Willow Glen Senior Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Mary Ann Trinidad. During the visit, LPA observed 6 residents and 2 staff. LPA explained the purpose of the visit. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 6 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured to range from 116-119 degrees F in resident bathrooms. Fire extinguisher was serviced in March 10, 2026. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on May 26, 2026. The Emergency disaster plan was last reviewed on May 19, 2026 Page 1 Out of 2. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. While reviewing resident R1's Medications, LPA noted the white box container that was holding all of R1's medications had 2 loose tablets on the bottom of the box. ADM stated that medication was M1. ADM stated she talked with her staff and stated, staff attempted to administer the PRN at night and in the early in the morning, but R1 refused. ADM stated staff did not tape the tablets back in the bubble pack. A Deficiency is being cited during today's visit, see LIC809-D This report was reviewed with Administrator Mary Ann Trinidad and a copy of the signed report was provided. Appeal rights were provided. Page 2 Out of 2.the state’s words, verbatim · CDSS document, Jun 4, 2026

Allegation investigated: Staff member consumes alcohol during work hours, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care.

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator Mary Ann. On April 2, 2026, the Department received a complaint alleging Staff member consumes alcohol during work hours, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care. On April 3 & 6, 2026, the Department interviewed Witness W1. W1 stated the staff member who allowed drinking events at the facility was the Administrator Mary Ann. W1 stated the ADM will invite staff over to come drink at the care home for events such as a care givers birthday party. LPA asked W1 if the staff members, including ADM Marry Ann, were drinking and also providing care to residents. W1 stated the staff who were drinking were not providing care. Page 1 Out of 3. Unsubstantiated On April 6, 2026, Licensing Program Analyst Manuel Monter interviewed residents R1-R5. R1 stated he/she faintly remembers a staff member who smelled like they were intoxicated. R1 stated he/she doesn’t remember when this happened, or if the staff who smelled intoxicated was providing care to him/her or to other residents. 4 Out of 6 residents interviewed (R2-R5) stated they have not observed any staff drinking alcohol at the facility. 4 Out of 6 residents interviewed (R2-R5) stated they have not observed any staff under the influence/drunk/intoxicated at the facility. R6 stated he/she declined to be interviewed. On Apri 6, 2026, Licensing Program Analyst Manuel Monter interviewed staff S1 & S2. S1 and S2 stated they have never seen/heard about staff drinking (alcohol) inside the facility. S1 and S2 stated they have never drunk alcohol in the facility. S1 and S2 stated they have never seen staff working at the facility drunk/hungover/under the influence. On April 6, 2026, Licensing Program Analyst Manuel Monter interviewed Administrator Mary Ann. ADM stated there have been times when the care staff at the home might drink a glass of wine during their time off, inside the staff room. ADM stated they might also drink a glass of wine in the back yard, away from the residents. ADM stated the staff, even herself might have a glass of wine, but they have never done so when they are on the clock. ADM stated there is always staff scheduled, providing care, who do not drink. On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed staff S3 and S4. Staff S3 and S4 stated they are not aware of any instance were staff were under the influence and providing care. S3 and S4 stated they are not aware of any instance where the ADM was drinking / under the influence and providing care to residents. On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed Licensee Irish Ladwig, referred to as LN. LN stated there hasn't been any instance where a staff member was providing care, was also under the influence. Page 2 Out of 3. On April 24 and May 4, 2026, Licensing Program Analyst Manuel Monter interviewed staff S5-S7. S5 and S6 stated there has been many instances where staff were drinking at the facility. S5 and S6 stated they have never seen staff members who were drinking and providing care. S7 stated he/she has never seen other staff members drinking and providing care to residents. S7 stated he/she has never seen the ADM or staff members under the influence and providing care to residents. The Department reviewed the facility’s policy update, dated April 8, 2026, subject regarding: Strict Policy on Noise, Parties, Alcohol and smoking. The policy stated effective immediately, the following policies must be observed by all staff: No parties or loud activities: such as parties, gathering, karaoke- noting loud music or noise may disturb residents, families or neighbors. Alcohol consumption is prohibited inside the facility, whether on duty or off duty. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 3 Out of 3. End of Report.the state’s words, verbatim · CDSS document, May 7, 2026 · control 26-AS-20260402114257

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Merla Banglayan . During the visit, LPA observed 5 residents and 2 staff. LPA explained the purpose of the visit. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 6 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 118 degrees F in resident bathrooms. Fire extinguisher was serviced in February 11, 2025. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on April 14, 2025. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 1 resident. No deficiencies cited during today's visit. This report was reviewed with Licensee Irish Ladwig and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Jul 3, 2025

Type of visit: POC

On April 30, 2025, Licensing Program Analyst Manuel Monter conducted an unannounced POC visit. LPA met with Staff S1 Mila Gaton. S1 informed Licensee regarding LPA's visit. Licensee stated S1 could sign on her behalf. LPA explained the purpose of the visit. On April 24, 2025, the facility was cited the following type A deficiencies during a compliant investigation. The following code sections were cited on April 24, 2025, with a POC due date of April 25, 2025: 1. 87303 Maintenance and Operation (a) 2. 87555 General Food Service Requirements (b)(28) On April 25, 2025, the Department received the written plan of corrections. On April 30, 2025, LPA conducted a POC visit to clear the Type A POC's. A copy of the Letter of Deficiencies Cleared letter was provided. No deficiencies cited during today's visit. This report was reviewed with Staff Mila Gaton and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Apr 30, 2025

Allegation investigated: Facility is not meeting needs of residents with bladder/bowl incontinence at night

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with ADM Banglayan On February 21, 2025, the Department received a complaint alleging Facility is not meeting needs of residents with bladder/bowl incontinence at night. It has been alleged that the facility could not meet resident R1’s bladder/bowl incontinence needs at night. On February 27 and April 22, 2025, LPA interviewed Witness W1. W1 stated the Licensee complained to him/her that she had to pay for overtime, to meet R1’s needs at night. W1 acknowledged that he/she doesn’t know if the facility were or were not meeting R1’s incontinence needs at night. W1 stated it might have been happening, but he/she doesn't know for a fact. Page 1 Out of 3 Unsubstantiated On February 28, 2025, Licensing Program Analyst Monter interviewed residents R2-R7. R2 and R6 stated his/her bathroom needs are being meet at night. R3-R5 stated they doesn’t need assistance to use the restroom. Residents R2-R6 stated they have a call pendant they can press at night, and a care giver will assist them at night. Resident R7 stated he/she declined to be interviewed. LPA interviewed staff S1 and S2. S1 stated all the residents have a pendant. S1 and S2 stated if the residents need help, they press the pendant, and staff will go help them. S1 and S2 stated assistance is always provided when residents press the pendant. LPA interviewed Licensee Ladwig. LN stated R1 has the condition of going to the bathroom at night. LN stated R1 had an issue of having the sensation of needing to go to the bathroom. LN stated the staff was able to meet R1 needs incontinence needs at night. On April 9 and 21, 2025, LPA Monter interviewed staff S3-S5. Staff S3 stated he/she works the night shift. S4 stated he/she will cover the night shift for S3 when he/she calls in sick. S3 and S4 stated residents are checked/ changed every 2 hours at night. S3 and S4 stated staff respond to pendants, when pressed during the day and night. S3 and S4 stated they didn’t work with R1. Staff S5 stated he/she did work with R1 during the night shift. S5 stated resident R1 will get up multiple times at night, at least 4 times a night. S5 stated R1 will go to the bathroom by him/herself. S5 stated resident R1 has unsteady balance and for R1’s safety staff needs to be there to assist R1 in walking. S5 stated R1 will get out of his/her bed and use his/her walker to go to the bathroom, which is only 5 feet away from the bathroom. S5 stated he/she will hear a noise and will hear R1’s walker and S5 will go to assist R1. S5 stated R1 will sometimes use the pendant, call button to get assistance, but R1 most of the time would rather go by him/herself to the bathroom. Page 2 Out of 3. LPA interviewed Facility ADM. ADM stated at nighttime R1 would go to the bathroom by him/herself. ADM stated R1 would get up 1-4x a night and has the sensation of wanting to pee. ADM stated R1’s bedroom was directly across from the restroom, two steps away. ADM stated R1 can get up and walk with his/her cane to the bathroom. ADM stated the night staff know to assist R1 at night and do assist R1 when he/she wants to use the restroom. On April 23, 2025, LPA Monter interviewed Witness W1 and W2. Both witnesses interviewed stated R1 can stand up by him/herself and walk, with a walker, to the restroom across his/her bedroom to use the restroom, with supervision for his/her safety. W1 stated based on his/her observations, he/she didn’t witness him/herself any signs that R1’s incontinence needs were not being met. W2 stated there have been instances where he/she has found R1 sitting in soiled sheets that have already been dried but does not recall the dates when this occurred. W2 stated he/she has also found the resident soaked but stated he/she doesn’t know if it had been left soaked for an extended period and does not recall. Based on a review of R1’s Physician’s Report, dated July 15, 2024, R1 is able to independently transfer to and from bed. R1 also has bladder impairment. The Department reviewed R1’s Appraisal/Needs and Services Plan (ANS), dated October 29, 2024. The ANS states R1 is ambulatory with steady gait, able to move around independently, required supervision and assistance as needed in activity of daily living. R1 will be provided assistance as needed for toileting. Facility staff will check if wet and assist when changing diaper. The Department was unable to interview Resident R1, who no longer lives at the facility. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 3 Out of 3. END OF REPORT. R6 stated a couple months ago, he/she saw a cockroach in the bathroom. R6 stated he/she hasn’t seen the cockroaches or pests recently. Resident R7 stated he/she declined to be interviewed. On February 28, 2025, LPA Monter interviewed Licensee Ladwig (LN). LN stated ever since November 2024, the facility has been aware of the cockroaches and has been spraying. LN stated it’s an ongoing issue, and the facility has traps, cleaning and people who come and spray. On February 28, April 9 & 22, 2025, LPA Monter interviewed Staff S1-S5. S1 stated he/she hasn’t seen cockroaches inside the facility. S2 stated he/she has seen cockroaches in the facility kitchen. S2 stated he/she hasn’t seen cockroaches lately. S2 stated the first time he/she saw the cockroaches was in January 2025. S2 stated the last time he/she saw a cockroach was in the middle of February 2025. S3 he/she has not seen cockroaches or pests in the facility. S4 stated he/she has not seen cockroaches or pests in the facility. S5 stated he/she has seen cockroaches all over the facility. S5 stated the last time he/she saw cockroaches in the facility was in December 2024. On April 9, 2025, LPA Monter interviewed facility ADM. ADM stated she has seen cockroaches, in kitchen and both restrooms. ADM stated the facility is currently spraying to address the pest issue. ADM stated the pest control company just came yesterday. On April 23, 2025, LPA Monter interviewed Witness W1 and W2. Both witnesses interviewed stated they have seen cockroaches in R1’s bedroom and kitchen. Both witnesses interviewed stated the last time they saw cockroaches in the facility was in November 2024. Based on a review of the facility’s Pest Control Log, the log states the facility took actions to address cockroaches, on April 3, 2024. The Pest Control Log notes, the facility took actions to address cockroaches in May 2024, July 2024, August 2024, October 2024, November 2024, December 2024, February 2025, and March 2025. Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Page 2 Out of 4 Facility is not following food storage procedures, which endangers food safety, acceptability and nutritive values. On February 21, 2025, the Department received a complaint alleging facility is not following food storage procedures, which endangers food safety, acceptability and nutritive values. On February 28, 2025, Licensing Program Analyst Monter arrived unannounced to open the initial complaint investigation. During visit, LPA toured the facility inside and out. While touring the kitchen, LPA exited toward the backyard. LPA observed a stack of 5 cardboard boxes. LPA observed an assortment of cucumbers, apples, potatoes, eggplants in the first 3 boxes. Directly below these 3 boxes, was an additional two cardboard boxes. These boxes were designed with openings on the side to pick up. On the top of these two cardboard boxes was a gap reveling the contents of the box. Inside the bottom 2 boxes, LPA observed several broccoli and pieces of carrot. LPA observed the head of the broccoli had yellow and brown spots. LPA Monter interviewed Staff S1 and S2. S1 stated the broccoli food box is outside, near the sliding screen door, because the trash can is already full, and the broccoli was moldy. LPA asked S1 why the box of squash, eggplant and apples was placed on top of the spoiled broccoli. S1 stated they put the box of food there because there wasn’t any room inside the kitchen. S2 stated they put the broccoli outside, next to the sliding screen door because there is not enough room in the trash can. LPA asked why the box of vegetables is on top of the broccoli. S2 stated the facility kitchen is full and they have no space. S2 stated they put the box of food there while they make more room in the kitchen. Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Page 3 Out of 4. A civil penalty of $250 is being cited for a repeat violation, for the following code section: 87303 Maintenance and Operation (a), which was cited during a complaint investigation visit on August 14, 2024. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with ADM Banglayan and a copy of the report was provided. Appeal Rights was provided. Page 4 Out of 4. END OF REPORT. On February 28, 2025 LPA Monter interviewed Licensee Ladwig (LN). LN stated the facility has been administering resident’s medications and there hasn’t been any issue with medications and residents haven’t missed their medications. On April 9 and 22, 2025, LPA interviewed staff S3, S4, S5 and Administrator Merla Banglayan. Staff S3-S5 stated residents get their medications every day and there hasn’t been a day when a resident has missed their medication. ADM stated residents get their medications every day. ADM stated there hasn’t been a time when residents medications were missed or not administered. On April 9, 2025, LPA Manuel Monter randomly audited 3 resident’s medications. LPA audited the medications by cross referencing the medication bottles/ containers and cross referencing with the Centrally Stored Medication Record and Medication Administration Record. No discrepancies were noted during review. On April 23, 2025, LPA Monter interviewed Witness W1 and W2. W1 stated there has been an instance when medication had been prescribed but was not administered to R1. W1 stated he/she observed the medication administration was not marked on the Medication Administration Log. W1 stated he/she did not do an actual medication audit at the time and does not know for sure if the medication was or was not administered. W1 stated he/she does not remember the name of the medication with the noted discrepancy. W2 stated he/she did not observe any issues with regarding residents medications. Based on a review of R1’s Centrally Stored Medication Record, Medication Administration Record & PRN log, there was no discrepancy in R1’s medication records. The Department was unable to interview Resident R1, who no longer lives at the facility. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 2 Out of 4 Staff do not ensure facility is free from tripping hazards. On February 21, 2025, the Department received a complaint alleging Staff do not ensure facility is free from tripping hazards. On February 28, 2025, Licensing Program Analyst Monter arrived unannounced to open the initial complaint investigation. During visit, LPA toured the facility inside and out. While touring the facility LPA did not observe any tripping hazards. LPA Monter interviewed Licensee Ladwig. LN stated the home does not have any tripping hazards. LN stated she and her staff know to remove any tripping hazards or obstructions in the home. On April 9, 2025, LPA Monter arrived unannounced to conduct a follow up visit to continue the complaint investigation. During visit, LPA toured the facility inside and out. While touring the facility LPA did not observe any tripping hazards. LPA interviewed Facility Administrator. ADM stated the home does not have any tripping hazards. ADM stated she and staff ensure there isn’t any tripping hazards in the home. ADM stated she always removes anything potential tripping hazards. On April 23, 2025, LPA Monter interviewed Witness W1 and W2. Both witnesses interviewed stated they have not seen tripping hazards in the facility. On April 24, 2025, LPA Monter arrived unannounced to conduct a follow up visit to continue the complaint investigation. During visit, LPA toured the facility inside and out. While touring the facility LPA did not observe any tripping hazards. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 3 Out of 4. Staff are unable to communicate with residents due to language barrier. On February 21, 2025, the Department received a complaint alleging Staff are unable to communicate with residents due to language barrier. On February 28, 2025, Licensing Program Analyst Monter interviewed residents R2-R7. R2-R6 stated they are able to communicate with staff, and staff are able to respond to their requests. Resident R7 stated he/she declined to be interviewed. On February 28, April 9 & 21, 2025, LPA interviewed Staff S1-S5. All staff interviewed were able to answer LPA’s questions regarding the other allegations. All staff interviewed were able to answer that staff are supposed to do in an emergency situation such as a fire. LPA interviewed ADM and Licensee. ADM and LN stated all facility staff are able to communicate in English with residents in care. On April 23, 2025, LPA Monter interviewed Witness W1 and W2. Both witnesses interviewed stated staff are able to communicate when speaking to facility staff. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 4 Out of 4. END OF REPORTthe state’s words, verbatim · CDSS document, Apr 24, 2025 · control 26-AS-20250221111446

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Apr 25, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by; Based on observation, record review and interview the licensee did not ensure the facility was free of cockroaches. This poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: ADM stated they will submit a written plan of action on how they will ensure the facility is free from cockroaches. Licensee/ADM will seek professional help if the issue cannot be addressed. ADM stated they will submit the written plan of action to the Department by POC due date April 25,2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(28) · Plan of correction due date: Apr 25, 2025

87555 General Food Service Requirements (b)(28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement was not met as evidence by: Based on interview and observation, staff stored vegetables, fruits on top of a cardboard box of molding broccoli. This poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: ADM stated to submit a Plan of Correction on how she will ensure all Contaminated food shall be discarded immediately upon discovery. ADM stated she will submit the plan of correction to LPA by POC date, 4/25/25.

Allegation investigated: Facility staff are not meeting the needs of the resident Private care givers administer medications to resident Facility is in disrepair Facility water temperature is too hot Facility is not following resident's admission agreement

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding for the above allegations. LPA met with Licensee Irish Ladwig. On 07/13/2023, the Department received the complaint. On 07/19/2023, the initial complaint investigation was conducted. The following documents were obtained to include the, LIC500, sample menu, water heater invoice, email correspondences, text message exchanges, R1’s admission agreement, pre-placement appraisal, appraisal/needs and services plan, physician’s report, centrally stored medication record, sitter & companion role and responsibilities and other resident records. PAGE 1 OF 6. Substantiated Facility staff are not meeting the needs of the resident It was alleged that the facility staff are not meeting the needs of the residents due to resident (R1)’s private caregiver providing all activities of daily living (ADL) care to include showers, dressing, transportation to medical appointments, and medication administration. Based on review of R1’s needs and services plan, it’s indicated the facility will provide assistance as needed e.g. positioning, ambulation, toileting, feeding, dressing, bathing, way-finding, encourage daily physical activities such as walking, schedule daily walks, give medications as needed, and perform regular intentional rounding to assess need for position change, pain assessment, and personal needs such as toileting. Based on review of R1’s signed admission agreement, R1 was paying a monthly fee for “total care: personal full assistance with ADLs…” and “basic services”. The facility’s basic services includes, “assistance with bathing, dressing, grooming, toileting, eating, continence, transferring from bed or chair, and other personal needs”. Throughout the course of this investigation, 6 residents, 4 staff, and 1 witness was interviewed. Based on interview with R1’s private caregiver (W1), it was stated that W1 assists R1 with dressing, bathing, hygiene, grooming, daily activities like walks, and appointments. W1 states the facility’s caregivers dispenses R1’s medication and W1 gives the medication in a cup to R1. W1 states the facility’s caregivers does the laundry and cleans R1’s room. Based on staff interview, 4 out of 4 staff confirmed that R1 has a private caregiver during the day that assist R1 with his/her activities of daily living (ADL) care to include dressing, bathing, toileting, and activities. 4 out of 4 staff state that the facility’s staff only assists the resident during the night. During the day, the facility’s staff assists only with dispensing medications, meals, laundry, and cleaning. PAGE 2 OF 6. Based on interview with the Administrator on 07/19/2023, it was states that the facility staff manages the medications, prepares the food, does laundry, and clean R1’s room. ADM stated that R1’s 1:1 caregiver does “everything” and the facility staff helps out when R1’s 1:1 private caregiver goes on break. On 02/09/2024, the Administrator (ADM) was re-interviewed. Based on interview, it was stated that due to the time it took to assist R1 with activities such a walking, walking to a coffee shop, and to medical appointments they started the topic of a private caregiver for R1’s safety. The private caregiver was like a companionship. ADM stated that the facility’s staff are responsible for ADL care to include showers, grooming, and toileting. It was stated that at that time, there was confusion on the facility staff and private caregivers’ responsibilities. Private care givers administer medications to resident It was alleged that R1’s private caregivers will get the cup of medication and administer R1’s medications. Throughout the course of this investigation 4 staff, and 1 witness was interviewed. Based on interview with R1’s private caregiver (W1), it was stated the facility’s caregivers dispenses R1’s medication and W1 gives the medication in a cup to R1. Based on staff interview, 4 out of 4 staff state R1’s private caregiver administers R1’s medications. S1 states R1’s private caregiver asks for permission to get R1’s medication cup and will give it to R1. S4 stated when dispensing R1’s medication they dispense the medication in the cup then hand it over to the personal caregiver. Staff then checks on R1 to make sure R1 take his/her medication. Based on interview with the Administrator and Licensee, it was stated that the private caregiver did administer the medication to R1 and that it did happen. Licensee states R1's private caregiver is trained on medication administration. PAGE 3 OF 6. Facility is in disrepair It was alleged that the facility is in disrepair as there was only one shower available for the residents and staff to use in the home. It was also alleged that the bathroom near R1’s bedroom had a hole on the left side of the toilet, and the bathroom fan was dysfunctional. On 07/19/2023, LPA Dolores toured the facility and observed the bathroom shower located in the hallway contained a large chair and boxes. Based on staff interview, it was stated that the shower was not in use because it is in disrepair. It was stated that all residents and staff used the shower near R1’s bedroom. On 01/24/2024, LPA Monter toured the facility and observed the bathroom shower located in the hallway was fixed. Based on review of the photographs obtained, it shows the bathroom near R1’s bedroom contained a hole behind the left side of the toilet. The photo also shows the lid of the fan was placed on top of the toilet. It was stated that the fan was replaced by the Licensee. Based on interview, R1’s responsible party voluntarily hired a contractor to fix the hole behind the toilet. Facility water temperature is too hot It was alleged that the facility’s water temperature is too hot. On 07/19/2023, LPA Dolores measured the hot water temperature near R1’s bedroom. The hot water temperature was measured at 125 degrees Fahrenheit. On 07/19/2023, the Administrator was interviewed. Based on interview, it was stated that they had an issue with the water heater and shower. It was stated that they hired a plumber who came to the facility 2 weeks ago. It was stated that sometimes the staff doesn’t tell the Administrator right away, when things are broken. On 01/24/2024, LPA Monter measured the hot water temperature near R1’s bedroom. The water temperature rose to 125 degrees Fahrenheit then dropped to 100 degrees Fahrenheit. Staff stated it might be due to the washing machines currently running. On 02/09/2024, LPA Dolores measured the hot water temperature to be maintained at 130 degrees Fahrenheit. PAGE 4 OF 6. Facility is not following resident's admission agreement It was alleged that the facility is not following R1’s admission agreement as the facility did not provide R1 with basic services to include hygiene items, weekly laundry, cleaning of R1’s room, assistance for transportation to appointments, and activity of daily living (ADL) care. It was alleged that R1’s private caregiver assisting R1 with bathing assistance, dressing assistance, tray for meals, changing, brushing of teeth, providing R1’s responsible party with updates, and medication administration. Based on review of R1’s signed admission agreement, it’s stated that the licensee will provide the resident with basic services to include (but not limited to): hygiene items or general use of such soap and toilet paper; plan/arrange/and/or provide for basic transportation to medical and dental appointment; assistance with bathing, grooming, toileting, eating, continence, transferring from bed or chair, and other personal needs; assistance in meeting necessary medical and dental needs; assistance with taking prescribed and over-the-counter medications. Throughout the course of this investigation, 6 residents, 4 staff, and 1 witness was interviewed. Based on interview with R1’s private caregiver (W1), it was stated that W1 assists R1 with dressing, bathing, hygiene, grooming, daily activities like walks, and appointments. W1 states the facility’s caregivers dispenses R1’s medication and W1 gives the medication in a cup to R1. W1 states the facility’s caregivers does the laundry and cleans R1’s room. Based on staff interview, 4 out of 4 staff confirmed that R1 has a private caregiver during the day that assist R1 with his/her activities of daily living (ADL) care to include dressing, bathing, toileting, and activities. 4 out of 4 staff state that the facility’s staff only assists the resident during the night. During the day, the facility’s staff assists only with dispensing medications, meals, laundry, and cleaning. PAGE 5 OF 6. Based on interview with the Administrator on 07/19/2023, it was states that the facility staff manages the medications, prepares the food, does laundry, and clean R1’s room. ADM stated that R1’s 1:1 caregiver does “everything” and the facility staff helps out when R1’s 1:1 private caregiver goes on break. On 02/09/2024, the Administrator was re-interviewed. Based on interview, R1’s private caregiver’s role was to provide companionship as R1 was a high fall risk due to his/her medical condition. It was stated that there was initially confusion with staff and the private caregiver of their roles and responsibilities. The Administrator states the facility provides basic hygiene items, however, the resident's and/or resident's responsible parties may provide their own if there are specific brands they prefer. It was stated that R1's responsible party wanted to take R1 to medical appointments and sometimes the private caregiver would take R1 to R1's medical appointment and meet with R1's responsible party. During the initial investigation on 07/19/2023, there was no written agreement or contract that was produced to differentiate the responsibilities of the facility staff and private caregiver. Based on record review, on 08/23/2023 a “sitter & companion role and responsibilities” contract was written showing the breakdown of duties for caregivers and the private care giver. The Department has investigated the above allegations. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegations are SUBSTANTIATED. Deficiencies were cited per California Code of Regulations, Title 22. LIC9099-D. This report was reviewed with Licensee, Irish Ladwig and a copy of the report and appeal rights were provided. PAGE 6 OF 6. Facility staff inappropriately touched resident It was alleged that a male staff had inappropriately touched R1. It was alleged that an alarm went off in R1’s room and the staff (S2) saw R1 was almost falling out be bed. S2 caught R1 and R1 perceived it to be inappropriate touching. It was alleged that S2 touched R1 around the abdomen area. Throughout the course of this investigation, 6 residents, 4 staff, and 1 witness was interviewed. Based on staff interview, S2 denied any incidents of inappropriately touching of residents. S2 stated there was an incident that happened at the dining table where R1 looked like he/she was about to fall. S2 ran and grabbed R1 under his/her arm because R1 almost fell down. S2 did not remember where he/she touched R1. S2 states it happened once and it was only to help R1 because he/she was about to fall. 3 out of 3 staff denied the observation of staff touching residents and R1 inappropriately. Based on resident interview, 5 out of 6 resident’s denied staff inappropriately touching them. 5 out of 6 residents’ denied the observation of staff inappropriately touching another residents. 1 out of 6 resident’s was unable to be interviewed. Based on interview with R1's private caregiver (W1), W1 only heard of the incident. It was stated that R1 did not have a private caregiver at the time. Facility is not securely storing medication It was alleged that R1’s private caregiver kept one of R1's medication in R1’s room. Based on interview with R1’s private caregiver (W1), it was stated the facility’s caregivers dispenses R1’s medication and W1 gives the medication in a cup to R1. W1 states the medication is locked in the kitchen, which W1 does not have access to the medication cabinet. PAGE 2 OF 4. On 07/19/2023, LPA Dolores entered into R1’s room and did not observe medication that was left out in R1's room. LPA Dolores toured the facility and entered in all resident bedrooms and did not observe any medication that was accessible to the residents. LPA observed the medication storage area was secured in a locked cabinet and inaccessible to residents in care. On 01/24/2024, LPA Monter observed the medication storage area was secure and inaccessible to residents in care. Facility is not following facility meal plan It was alleged that the facility is not following the meal plan because there was a time where there were no fresh fruits or vegetables delivered and the resident’s were eating canned food and microwave foods. It was also alleged that the resident’s were not being served green salads. Throughout the course of this investigation, 6 residents and 3 staff were interviewed. Based on resident interview, 5 out of 6 residents states they get vegetables and fruits every day. 1 out of 6 residents was unable to be interviewed. R2 states they eat a lot of frozen food like vegetables and meat. It was stated they have Salisbury steak with fresh mashed potatoes and vegetables. It was stated that the facility serves them salad. It was stated that they have fruit every day. R3 states they get fresh vegetables practically every day to include a salad. R3 states he/she doesn’t always eat the salad. R4 states the vegetables are mushy and frozen. R4 states they get frozen vegetables 5 days a week. R4 states that sometimes they get fresh beats and carrots. R4 preferred certain fruits than what the facility was serving. R5 states the food is very good. R4 states they serve both frozen and fresh fruits and vegetables. R6 states the facility serves ordinary things to include fruits and vegetables. PAGE 3 OF 4. Based on staff interview, S1 states to ask the resident’s what they want to eat. It was stated that they serve salad every afternoon. S1 states they do not serve frozen vegetables and it’s always fresh. S2 states they ask the residents what they want to eat because each resident likes different dishes. S2 states they use both frozen and fresh vegetables but usually use fresh vegetables. The Administrator states that groceries are delivered every 2 weeks and as needed. It was stated that the resident’s are very specific with what they want to eat and ADM accommodates to their needs if able. ADM states the menu posted on the refrigerator is only a sample. On 07/19/2023, LPA Dolores observed the kitchen had at least 2 days worth of perishables and 7 days worth of non-perishable foods. LPA Dolores observed fruits to include apples and watermelon and vegetables to include lettuce, tomatoes, onions, and potatoes. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the allegations did/did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee Irish Ladwig and a copy of the report was provided. PAGE 4 OF 4.the state’s words, verbatim · CDSS document, Aug 14, 2024 · control 26-AS-20230713135124

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(a) · Plan of correction due date: Aug 15, 2024

(a) The services provided by the facility shall be conducted so as to continue and promote, to the extent possible, independence and self-direction for all persons accepted for care. Such persons shall be encouraged to participate as fully as their conditions permit in daily living activities both in the facility and in the community. This requirement is not met as evidenced by: Based on interview, record, and observation the licensee did not ensure the facility staff provided basic services to include ADL care to resident (R1) which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 14, 2024

Plan of correction: Licensee has corrected their deficiency prior to visit by completing a sitter & companion role and responsibilities contract in collaboration with R1's family member.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 15, 2024

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interview, the licensee did not ensure to assist R1 with self-administration of medication as R1’s private caregiver was administering R1’s medication which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 14, 2024

Plan of correction: Licensee has corrected their deficiency prior to visit by completing a sitter & companion role and responsibilities contract in collaboration with R1's family member.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Aug 15, 2024

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was met as evidenced by: Based on interview, record review, and observation the licensee did not ensure the bathrooms were in good repair which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 14, 2024

Plan of correction: Licensee has already corrected the deficiency prior to visit by repairing the bathroom shower in the hallway and items that were in disrepair near R1's bedroom.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Aug 15, 2024

(e) Water supplies and plumbing fixtures shall be maintained as follows (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was met as evidenced by: Based on interview, record review and observation the licensee did not ensure the hot water temperature was not more than 120 degrees F measuring between 125 – 130 degrees F which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 14, 2024

Plan of correction: Licensee will submit a statement of understanding of the section cited to LPA Dolores via email by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Aug 21, 2024

(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by: Based on interview, record review, and observation the licensee did not ensure to comply with all the applicable terms and conditions set forth in the admission agreement as R1’s private caregiver was providing R1 with basic services which poses an potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 14, 2024

Plan of correction: Licensee will submit a statement of understanding of the section cited above to LPA Dolores via email by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Licensee (LN) Irish Ladwig. During the visit, LPA observed 5 residents and 3 staff. LPA toured the facility inside out with LN which included the Living room, kitchen, dining room, 2 restrooms and 6 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 79 degrees F, and hot water temperature was measured at 119 degrees F in both resident bathrooms. Fire extinguisher was serviced in March 7, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by LN, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on April 18, 2024. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff and 2 residents. No deficiencies cited during today's visit. This report was reviewed with Licensee Irish Ladwig and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Jul 5, 2024