residents’ glucose tests. Per record reviews, resident was on hospice care. No doctor prescription to order blood test on resident. As a result, there was not preponderance of evidence to show staff failed to address diabetic needs. In regards to the allegation of: staff are using a resident's room for work breaks, it was alleged that staff used resident’s room as a break room. Seven (7) out of eight (8) residents interviewed could not corroborate the allegation. Resident interviews revealed that staff did not use their room as staff's break room. All staff interviewed denied the allegation. Per staff interviews, staff stated they had their staff break room and did not need to use resident’s room for taking breaks. Per observation, staff took breaks in their staff break room. Therefore, staff did not use resident's room for work breaks. (-continued in LIC 9099 C-) Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted with Administrator. A hard copy of this reports were provided.the state’s words, verbatim · CDSS document, Jan 9, 2024 · control 28-AS-20220322090350

Allegation investigated: Administrator Speaks to residents in a disrespectful manner Facility staff did not perform room checks as needed Facility did not address bed bugs in resident room Residents not afforded comfortable accommodations

Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit for the allegation above. LPA met with Business/ HR Manager Lizbeth Acuna and the purpose of the visit was discussed. Initial visit conducted on 9/7/22 consisted of the following: LPA toured the physical plant. LPA requested a copy of the resident/staff roster. LPA interviewed Staff #1-#5 (S1-S5), LPA collected the following documents from Resident #1's (R1) file; physicians report, identification and emergency information, needs and services plan and Medication record for July/August 2022. LPA also collected documents from S2's staff file. As of todays visit. LPA has interviewed resident #1-#5 (R1-R5) and Staff #6-#7 (S6-S7). The investigation revealed the following: Continued on LIC 9099-C Unsubstantiated In regards to the allegation "Administrator Speaks to residents in a disrespectful manner" it was alleged that S1 speaks to residents inappropriately. (7) of (7) Staff interviewed denied the allegation. (4) of (5) Residents interviewed could not corroborate the allegation. (1) of (5) residents interviewed stated that S1 has spoken to them disrespectfully when they were greeting S1 and S1 spoke rude comments under their breath. S1 denied ever speaking disrespectfully to any residents in care. LPA was not provided proof that S1 speaks to residents in a disrespectful manner. LPA did not observe S1 speak disrespectfully to and about residents in care. Based on observation, interviews and file review; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. In regards to the allegation "Facility staff did not perform room checks as needed" it was alleged that the facility staff did not conduct room checks for R1 between 7/12/22-7/16/22. (7) of (7) staff interviewed denied the allegation. (4) of (5) Residents could not corroborate the allegation. Interviews with staff state that R1 is not on a plan that requires wellness checks throughout the day. Staff stated that rooms are visited everyday by housekeeping staff and room checks are done when residents are not observed to eat meals or get their medications. Interviews with staff show that R1 was leaving their room for meals and was receiving medications as scheduled. LPA did not observe documentation or reports stating that R1 required wellness checks from staff or was not able to get out of bed for the dates provided. Based on observation, interviews and file review; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. In regards to the allegation "Facility did not address bed bugs in resident room" it was alleged that R1 had bed bugs in January 2021 and staff did not address the issue in a timely manner. (7) of (7) Staff interviewed denied the allegation. (4) of (5) Residents interviewed could not corroborate the allegation. Interviews showed that R1 had bed bugs in their room in January of 2021 and were temporarily relocated rooms while their room received treatment. File review shows that the facility received pest control services for R1's room on 1/5/2021. Interviews could not inform LPA on when the facility was aware of the bed bugs up to the time that the pest control was provided as the staff who would have been in charge no longer work here. Based on observation, interviews and file review; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Continued on LIC 9099-C In regards to the allegation "Residents not afforded comfortable accommodations" it was alleged the R1 was relocated to a room with no blankets, no sheets, no pillowcase, no towels and no basic toiletries in January 2021 while their room was treated for bed bugs. (7) of (7) Staff interviewed denied the allegation. (4) of (5) Residents interviewed could not corroborate the allegation. S3 interview stated that they personally provided R1 with blankets, towels, and hygiene products while they were temporarily relocated rooms. All rooms in the facility have their own bathrooms for residents to use so R1 was not left without any accommodations. LPA was not provided proof that staff left R1 without their basic necessities or neglected assistance when needed. Based on observation, interviews and file review; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit Interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 28-AS-20220830111314

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff do not treat resident with dignity and respect.

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced initial 10 days complaint visit. LPA met with Staff/ Receptionist/ Michelle Bascom and shortly after met with Wellness Director/ Kathleen McDonald and discussed the purpose of today's visit. The investigation consisted of the following: On today's date, LPA interviewed Staff #1 - Staff #3, Staff #5 (S1-S4, and S5), attempt to interview Staff #4 via telephonically and interviewed Resident #2- Resident #7 (R2-R9), attempt interview Resident #1 (R1) via telephonically and obtained copy of staff and residents roster, R1's Face sheet, recent incident reports and Physician report. LPA collected training related to complaint topic regarding dignity and respect. LPA toured common areas and facility outside and inside premises. Continuation 9099-C... Unsubstantiated The investigation revealed of the following: Allegation 'Staff do not treat resident with dignity and respect. Interviews LPA conducted with Staff revealed (3) out of (4) staff denied the above allegation and informed LPA that Staff treat residents with dignity and respect and (4) out of (4) staff stated receiving training on how to treat, respect and communicate with residents in care. Interviews with residents (4) out of (6) residents informed LPA that the facility staff treats them and other residents nice and treat them with dignity and respect. LPA reviewed training's for S2-S5 related to topics of dignity and respect like Employee Handbooks/ duties and responsibilities, Compliance, Direct Care and Sexual Harassment. LPA observed staff and residents interactions during time of visit and staff were observed treating residents with dignity and respect. Based on statements gathered from interviews conducted with staff and residents, observations, record review, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held. A copy of the report will be emailed to Wellness Director Kathleen McDonald.the state’s words, verbatim · CDSS document, Dec 7, 2023 · control 28-AS-20231127095511

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Jose Villalobos conducted subsequent unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Staff Kim Mims. The following (3) of (12) CARE tool domains were completed during the inspection: Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar was reviewed Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. Last Emergency Drill completed 8/24/23 Residents with Special Health Needs: There are currently (6) residents on Hospice and (25) on Home Health Individual Service Plans and Appraisals are on file. No residents have prohibited health conditions. Auditory signals for emergency exits observed and operational No bodies of water observed and fireplace is blocked and inaccessible to residents All (12) domains have been completed as of todays visit. Per California Code of Regulations, Title 22, Deficiencies are being cited. Please see LIC 809-D page Exit interview was conducted and a copy of this report and appeal rights were provided and discussed.the state’s words, verbatim · CDSS document, Oct 31, 2023

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Staff Kim Mims. The following (9) of (12) CARE tool domains were completed during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan and Dementia Care Plan observed. A Hospice Waiver for 6 is approved. A fire clearance for 93 residents of which (93) may be non ambulatory; 0 may be bedridden. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. Physical Plant/Environment Safety: The physical plant consists of a two story building structure that contains the following: First floor consists of resident rooms with individual bathrooms, 1 living room, Dining Rooms, courtyard, 3 offices, medication room, kitchen, and laundry area. The facility second floor consists of the following: resident bedrooms with individual bathrooms, laundry room, outdoor porch seating area, and Activity room. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents.... Continued on LIC 809-C On 8/24/23, The sprinkler system, alarms, fire connections, and Fire panel were inspected. The facility has fully charged fire extinguishers. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. LPA tested rooms #109 , #118 , #121, #128, #125, #206, #215. #218, #221, #226, and #232. Staffing: A total of 42 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator on record is not current. Documents are pending Department review. Staff have criminal background clearance and training. Seven (7) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training was observed. Resident Records/Incident Reports: A total of seven (8) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records. Resident Rights-Information RCFE complaint poster and other required postings were observed. Training on personal rights observed Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies observed. Physician orders for modified diets are on file. Sanitation practices and kitchen cleanliness was observed. Incident Medical and Dental: Seven (7) centrally stored resident medications were reviewed. Medical and dental transportation is provided. Due to time constraints, LPA is unable to complete the annual inspection and will return at a later time to completed the remaining (3) of (12) Domains and conduct remaining interviews. Per California Code of Regulations, Title 22, NO deficiencies were cited. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 27, 2023

Allegation investigated: Resident sustained a fracture while in care.

Licensing Program Analyst (LPA) V. Maldonado made a subsequent, unannounced complaint visit at the facility for the purpose of investigating the above-mentioned allegation. LPA Maldonado met with Administrator, Itzayana Barba, and explained the purpose of the visit. On 03/21/22, LPA Angelica Rea made an initial visit and conducted a health and safety check. The following was reviewed: tour of the facility, including food supply, resident rooms, bathrooms, and common areas. LPA Rea requested copies of staff and resident roster along with other pertinent documents from resident #1's file. It was determined that further investigation was required. During today's visit, LPA Maldonado obtained a copy of the resident/staff roster, and conducted interviews with Staff# 1-5 (S1-S5) and Residents# 2-5 (R2-R5). LPA was unable to interview Resident#1 (R1) due to resident no longer residing at the facility. (Report Continued on LIC9099-C...) Unsubstantiated The investigation consisted of the following: Regarding allegation: Resident sustained a fracture while in care. It is alleged that R1 fell at the facility, which resulted in a fractured shoulder. Per incident report obtained, dated: 03/03/22, it is noted that facility reported to the licensing agency about R1 falling off R1's wheelchair on their left side, while being escorted to the dining room by staff and was attempting to reach to grab an object, while passing by. It was indicated that R1 was assisted up, observed for injury, and first aid was rendered. R1's family and hospice agency was notified. Per x-ray records obtained, it was noted that a mobile x-ray was completed by R1's hospice agency on 03/09/22, indicating that R1 had a "left humeral surgical neck fracture and AC separation". There is no indication on the report that the fracture was sustained due to a fall the resident had. Per interviews conducted with S1, S1 witnessed this fall and immediately notified R1's family, physician, and hospice care. S1 stated that R1 was assessed for injuries and did not have any. S1 also stated that R1 did not exhibit symptoms or express to be in pain at that time. S1 stated that R1 expressed pain a few days after, during a nurse visit from Hospice, and the hospice agency requested a mobile x-ray to be completed at the facility at that time. The x-ray showed a fracture, but it was not confirmed if it was due to the fall. Per S2, S2 recalls R1 getting diagnosed with a hairline fracture, however denies it occurring at the facility. S2 believes it was deemed to be an old fracture, but R1's family insisted it was new. (3) of (5) staff interviewed denied the allegation. Per R1's Physician's Report, Pre-Placement Appraisal, Needs and Services plan, and Current Appraisal, R1 was wheelchair bound and had a speech impairment due to diagnosis of hemiplegia and hemiparesis. There was also no indication that R1 had a history of falls. R1 required two-person assist for transferring, but was able to propel self on their wheelchair. (4) of (4) residents interviewed could not corroborate the allegation. Based on the interviews conducted, observations and files reviewed, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are Unsubstantiated. During the visit, no deficiencies were observed or cited. An exit interview was conducted with Cluster Nurse, Kim Mims and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 24, 2023 · control 28-AS-20220318093921

Allegation investigated: Staff did not assist resident with obtaining medical care. Licensee does not ensure staff dispensing medication to residents are appropriately trained. Staff did not dispense medication to resident as prescribed.

Licensing Program Analyst (LPA) Jose Villalobos conducted an initial complaint investigation visit for the allegation(s) above. LPA met with Administrator Itzy Barba and the purpose of the visit was discussed. On todays visit, LPA conducted the following: Toured the physical plant, Interviewed Staff #1-#7 (S1-S7) , interviewed residents #1-#6 (R1-R6), reviewed resident file for R1-R2, collected documents from R1 and R2's files, reviewed and collected documents from S1's file , and collected a copies of the staff and resident roster. The investigation revealed the following: In regards to the allegation "Staff did not assist resident with obtaining medical care." it was alleged that the facility staff do not assist with scheduling doctor appointments and transportation for R1. (7) of (7) Staff interviewed denied the allegation. (5) of (5) Residents interviewed could not corroborate the allegation. Interviews show that there was a lack of communication between the facility and R1's relative, who has Power of Attorney for Healthcare of R1.... Continued on LIC 9099-C Unsubstantiated There was a lack of confirmation regarding the doctor appointment schedule for R1 on 10/19/23, but the appointment and transportation were set and provided. Interviews showed that R1 was able to make their appointment and were transported by the facility. Interview with other residents of the facility do not show that there is no assistance with obtaining medical care. Based on interviews, files reviewed, and observations conducted, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Licensee does not ensure staff dispensing medication to residents are appropriately trained" it is alleged that S1 is not appropriately trained to dispense medications. (7) of (7) Staff interviewed denied the allegation. (5) of (5) Residents interviewed could not corroborate the allegation. LPA reviewed S1's file and observed required medication management training along with required hours to have been completed. Interviews with staff shows the staff is aware of the duties and tasks of staff who dispense medications. LPA was not provided with proof that S1 is not appropriately trained to dispense medications. Based on interviews, files reviewed, and observations conducted, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Staff did not dispense medication to resident as prescribed" it is alleged that staff did not provide R2 with their blood pressure medication for a week. (7) of (7) Staff interviewed denied the allegation. (5) of (5) Residents interviewed could not corroborate the allegation. Interviews do not show that staff have refused to provide R2 with their medications. Interview with R2 stated that it was only 1 day that was missed and it was on 10/19/23. Staff interviewed denied that medications was not provided to R2 on 10/19/23. LPA reviewed R2's medication record and observed that it was logged that R2 received their prescribed medications on 10/19/23. Based on interviews, files reviewed, and observations conducted, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit Interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 24, 2023 · control 28-AS-20231020093532

Allegation investigated: Staff serves resident cold meal(s).

This report is written to correct the citation from 97555(a) to 87555(a). Nothing else has changed. Allegation: Staff serves resident cold meal(s). it is alleged that the facility servers meals undercooked and cold. LPA interviewed six staff (S#1-S#6) and nine Residents (R#1-R#9). 4 of 6 staff interviewed stated that food is served hot but when served onto the cold plates it losses heat rapidly. 8 of 9 residents collaborated the allegation that food is served cold most of the time.9 of 9 residents could not collaborate the allegation that food is undercooked. Some staff stated they will reheat food for residents in micro-wave when asked. Some staff stated that 3 ovens in the kitchen are in disrepair and staff had used the ovens previously to warm the plates. Several staff stated that facility does not own a dish warmer that would solve the issue of food being served cold. Based on observation, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.the state’s words, verbatim · CDSS document, Oct 2, 2023 · control 28-AS-20230928134929

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)3) · Plan of correction due date: Oct 9, 2023

Managed Incontinence. Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidence by: 5 of 6 staff and 8 of 9 residents collaborated the allegation that there is a odor of urine in the common dining area and kitchen area on most days.the state’s words, verbatim · CDSS document, Oct 2, 2023

Plan of correction: The Executive Director will submit a written plan on how the facility will address the issue of keeping the clients clean and dry and the facility free of odors from incontinence and send it to LPA by POC dat

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Oct 9, 2023

General Food Service Requirements: The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be served in a safe and healthful manner. This requirement was not met as evidence by, 8 of 9 of the residents state, there was occasions when the meals were served to them cold; meaning, it was served to them in a way that was not in a healthful manner. 4 of six staff stated the they place the food while hot on the plates but the cold plates absorb the heat and the food arrives cold.the state’s words, verbatim · CDSS document, Oct 2, 2023

Plan of correction: The Executive Director shall provide a written meal service plan detailing how all meals will be served to the residents hot in a healthful manner. The required plan shall be submitted to CCL by the POC Date.

Allegation investigated: Facility smells of urine. Staff serves resident cold meal(s).

Licensing Program analyst (LPA) Alberto Lopez made unannounced 10-day visit to investigate the above allegations. LPA met with Executive Director Itzayana (Itzy) Barba Aguirre and discussed the purpose of the visit. The investigation consisted of taking a tour of the facility including the kitchen, dining room and TV rooms on the first and second floor. LPA reviewed and obtained copy of staff, facility rosters and Facility Admiission Agrement and interviewed six staff (S#1-S#6) and nine residents (R#1-R#9). The investigation revealed of the following: Allegation Facility smells of urine. It is alleged that facility common area such as dining room and TV rooms has bad order of urine and or body odor. Substantiated LPA interviewed 6 staff and 5 of 6 staff collaborated the allegation. S1 has only been here a week and could not comment on allegations and stated no complaints had been brought to her attention as of today. 5 staff all stated that some residents refuse showers and/or do not let the staff know if they need a change of diaper which is the source of the odor. S6 stated that residents that require a change of diaper are check every hour and are told that refusing impinges on other residents rights. 4 of 6 staff stated that even after residents leave their chairs, and after staff clean and disinfects, the odor remains in the dining room and TV rooms. Allegation: Staff serves resident cold meal(s). it is alleged that the facility servers meals undercooked and cold. LPA interviewed six staff (S#1-S#6) and nine Residents (R#1-R#9). 4 of 6 staff interviewed stated that food is served hot but when served onto the cold plates it losses heat rapidly. 8 of 9 residents collaborated the allegation that food is served cold most of the time.9 of 9 residents could not collaborate the allegation that food is undercooked. Some staff stated they will reheat food for residents in micro-wave when asked. Some staff stated that 3 ovens in the kitchen are in disrepair and staff had used the ovens previously to warm the plates. Several staff stated that facility does not own a dish warmer that would solve the issue of food being served cold. Based on observation, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies cited according to California Code of Regulations, Title 22. See LIC 9099D. NOTE: Please see Case Management - Deficiencies report.the state’s words, verbatim · CDSS document, Oct 2, 2023 · control 28-AS-20230928134929

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Oct 9, 2023

Managed Incontinence. Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidence by: 5 of 6 staff and 8 of 9 residents collaborated the allegation that there is a odor of urine in the common dining area and kitchen area on most days.the state’s words, verbatim · CDSS document, Oct 2, 2023

Plan of correction: The Executive Director will submit a written plan on how the facility will address the issue of keeping the clients clean and dry and the facility free of odors from incontinence and send it to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 97555(a) · Plan of correction due date: Oct 9, 2023

General Food Service Requirements: The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be served in a safe and healthful manner. This requirement was not met as evidence by, 8 of 9 of the residents state, there was occasions when the meals were served to them cold; meaning, it was served to them in a way that was not in a healthful manner. 4 of six staff stated the they place the food while hot on the plates but the cold plates absorb the heat and the food arrives cold.the state’s words, verbatim · CDSS document, Oct 2, 2023

Plan of correction: The Executive Director shall provide a written meal service plan detailing how all meals will be served to the residents hot in a healthful manner. The required plan shall be submitted to CCL by the POC Date.

Type of visit: Case Management - Deficiencies

During the course of a complaint investigation, Licensing Program Analyst (LPA) Alberto Lopez discovered that 3 ovens in the kitchen and the overhead vent is not operable which posed/poses a health and safety risk to residents in care. Deficiency cited under Title 22, Division 6 Chapter 8 Article 10. Food Services Please see 809D for details. Exit interview conducted and copy of report and appeals rights provided to Executive Director.the state’s words, verbatim · CDSS document, Oct 2, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(29) · Plan of correction due date: Oct 30, 2023

(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by: LPA observed 3 ovens and over head vent in the kitchen not operable which poses a health and stafety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 2, 2023

Plan of correction: Executive Director will repair or replace the 3 ovens and over head vent by POC date and send proof to LPA by POC date.