Windsor Court Assisted Living

Allegation investigated: Staff do not ensure that facility is free of pests.

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to initiate the investigation into the allegation listed above. The LPA met with Samara Harris, Director of Business Development, and informed them of the purpose of the LPA’s visit. On July 1, 2026, Community Care Licensing (The Department) received a complaint report with the following allegation. It was alleged that staff do not ensure that facility is free of pests. Information received indicated that residents' rooms are infested with insects. LPA conducted a tour of interiors of the facility and observed dead insects in Resident #1's (R1) room floor. LPA conducted interviews with nine (9) additional residents. Seven (7) out of none (9) residents interviewed stated that there have been ongoing insect issues in their rooms and bathrooms. LPA conducted interviews with three (3) staff members. Continued on LIC9099-C.... Substantiated Two (2) out of three (3) staff members interviewed stated that they have seen insects in the residents rooms on daily basis. Based on interviews conducted and observation, the evidence found during the Department’s investigation met the preponderance of evidence standard. Therefore, this allegation is substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where a copy of this report was provided, along with a copy of LIC9099D, and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jul 3, 2026 · control 18-AS-20260701142111

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80087(a)(1) · Plan of correction due date: Jul 17, 2026

80087 Buildings and Grounds, (a) The facility shall be clean, safe, sanitary and in good repair at all times..., (1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement was not met as evidenced by: Based on interviews conducted and observation, staff did not ensure residents' rooms were free of insects. This posed potential personal rights and/or health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 3, 2026

Plan of correction: Director of business development agree to discuss the matter with the Administrator and the Licensee and send proof of pest control services to LPA by the POC due date via email.

Allegation investigated: Staff do not answer resident's call button in a timely manner Staff do not ensure resident's showering needs are being met Staff do not ensure residents’ incontinence needs are being met Staff do not ensure that resident's have clean linen Staff are smoking inside the facility

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Aurelien Fruit, Administrator, and informed them of the purpose of the LPA’s visit. The Department’s investigation involved interviews with staff and residents and review of records. On October 8, 2024, Community Care Licensing (The Department) received a complaint report with the following allegations. It was alleged that staff do not answer resident’s call button in a timely manner. Information received indicated that PM shift staff members did not respond to residents’ call button. LPA conducted interviews with nine (9) residents. Seven (7) residents interviewed stated that they were satisfied with staff’s call button response time. Two (2) residents interviewed stated that they have experienced delayed staff response time a few times in the past. Continued on LIC9099-C.... Unsubstantiated LPA conducted interviews with five (5) staff members, all of whom stated that call button response time could vary depending on what the staff member were working on, but staff members usually responded in about 10 to 15 minutes. All five (5) staff members interviewed expressed that they had to finish what they were doing for a resident before they can respond to the next resident. Based on interviews conducted, the Department’s investigation did not provide enough information to corroborate the allegation that staff do not answer resident’s call button in a timely manner. This allegation is unsubstantiated. It was alleged that staff do not ensure resident’s showering needs are being met. Information received indicated that Resident #1 (R1) did not receive shower or bathing services. LPA conducted an interview with R1 who stated that they did not have any problems receiving bathing services from the facility staff members. R1 did not have any concerns with the facility staff. LPA conducted interviews with additional eight (8) residents, all of whom stated that they received shower/bath services per their schedules. All eight (8) residents interviewed denied missing any shower/bath service in the past. LPA’s interviews with five (5) staff members confirmed the statements from the residents interviewed. The staff members stated that some residents do refuse shower/bath service, and staff members just note the resident’s file for record keeping. Based on interviews conducted, the Department’s investigation did not provide enough information to corroborate the allegation that staff do not ensure resident’s showering needs are being met. This allegation is unsubstantiated. It was alleged that staff do not ensure residents’ incontinence needs are being met. Information received indicated that residents were left in soiled diapers during PM shift due to staff neglect. LPA conducted interviews with nine (9) residents, all of whom stated that they were satisfied with the incontinence care services provided by the staff. LPA conducted interviews with five (5) staff members, all of whom stated that incontinence care services were provided every two (2) hours or per request from residents. LPA’s records review revealed that staff did not have incontinence care logs. Based on the interviews conducted and records review, the Department’s investigation did not provide enough information to corroborate the allegation that staff do not ensure residents’ incontinence needs are being met. This allegation is unsubstantiated. It was alleged that staff do not ensure that residents have clean linen. Information received indicated that staff did not change residents’ wet bedding. LPA conducted interviews with nine (9) residents, all of whom denied experiencing wet bedding or lack of laundry services from staff. Continued on LIC9099-C.... LPA conducted interviews with five (5) staff members, all of whom stated that laundry services were done according to the facility schedule which is two (2) times per week or right after shower/bath service. None of the five (5) staff members interviewed heard any complaints about linen change from residents. Based on interviews conducted, the Department’s investigation did not provide enough information to corroborate the allegation that staff do not ensure that residents have clean linen. This allegation is unsubstantiated. It was alleged that staff are smoking inside the facility. Information received indicated that staff members were observed to be smoking in a vacant resident room while they were on duty. The information was referring to PM shift caregivers. LPA conducted interviews with nine (9) residents, all of whom denied witnessing staff members smoking inside the facility. LPA conducted interviews with five (5) staff members, all of whom denied witnessing or smoking inside the facility. LPA conducted a tour of the facility and observed several residents smoking outside the residential building by the swimming pool. LPA did not observe anyone, including staff members, smoking inside the facility during the facility tour. Based on interviews conducted and observations, the Department’s investigation did not provide enough information to corroborate the allegation that staff are smoking inside the facility. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, May 29, 2026 · control 18-AS-20241008114454

Allegation investigated: Staff confine residents to bedrooms Staff do not ensure that residents' dietary needs are being met Staff do not communicate with residents regarding care

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Aurelien Fruit, Administrator, and informed them of the purpose of the LPA’s visit. The Department’s investigation involved interviews with staff and residents and records review. On October 21, 2025, Community Care Licensing (The Department) received a complaint report with following allegations. It was alleged that staff confine residents to bedroom. Information received indicated that Staff #1 (S1) confined residents who had COVID to their bedrooms. LPA conducted interviews with ten (10) residents, all of whom denied being confined by S1 or any other staff members. All ten (10) residents interviewed stated that the infected residents isolated in their rooms by themselves, and no one was forced to be isolated. Continued on LIC9099-C.... Unsubstantiated LPA conducted interviews with three (3) staff members, all of whom denied confining any residents. All three (3) staff members interviewed stated that none of the residents expressed any concerns or complaints regarding isolation during COVID outbreak. LPA’s records review revealed that staff followed the procedures according to their plan of operation. Based on the interviews conducted and records review, the Department’s investigation did not provide enough information to corroborate the allegation that staff confine residents to bedroom. This allegation is unsubstantiated. It was alleged that staff do not ensure that residents’ dietary needs are being met. Information received indicated that those residents who were in isolation missed their meals. LPA conducted interviews with ten (10) residents, all of whom denied missing any meals. Six (6) of the ten (10) residents interviewed were tested positive for COVID, and staff delivered three (3) meals to their rooms during the isolation periods. LPA conducted interviews with three (3) staff members, all of whom stated that all meals were delivered to the residents’ rooms during their isolation periods. None of the three (3) staff members interviewed heard any complaints about missed meals from residents. Based on interviews conducted and records review, the Department’s investigation did not provide enough information to corroborate the allegation that staff do not ensure that residents’ dietary needs are being met. This allegation is unsubstantiated. It was alleged that staff do not communicate with residents regarding care. Information received indicated that some residents who were in isolation for five (5) days were asked to be isolated again for another five (5) days without any explanation. LPA conducted interviews with six (6) residents who were tested positive for COVID. One (1) resident tested positive stated that they were in isolation for 10 days. Five (5) residents tested positive stated that they were in isolation for five (5) days only. LPA conducted interviews with three (3) staff members, all of whom stated that staff followed the facility’s plan of operation regarding COVID outbreak. Residents who were tested negative on day six (6) were given OK stop isolation. Residents who were tested positive on day six (6) were asked to continue isolation for another five (5) days. LPA’s records review confirmed the statements from the staff members interviewed. Based on interviews conducted and records review, the Department’s investigation did not provide enough information to corroborate the allegation that staff do not communicate with residents regarding care. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, May 29, 2026 · control 18-AS-20251021122436

Allegation investigated: Facility did not maintain a safe vehicle for clients in care

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Aurelien Fruit, Administrator, and informed them of the purpose of the LPA’s visit. The Department’s investigation involved interviews with staff and residents and review of records. On July 24, 2024, Community Care Licensing (The Department) received a complaint report with the following allegation. It was alleged that facility did not maintain a safe vehicle for clients in care. Information received indicated that the facility’s transportation vehicle did not have a working air conditioner. LPA’s interviews with the Administrator, Director of Nursing, and maintenance manager revealed that the transportation vehicle did not have working air conditioner for over 30 days. Staff provided transportation services to residents in the morning only to avoid hot weather. Continued on LIC9099-C.... Substantiated LPA obtained and reviewed the maintenance record and confirmed the air conditioner repair. Based on interviews conducted and records review, the Department’s investigation provided enough information to corroborate the allegation that facility did not maintain a safe vehicle for clients in care. This allegation is substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where a copy of this report was provided along with LIC9099D, and Appeal Rights were provided. R1 asked to be relocated to the newly renovated room, but the facility management denied R1’s request by stating that the room was reserved for a resident with a private residence agreement. LPA conducted interviews with the Administrator and Director of Nursing, both of whom stated that no residents had been promised any specific rooms. Rooms are assigned upon availability. R1 is a resident who is under a special program that requires a shared room. The room that R1 had requested is a private residence, not a shared room. LPA conducted records review and verified the statements from the Administrator and Director of Nursing. LPA conducted interviews with eight (8) residents, all of whom stated that staff members have treated residents with respect. Based on interviews conducted and records review, the Department’s investigation did not provide enough information to corroborate the allegation that staff are not treating resident with respect and dignity. This allegation is unsubstantiated. It was alleged that licensee is not maintaining the facility in good repair. Information received indicated that staff did not fix a leak in Resident #1’s (R1) bathroom where there was mold. LPA conducted an interview with R1 in their room. LPA did not observe any leaks in the bathroom. LPA did not observe any mold anywhere in R1’s room. R1 wanted to talk about changing their room only while LPA conducted the interview and room observation. LPA conducted interviews with eight (8) residents, all of whom denied having any problems with facility maintenance. LPA did not observe any leaks or mold during the tour of the facility and interviews with residents. LPA did not observe any maintenance concerns throughout the facility. Based on interviews conducted and observations, the Department’s investigation did not provide enough information to corroborate the allegation that licensee is not maintaining the facility in good repair. This allegation is unsubstantiated. It was alleged that staff do not assist resident with arranging transportation for medical care. Information received indicated that staff did not help with Resident #1 (R1) getting to the doctor’s appointment. LPA conducted an interview with R1 who stated that R1 could call and make appointments with their doctors, but staff did not arrange transportation. R1 stated that they missed some of the doctors’ appointments due to lack of help from staff. LPA conducted interviews with the Administrator and Director of Nursing, both of whom stated that all residents can arrange transportation at the front desk 48 hours in advance. LPA’s records review confirmed the statements from the Administrator and Director of Nursing. LPA conducted interviews with eight (8) residents, all of whom stated that they either take the facility transportation vehicle or healthcare provided transportation for their healthcare needs. Continued on LIC9099-C.... None of the residents interviewed expressed any problems with staff arranging transportation. Based on interviews conducted and records review, the Department’s investigation did not provide enough information to corroborate the allegation that staff do not assist resident with arranging transportation for medical care. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, May 29, 2026 · control 18-AS-20240724160551

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87312 · Plan of correction due date: May 29, 2026

Motor Vehicles Used in Transporting Residents: Only drivers licensed for the type of vehicles,,, Any vehicle used by the facility to transport residents shall be maintained in a safe operating condition. This requirement was not met as evidenced by: Based on interviews conducted and records review, the facility transportation vehicle did not have working air conditioner for over 30 days. This posed potential personal rights and health and safety risks to residents in care.the state’s words, verbatim · CDSS document, May 29, 2026

Plan of correction: Licensee replaced the air conditioner in the transportation vehicle as evidenced by repair invoice observed by LPA.

Allegation investigated: Licensee does not ensure the facility is sufficiently staffed Staff do not ensure residents receive bathing assistance in a timely manner

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Aurelien Fruit, Administrator, and informed them of the purpose of the LPA’s visit. The Department’s investigation involved interviews with staff and residents and review of records. On November 10, 2025, Community Care Licensing (The Department) received a complaint report with the following allegations. It was alleged that licensee does not ensure the facility is sufficiently staffed. Information received indicated that the facility is understaffed, and the staff members are working double-shifts frequently. LPA conducted interviews with eleven (11) residents, all of whom denied experiencing staff shortages. None of the residents interviewed missed any scheduled facility services. Continued on LIC9099-C.... Unsubstantiated LPA conducted interviews with six (6) staff members. Four (4) staff members interviewed stated that staff coverage was sufficient. One (1) staff member interviewed stated that they sometimes were asked to cover another caregiver’s duty about once a week when a caregiver did not show up to work. Another staff member interviewed stated that some staff members were asked to work double shifts but denied having staff shortage. LPA’s records review did not reveal any staff shortages. Based on interviews conducted and records review, the Department’s investigation did not provide enough information to corroborate the allegation that licensee does not ensure the facility is sufficiently staffed. This allegation is unsubstantiated. It was alleged that staff do not ensure residents receive bathing assistance in a timely manner. Information received indicated that some residents did not receive scheduled weekly showers due to staff being tired from working too many hours. LPA conducted interviews with eleven (11) residents, all of whom denied missing shower or bath assistance from staff members. All residents interviewed stated that staff members provided shower/bath services per the weekly schedule. LPA conducted interviews with six (6) staff members. Four (4) staff members interviewed stated that they have not heard about missing shower from any residents. Two (2) staff members interviewed stated that they have heard from some residents that shower was never refused, but the shower logs showed “refused”. But neither staff members provided the names of the residents showing “refused” in the logs. Based on interviews conducted, the Department’s investigation did not provide enough information to corroborate the allegation that staff do not ensure residents receive bathing assistance in a timely manner. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, May 29, 2026 · control 18-AS-20251110084541

Allegation investigated: Kitchen staff vapes during working hours

Licensing Program Analysts (LPA) Seo Jeon and Janira Arreola conducted an unannounced visit to the facility to initiate an investigation into the above allegation. LPA met with Aurelien Fruit, Administrator. The Department’s investigation involved interviews with staff and review of records. On April 20, 2026, Community Care Licensing (The Department) received a complaint report with the following allegation. It was alleged that kitchen staff vapes during working hours. Information received indicated that one kitchen staff member was observed vaping inside the facility kitchen while on duty once in January 2026. LPA conducted interviews with five (5) kitchen staff members, all of whom denied witnessing any staff members smoking or vaping inside the facility kitchen. All staff members interviewed stated that there was a designated smoking area outside the facility builing where a few staff members smoke cigarettes during their break. All staff members interviewed stated that they have not seen any staff members who use vapes. Continued on LIC9099-C.... Unsubstantiated LPA conducted an interview with the Administrator who stated that the management conducted an internal investigation into an allegation similar to this complaint report, but the management did not find any corroborating information or witnesses to the alleged incident. Based on interviews conducted, the Department's investigation did not provide enough information to corroborate the allegation that kitchen staff vapes during working hours. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 27, 2026 · control 18-AS-20260420125053

Allegation investigated: Facility staff are not ensuring elevator is maintained in good repair. Facility staff did not respond to resident's call button. Facility staff did not dispense medications as prescribed.

On March 29, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent complaint visit. Bobbie Rodriquez, Memory Care Director, greeted the (LPA). (LPA) explained the purpose of the visit is to investigate the allegations mentioned above. The investigation included the collection of records, interviews, and observations of the facility on January 31, 2026, March 05, 2026, and March 28, 2026. The Department obtained several documents, including the Facility Roster (dated 03/26/26), the Resident Roster (dated 03/26/26), Mandatory Training for Med-Techs, Facility Work Order Summary (dated 05/22/25), and Resident #1 (R1)'s service records and other pertinent documents associated with this complaint. Interviews conducted with Resident #1-#20 and Staff #1-#9. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Facility staff are not ensuring elevator is maintained in good repair It is alleged that the facility staff is not ensuring the elevator is maintained in good repair. There are concerns about the broken elevator at the facility, which has been out of service for 3 months and is affecting emergency evacuation. It is feared that, in an emergency, residents on the upper level may not be able to evacuate. No further information is provided regarding this matter. On June 2, 2025, and March 28, 2026, between 09:15 AM and 03:10 PM, the Department interviewed resident members identified as Resident #1 through Resident #20 (R1-R20). Ten (10) out of twenty (20) could not validate this claim. Residents acknowledge that the rear elevator occasionally breaks down, but 10 residents could not support the claim that the elevators were down for 3 months and that facility staff did not ensure they were maintained in good repair. (R2-R10 and R20) verified that the facility has a service contract with the elevator contractor and has observed them providing services to the elevators to maintain them in working condition, and that there was always one working elevator in service, and never encountered both elevators being out of service. Residents will be informed that when elevators are out of service, their status and any delays will be communicated by facility staff. On June 02, 2025, and March 28, 2026, between 12:40 PM and 3:10 PM, the Department interviewed staff members identified as Staff #1 through Staff #9 (S1-S9). Five (5) out of nine (9) staff members could not validate this claim. (S1-S5) confirmed that the facility is committed to ensuring elevators are in good repair. (S1-S5) verified that there was always one elevator in working condition; they never had both elevators out of service. (S1 and S5) confirmed that the process for submitting work orders through the front desk is verified and that compliance documentation is up to date. The maintenance team reviews the work order summary daily, prioritizes tasks, and documents the time taken for each completed task. While most repairs are handled promptly, some may face delays due to the need for outside vendors or parts, as vendor-part orders delayed the rear elevator repair, which the facility had no control over. (S5) highlighted that recognizing the facility's limited control over delays can help set realistic expectations and improve communication about repairs. (Evaluation Report continues LIC 9099-C) During the visits on January 31, 2026, March 5, 2026, and March 28, 2026, an inspection of the facility found both elevators in working condition and that the physical plant, including floors, windows, and doors, fixtures, and furniture, was in good repair. The Department observed that two evacuation chairs are available to transport residents with limited mobility downstairs during emergencies, when elevators cannot be used. A review of Amtech Elevator Services service contract invoices (dated 01/09/25, 01/13/25, 04/01/25, and 07/07/25) and email communications between Amtech and the administrator revealed that the facility was committed to ensuring elevators are in good working order. Upon further review of the Facility's Work Order Summary (dated 05/05/25 through 06/30/25), it was revealed that 70% of work orders are completed within 24 hours. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Allegation #2: Facility staff did not respond to resident's call button. It is alleged that the facility staff did not respond to Resident #1’s (R1) call button. It is reported that on May 27, 2025, (R1’s) call went unanswered after requesting a vital check from staff, who was not available, leading (R1) to seek assistance elsewhere. No further information is provided regarding this matter. On June 2, 2025, and March 28, 2026, between 09:15 AM and 03:10 PM, the Department interviewed resident members identified as Resident #1 through Resident #20 (R1-R20). Fifteen (15) out of twenty (20) could not support this claim. Residents have reported that response times for staff assistance via call buttons can vary. However, none of the wait times exceed 45 minutes, depending on the urgency of the situation and the time of day, according to (R2-R10, R14-R17, and R19-R20). Residents (R2-R10) expressed that they do not require their vital signs to be checked throughout the day, as their physicians specifically mandate this. Resident (R1) was interviewed on June 2, 2025, and March 28, 2025. On June 2, 2025, (R1) stated that the response time from staff after using the call button can be up to 2 hours. However, on March 28, 2025, (R1) reported that the response time could be as quick as 15 minutes and stated that there were no issues or concerns regarding assistance with vital signs. (Evaluation Report continues LIC 9099-C) On June 02, 2025, and March 28, 2026, between 12:40 PM and 3:10 PM, the Department interviewed staff members identified as Staff #1 through Staff #9 (S1-S9). Nine (9) out of nine (9) staff members could not corroborate this claim. All staff members respond at different times, but they do so as promptly as possible—no response within 2 hours of the call request is false. Staff members explained that the call buttons enable two-way communication, allowing them to ask residents whether a matter should be prioritized over other call requests. When a resident uses the call button in their room, it indicates a non-emergency situation. However, when the call button is used in the bathroom, it triggers an emergency call alert and sends a different signal tone to the front desk for immediate assistance. Caregivers and med-techs collaborate as a team in accordance with (S2). If a caregiver cannot respond quickly, the med-techs will step in to assist, or vice versa. On January 31, 2026, the Department conducted inspections of call buttons for residents in rooms #115, #118, #120, #132, #137, #143, #208, #226, and #252. The inspection found that all call buttons were functioning properly, with response times for assistance ranging from one to five minutes. On March 28, 2026, the Department inspected room #254 for Resident #1 (R1) and tested both the room and bathroom call buttons. Both were found to be in working order, with response times under 3 minutes. A review of Resident #1's (R1) Medical Assessment for Residential Care Facilities for the Elderly, LIC 602A (dated 09/19/25), and the Department of Health Care Services In-service Plan (dated 09/18/25) revealed that primary physicians prescribe no mandated requirements for vital sign monitoring. Further review revealed that (R1's) medical diagnosis profoundly impacts (R1's) thought processes and belief system, intricately shaping (R1) perspective, understanding, and behavior. Further review of personnel training requirements revealed the facility is committed to training to improve the quality of care for residents. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Allegation #3: Facility staff did not dispense medications as prescribed. It is alleged that the facility staff did not dispense medications to residents. It is reported that medications were not dispensed correctly to another resident, with a med-technician taking away a pill after that resident refused it. It is reported that there are concerns about the qualifications of the med-technicians. No further information is provided regarding this matter. (Evaluation Report continues LIC 9099-C) On June 2, 2025, and March 28, 2026, between 09:15 AM and 03:10 PM, the Department interviewed resident members identified as Resident #1 through Resident #20 (R1-R20). Eighteen (18) of the twenty (20) residents reported no medication errors. Moreover, the overwhelming majority (18) of twenty (20) reported no awareness of any incidents involving the dispensing of incorrect medications and were complimentary of staff and their qualifications. The (2) residents who asserted knowledge of medication errors were unable to provide details such as the date, time, or names of the staff involved or residents and failed to notify management of the incident. On June 02, 2025, and March 28, 2026, between 12:40 PM and 3:10 PM, the Department interviewed staff members identified as Staff #1 through Staff #9 (S1-S9). Nine (9) out of nine (9) staff members could not support this claim. (S1-S2 and S6) stated that facility staff have previously made medication errors in the past, which they are required to report to Community Care Licensing, the resident's physician, and the family representative using an incident report. However, (S1-S2) stated that no errors related to the specific complaint being discussed have ever occurred. According to (S1-S2), all med-technicians must complete mandatory initial training of 16 hours. This includes 8 hours of shadowing and 8 hours of instruction. Furthermore, they must pass a competency exam within the first two weeks of hire. To ensure ongoing, an additional 4–8 hours of annual refresher training is also required. An evaluation of Resident #1's (R1) Medication Administration Record from (dated 02/01/25 to 06/30/25), along with the records for Residents #2 to #7 (R2-R7) (dated 03/01/26 to 03/31/26), reveals that all entries are accurate with no errors or discrepancies. Further review of the mandatory training requirements revealed that the facility is committed to training not only to enhance skills but also to improve the quality of care for residents. The Department conducted inspections on March 5, 2026, and March 28, 2026, and observed that all resident medications were kept securely locked. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. No deficiencies were cited An exit interview was conducted with Bobbie Rodriquez, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Mar 29, 2026 · control 18-AS-20250527094234

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced annual required visit. Upon entry, LPA was greeted by Carminia Meza, Director of Nursing, and informed them of the purpose of the visit. Facility Overview: The facility is a two story building. There is a fenced swimming pool which is in compliance with local building and safety code. There are no known firearms in the facility. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility has infection control plan in file. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. There is a dedicated laundry facility in the premises. LPA observed operating/functioning laundry machines. Sharp and dangerous objects were securely locked and inaccessible to residents. LPA reviewed the annual fire marshal's inspection reports dated 09/03/2025 and 09/12/2025 and observed that the facility passed the inspection without any deficiencies. LPA reviewed 12 months history of water temperature logs and observed that the water temperatures have been within the regulatory limits. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Continued on LIC809-C.... Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate. Record Review and Resident/Staff Files: LPA reviewed files for five (5) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Five (5) resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for five (5) residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 02/04/2026, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided.the state’s words, verbatim · CDSS document, Mar 5, 2026

Allegation investigated: Staff are not administering resident's medication Staff did not ensure resident was fed Staff are not meeting resident's showering needs Staff did not safeguard resident's personal belongings

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Aurelien Fruit, Administrator. The Department's investigation involved interviews with staff and residents and review of records. On 02-06-2026, Community Care Licensing (The Department) received a complaint report with the following allegations. It was alleged that staff are not administering resident's medication. Information received indicated that staff did not dispense all prescribed medications to Resident #1 (R1). LPA’s review of R1’s file revealed that R1 required various medications ordered by R1’s physician. LPA conducted an interview with R1 who stated that R1 did not receive all the prescribed medications from the facility staff. LPA conducted an interview with Staff #1 (S1) who stated that R1 frequently has refused to take the medications. Continued on LIC9099-C.... Unsubstantiated S1 stated that medication technicians have recorded in the facility’s electronic medication administration system every time R1 refused to take the prescribed medications. LPA’s review of R1’s medication administration records confirmed the S1’s statement. LPA conducted interviews with seven (7) other residents, all of whom stated that staff have provided good medication dispense services. Based on records review and interviews conducted, the Department’s investigation did not find enough information to corroborate the allegation that staff are not administering resident’s medication. This allegation is unsubstantiated. It was alleged that staff did not ensure resident was fed. Information received indicated that Resident #1 (R1) had not eaten for three (3) days. LPA conducted an interview with R1 who stated that R1 had not eaten for four (4) days. LPA observed that R1 appeared to be well dressed and cared for. LPA conducted interviews with seven (7) other residents, all of whom stated that they have never missed any meals. LPA conducted interviews with four (4) staff members, all of whom stated that staff have provided assistance to residents with mealtimes if the residents required reminder or assistance for meals. Based on interviews conducted, the Department’s investigation did not find enough information to corroborate the allegation that staff did not ensure resident was fed. This allegation is unsubstantiated. It was alleged that staff are not meeting resident's showering needs. LPA conducted an interview with Resident #1 (R1) who stated that R1 had received one (1) shower service per month. LPA conducted interviews with seven (7) other residents, all of whom stated that staff have provided two (2) shower services per week. LPA’s interviews with four (4) staff members confirmed the statements from the residents interviewed. LPA’s review of R1’s progress notes revealed that R1 has refused shower services in the past. Based on interviews conducted and records review, the Department’s investigation did not find enough information to corroborate the allegation that staff are not meeting resident’s showing needs. This allegation is unsubstantiated. It was alleged that staff did not safeguard resident's personal belongings. LPA conducted an interview with Resident #1 (R1) who stated that R1 lost 15 pairs of pants and 20 shirts. LPA conducted review of R1’s records which did not show any of R1’s lost items. LPA conducted interviews with seven (7) other residents, all of whom denied experiencing stolen or lost valuable items. LPA conducted an interview with Staff #2 (S2) who stated that R1 did not arrive with any of those items mentioned by R1. Continued on LIC9099-C.... Based on records review and interviews conducted, the Department’s investigation did not find enough information to corroborate the allegation that staff did not safeguard resident’s personal belongings. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 18-AS-20260206093119

Allegation investigated: Facility retained resident requiring a higher level of care. Resident did not receive medications as prescribed. Staff did not treat resident with dignity and respect. Staff did not follow COVID-19 protocol.

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Aurelien Fruit, Administrator. The Department's investigation involved interviews with staff and residents and review of records. On 07-30-2021, Community Care Licensing (The Department) received a complaint report with the following allegations. It was alleged that facility retained resident requiring a higher level of care. Information received indicated that Staff #1 (S1) told Resident #1 (R1) that the facility was not the right place when R1 arrived from a skilled nursing facility. R1’s relevant party advised S1 that R1 was assessed by the facility nurse. The Department conducted an interview with S1 who stated that the facility did not have an acting nurse from 06-21-2021 to 08-09-2021. S1 did not know who assessed R1 prior to R1’s admission. Continued on LIC9099-C..... Unsubstantiated LPA’s review of R1’s record revealed that R1 arrived on 07-26-2021 and moved out on 07-29-2021. R1 returned to the skilled nursing facility where R1 was transferred from after request was made by the facility staff. R1 had resided for three (3) days at the facility. LPA’s record review revealed that R1’s resident file was no longer available for review. LPA conducted an interview with Staff #2 (S2) who stated that R1’s resident file was no longer available due to expiration of resident record retention periods. Based on record review, the Department’s investigation did not find enough information to corroborate the allegation that facility retained resident requiring a higher level of care. This allegation is unsubstantiated. It was alleged that resident did not receive medication as prescribed. Information received indicated that R1’s medication did not arrive when R1 moved in from a skilled nursing facility. LPA’s review of R1’s record did not reveal any history of R1’s medication. LPA’s interview with Staff #2 (S2) revealed that R1’s resident file was no longer available due to expiration of resident record retention period. R1’s progress notes were the only record available at the facility. R1 moved in on 07-26-2021 and returned to the skilled nursing facility on 07-29-2021 per R1’s progress notes. The Department conducted an interview with S1 who stated that R1 arrived with a list of medications but without doctor’s order. Doctor’s order for R1 came in from the skilled nursing facility on the day after R1’s arrival. LPA conducted interviews with eight (8) residents, all of whom stated that staff have provided medication dispense services as prescribed. Based on record review and interviews conducted, the Department’s investigation did not find enough information to corroborate the allegation that resident did not receive medication as prescribed. This allegation is unsubstantiated. It was alleged that staff did not treat resident with dignity and respect. Information received indicated that facility staff did not assist R1 with feeding. R1’s relevant party observed a food tray next to R1’s bed while R1 was still in bed. LPA’s review of R1’s record revealed that R1’s care plan and assessment were no longer available for review. LPA’s interview with Staff #2 (S2) revealed that R1’s resident file was no longer available due to expiration of resident record retention period. LPA could not determine if R1 required assistance with feeding. LPA conducted interviews with eight (8) residents, all of whom stated staff treat residents with respect. Based on record review and interviews conducted, the Department’s investigation did not find enough information to corroborate the allegation that staff did not treat resident with dignity and respect. This allegation is unsubstantiated. Continued on LIC9099-C.... It was alleged that staff did not follow COVID-19 protocol. Information received indicated that R1 did not receive COVID-19 test prior to entering the facility and was permitted to eat in the dining room with other residents. LPA conducted review of R1’s records, but R1’s resident file was no longer available for review. LPA conducted an interview with S2 who stated that R1’s records were not available due to expiration of resident records retention periods. R1’s progress notes were the only record for R1. Per the record, R1 arrived on 07-26-2021 from a skilled nursing facility and returned to the skilled nursing facility on 07-29-2021. The Department’s interview with S1 revealed that R1 already had COVID test or vaccination card as R1 came from a skilled nursing facility. The Department’s interviews with S1 and a resident ambassador revealed that staff had followed COVID protocol. LPA conducted interviews with eight (8) residents, all of whom stated that staff have followed COVID protocol. Based on record review and interviews conducted, the Department’s investigation did not find enough information to corroborate the allegation that staff did not follow COVID-19 protocol. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 18-AS-20210730140741

Allegation investigated: Facility staff are retaining residents that require a higher level of care. Staff do not ensure that food is prepared and served in a safe and healthful manner. The facility is in disrepair.

On January 31, 2026, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit. Aurelien Fruit, Administrator greeted the (LPA). (LPA) explained the purpose of the visit is to investigate the allegations mentioned above. The investigation included a collection of records interviews, and an observation of the facility. The Department obtained several documents, including the Facilty Roster (date 01/31/26), the Resident Roster (dated 01/31/26), House Rules, Master Sign In Sheet Resident Rights (dated 02/10/25) Resident Rights Training for Cargivers, Faciltiy Work Order Summary (dated: 0522/25), Facility Menu (dated 05/25/25 through 07/05/25) and other pertinent records assocaited with this complaint. Interviews conducted with Resident #1-#10 and Staff #1-#7, (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Facility staff are retaining residents that require a higher level of care. It is alleged that the facility staff are retaining residents who require a higher level of care. Reports suggest that the facility allows residents who should not be there to remain at the facility. It has been noted that residents with Neurocognitive Disorder (NCD) wander around the facility, often not knowing where they are. No additional details regarding this allegation have been provided. On January 31, 2026, between 08:40 AM and 3:35 PM, the Department interviewed staff members identified as Staff #1 through Staff #7 (S1-S7). Seven (7) out of seven (7) staff members could not validate this claim. (S1) confirmed that there are no residents currently retained in the facility who require a higher level of care. The facility is licensed to provide assisted living and memory care. (S1) stated that the facility collaborates with home health and hospice agencies and is licensed to accommodate 25 hospice residents, but currently only 10 are receiving care. To ensure the facility does not retain a resident who needs a higher level of care, they typically follow these steps: monitor changes in condition, review facility admission and retention criteria, engage healthcare professionals, communicate with residents and their families, and document everything. (S1) further explained that these steps are performed when the resident has been hospitalized for several days. (S2-S7) verified that there are no residents that are being retained with restricted or prohibited health conditions at the facility. On January 31, 2026, between 09:00 AM and 11:59 AM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Ten (10) out of ten (10) could not validate this claim. All residents are unaware of any resident being retained at the facility that requires a higher level of care. During the visit on January 31, 2026, an inspection included observing residents in rooms #115, #118, #120, #132, #137, #143, #208, #226, and #252, in the assisted living and memory care units. The Department did not observe any residents who required higher acuity of care. A review of the facility Resident Roster (dated: 01/31/26) and Personnel Roster (dated 01/31/26) along with personnel training requirements. Upon further review of the two random resident physicians' report, LIC 602A, it was determined that the residents do not require a higher level of acuity in care. Due to a lack of sufficient information, including the absence of names of residents or demonstrative evidence, there is insufficient evidence to support the allegation mentioned above. (Evaluation Report continues LIC 9099-C) Allegation #2: Staff do not ensure that food is prepared and served in a safe and healthful manner. It is alleged that the facility staff does not ensure that food is prepared safely and healthfully. Reports indicate that the food at the facility is substandard and that staff prepare food in unsafe or unsanitary conditions without wearing gloves. No additional details regarding this allegation have been provided. On January 31, 2026, between 08:40 AM and 03:35 PM, the Department interviewed staff members identified as Staff #1 and Staff #7 (S1-S7). Seven (7) out of seven (7) staff members could not validate this allegation. (S1) stated they were not aware of any substandard food served or misconduct by food service staff regarding safe handling practices. (S5-S6) claimed safe handling practices for kitchen workers include regular handwashing, preventing cross-contamination, thorough cooking and reheating of food, and maintaining food at safe temperatures. They clean and sanitize surfaces and equipment frequently, store food properly, and be aware of fire safety. (S5-S6) stated that they receive training titled "Food Safety for Food Handlers." (S5-S6) emphasized that servers are required to wear appropriate and clean uniforms, aprons, hair restraints, and gloves. They also clarified that all contaminants are carefully managed and never served to residents, as ensuring their safety and well-being is the top priority. Additionally, the facility collaborates with a nutritionist who assesses nutritional needs, develops meal plans and special diets, monitors food services, provides staff education, and ensures compliance with documentation. On January 31, 2026, between 09:00 AM and 11:59 AM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Ten (10) out of ten (10) could not support this claim. All residents indicated that they had no issues or concerns about the quality of the food or its handling procedures. All residents emphasized that they have consistently observed the kitchen staff practicing safe food handling. On January 31, 2026, between 02:15 PM and 02:25 PM, the Department inspected the main kitchen, dining room, and the ice cream café. During the inspection, the Department observed that kitchen staff were wearing gloves, hair restraints, aprons, and clean uniforms. The food supply was managed with appropriate dates to prevent spoilage and was stored at the correct temperatures according to Title 22 regulations. Moreover, the Department observed the presence of additional supplies of food thermometers, gloves, cleaning and sanitation supplies (like spray bottles and brushes), food preparation tools (such as cutting boards and labels), storage containers, and personal protective equipment (PPE), including aprons and masks. (Evaluation Report continues LIC 9099-C) A review of the facility’s Weekly Menu (dated: 05/25/25 through 07/05/25), Food and Safety Handling and Riverside County Food Handler Certification, and Chevon Raich, Clinical Registered Dietitian information. Due to a lack of sufficient information, including the absence of names of staff or demonstrative evidence, there is insufficient evidence to support the allegation mentioned above. Allegation #3: Facility is in disrepair. It is claimed that the facility is in disrepair and not operating to standard. No further details regarding this claim have been provided. On January 31, 2026, between 08:40 AM and 03:35 PM, the Department interviewed staff members identified as Staff #1 and Staff #7 (S1-S7). Seven (7) out of seven (7) staff members could not corroborate this allegation. (S1) stated that the facility is not in poor condition due to neglect. (S1) claimed the facility was built in the 1980s, and anything in use for that long will require maintenance and upkeep. The facility has an in-house maintenance team that attends to all the work orders and prioritizes each order based on priority. (S7) reported the process for submitting work orders through the front desk has been verified, ensuring compliance documentation remains up to date. The maintenance team diligently reviews the work order summary each day, prioritizes tasks, and takes appropriate actions to address them. Each completed task is documented with the time required to resolve it. It’s worth noting that while many repair services are handled promptly, some may experience delays due to the need to engage outside vendors or wait for necessary parts. (S7) noted that recognizing the facility's lack of control over delays can help establish realistic expectations and improve communication regarding repair timelines. On January 31, 2026, between 09:00 AM and 11:59 AM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Ten (10) out of ten (10) could not validate this claim. All residents stated they had no concerns about the facility's upkeep. All residents affirmed that the facility is prompt in addressing repairs in their rooms and in the facility's common areas. During the visit on January 31, 2026, an inspection included observation of rooms #115, #118, #120, #132, #137, #143, #208, #226, and #252, assisted living and memory care floors, pool, spa, laundry, main kitchen, main dining, living room, activities room, rear lobby, offices, conference room, stairs and elevators. Inspection revealed the facility to be clean and sanitary, with hot and cold water, air conditioning, electrical systems, signal systems, telecommunications system and smoke detectors in working order. (Evaluation Report continues LIC 9099-C) A review of the facility Resident Roster (dated: 01/31/26) and Personnel Roster (dated 01/31/26). Additional review of Facility’s Work Order Summary (dated 05/05/25 through 06/30/25) revealed that work orders are completed 70% within 24-hour period. Due to a lack of sufficient information, there is insufficient evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. No deficiencies were cited An exit interview was conducted with Aurelien Fruit, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Feb 1, 2026 · control 18-AS-20250326140045

Allegation investigated: Staff did not accord resident privacy. Staff took pictures without resident's consent.

On February 01, 2026, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit. Aurelien Fruit, Administrator greeted the (LPA). (LPA) explained the purpose of the visit is to investigate the allegations mentioned above. The investigation included a collection of records interviews, and an observation of the facility. The Department obtained several documents, including the Facilty Roster (date 01/31/26), the Resident Roster (dated 01/31/26), service records for Resident #1 (R1's) Physicians Report LIC 602 (dated 04/17/25), Welbe Assessment (dated 03/12/25), Admissions Agreement (dated 05/03/25), and other pertinent records associated with this complaint. Interviews conducted with Resident #1-#10, Staff #1-#7, and Witness #1. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not accord resident privacy. Allegation #2: Staff took pictures without resident's consent. It is alleged that the staff did not provide Resident #1 (R1) with privacy and took photographs without (R1’s) consent. Reports indicated a staff member observed resident (R1) participating in a private consensual interaction with another resident. It was noted that the staff member subsequently took photographs of (R1) inappropriately. No additional details about this allegation have been provided. On January 31, 2026, between 08:40 AM and 3:35 PM, the Department interviewed staff members identified as Staff #1 through Staff #7 (S1-S7). Seven (7) out of seven (7) staff members could not validate these claims. (S1) stated that the incident involving (R1) and a staff member was fabricated, which is why no incident report was filed. (S2-S7) claimed that they did not know of any violation of (R1's) rights or any incidents involving another resident. (S1-S7) has confirmed that the facility has implemented mandatory training on Resident Rights, and every staff member has completed this essential training. On January 31, 2026, between 09:00 AM and 11:59 AM, the Department interviewed resident members identified as Resident #2 through Resident #10 (R2-R10). Nine (9) out of nine (9) could not support these claims. All residents are unaware of such an incident and do not believe any of their rights have been violated. All residents stated that they are appreciative of being treated with respect and accorded privacy by the staff.of Resident #1 (R1) has transitioned out the facility. The Department made several attempts to reach out by phone, but none of the calls were returned. On January 31, 2026, between 11:00 AM and 11:21 AM, the Department interviewed witness member identified as Witness #1 (W1). (W1), who has a close relationship with (R1), asserts that these allegations are false. (W1) stated that the incident involving (R1) never happened and it is fabricated story intended to gain attention. (W1) added the staff offered great support and respect for (R1), making sure (R1's) personal rights were always protected during (R1’s) stay at the facility. (Evaluation Report continues LIC 9099-C) During the visit on January 31, 2026, an inspection involved observing staff interactions with residents and examining how caregivers approached their responsibilities. The Department monitored the quality of communication, the appropriateness of activities, and the overall atmosphere to assess the level of care provided to each resident. The Department observed a staff member professionally interacting with residents. The Department identified that the facility promotes the rights of its residents. Posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster, Rights of Resident Council were displayed prominently throughout the facility. A review of Resident #1 (R1’s) Admission Agreements for Residential care Facilities for the Elderly LIC 604A (dated 05/03/25), Welbe Health facility Assessment (dated 03/12/25), Personal Rights Residential Care Facilities for the Elderly LIC 613A (dated 05/03/25), Physician’s Report for Residential Care Facilities for the Elderly LIC 602A (dated 04/17/25) and Medication List (dated 01/29/25). Further review of staff training records confirmed that personnel staff had completed the mandatory Resident Rights for Caregivers and Master Sign-In Training (dated 02/10/25 & 03/10/25). Based on information gathered, there is insufficient evidence to support the allegations mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. No deficiencies were cited An exit interview was conducted with Aurelien Fruit, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Feb 1, 2026 · control 18-AS-20250529113405

Allegation investigated: Resident was physically abuse while in care. Lack of supervision resulted in the resident sustaining an injury.

On 1/18/2026, LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met Aurelien Fruit/Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: the department conducted the following interviews: Administrators Interview (A#1), Residents Interviews (R#1-R#9) and Staff Interviews (S#1-S#4).The department gathered the following documents copy of resident roster dated: 1/17/26, staff roster dated: 1/17/26, copy of (R#1)’s assessment tool dated:12/28/23, copy of (R#1)’s Physicians Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A dated:2/27/25, copy of census list dated:10/19/24, copy of facility progress notes for (R#1) dated:9/25/24. Evaluation Report continues LIC 9099-C Unsubstantiated Allegation: Resident was physically abuse while in care. The details of the complaint alleged that (R#1) was physically attacked by (R#2). On January 18, 2026, during a comprehensive records review, the department examined facility progress notes for (R#1) dated 9/25/24. The department observed that on 9/25/24, the day of the alleged abuse, facility staff found (R#1) face down on the floor without underwear and appearing to be under the influence. Staff noticed blood on (R#1) but could not locate the source, as no open wounds were visible. Due to (R#1)’s condition at the time, staff could not conduct a proper assessment. They promptly called emergency services, and (R#1) was transported to the emergency room. The progress notes contained no documentation indicating that (R#1) reported being physically attacked by (R#2). Moreover, the department observed (R#1)’s Physicians Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A, dated 2/27/25. Under the physical health status, it is noted that (R#1) has mild cognitive impairment and uses alcohol. On January 17, 2026, at approximately 10:30 AM, the department interviewed (A#1), who provided his statement regarding the allegation. He stated that when the facility became aware of the alleged physical assault on September 29, 2024, staff immediately moved (R#1) to a different room and initiated an internal investigation. The investigation concluded that (R#2) did not physically abuse (R#1). There were no reports from any facility staff indicating they heard or observed an altercation between (R#1) and (R#2) at the time of the incident. Following the allegation, the facility interviewed (R#2) and determined there was insufficient evidence to substantiate the claim. The facility reported implementing measures to ensure resident safety during the investigation process. On January 17, 2026, at approximately 11:00 AM, the department interviewed (R#1), who stated that their interaction with their former roommate (R#2) was minimal, as they were simply roommates. When asked if (R#2) had ever physically abused them, (R#1) responded that (R#2) did not touch them at all. Evaluation Report continues LIC 9099-C On January 17, 2026, at approximately 2:00 PM, the department interviewed facility staff (S#1–S#4), (4) out of (4) stated that the facility monitors interactions between residents by redirecting them in ways that prevent conflicts. Staff reported that if they observe or hear a disagreement or altercation between residents, they intervene immediately and separate the individuals involved. In addition, (4) out of (4) facility staff stated that when asked if they were aware of (R#2) physically attacking (R#1), they had not seen that occur. Allegation: Lack of supervision resulted in the resident sustaining an injury The details of the complaint alleged that due to insufficient staff supervision, (R#1) sustained an injury. On 1/18/2026, during a comprehensive records review, the department examined the copy of (R#1)’s assessment tool dated:12/28/23, the department noted that it is written to support and mitigate (R#1)’s fall risk, caregivers should implement several interventions like closely monitoring their alcohol consumption and encourage them to participate in alcohol-free activities, check on them regularly especially the times when they are more likely to drink and provide companionship to reduce their isolation. In addition, ensure their living space is free of hazards that could contribute to falls, and consider arranging for a physical therapist to work on balance and strength exercises. In addition, the department examined facility progress notes for (R#1) dated 9/25/24; the progress notes contained no documentation indicating that (R#1) reported being physically attacked by (R#2). On January 17, 2026, at approximately 10:30 AM, the department interviewed (A#1), who stated that on September 29 and 30, 2024, since (R#1) and (R#2) were roommates and (R#1) uses alcohol, staff were checking on both residents every hour and as needed. Regarding the facility’s policy for preventing resident-to-resident altercations, (A#1) explained that the facility addresses complaints that may arise and, if necessary, separates residents who share a room. In addition, when asked if staff were aware of any prior conflicts or behavioral concerns involving (R#1) or other residents, (A#1) stated there was no documentation from facility staff witnessing any altercation between (R#1) and (R#2). Evaluation Report continues LIC 9099-C On January 17, 2026, at approximately 11:00 AM, the department interviewed residents (R#1–R#9), (9) out of (9) stated that they receive the help they need from staff and described staff as very helpful and they reported that there are enough staff available when assistance is needed and expressed that they feel safe living in the facility. On January 17, 2026, at approximately 12:00 PM, the department interviewed facility staff (S#1–S#4), (4) out of (4) stated that the facility ensures residents are adequately supervised throughout the day by observing them and listening to their concerns. In addition, (4) out of (4) facility staff stated that when asked whether they feel the residents are safe living in the facility, they responded that they do. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Aurelien Fruit/Facility Administrator.the state’s words, verbatim · CDSS document, Jan 18, 2026 · control 18-AS-20241010154056

Allegation investigated: Resident was illegally evicted from the facility. Facility did not reimburse rent. Facility did not provide copies of discharge paperwork to responsible party.

On 1/17/2026, LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met Aurelien Fruit/Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: the department conducted the following interviews: Administrators Interview (A#1), Residents Interviews (R#1-R#9) and Staff Interviews (S#1-S#4).The department gathered the following documents copy of facility staff roster dated:1/17/26, copy of resident roster dated: 1/17/26, copy of (R#1)’ Admission Agreements for Residential Care Facilities for the Elderly or LIC 504A dated:4/27/23 and copies of (R#1)’s file and facility discharge file. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Resident was illegally evicted from the facility. The details of the complaint alleged that (R#1) was illegally evicted from facility. On 01/17/2026, at approximately 1:30 PM, the department conducted a comprehensive review of records and observed (R#1)’s file and the facility discharge file. The department found no evidence to support the allegation that (R#1) was illegally evicted from the facility. In addition, the department observed that there were no eviction notices or discharge documents indicating an involuntary removal, and the admission agreement clearly outlines refund policies. On 01/17/2026 at approximately 10:30 AM, the Department interviewed the facility administrator (A#1). (A#1) stated that no verbal or written 30-day eviction notice was given to (R#1) or their responsible party and confirmed that (R#1) left voluntarily. In addition, (A#1) further explained that (R#1)’s responsible party arrived at the facility on 2/27/2024 with a moving company and departed on their own accord. On January 13, 2026, the Department attempted to contact (R#1) via telephone; however, (R#1) did not answer, and a voicemail message was left. On January 14, 2026, a second attempt was made to contact (R#1) by telephone, but there was no response, and another voicemail message was left. On January 16, 2026, the Department made a third attempt to contact (R#1) by telephone, but (R#1) again did not respond, and a voicemail message was left. On 1/17/26 at approximately 11:00 AM, during interviews with facility residents (R#2-R#9), (8) out of (8) stated that they had never seen or heard of a resident being asked to leave the facility, and that they had not received a 30-day notice from the facility. Evaluation Report continues LIC 9099-C On 1/17/26 at approximately 12:00 PM, during interviews with facility staff (S#1-S#4), (4) out of (4) stated that they have never witnessed or heard of any resident being asked to leave the facility. In addition, (4) out of (4) facility staff stated that a 30-day notice was not given to (R#1). Allegation: Facility did not reimburse rent. The details of the complaint alleged that facility did not reimburse rent to (R#1). On 1/17/2026, at approximately 1:30 PM, during a comprehensive records review, the department examined (R#1)’ Admission Agreements for Residential Care Facilities for the Elderly or LIC 504A dated:4/27/23, the department observed on the agreement under section 9B Refund Policy, it is written that refunds will be granted as follows: community fees, scooter fee, and pet deposit are all non-refundable. Rent refunds are prorated only with 30 days' written notice to vacate. In addition, the department observed that there were no eviction notices or discharge documents indicating an involuntary removal, and the admission agreement clearly outlines refund policies. On 01/17/2026, at approximately 10:30 AM, the Department interviewed the facility administrator (A#1). He explained that residents are required to provide 30 days' written notice before leaving. If a resident has paid for the full month, the facility refunds the prorated amount for any unused days after the notice period. In addition, when asked if the facility issued any refund or credit to (R#1) after they left, (A#1) stated that no refund was issued because (R#1)’s Power of Attorney (POA) did not provide a formal written 30-day notice, as required by the admissions agreement. On January 13, 2026, the Department attempted to contact (R#1) via telephone; however, (R#1) did not answer, and a voicemail message was left. On January 14, 2026, a second attempt was made to contact (R#1) by telephone, but there was no response, and another voicemail message was left. On January 16, 2026, the Department made a third attempt to contact (R#1) by telephone, but (R#1) again did not respond, and a voicemail message was left. Evaluation Report continues LIC 9099-C On 1/17/26 at approximately 11:00 AM, during interviews with facility residents (R#2-R#9), (8) out of (8) stated that, to their knowledge, the facility usually refunds any prepaid rent or deposits when residents leave, and they had never heard of any resident or family complaining about not receiving a refund after leaving. On 1/17/26 at approximately 12:00 PM, during interviews with facility staff (S#1-S#4), (4) out of (4) stated that based on their knowledge, the facility typically refunds prepaid rent and deposits when residents move out, as specified in the admissions agreement. In addition, (4) out of (4) facility staff stated that they had not heard of a resident or family member complaining about not receiving a refund after leaving, including (R#1). Allegation: Facility did not provide copies of discharge paperwork to responsible party The details of the complaint alleged that facility did provide (R#1) discharge paperwork to (R#1) and their representative. On 1/17/2026 at approximately 10:30 AM, the department interviewed the facility administrator (A#1). He stated that when (R#1)’s Power of Attorney (POA) came to move (R#1) out of the facility, they did not request any documentation related to (R#1)’s records. In addition, when asked whether the facility failed to provide discharge paperwork to (R#1), (A#1) explained that no paperwork was provided because the responsible party did not request any documentation. On January 13, 2026, the Department attempted to contact (R#1) via telephone; however, (R#1) did not answer, and a voicemail message was left. On January 14, 2026, a second attempt was made to contact (R#1) by telephone, but there was no response, and another voicemail message was left. On January 16, 2026, the Department made a third attempt to contact (R#1) by telephone, but (R#1) again did not respond, and a voicemail message was left. Evaluation Report continues LIC 9099-C On 1/17/26 at approximately 11:00 AM, during interviews with facility residents (R#2-R#9), (8) out of (8) stated that, to their knowledge, when residents move out, they usually receive written discharge paperwork from the facility, and they believe the facility will provide copies of their records to them or their responsible party when requested. On 1/17/26 at approximately 12:00 PM, during interviews with facility staff (S#1-S#4), (4) out of (4) stated that when residents move out, written discharge paperwork is generally provided upon request. In addition, (4) out of (4) facility staff stated that when asked if (R#1) or their responsible party received discharge paperwork, staff confirmed that no paperwork was provided because it was not requested. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Aurelien Fruit/Facility Administrator.the state’s words, verbatim · CDSS document, Jan 17, 2026 · control 18-AS-20240404160258

Allegation investigated: Staff did not provide reasonable transportation services to resident in care

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with Arlene Barrett and explained the reason for the visit. The investigation consisted of the following: On 10/14/24 LPA Jeon conducted an initial complaint investigation visit. On 10/30/24 LPA Jeon conducted a subsequent complaint investigation visit and interviewed 7 residents and 1 staff. On 12/16/25 LPA Flores interviewed 3 residents and 7 staff, requested copies of the following documents Resident #1(R1)’s physician’s report, admission agreement, face sheet, house rules, needs and care plan, transportation facility’s plan of operation/policy, staff schedule for October 2024, and delivered findings. The investigation revealed the following: Regarding allegation: Staff did not provide reasonable transportation services to resident in care. (CONTINUED ON LIC 9099C) Unsubstantiated It is alleged transportation was requested on 10/10/24 at 7:00pm for R1 to return to the facility and it was not available. Interviews with residents revealed 8 out of 10 residents stated to have no issues with transportation services. They have been assisted, and transportation is always available. 2 out of 10 residents stated they have not used the transportation services as they did not need it. Interviews with staff revealed facility has a driver, who is scheduled to provide transportation services Monday – Friday between 8:30am – 5:00pm. Per driver during that time Care Coordinator or LVN communicates with hospital staff and arranges pick up based on the availability of the driver. Per administrator if a resident needs to be picked up during the night shift, only if a Med-Tech is available, meaning they do not need to pass medication and staff coverage is available they will send the Med-Tech to pick up the resident during the night shift. Otherwise, accommodation is arranged for residents to be picked up during the available hours of transportation. Documents review revealed that R1’s admission agreement signed on 7/25/24 notes R1 is to receive assistance with planning, arranging, and/or providing transportation to medical/dental appointments. Facility’s Policy regarding transportation notes “between 5:00pm – 8:30am, transportation is not systematically offered…” Although, R1 was not picked up on 10/10/24 due to staff not being available. The facility has assigned hours between 8:30am – 5:00pm to provide transportation to residents per their policy. Therefore, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Aurelien Fruit Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 18-AS-20241011160324

Allegation investigated: Staff did not assist resident in a timely manner. Staff left resident unattended for a period of time. Staff did not safeguard resident’s personal belongings.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint regarding the above allegations. LPA met with Jillian Espinueva and explained the reason for the visit. The investigation consisted of the following: On 12/18/23 LPA Banrasavong conducted an initial complaint investigation visit. On 1/21/25 LPA Banrasavong conducted a subsequent visit. On 11/7/25 LPA Flores contacted administrator and requested pertaining documents for resident #1(R1). On 11/10/25 LPA Flores interviewed R1's responsible party over the phone. On 11/12/25 LPA Flores interviewed 2 staff over the phone. On 11/18/25 LPA Flores interviewed 4 additional staff over the phone. On 11/20/25 LPA Flores interviewed 10 residents, conducted a tour of the facility, and delivered findings. The investigation revealed the following: Regarding allegation: Staff did not assist resident in a timely manner. It is alleged resident used pulled cord to requested assistance and staff did not respond timely. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews with residents revealed 6 out of 10 residents stated they have not used the call light button as they are independent and do not need assistance. 2 out of 10 stated staff do not respond right away and it can take them about 30 minutes to respond, 1 out of 10 residents stated they respond right away, and 1 out of 10 residents refused to be interviewed. Interviews with staff revealed staff respond to call light calls within 5-10 minutes. LPA was unable to interview R1 as R1 is no longer at the facility. Documents review revealed physician’s report dated 12/12/22 notes R1 did not need assistance with toileting needs. Independent Service Plan dated 3/11/23 notes R1 needed limited to total assist with activities of daily living (ADLs) including assistance with toileting. Facility's call light system does not track the calls made by the residents. During today’s tour LPA Flores tested call light buttons in 9 resident rooms and a caregiver responded within 1-7 minutes. Although R1 required assistance with toileting at the time of the allegation based on the preponderance of evidence standard there is not enough evidence to say residents are not being assisted in a timely manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Regarding allegation: Staff left resident unattended for a period of time. It is alleged resident was left in the bathroom unassisted for an hour and a half. LPA was unable to interview R1 as R1 is no longer at the facility. Interviews with residents revealed 5 out of 10 residents interviewed stated to be independent and do not require assistance. 3 out of 10 residents stated caregivers stay with them when providing assistance until they are done either with showers or toileting. 1 out of 10 residents stated a staff did not stay with them in the bathroom while assisting with shower. 1 out of 10 residents refused to be interviewed. Interviews with staff revealed staff are to stay with the residents while the residents are using the bathroom. Staff use their walkie talkie to communicate to other caregivers that they are assisting a resident and ask if another staff can assist the resident. Incident report dated 12/9/23 notes R1 was assisted to the bathroom and back to R1’s chair. However, R1 used the bathroom alone and staff were unaware that R1 had returned to the bathroom. Although the incident may have happened, we have insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. (CONTINUED ON LIC 9099C) Regarding allegation: Staff did not safeguard resident’s personal belongings. It is alleged resident’s roommate broke R1’s vase and it was not replaced. LPA was unable to interview R1 as R1 is no longer at the facility. Interview with residents revealed 7 out of 10 residents stated to not have lost any valuable items while living at the facility. 2 out of 10 residents stated items have been lost and weren’t sure if they were replaced and 1 out of 10 residents refused to be interviewed. Interviewed with staff revealed residents have not reported items lost or lack of facility’s responsibility for missing items. Per administrator R1 did not sign resident personal property and valuables which list the resident's belongings. Administrator stated that R1’s roommate broke a vase that belonged to R1 by accident. However, there was no reimbursement done as R1's responsible party did not want to pursuit one. Documents reviewed revealed on 8/9/23, R1 signed Windor’s Court policy stating that residents “will not bring to the facility items of a higher value of $25.00 dollars … and will reimburse items valued at $25.00 and under”, as long as they are listed in the resident personal property and valuables. Interviewed with responsible party revealed R1 had a vase that was worth over $250.00 in the shared resident's bedroom. The roommate accidentally pushed a standing divider and broke the vase. However, no one offered to reimburse the cost of the item. Responsible party does not recall filling out documentation to ensure personal belongings were listed. LPA reviewed copy of residents personal property and values for R1 and was not sign and did not have any items listed. Although the incident happened, per documents review R1 signed a document in which acknowledges facility will not reimburse items valued over $25.00. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted with Aurelien Fruit - Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 20, 2025 · control 18-AS-20231212144731

Allegation investigated: Staff are not meeting resident's personal hygiene needs Staff are not safeguarding residents personal property Staff do not ensure an appropriately skilled professional is performing catheter care Staff changed resident's primary doctor withour POA's consent Staff do not dispense resident their prescribed medication

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Aurelien Fruit, Administrator. The Department investigation involved interviews with staff and residents and reviews of records. On June 6, 2025, Community Care Licensing (The Department) received a complaint report with the following allegations. It was alleged that staff are not meeting resident’s personal hygiene needs. According to the information received, Resident #1 (R1) has not received personal hygiene care for 1 year. Upon investigation, the LPA reviewed records and found that R1 has resided in the facility for one year and has a cognitive condition that requires reminder assistance with daily living activities, including hygiene. Continued on LIC9099-C.... Unsubstantiated During interviews, R1 reported receiving daily personal hygiene assistance from staff. Additional interviews with other ten (10) residents confirmed that they had consistently received all necessary hygiene care from facility staff. Furthermore, interviews with three (3) staff members supported the residents’ accounts. A review of R1’s care plan also aligned with R1’s statement, indicating that hygiene care had been provided as agreed. Based on the record review and interviews conducted, there is insufficient evidence to support the allegation that staff are not meeting resident's personal hygiene needs. Therefore, the allegation is unsubstantiated. It was alleged that staff are not safeguarding residents personal property. According to the information received, several items from R1’s room were missing. LPA conducted an interview with R1, who stated they did not know if any personal items were missing from their room. LPA conducted additional interviews with other ten (10) residents, all of whom denied experiencing any personal items stolen from their rooms. LPA conducted an interview with Staff #1 (S1), who stated they have not received any reports of missing or stolen items from R1 or their representative. LPA conducted interviews with two (2) other staff members, all of whom denied any knowledge of R1’s missing personal items. Based on the record review and interviews conducted, there is insufficient evidence to support the allegation that staff are not safeguarding residents personal property. This allegation is unsubstantiated. It was alleged that staff do not ensure an appropriately skilled professional is performing catheter care. According to the information received, R1 has a Foley catheter, and no one at the facility is qualified to provide care for the catheter as the authorization for home health nurses to assist R1 with the catheter had expired. LPA’s record review revealed R1 required use of Foley catheter. LPA conducted an interview with R1, who stated they did not have any problem with their catheter. LPA conducted an interview with S1, who stated that R1 has been receiving catheter care from their home health nurses. S1 added that the facility staff do not provide catheter care for any residents as it is a responsibility for trained professionals. LPA conducted an interview with a case manager (CM) from R1’s home health agency, who stated that there has been no issue with providing care for R1’s catheter. CM added that there is no such thing as expiration of catheter service authorization. Continued on LIC9099-C.... Based on record review and interviews conducted, there is insufficient evidence to support the allegation that staff do not ensure an appropriately skilled professional is performing catheter care. This allegation is unsubstantiated. It was alleged that staff changed resident’s primary doctor without POA’s consent. According to the information received, R1’s primary doctor has been changed frequently without the POA’s consent. LPA’s record review revealed that R1 was admitted to the facility in October 2024 from a skilled nursing facility in Banning, California. Upon transfer to this facility, R1 was transferred to RUHS healthcare network which provided R1 with a new primary physician who is within the healthcare network. LPA conducted an interview with S1, who stated R1’s primary physician was selected either by R1’s POA or assigned by the healthcare network. S1 added that all residents, including R1, arrive with documentation showing their healthcare network and primary physician. S1 stressed that no facility staff can change or participate in selecting residents’ primary physician. LPA’s record review revealed that R1 has had the same primary physician since their admission in October 2024. Based on record review and interview conducted, there is insufficient evidence to support the allegation that staff changed resident’s primary doctor without POA’s consent. This allegation is unsubstantiated. It was alleged that staff do not dispense resident their prescribed medication. LPA conducted an interview with the relevant party (RP) associated with R1, who stated that they were not sure what medication the staff are dispensing to R1. RP was unable to provide any additional information. To further investigate, LPA interviewed Staff #3 (S3), who asserted that all residents had received their prescribed medications without any omissions. S3 supported this claim by presenting records from the facility’s electronic medication administration system. Additionally, LPA conducted a medication count of R1’s inventory, which aligned with the documentation and confirmed S3’s statement. Based on the observations made and interviews conducted, there is insufficient evidence to support the allegation that staff do not dispense resident their prescribed medication. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 3, 2025 · control 18-AS-20250606124624

Allegation investigated: Resident was issued an unlawful eviction notice.

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to initiate an investigation for the above allegation. LPA met with Carminia Meza, Director of Nursing, and informed them of the purpose the LPA's visit. On 09-18-2025, Community Care Licensing (The Department) received a complaint report with the following allegation. It was alleged resident was issued an unlawful eviction notice. LPA conducted review of records and staff interview. LPA determined that the eviction notice was issued to the responsible person of Resident #1 (R1) on 09-17-2025 without an approval from The Department. A citation regarding this same deficiency was issued by the LPA during the LPA's case management visit on 09-18-2025. This allegation is Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where a copy of this report was reviewed and provided. Substantiated Based on record reviews and interviews, above allegations are Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 19, 2025 · control 18-AS-20250918170221

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Seo Jeon made an unannounced visit to the facility to conduct a Case Management visit regarding an eviction notice received by the Department on September 17, 2025. LPA spoke with Carminia Meza, Director of Nursing, and informed them the purpose of the LPA's visit. LPA conducted a tour of the interior and exterior of the facility. LPA did not find any health and safety concern for the residents in care at the time of the visit. LPA obtained documents for Resident #1 (R1).LPA's records review revealed that staff have already served the eviction notice to R1's responsible person without approval from the Department. A citation was issued. One (1) citation was issued per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted where a copy of this report was discussed with and provided along with LIC809-D and Appeal Rights.the state’s words, verbatim · CDSS document, Sep 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(b) · Plan of correction due date: Oct 2, 2025

Eviction Procedures. (b) The licensee may, upon obtaining prior written approval from the licensing agency...The licensing agency may grant approval for the eviction upon a finding of good cause. This requirement was not met as evidenced by: Based on records review and staff interview, the licensee issued the eviction notice to the resident's responsible person without the Department's approval. This posed potential heath, safety or personal rights risk to the resident in care.the state’s words, verbatim · CDSS document, Sep 18, 2025

Plan of correction: Licensee will rescind the eviction notice sent to the resident's responsible person and obtain formal training for the staff including the Licensee, Administrator and the staff left in charge on eviction procedures from an outside vendor and send proof of the said training.

Allegation investigated: Staff are not providing adequate meal service to the residents

Licensing Program Analysts (LPAs), Blanca Gonzalez and Mayra Cota conducted another subsequent complaint visit to investigate the allegations listed above. The initial complaint visit was conducted by LPA Seo Jeon on 09/04/24. A subsequent visit was conducted by LPAs Gonzalez and Cota on 08/09/25. During today’s visit, LPAs met with Bobbie Rogriuez, Director of Memory Care and explained the reason for the visit. During the initial 10-day complaint visit, LPA Jeon toured interior and exterior of the facility, conducted record review, obtained copies of pertinent documents, interviewed staff and residents. During the subsequent complaint visit on 08/09/25, LPAs obtained staff and resident rosters. LPAs toured the facility with focus on inspecting a themed diner, dining area, kitchen, and food storage areas. LPAs conducted interviews with staff # 6-11 (S6-S11) and residents #7-10 (R7-R10). During today’s visit, LPAs toured the facility and delivered findings for allegation listed above. continued on 9099C Unsubstantiated Regarding the allegation “Staff are not providing adequate meal service to the residents” it is alleged that on or around 08/16/2024, residents were served dinner and some residents, and a staff member became sick by the meal and residents continue to get served food that is expired. The investigation revealed the following: Per LPAs' observations of facility kitchen, food pantries, refrigerator, and freezer, the facility provides adequate food service. The food is fresh and not expired. LPAs observed well stocked food storage area, refrigerator and freezer. LPAs observed meal preparation and afternoon meal service. During interviews with staff, 10 out of 10 staff deny allegation of not providing adequate meal service to residents, serving expired food and had not heard of residents getting sick from the meals served. S6 stated they had not heard of an incident where residents got sick after a meal service. S7 stated meals are prepared daily per the menu. S7 stated food is delivered twice a week and is ordered according to the menu. LPAs asked about pies observed in the refrigerator, S7 stated” the pies were baked yesterday for today’s meal.” S7 stated they had not heard of any residents being sick from the meals served at the facility. During interviews with residents, 9 out of 10 residents deny getting sick from the meals served at the facility. R5 stated they became sick after dinner on 08/16/2024. R5 stated they did not see a doctor for it. R8 stated the food is good and is fresh. Based on LPA observations and interviews with staff and residents, it is determined that there was not enough supportive evidence to corroborate with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 10, 2025 · control 18-AS-20240827114012

Allegation investigated: Facility took resident's medication from the room without the resident's permission. Facility did not order refill for the resident's prescription medications on time.

Licensing Program Analysts (LPAs) Mayra Cota and Blanca Gonzalez conducted another subsequent visit to investigate the allegations listed above. LPAs met with Bobbie Rodriguez, Director of Memory Care Unit and the reason for the visit was explained. Initial 10 day visit was conducted on 1/6/25 by LPA Jeon which followed by subsequent visits from LPAs Cota and Gonzalez on 8/9/25 and 8/10/25. During initial 10-day visit, LPA Jeon, conducted tour of the facility, conducted record review, obtained requested copies of pertinent documentation, and interviewed staff and residents. During subsequent visit conducted on 8/9/25, LPAs obtained copies of staff and resident rosters, toured the facility and conducted interviews with Resident 1 (R1) and Resident 7 - Resident 10 (R7-R10), and Staff 2 - Staff 6 (S2-S6). LPAs also obtained copies of R1's Physician Report and Medication Administation Record (MAR) for May - August 2025. During today’s visit, LPAs toured common areas of the facility, and delivered findings. The investigation revealed the following: ***Continues on LIC 9099-C Unsubstantiated Regarding: Facility took resident's medication from the room without the resident's permission. It is alleged that medication was taken by facility staff from resident's room without their permission. It is also alleged that resident has permission from physician to handle their own medication. Interviews with (6) out of (6) staff, deny the allegation. Interviews with S1-S6 indicated, staff do not take medication from resident rooms without permission. Staff indicated, they help residents manage medication when there is a physician's order which states resident needs assistance with medication administration and that resident is in agreement via signed release form. Interview with S2 revealed, facility has been managing R1's medication because R1 has agreed to due to R1 mismanaging their medication in the past. Interviews with S2-S4 further indicated, R1 receives their medication daily from med-tech staff who order and store R1's medication in the medication cart and document medication taken accordingly on MAR. Interviews with S5 and S6 indicated, R1 willingly takes medication provided by med-tech staff during medication pass and has never complained about med-techs assisting with managing R1's medication. Interviews with R2-R10 also deny the allegation. Residents stated, staff do not enter rooms to take medication belonging to residents. Additional interview conducted with R1 during visit on 8/9/25 indicated, facility manages their medication which they are in agreement with. R1 stated, they get their medication on time every day from staff at the facility. Record review indicated, Individual Service Plan from 3/11/24 - 9/11/2024 stated, "resident will require medication to be administered by RCFE staff as prescribed by physician." Most current physician report on file for R1 dated, 4/29/25 also indicates, R1 is not able to administer their own prescribed medication and thus, medication needs to be given to them by staff. Review of MAR from May - August, 2025 indicate, facility continues to administer medication to resident and is documented accordingly on MAR. Interviews with staff, residents and record review do not corroborate the allegation. ****Continues on LIC 9099-C page 2 Regarding: Facility did not order refill for the resident's prescription medications on time. It is alleged that staff forgot to order medication refill for resident for about 2 months and it was the facility's responsibility to order the refill. Staff deny the allegation. Interviews with (6) out of (6) staff indicated, resident's medication is ordered on time. Interviews with R3-R4 revealed, there has not been a (2) month lapse in medication administration for R1. R3-R4 indicated, medication is ordered on time and given to residents correctly without interruptions. R3 stated, if R1 would have had such a long interruption in taking their medication, it would have been detrimental for their health. R3 further stated, "Residents need their medication to be administered without interruptions in order to live." Interviews with S5-S6 indicated, R1 receives their medication, daily, on time and without interruptions. Interviews with (9) out of (10) residents indicated, their medication refills are always ordered by the facility on time and there are no interruptions on taking their medication. Additional interview conducted on 8/9/25 indicated, R1 has been receiving her medication from med-tech staff since their initial admission to the facility. R1 also stated, they receive their medication daily and on time. Record review indicated, MAR from May - August 2025 reflect medication has been administered correctly to R1 without interruptions by facility staff. Staff and resident interviews and record review, does not corroborate the allegation. .Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, with Bobbie Rodriguez, Director of Memory Care Unit and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 10, 2025 · control 18-AS-20240904075959

Allegation investigated: Staff did not ensure resident was adequately hydrated.

Licensing Program Analysts (LPAs) Mayra Cota and Blanca Gonzalez conducted another subsequent visit to investigate the allegation listed above. LPAs met with Bobbie Rodriguez, Director of Memory Care Unit and explained the reason for today’s visit. Initial 10 day visit was conducted on 9/20/24 by LPA Jeon which followed by subsequent visits from LPAs Cota and Gonzalez on 8/9/25 and 8/10/25. During initial 10-day visit, LPA Jeon, conducted tour of the facility, conducted record review, obtained requested copies of pertinent documentation, and interviewed staff and residents. During subsequent visit conducted on 8/9/25, LPAs obtained copies of staff and resident rosters, toured the facility and conducted interviews with Resident 8 – Resident 13 (R8-R13) and Staff 3 – Staff 10 (S3-S10). During today’s visit, LPAs toured common areas of the facility, and delivered findings. The investigation revealed the following: ***Continues on LIC 9099-C Unsubstantiated Regarding: Staff did not ensure resident was adequately hydrated. It is alleged that resident was hospitalized on 9/2/due to dehydration because staff did not provide them with water and ice during a heat wave. It is also alleged, staff keep water and ice machine in the office which closes and is locked at 5:00 p.m. LPAs observations revealed, the facility has (3) water filtration systems, one in the main lobby and one on each floor which deliver cold water. At the time of inspection, both systems were found to be working properly and are accessible to residents. LPAs also observed an ice water and sweet tea self- serve dispenser which is accessible to clients 24 hours a day in the themed diner. The afternoon meal service was also observed during visit and several types of drinks like ice water, juices, coffee and milk were available for residents. Also observed during visit, caregivers delivering pitchers of water with cups of ice to resident rooms during rounds. Interviews with (10) out of (10) staff indicated that the facility provides water to residents at all times during routine rounds and upon request. Staff stated, the facility has water stations throughout the building which are always available for residents to obtain cold drinking water. Interview with S3 indicated, “Residents are provided with water and ice, 24/7. The facility has three water filtration systems which deliver cold water. Residents can have water 24/7 via the water dispensers, by getting it through their caregivers and during every meal service. Staff will never deprive residents of drinking water.” S3 further indicated that the ice box is located in the office; however, staff who distribute the ice always have access to the office. Interview with staff further indicated, if residents want ice, staff will assist by preparing ice cups and providing them to residents. The distribution of ice is handled by staff for sanitary purposes; however, residents are never deprived of getting ice. Interviews with (12) out of (13) residents indicated, they can have water any time. Residents stated, they have access to water through the three water fountains in the facility and by asking caregivers to provide water and ice. Residents also stated, they are never deprived of drinking water by staff. Interview with R1 indicated, at times, they have to wait for their ice and water to be brought to their room, but R1 knows, water can be obtained through the (3) water fountains in the facility and by requesting it from the caregivers. Record review indicated that R1 was hospitalized on 9/2/24 due to right knee pain. Record review conducted, did not indicate R1 was admitted to the hospital for dehydration. LPA observations, staff and resident interviews and record review, does not corroborate the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Bobbie Rodriguez, Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 10, 2025 · control 18-AS-20240916151514

Allegation investigated: Staff does not keep resident's room free from pests. Staff does not treat resident with dignity and respect.

Licensing Program Analysts (LPAs), Blanca Gonzalez and Mayra Cota conducted another subsequent complaint visit to investigate the allegations listed above. The initial complaint visit was conducted by LPA Seo Jeon on 08/14/24, a subsequent visit was conducted by LPAs Gonzalez and Cota on 08/09/25. During today’s visit, LPAs met with Bobbie Rodriguez, Director of Memory Care and explained the reason for the visit. During the initial complaint visit, LPA Jeon toured interior and exterior of the facility, conducted record review, obtained copies of pertinent documents, interviewed staff and residents. During the subsequent complaint visit, LPAs obtained staff and resident rosters, toured facility including common areas and six (6) resident rooms. LPAs interviewed eight (8) staff (S2-S9) and six (6) residents (R5-R10). During today’s visit, LPAs toured facility and delivered findings for allegations listed above. continued on 9099C Unsubstantiated Regarding allegation “Staff does not keep resident's room free from pests,” it is alleged that resident observed cockroaches and other pests in their room. The investigation revealed the following: Per LPAs' observations of facility common areas including hallway bathrooms, themed diner, dining room, kitchen, food pantries and 7 out of 7 resident rooms were found to be clean and free from cockroaches and pests. Further inspection revealed: LPAs did not observe bait traps or droppings throughout the facility. Interviews with the S2 and S3 revealed pest control sprays the facility twice a month and as needed. Additional staff interviewed had not seen any cockroaches in the facility or resident rooms. 10 out of 10 residents have not seen any cockroaches in the facility or in their room. Regarding allegation” Staff does not treat resident with dignity and respect,” it is alleged that when resident informed staff of cockroaches in their room, staff replied “if you don’t like it leave,” making resident feel as if they are not treated with respect. During interviews with residents, 10 out of 10 residents interviewed could not corroborate the allegation that staff do not treat residents with dignity and respect. Residents stated staff is attentive, friendly and helpful. R6 stated staff is good and respectful. R7 stated most staff is respectful. R9 stated they are treated with respect by staff. During interviews with staff, 9 out of 9 staff interviewed could not corroborate the allegation that staff do not treat residents with dignity and respect. S2 stated staff is patient with residents and just let them talk. S2 stated they remind staff of expectations. S4 stated they had not heard of staff being disrespectful toward residents. Based on LPA observations and interviews with staff and residents, it is determined that there was not enough supportive evidence to corroborate with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 10, 2025 · control 18-AS-20240809170133

Allegation investigated: Facility did not report that resident was missing Resident's needs are not being met.

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Administrator Aurelien Fruit and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 12/08/2022, LPA Colvin conducted preliminary interviews and collected documents from prior resident's (R1) file. On 06/28/2025 LPA Gutierrez interviewed Administrator, Staff #2- Staff #4, and Residents #2 -Residents #14.LPA obtained copies of the following documents: staff roster, resident roster, R1’s physicians report (LIC 602), face sheet, admission agreement, POA documents, and rent receipts. During today’s visit LPA Gutierrez interviewed two additional staff S5-S6 and delivered findings. SEE 9099C Unsubstantiated In regard to the allegation “Facility did not report that resident was missing”, It is alleged that R1 was missing for two weeks. During interviews with Administrator and staff six (6) out of six (6) stated that to their knowledge no resident had ever been missing for two weeks. Administrator stated that residents can leave at any time, but they check in with the office so that its notated. During interviews with residents thirteen (13) out of fourteen (14) stated to their knowledge no resident has ever went missing. During record review there were no notes or complaints from POA indicating that R1 was ever missing from facility. In regard to the allegation” Resident's needs are not being met”, it is alleged that R1 was found on bed in pile of clothes shivering and was in a shared room instead of private room. During interviews with Administrator and staff six (6) out of six (6) stated that no resident has ever been neglected. Administrator stated that R1’s health rapidly declined and was placed on hospice care until passing. It was also stated that R1 initially had a private room but due to cost POA had switched to a shared room. During interviews with residents twelve (12) out of fourteen (14) stated that staff meets their needs and thirteen (13) out of fourteen (14) felt safe with staff. Based on interviews conducted, and information that was gathered, there is insufficient evidence to support the allegation(s). Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. A copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jun 29, 2025 · control 18-AS-20221130170150

Allegation investigated: Residents not accorded dignity

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Administrator Aurelien Fruit and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 03/15/2024, LPA Banrasavong conducted a tour of the interior/exterior areas of the facility, conducted a review of records, obtained, and requested copies of pertinent documentation. On 06/28/2025 LPA Gutierrez interviewed Administrator, Staff #2- Staff #4, and Residents #2 -Residents #14.LPA obtained copies of the following documents: staff roster, resident roster, R1’and R2’s physicians report (LIC 602), face sheet, admission agreement, and employees documents. During today’s visit LPA Gutierrez delivered findings. See 9099C Substantiated In regard to the allegation “Residents not accorded dignity”, It is alleged that S1 took a video of R1 and R2 having intercourse without permission or consent and shared it with staff. During interviews with Administrator, it was revealed that there was a recording by S1 and several staff did see it. A full-blown investigation was conducted by the corporate office and S1 was terminated and staff that saw and did not report video were given a final write up. During interviews with staff three (3) out of three (3) interviewed denied ever seeing a video and stated they have never recorded residents nor heard of staff doing so. During interviews with residents thirteen (13) out of fourteen (14) stated to their knowledge staff has never recorded or taken a picture of them without their permission. Based on record review and interviews conducted, 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. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 29, 2025 · control 18-AS-20240312135821

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1)(3) · Plan of correction due date: Jul 4, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This deficiency is evidenced by the following: R1 and R2 were video recorded by S1 having intercourse without their knowledge or consent. This poses a health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Jun 29, 2025

Plan of correction: Administrator suspended then terminated S1 due to this behavior. Administrator agrees to conduct personal rights training for all current staff and send a list of material and a log of all employees who participated in training to LPA by POC due date.

Allegation investigated: Resident's motorized wheelchair broke due to staff neglect

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Administrator Aurelien Fruit and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 03/20/2025, LPA Banrasavong conducted a tour of the interior/exterior areas of the facility, conducted a review of records, obtained, and requested copies of pertinent documentation. On 06/28/2025 LPA Gutierrez interviewed Administrator, Staff #2- Staff #4, and Residents #1(Telephone) -Residents #13.LPA obtained copies of the following documents: staff roster, resident roster, R1’s physicians report (LIC 602), face sheet, and staff documents. During today’s visit LPA Gutierrez delivered findings. See 9099C Unsubstantiated In regard to the allegation “Resident's motorized wheelchair broke due to staff neglect”, It is alleged that S1 broke R1’s motorized wheelchair by turning it off and on. During interviews with Administrator, it was revealed that the wheelchair had never actually been broken and that the battery had just died. Three (3) out of three (3) staff all stated they have never witnessed staff break residents belongs. During interviews with residents’ thirteen (13) out of thirteen (13) stated that staff has never broken any of their belongs. R1 stated that S1 liked to turn their wheelchair off and on preventing it from working when the battery would die. Based on interviews conducted, and information that was gathered, there is insufficient evidence to support the allegation(s). Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. A copy of this report was given to the Administrator. In regard to the allegation “Resident was abandoned due to staff neglect”, It is alleged that S1 left R1 in an inoperable motorized wheelchair unable to call for assistance. During interviews with Administrator, it was revealed that S1 left R1 knowingly in wheelchair not working unable to reach for call button or phone to ask for assistance. It was also revealed that S1 admitted to Administrator to leaving R1 alone because of the behavior issues R1 displays. During interviews with residents twelve (12) out of thirteen (13) stated they have never been neglected by staff. R1 stated that S1 knew the chair was not working and did not assist them to bed leaving him/her sitting waiting for another caregiver to find them. Based on record review and interviews conducted, 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. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 29, 2025 · control 18-AS-20240314114727

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jul 4, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This deficiency is evidenced by the following: R1 was left in a non-working motorized wheelchair in room unable to call for assistance by S1. This poses a health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Jun 29, 2025

Plan of correction: Administrator suspended then terminated S1 due to this behavior. Administrator agrees to conduct personal rights training for all current staff and send a list of material and a log of all employees who participated in training to LPA by POC due date.

Allegation investigated: Staff are not providing proper accommodations to residents in care.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit regarding the allegation listed above. LPA arrived unannounced and met with the administrator, Aurelien Fruit. The purpose of the visit was explained. The investigation consisted of the following: On 1/18/2023, LPA Janira Arreola conducted the initial visit and requested documentation. During the visit today, LPA Chan conducted interviews with the administrator, 6 staff, and 8 residents. The investigation revealed the following: Allegation - Staff are not providing proper accommodations to residents in care. It was alleged that the facility had a water main break in January 2023, and residents were not provided with alternative accommodations. Additionally, it stated that residents had not taken showers, were not able to flush their toilets, and were not assisted with transporting the water jugs. Unsubstantiated LPA conducted interviews regarding this allegation. The administrator recalled that the city replaced the main water line in front of the facility around January 2023. The facility then went through a testing process to ensure the water was free of legionella. Staff stated that, at that time, they ran the water twice a day in the showers and sinks and installed filters on the shower heads and sinks for all the rooms. Staff stated the water was not turned off for days, and residents were able to shower and flush their toilets. They stated residents were given bottled water in their rooms for drinking, taking medications, and brushing their teeth. LPA interviewed 8 residents. Residents, who had lived at the facility for over 2 years, stated that the facility provided them with drinking water when they were repairing the main water line. They stated the facility turned off the water briefly, and they were able to shower after. They had never experienced water off for days. 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 Administrator Fruit. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Jun 27, 2025 · control 18-AS-20230112103050

Allegation investigated: Facility has vermin.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit regarding the allegation listed above. LPA arrived unannounced and met with the administrator, Aurelien Fruit. The purpose of the visit was explained. The investigation consisted of the following: On 1/6/2023, LPA Janira Arreola conducted the initial visit. During today’s visit, LPA Chan toured the facility and interviewed the administrator, 6 staff, and 8 residents. LPA also reviewed and obtained copies of the pest control reports. (Continue on LIC9099C) Unsubstantiated The investigation revealed the following: Allegation – The Facility has vermin. It was alleged that the facility has roaches and is often in the food served to residents. LPA Chan toured the facility including the kitchen and did not observe any roaches or other vermin. Interviews with the administrator and staff indicated that the facility takes measures to prevent cockroaches and other insects/rodents from coming into the facility. They stated the pest control technician sprays the facility twice a month and as needed. Most of the staff had not seen any roaches in the facility. None of the staff had seen them in the residents’ food. LPA reviewed pest control reports from the Western Exterminator Company dated as far back as 2020. It appears that the facility receives pest control maintenance at least once a month. There were no reports of cockroach infestation alleged in 2022. LPA also interviewed 8 residents. 7 out of 8 residents have not seen any cockroaches in the facility or in their food. One stated there might be one or two occasionally in the room but does not want anybody to spray the room. 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 Administrator, Aurelien Fruit. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Jun 27, 2025 · control 18-AS-20221227143725

Allegation investigated: Facility did not provide notice to residents of rent increase.

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegation. LPA met with Aurelien Fruit, Administrator, who was informed of today's visit. The Department investigation involved interviews with staff and review of records. The Department staff reviewed a sampling of five (5) files for residents participating in the Assisted Living Waiver (ALW) Program who reside at the facility. The Department staff additionally requested and reviewed the billing history from the facility for the time period of November 2021 - February 2022. The Department staff additionally interviewed the facility staff regarding the rate increase and the notice that was sent out to the residents regarding this increase. The Department staff observed the residents were provided with a written notice of rate increase on or around 2/6/2022 stating that due to the Social Security Income (SSI) benefits increasing for the year 2022, the rate payable for services provided by the facility would be increasing as well. Continued on LIC9099-C..... Substantiated This notice provided residents with the new benefit amount allotted by SSI, and the new "amount payable for basic services". Nowhere in the notice did it clearly outline what the residents would be charged and what the effective date of this new charge would be. However, from review of the billing documents as well as interview with the facility staff, it was revealed the residents were charged the new monthly rate as of the date of the notice (around 2/6/2022) and that the facility additionally retroactively billed the residents for the same rate for prior month, January 2022. The Department staff additionally observed in some of the resident files reviewed that in prior years the facility was able to increase the monthly rate for those residents receiving SSI when the SSI benefits increased. A rate increase notice was sent out to the residents informing them of the increase and providing them with notice it will be in effect on a specified future date. Based on record reviews and staff interviews, the allegation that facility did not provide notice to residents of rent increase is Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where a copy of this report was provided, along with a copy of LIC9099-C, LIC9099-D, and Appeal Rights were provided.the state’s words, verbatim · CDSS document, May 2, 2025 · control 18-AS-20220224100404

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655(a) · Plan of correction due date: May 2, 2025

Health and Safety Code (a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents Based on record reviews and staff interviews, staff did not provide notice to residents of rent increase. This posed a potential health and safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 2, 2025

Plan of correction: Administrator corrected the deficiency already in 2022.

Allegation investigated: Staff did not ensure the facility was free of pests

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to investigate the allegation mentioned above. LPA met with Aurelien Fruit, Administrator, and explained the purpose of the visit. On March 18, 2025, Community Care Licensing received a complaint report alleging that staff did not ensure the facility was free of pests. LPA's investigation involved a comprehensive review of the facility records, thorough inspection of the facility kitchen, hallways, and residents’ rooms. LPA also conducted resident/staff interviews. The records review included four (4) reports (summary of services) from a pest control company for past 2 months. LPA’s records review revealed the facility has regular weekly/monthly services from a pest control Continued on LIC9099-C.... Unsubstantiated company. LPA’s kitchen inspection revealed the facility kitchen was free of any pests. LPA inspected all areas of the facility kitchen including under the kitchen sinks. LPA inspected hallways and random residents’ rooms and did not find any pests or any sign of. LPA conducted ten (10) resident interviews and twelve (12) staff interviews. Ten out ten residents interviewed have not seen or heard of any pest issues in the facility. Twelve out twelve staff interviewed have not seen or heard of any pest issues. Based on interviews, observation, and records review, staff did not ensure the facility was free of pests is determined to be Unsubstantiated. A finding of Unsubstantiated means that the allegation may have happened or is valid, but there is no preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 21, 2025 · control 18-AS-20250318143624

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced annual required visit. Upon entry, LPA was greeted by Aurelien Fruit, Administrator, and informed them of the purpose of the visit. At the time of the visit, there were thirty (30) staff members and one hundred twenty six (126) residents present. Facility Overview: The facility is a two story building. There is a fenced swimming pool which is in compliance with local building and safety code. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents. LPA reviewed fire marshal inspection report dated 6-4-2024. Hot water temperature was 107°F. There are 26 fire extinguishers. LPA observed random fire extinguishers located at hallways and found them to have current inspection tags. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate. Continued on LIC809-C.... Record Review and Resident/Staff Files: LPA reviewed files for five (5) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Ten (10) resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for five (5) residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 2-19-2025, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided.the state’s words, verbatim · CDSS document, Mar 21, 2025

Allegation investigated: Staff did not ensure resident's restroom was not leaking Staff did not ensure resident's restroom was free of mildew Staff made inappropriate comments towards resident

Licensing Program Analyst (LPA), Kathleen Banrasavong, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA met with Administrator, Aurelien Fruit, who explained the purpose of the visit and the elements of the allegation. The investigation included observations, interviews with staff members and residents, and a review of records. On June 21, 2024, Community Care Licensing received a complaint alleging that facility staff did not ensure the resident's restroom was not leaking, staff did not ensure the resident's restroom was free of mildew, and staff made inappropriate comments towards the resident. It was alleged that the facility staff did not ensure the resident’s restroom was not leaking. Unsubstantiated In regards to the allegation that staff did not ensure resident’s restroom was not leaking, on June 17, 2024, a leak in the dining room was observed. Maintenance Director, Anthony Brown, indicated that the leak was from R1’s shower. During the facility inspection, LPA observed the leak. A work order was created on June 14th and the leak was repaired on June 20th. Administrator corroborated the information and stated that the leak was fixed within 48 hours. Administrator stated during that time, R1 was offered to use the communal shower, but R1 refused. It was reported that Administrator spoke inappropriately to R1, by advising that the use of the communal shower was “not that bad.” Administrator denied making the inappropriate comment to R1. Information obtained from R1 stated that inappropriate comments were made. On a subsequent visit, LPA observed R1’s restroom to be in good repair and did not observe any leaks. LPA was unable to interview R1’s roommate. It was also alleged that staff did not ensure the resident's restroom was free of mildew. R1 indicated that there was mildew in the restroom due to the leaks. During visits, LPA did not observe any mildew in the restroom. Administrator indicated that the rooms were free from mildew. LPA interviewed staff members who indicated no issues within the facility. LPA interviewed other residents who indicated that the facility was free from mildew. Based on the information obtained during the investigation, this agency has investigated the allegations that staff did not ensure the resident's restroom was not leaking, staff did not ensure the resident's restroom was free of mildew, and staff made inappropriate comments towards the resident and determined that allegations are unsubstantiated. Although the allegations may have occurred or may be valid, there is not enough evidence to prove that the alleged violations did or did not occur. An exit interview was conducted, and a copy of this report was discussed with and provided to the Administrator.the state’s words, verbatim · CDSS document, Jan 23, 2025 · control 18-AS-20240621162245

Allegation investigated: Staff does not keep residents room free from odor. Resident’s sink is in disrepair.

Licensing Program Analyst (LPA), Kathleen Banrasavong, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA met with Administrator, Aurelien Fruit, who explained the purpose of the visit and the elements of the allegation. The investigation included observations, interviews with staff members and residents, and a review of records. On February 02, 2024, Community Care Licensing received a complaint alleging that facility staff does not keep residents' rooms free from odor and that the resident’s sink is in disrepair. It was alleged that the facility staff brought a mattress into Resident 1 (R1)’s room and the mattress smelled like urine. It was also alleged that the sink in R1’s bathroom was not draining due to being in disrepair. LPA interviewed Administrator who stated that the mattress was in good condition and did not have any urine odor. This information was corroborated by Business and Development Director, Samara Harris. Unsubstantiated Fruit and Harris indicated that the urine smell could have possibly been caused by R1’s dog as it was observed that R1’s dog would urinate in the room. Information obtained from an interview with R1 stated that the smell was originated from the mattress. R1 denied that their dog was the cause of the urine smell present in the room. At the time of the inspection and follow up visits, the mattress was no longer in R1’s room. LPA interviewed R1’s current roommate, Resident 2 (R2), who indicated that they had no issues with the odor in the room. LPA interviewed other residents’ who indicated that the facility was free from odors. LPA did not interview R1’s previous roommate due to the fact that the previous roommate had moved out of the facility and LPA was unable to obtain contact. Regarding the allegation that the sink was not in good repair, LPA interviewed Maintenance Director, Anthony Brown, who stated that the sink was in good repair. Maintenance Director indicated that the sink was operational and able to drain. Maintenance Director also noted that R1’s room did not have any work orders related to drain issues when he pulled up the work order history for the room. Observations during the LPA’s initial and subsequent visits showed that the sink was in good repair and draining properly. Information obtained from Resident stated that the facility took 24 hours to check the seals around the sink. LPA conducted a random sampling of residents regarding the facility’s condition. Information obtained from residents indicated that they had not experienced any issues with the facility being in disrepair. It was also stated that residents would submit a work order and the issue would be addressed in a reasonable amount of time. Information obtained from staff members also indicated that work orders are fixed within a reasonable amount of time. Based on the information obtained during the investigation, the allegations that facility staff does not keep residents' rooms free from odor and that the resident’s sink is in disrepair are unsubstantiated. Although the allegations may have occurred or may be valid, there is not enough evidence to prove that the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was discussed with and provided to the Administrator.the state’s words, verbatim · CDSS document, Jan 23, 2025 · control 18-AS-20240131110434

Allegation investigated: Lack of staff to meet residents needs Staff not responding to resident calls in a timely manner Staff are medicating resident to keep resident calm. Food service is inadequate

Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to conclude the investigation into the allegation listed above. LPA met with Director of Nurses Carmina Meza and explained the purpose of the visit. LPA’s complaint investigation consisted of a tour of the interior/exterior areas of the facility, observations, interviews with staff and residents, and records review of requested pertinent documents. Regarding the allegation “Lack of staff to meet residents needs”, it was reported resident one (R1) and other residents admitted to the memory care unit were not getting the care and services needed due to lack of staff. LPA interviewed three (3) out of three (3) staff working at the facility in 2022 who denied the allegation. Interviews with staff revealed in 2022 the facility had three caregivers and one MedTech scheduled for AM shift and PM shift. NOC shift had two caregivers and one MedTech. Records of the staff schedule from 2022 could not be Interview obtained. Staff One (S1) revealed R1 needed more assistance and supervision but that did not prevent staff from providing needs and services to the other residents in care. Unsubstantiated LPA was not able to interview R1 due to R1 no longer residing at the facility and R1’s contact information is not available. Therefore the allegation is unsubstantiated. Regarding the allegation “Staff not responding to resident calls in a timely manner”, it was reported staff were not responding to call button requests in a timely manner. LPA’s interviews with three (3) out of three (3) staff who worked at the facility in 2022 revealed no corroboration to the allegation. Records of call button system response times were not available for review due to the call button system being lights flashing on and off on a switchboard. Interview with five (5) out of seven (7) residents currently residing at the facility reported staff response times to call button requests vary but staff respond in an adequate amount of time. Therefore the allegation is unsubstantiated. Regarding the allegation “Staff are medicating resident to keep resident calm”, it was reported due to R1’s behaviors, medication was being administered to keep R1 calm. LPA’s interviews with three (3) out of three (3) staff who worked at the facility in 2022 denied over medicating R1 or the other residents in care. LPA conducted a record review of R1’s Medication Administration Record (MAR) but was not able to review R1’s medication due to R1 no longer residing at the facility. LPA was not able to interview R1 due to R1 no longer residing at the facility and R1’s contact information not available. LPA was unable to obtain evidence to corroborate or refute the allegation therefore the allegation is unsubstantiated. Regarding the allegation “food service is inadequate”, it was reported the meals served to the residents in care are limited in quantity. Interviews conducted revealed facility receives two food supply deliveries a week. During the visit LPA observed for the facility food supply to meet the minimum requirements of a 2-day supply of perishable food items and a 7-day supply of nonperishable food items. Interview with three (3) out of three (3) staff working at the facility in 2022 revealed that meals served to the residents were not limited in quantity and quality. LPA’s interviews with six (6) out of seven (7) residents currently residing at the facility deny allegation of food service being inadequate. LPA observed facility had a restaurant style dining room and observed lunch menu that had an adequate amount of items to select from. LPA observed lunch being served during this visit and did not observe an inadequate amount of food being served to residents in care. Therefore the allegation is unsubstantiated. Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Director Of Nurses Meza.the state’s words, verbatim · CDSS document, Aug 7, 2024 · control 18-AS-20220207113002

Allegation investigated: Facility staff over-medicated resident

Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to conclude the investigation into the allegation listed above. LPA met with Director of Nurses Carmina Meza and explained the purpose of the visit. LPA’s complaint investigation consisted of a tour of the interior/exterior areas of the facility, observations, interviews with staff and residents, and records review of requested pertinent documents. Regarding the allegation “Facility staff over-medicated resident”, it was reported Resident One (R1) was overmedicated and had in their possession half a tablet of medication that did not belong to R1. Records review of facility progress report dated 05/30/2021 shows R1 was having a behavior in the AM and refused to take their AM medication. R1’S Power of Attorney (POA) was called and POA stated they would arrive to the facility at 1:00pm. Staff contacted 911 services at 10:50am to seek additional assistance due to safety concerns for staff and other residents in care. Palm Springs PD arrived to the facility to provide assistance at approximately 12:30pm. Unsubstantiated R1 requested two PRNs for pain management. One PRN was given at 12:54pm and the second PRN was given at 01:01pm. R1’s POA arrived at approximately 1:30pm and R1 reported to the POA and Palm Springs Officer the facility was giving R1 medication that did not belong to them. During the initial visit to the facility on 06/09/2021, a medication count was conducted for R1 and Resident Two (R2) and found no discrepancies with the pill count and documentation on the medication administrator record (MAR). Interview with three (3) staff deny R1 being over medicated or R1 being administered medication that was not prescribed to them. Interview with R1 revealed they do not take medication that is not prescribed to them and does not store extra medication in their room or personal belongings. Records review of R1’s MAR shows staff had documented the time and day the two PRNs were given to R1 on 05/30/2021. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Director Of Nurses Meza.the state’s words, verbatim · CDSS document, Aug 2, 2024 · control 18-AS-20210602143558

Allegation investigated: Staff do not ensure that resident's grooming needs are met Staff not responding to resident calls in a timely manner

Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to conclude the investigation into the allegation listed above. LPA met with Director of Nurses Carmina Meza and explained the purpose of the visit. LPA’s complaint investigation consisted of a tour of the interior/exterior areas of the facility, observations, interviews with staff and residents, and records review of requested pertinent documents. Regarding the allegation “Staff do not ensure that resident's grooming needs are met” it was reported staff are not assisting residents with their grooming needs. Interview with five (5) out of six (6) residents reported staff are assisting residents with their grooming needs. Interview with Resident One (R1) reported they receive showers from caregivers twice a week has not experienced issues with caregivers assisting R1 with their activities of daily living (ADL). Interviews with four (4) staff revealed staff are assisting residents with their grooming and hygienic needs as much as possible. Records Review of R1 and Resident Two (R2) progress notes reveal they receive showers twice a week. Unsubstantiated LPA observed multiple residents in care during visits to be clean and well groomed. Therefore based on observation, interviews and record reviews, the allegation has been deemed Unsubstantiated at this time. Regarding the allegation “Staff do not answer residents' call buttons in a timely manner”, it was reported residents have to wait more than an hour to receive assistance from staff. LPA interviewed five (5) out of (6) residents who reported staff respond to the call buttons in a timely manner and they did not have to wait more than an hour to receive assistance. Interview with four (4) staff reported the front desk or the lead caregiver will communicate with the caregivers when a call button was pulled via walkie talkies and staff will respond to the resident’s call buttons request in an appropriate amount of time. Staff will attend to the residents’ call button request within a reasonable amount of time depending on if all staff are currently assisting other residents. Staff schedule review for June 2024 and July 2024 revealed AM shift has 3 caregivers and 1 MedTech, PM shift has 3 caregivers and 1 MedTech, and NOC shift has 2 caregivers and one MedTech. LPA observed call light system located in the front desk. During the initial visit, LPA observed receptionist use a walkie talking to inform caregivers about a call light button being activated and a caregiver responding to the receptionist acknowledging the resident’s request. Investigation did not reveal documents to corroborate nor refute call time responses. Therefore based on observation, interviews, and record reviews, the allegation has been deemed Unsubstantiated at this time. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided Director of Nurses Meza.the state’s words, verbatim · CDSS document, Aug 2, 2024 · control 18-AS-20240603143759

Allegation investigated: Staff did not prevent the residents from engaging in a physical altercation

Licensing Program Analyst (LPA) Sara Martinez made an unannounced visit to the facility to commence a complaint investigation regarding the allegation listed above. LPA was granted entry and met with Administrator Aurelien Fruit who was informed of the purpose of the visit and the elements of the allegation. During today's visit, LPA toured the facility, conducted staff and resident interviews, and reviewed documentation pertinent to Resident One (R1) and Resident Two (R2). Regarding the allegation “Staff did not prevent the residents from engaging in a physical altercation” it was reported a physical altercation occurred between R1 and R2 on May 17, 2024. R2 was sent to urgent care due to injuries sustained to the back of the head and R1 had a bruise on their left eye but refused medical treatment. Based on interviews conducted, R2 walked into R1’s room and initiated the physical altercation due to a closet door being left open. R2 reported R1 had used their cane to hit R2 on the back of their head. Unsubstantiated R2 walked to the facility’s front desk and informed staff of their injury and requested emergency services. Interviews revealed when staff entered R1’s room after the physical altercation, they noticed R1’s dresser drawer was open. They observed blood on the edge of the drawer and directly below the dresser drawer was a pool of blood on the carpet. It was reported when staff entered R1’s room, R1 had two canes, one on the wall and one on the floor with no traces of blood on either canes. Interview with R1 revealed R2 entered R1’s room and started hitting R1. R1 reported they are not aware of a prior verbal or physical dispute with R2 that initiated the physical altercation. R1 and R2 have two separate rooms but share one bathroom. Administrator Fruit reported arrangements were made to have R2 move into a different room when they returned from urgent care but R2 refused to move rooms. Interviews conducted with R1 and R2 revealed neither of the residents wanted to move rooms after the physical altercation. R2 reported no verbal disputes or physical altercations with R1 after May 17, 2024. Interviews and records review revealed R1 and R2 did not have any prior incidents involving physical aggression or verbal disputes while residing in the facility. Records review of Physician’s Report for R1 revealed R1 is able to perform their activities of daily living (ADL) with no supervision or assistance from staff which includes bathing self, grooming self, feeding self, and care for own toileting needs and R1 does not have a history of aggressive behavior. Physician’s Report for R2 revealed R2 is able to perform their activities of daily living (ADL) with no supervision or assistance from staff which includes bathing self, grooming self, feeding self, and care for own toileting needs. It is recorded R2 has aggressive behaviors “at times”. Interview with staff one (S1) reported after R1 and R2’s physical altercation, staff were instructed to conduct daily observations and monitoring during each shift and document R1 and R2’s behaviors. Staff interviews corroborated staff were informed and implemented a plan to increase monitoring of R1 and R2’s interactions. Staff also reported the plan included redirection of interactions between R1 and R2 when necessary. Records review revealed on May 20, 2024, staff began documenting R1 and R2’s behaviors daily based on a number system indicating aggressive behaviors observed. Zero (0) indicated no aggressive behavior observed, one (1) indicated yelling observed, two (2) indicated cursing was observed, and three (3) striking out or being physically aggressive was observed. R1 and R2 had zeros documented daily for each shift from May 20, 2024 to May 30, 2024. Based on interviews and records review, staff did not have any indication that the interaction between the two residents was escalating prior to R2 entering R1’s room to prevent the physical assault. Therefore based on interviews and records review, the allegation “Staff did not prevent a resident from physically assaulting another resident in care” has been deemed unsubstantiated at this time. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided. An exit interview was conducted with Administrator Fruit and a copy of this report, LIC 811, and LIC 9099C was provided.the state’s words, verbatim · CDSS document, May 30, 2024 · control 18-AS-20240521122020

Allegation investigated: Staff does not provide residents with a comfortable environment. Facility does not staff appropriately to meet the residents' needs. Residents are not provided with activities.

On May 24, 2024, Licensing Program Analyst (LPA), Venus Mixson conducted a visit to the facility and met with Carminia Meza, (LVN). The visit was conducted to provide the findings for the investigation pertaining to the listed allegations. During the investigation the LPA conducted staff and resident interviews, record reviews, and made observations pertaining to the listed allegations. On July 14, 2021, Community Care Licensing (CCL) received a complaint alleging staff does not provide residents with a comfortable environment, the facility does not staff appropriately to meet the residents' needs, and the residents are not provided with activities. It was reported that the administrator turned down the AC thermostat to 90 degrees. And that the facility was very hot. Regarding the allegation staff does not provide residents with a comfortable environment, it was reported that the air-conditioning thermostat was turned down to 90 degrees. The information obtained from staff and resident interviews; it was advised that the residents living units have an individual air-condition (AC)units. Several residents were interviewed, and each resident shared there are no concerns with the facility temperature and they each have their own respective air-conditioning unit in their rooms. Additional information obtained from record reviews and the LPA's observations demonstrated the facility has a maintenance team and is available to check and repair the facility thermostats if required. Information obtained from the LPA's observations revealed each resident's living unit has an individual air condition unit, which the residents can control and adjust to their preference. The information obtained did not corroborate the allegation that staff do not provide residents with a comfortable environment. Regarding the allegation, the facility does not staff appropriately to meet the residents' needs, it was reported that there was only 1 caregiver for 97 residents. Information obtained from interviews advised that, the facility has sufficient staff scheduled per shift. Additional information obtained from observations and record reviews revealed there are sufficient staff available to assist the residents in care. It was advised that the facility has on-call caregivers, nurses, and Hospice Nurses that are available as needed. The information obtained from the records reviewed does not corroborate the allegation. The information obtained from staff and resident interviews does not support this allegation. Regarding the allegation residents are not provided with activities, it was reported that due to inefficient staffing, resident do not have activities. The information obtained from interviews advised that the facility has an Activities Director, and the activities are planned and scheduled for the whole month. Additional information obtained from staff and resident interviews stated there are a variety of activities and the activities schedule is posted and provided to the residents in care. Further information obtained from the LPA's observations revealed the facility does provide activities to the residents in care, and activities schedules are posted for review throughout the facility. The LPA observed activities taking place and reviewed monthly activity schedules during the record reviews. Information obtained from interviews, observations, and record reviews, does not support the allegation. Based on interviews, record reviews, and observations, the allegations of staff do not provide residents with a comfortable environment, facility does not staff appropriately to meet the residents' needs, and residents are not provided with activities has been deemed "Unfounded." An allegation finding of unfounded means "the allegations are false, could not have happened and/or are without a reasonable basis." Therefore, the outcome of the investigation is regarded UNFOUNDED currently. The Department has investigated the listed allegations and the evidence obtained has demonstrated the listed allegations did not occur and therefore, has dismissed the listed allegations at this time. An exit interview was conducted, and a copy of this report was provided to the Carminia Meza, LVN. Unfoundedthe state’s words, verbatim · CDSS document, May 24, 2024 · control 18-AS-20210714121632

Allegation investigated: Staff speak inappropriately to resident in care.

On April 29, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to the facility to conducted additional interviews and conclude the investigation. LPA Mixson met with the Administrator, Aurelien Fruit, and stated the purpose of the visit. During the investigation, LPAs conducted staff and resident interviews, record reviews, and made observations pertaining to the listed allegation. On June 21, 2021, Community Care Licensing received a complaint alleging that staff speak inappropriately to a resident in care. It was reported that Resident Number 1 (R1), got angry and argued with the previous Administrator over various issues (R1) was having. It was also reported that the previous Administrator told (R1) "You can either go to jail, go to you room, or take the meds you've been given." Regarding the allegation Staff speak inappropriately to resident in care, it was advised that the two staff referenced in the allegation, ("Patrick" and "Jennifer") are no longer working at the facility and no forwarding contact information has been provided currently. Additionally, it was advised that (R1) does not recall what was said because it was a long time ago. Additional information obtained through resident interviews advised that the previous Administrator was admissive and did not take care of things the way that they should have been taken care of, but that (R2) never heard the Administrator disrespect any of the residents or act inappropriately. Information obtained was not sufficient to demonstrated that the allegation occurred. Based on the LPAs not able to contact additional pertinent parties to obtain sufficient information regarding the listed allegation, the allegation findings have been deemed "UNSUBSTANTIATED." An allegation finding of unsubstantiated means "Although the allegation may have happened or is valid, there is not a preponderance of the evidence strand to prove the alleged violations did or did not occur," therefore the allegation is unsubstantiated at this time. An exit interview was conducted and a copy of this report, along with the LIC 811, was provided to the Administrator, Aurelien Fruit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 29, 2024 · control 18-AS-20210621122750

Allegation investigated: Resident was not provided with an Admissions Agreement. Staff are not administering medications to resident according to physicians orders. Facility is overcharging resident in retaliation.

On March 22, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to deliver the findings and met with the Administrator. The visit was made to provide the findings for the investigation pertaining to the listed allegation. During the investigation, the LPA conducted staff and resident interviews, record reviews, and made observations pertaining to the listed allegation. On June 21, 2021, Community Care Licensing received a complaint alleging a Resident (R1), was not provided with an Admissions Agreement. It was reported that R1 was not provided a copy of their Admissions Agreement upon the transfer from the California Nursing and Rehabilitation Center to the listed facility. Regarding the allegation resident was not provided an admission agreement, it was advised that it is the policy and procedure to have each resident read, sign, and date their Admissions Agreement. Additionally, it was advised, if a resident is not able to sign and date the admissions agreement, then their responsible party may sign and date for the resident. The information obtained from interviews and record reviews does not corroborate the allegation. Additionally, it was advised that R1 signed and dated the Admissions Agreement without assistance. A signed and dated Admission Agreement was observed and reviewed by the LPA during the record review. Unfounded CONTINUATION Regarding the allegation, staff are not administering medications to resident according to physicians’ orders, it was advised that the facility staff followed the physicians’ orders and the medications on file as prescribed. Additionally, it was advised that when residents arrive to the facility the facility will make sure the medication orders are followed as prescribed by the physician. Finally, it was advised that it was not the current facility (referring to the listed facility), but the previous facility where R1 transferred from. The information received does not corroborate the allegation. Regarding the allegation, facility is overcharging resident in retaliation the information obtained from interviews and record reviews, revealed that R1's insurance covered all services. It was advised that Hospice covered the wheelchair, along with additional services provided, and R1 did not have to pay for any services rendered. The information obtained does not support the allegation. Based on information obtained from interviews, record reviews, and observations, the information obtained was not sufficient to demonstrate the listed allegations were valid. Therefore, the allegation has been deemed as unfounded, meaning the allegation is false, could not have happened, and/or is without a reasonable basis. The Department has investigated, and the information obtained has demonstrated the listed allegations did not occur and therefore, has dismissed the allegations. An exit interview was conducted, and a copy of this report was provided to the Administrator, Aurelien Fruit.the state’s words, verbatim · CDSS document, Mar 22, 2024 · control 18-AS-20210621122750

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that one hundred and twenty-nine (129) clients live at this facility at the time of the inspection. There was twenty- nine (29) staff members present. The Administrator, Aurelien Fruit conducted and completed the facility tour. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Five (5) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration: LPA reviewed employee records. Five (5) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Aurelien Fruit, Administrator’s certificate expiration date is 08/01/2024. Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a location for sharps in the kitchen. Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. The facility is a 2-story facility. LPA observed the facility to be clean and in good repair. The facility is maintained at 75 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 106.0 degrees F. Laundry is done in the designated laundry room on the 1st floor. There is a locked cabinet for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA dialed the facility’s landline number, which rang and was operable. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There are zero (0) fireplaces at this facility. There is one (1) secured and gated pool at the facility. There are two (2) gates that border the entrance to memory care. LPA observed five (5) emergency supplies and first aid with the required components. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training. Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed that they were dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed smoke and carbon monoxide detectors throughout the facility. The fire alarm is monitored by Fire Alarms, in which there is a hard wire system that is monitored 24 hours a day. There were twenty- four (24) fire extinguishers on site. Pursuant to the Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to the Administrator, Aurelien Fruit.the state’s words, verbatim · CDSS document, Mar 15, 2024

Allegation investigated: Resident's engaged in a physical altercation resulting in resident sustaining injuries.

Licensing Program Analyst (LPA) Jesse Gardner arrived at the facility unannounced to deliver findings for the complaint investigation related to the above listed allegation. LPA met with Business Office Manager Mariahoney Malasig and explained the purpose of today’s visit. LPA then toured the facility. Administrator Aurelien Fruit arrived while in the facility. During the investigation, the Department reviewed facility records, hospital records and law enforcement records. The Department also conducted interviews with the facility staff and residents. *Continued on LIC9099C Unsubstantiated It was alleged that due to staff’s neglect and lack of supervision, residents got into a physical altercation resulting in severe injuries. Facility interviews revealed facility staff reported seeing Resident 1 (R1) around the dining room and back patio area on the day of the incident. Staff also reported having checked on Resident 2 (R2) in their bedroom on an hourly basis on the same day. Neither resident had a history of aggression or assault. Therefore, no warnings were in place that would warrant staff taking measures to prevent such an occurrence. On the day of the incident, which as 01/24/2022, at approximately 5:30pm, a physical altercation took place, between R1 and R2, resulting in R1 suffering injuries to their face. After the residents were separated by facility staff, R1 was transported to a local hospital for evaluation and treatment. As a result of the interviews conducted and records reviewed, it was determined that R1 erroneously entered R2’s room and a physical altercation ensued. According to resident interviews, R1 attempted to punch R2, and R2 defended themselves by punching R1. According to all parties interviewed, staff were alerted to the altercation and responded immediately to separate the residents. Insufficient evidence exists to prove that this was as a result of facility staff’s neglect and/or lack of supervision as such the allegation is Unsubstantiated. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No citations are being issued as a result of this compliant investigation. An exit interview was conducted and a copy of this report was provided along with a copies of the LIC9099C, and LIC811 (confidential names list).the state’s words, verbatim · CDSS document, Jan 11, 2024 · control 18-AS-20220126125405

Allegation investigated: Staff did not administer resident's medication in a timely manner

Licensing Program Analyst (LPA), Kathleen Banrasavong made an unannounced visit to the facility to deliver findings for a complaint investigation regarding the allegations listed above. LPA met with Administrator, Aurelien Fruit and explained the purpose of the visit and the elements of the allegations. LPA Banrasavong conducted the investigation which consisted of observation, interviews with staff members and residents, and record review. On 10/26/2023, Community Care Licensing received a complaint stating that the staff did not administer resident’s medication in a timely manner. In regards to the allegation that the staff did not administer medication for Resident 1 (R1), it was reported that the facility did not apply and give R1 their prescribed treatment. LPA Banrasavong spoke to R1 who confirmed that they were provided their treatment twice. Unfounded It was corroborated by the R1’s Medication Administrator Record (MARS) which showed that the first application of the treatment was administrated on October 13, 2023. The second application for the cream was administered on October 21, 2023, which was according to doctor’s orders. Information obtained from staff interviews indicated that the medication was given to R1 which followed the doctor’s orders. After the medication was applied, the staff initialed that it was dispersed to R1. Based on LPA’s observation, interview conducted, and record reviews, the preponderance of evidence shows that the allegations that Staff did not administer resident's medication in a timely manner is unfounded. The Department has found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.the state’s words, verbatim · CDSS document, Jan 10, 2024 · control 18-AS-20231026092156

Type of visit: Case Management - Health Checks

During the course of a complaint investigation, in reference to Complaint Control number: 18-AS-20231026092156, Licensing Program Analyst (LPA) Kathleen Banrasavong reviewed staff files and discovered that S1 did not have a TB test result on file with the facility. In the complaint, the reporting party alleged that TB test were not being regularly asked and checked by the facility. During the course of this investigation, LPA pulled five random staff members’ TB test examination results. 4 out of 5 staff members had their TB test results in their employee files. LPA Banrasavong is issuing a technical violation per Title 22, Division 6 Health and Safety Code 1796.45 (a) Affiliated home care aides hired on or after January 1, 2016, shall submit to an examination 90 days prior to employment, or within seven days after employment, to determine that the individual is free of active tuberculosis disease. There are no health and safety concerns at this time. An exit interview was conducted, a copy of this report, a technical violation was provided to the Administrator, Aurelien Fruit as evidenced by his signature.the state’s words, verbatim · CDSS document, Jan 10, 2024

Allegation investigated: Facility did not follow eviction procedures

Licensing Program Analyst (LPA), Kathleen Banrasavong made an unannounced visit to the facility to commence a complaint investigation regarding the allegations listed above. LPA met with Administrator, Aurelien Fruit and explained the purpose of the visit and the elements of the allegations. LPA Banrasavong conducted the investigation which consisted of observation, interviews with staff members and residents, and record review. On 10/25/2023, Community Care Licensing received a complaint stating that the facility did not follow eviction procedures. The allegation stated that the facility did not follow the 30-day eviction notice, did not properly serve the resident, and did not give the resident proper resources to find alternative housing. During the LPA’s initial visit, LPA was able to speak to Resident 1 (R1) and confirmed that he was properly served with the 30-day notice on the date that the facility submitted the notice to Community Care Licensing’s Regional Office. Continued on a 9099-C Unfounded Continuation from the 9099 There has been documentation provided to the resident that indicated an outstanding balance, which included fees from unpaid rent since 2022. Some of the fees have already been submitted to collections. During the LPA’s interview with Administrator and staff, it was concluded that Administrator and Staff #1 hand delivered the eviction notice, along with several resources to help find alternate housing. Based on LPAs observations, records review, and staff and resident interviews, this agency has investigated the complaint alleging that the facility did not follow eviction procedures and we have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted and a copy of this report was provided to the Administrator, Aurelien Fruit as evidenced by his signature.the state’s words, verbatim · CDSS document, Nov 7, 2023 · control 18-AS-20231025153653

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit on the health, safety, and welfare of residents in care. LPA met with Administrator, Aurelien Fruit. Riverside RO received a serious incident report, regarding an incident that occurred on October 18, 2023. Resident 1 (R1) left the facility and was AWOL for approximately 2 hours. The LPA interviewed R1 and staff during the case management visit. LPA toured the facility and observed all facility utilities to be on and operating without issue, food supply is sufficient, there is no immediate concern for residents in care. Based on the information obtained during today’s visit, there are no deficiencies or civil penalties being cited per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with Administrator, Aurelien Fruit and a copy of this report is left with the Administrator, Aurelien Fruit as evidence by his signature.the state’s words, verbatim · CDSS document, Oct 30, 2023

Allegation investigated: Staff did not provide a comfortable environment for resident

Licensing Program Analyst (LPA), Kathleen Banrasavong made an unannounced visit to the facility to commence a complaint investigation regarding the allegation listed above. LPA met with Administrator, Aurelien Fruit and explained the purpose of the visit and the elements of the allegations. LPA Banrasavong conducted the investigation which consisted of observation, interviews with staff members and residents, and record review. On 09/15/2023, Community Care Licensing received a complaint stating that facility staff did not provide a comfortable environment for resident. In regards to the allegation that the staff did not provide a comfortable environment for resident, it was reported that Resident #1 (R1) had several incidents with R1’s roommate (R2). It was alleged that R2 was verbally abusive towards R1 and R2 used R1’s property without permission. (Continued on LIC9099C) Unfounded (Continuation from LIC9099) During LPA’s investigation, LPA was advised that the concerns were vocalized to Administrator and Administrator removed R2 from the shared room. R1 received a new roommate, R3. R1 and R3 had an incident where R1 came into the room and R3 was allegedly drinking his beverage. R1 addressed the new concerns to Administrator. Administrator then removed R3 from the room and reassigned another resident to the room. During interviews and record review, LPA concluded that the facility has made adjustments in a timely manner and acted in the best interest of the resident. Based on LPA’s observation, interview conducted, and record reviews, the preponderance of evidence shows the allegations that staff did not provide a comfortable environment for resident is unfounded. This agency has investigated the complaint alleging staff did not provide a comfortable environment for resident. The Department has found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, a copy of this report, appeal rights was provided to the Administrator, Aurelien Fruit as evidenced by his signature. (Continuation from LIC9099) Based on the LPA’s observation, interviews conducted and records review. The preponderance of evidence shows the allegation of staff did not safeguard resident’s personal property unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, a copy of this report, appeal rights was provided to the Administrator, Aurelien Fruit as evidenced by his signature.the state’s words, verbatim · CDSS document, Oct 20, 2023 · control 18-AS-20230915083849

Allegation investigated: Staff are not emptying resident trash bins in a timely manner Staff are not properly cleaning facility restrooms Staff do not ensure facility patio furniture are cleaned Staff do not keep dining room floor free from debris

Licensing Program Analyst (LPA), Kathleen Banrasavong made an unannounced visit to the facility to commence a complaint investigation regarding the allegations listed above. LPA met with Administrator, Aurelien Fruit, and explained the purpose of the visit and the elements of the allegations. LPA Banrasavong conducted the investigation which consisted of observation, interviews with staff members and residents, and record review. On 09/07/2023, Community Care Licensing received a complaint stating that staff are not emptying resident trash bins in a timely manner, staff are not properly cleaning facility restrooms, staff do not ensure facility patio furniture are cleaned, and staff do not keep dining room floor free from debris. (Continued on 9099-C) Unfounded (Continuation from 9099) In regards to the allegation that staff are not emptying resident trash bins in a timely manner, it was reported that staff was not emptying Resident #1 (R1)’s trash in a timely manner. During the investigation, LPA observed the R1’s trash which did not corroborate the allegation. LPA made random visit to other resident’s room with their approval and did not observe any issues or concerns regarding the trash not being emptied. LPA spoke to R1 and R2, which is R1’s roommate and the residents denied that there were ever any issues regarding their trash not being emptied. Regarding the allegation that facility staff are not properly cleaning facility restrooms and staff do not keep dining room floor free of debris, it was alleged that the bathroom was not sanitary and the trash was full. It was also stated that facility staff do not clean the dining room after mealtimes. During the LPA’s inspection of the facility, on multiple dates, the visitor’s restroom was clean and sanitary. The facility dining room was also observed to be free of debris. LPA interviewed residents that indicated that there were no issues or concerns regarding the cleanliness of the bathrooms, dining room, or facility. The allegation that staff do not ensure facility patio furniture is cleaned. LPA made several field day inspections and observed the patio furniture to be in good repair and clean. LPA interviewed staff that indicated that they had a rotation list that they signed off on after they completed the cleaning for that area. Staff also indicated that they would clean and empty the trash more frequently if requested, in additional to the normal cleaning schedule. During interviews and record review, the LPA concluded that the facility has protocol in place to clean and disinfect the facility on a regular and consistent basis. It was advised and documented that the facility has a cleaning schedule that is completed throughout the day. (Continued on 9099-C) (Continuation from 9099) Based on LPA’s observation, interviews conducted, and record reviews, the preponderance of evidence shows that the allegations of staff are not emptying resident trash bins in a timely manner, staff are not properly cleaning facility restrooms, staff do not ensure facility patio furniture are cleaned, and staff do not keep dining room floor free from debris have been deemed as unfounded. This agency has investigated the complaint allegations and we have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, a copy of this report was provided to the Administrator, Aurelien Fruit as evidenced by his signature.the state’s words, verbatim · CDSS document, Oct 20, 2023 · control 18-AS-20230907152452

Allegation investigated: Staff are not following resident's care plan Staff mismanaged resident's medication

Licensing Program Analyst (LPA), Kathleen Banrasavong made an unannounced visit to the facility to commence a complaint investigation regarding the allegations listed above. LPA met with Administrator, Aurelien Fruit, and explained the purpose of the visit and the elements of the allegations. LPA Banrasavong conducted the investigation which consisted of observation, interviews with staff members and residents, and record review. On 08/18/2023, Community Care Licensing received a complaint stating that facility staff are not following resident's care plan and staff mismanaged resident's medication. In regards to the allegation that staff did not follow the residents care plan, it was reported that the facility did not follow orders from Above and Beyond Hospice for Resident #1. The order was for medication queued date of 08/10/2023. Medication was never given or distributed due to the facility not receiving order and directions to distribute the medication. Information obtained from interviews and record reviews, show that the facility did not receive orders to distribute the medication to Resident #1. The request for orders to be provided was made by the facility until the resident’s medical condition had subsided. Through interviews conducted, LPA concluded that the facility had procedures in place before giving medication and has followed the resident’s care plan. (Continued on 9099-C) Unsubstantiated (Continuation from 9099) In regards to the allegation that staff mismanaged resident's medication. It was reported that the facility staff did not give medication to Resident #1. LPA learned that the proper orders were never provided to the facility and per facility procedures, medication will not be distributed without proper orders. Medication was properly destroyed and logged. The record shows the medication were queued in the facility’s digital log on 08/10/2023. When Resident #1’s medical issues occurred again, the facility reported it to hospice. Facility staff made the request to hospice to provide a new order and mediation be sent for the Resident #1’s condition. The request was denied by hospice, due to hospice stating that they already sent the medication and order for Resident #1’s medical issue. However, the facility had destroyed the medication due to no orders being sent and the resident’s condition improving on its own. Per facility protocols, all medication is destroyed, that are not being used or that do not have orders attached to them. Based on LPA’s observation, interview conducted, and record reviews, the preponderance of evidence shows that the allegations of staff are not following resident's care plan and staff mismanaged resident's medication is not supported or proven by evidence. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, a copy of this report, appeal rights was provided to the Administrator, Aurelien Fruit as evidenced by his signature.the state’s words, verbatim · CDSS document, Oct 16, 2023 · control 18-AS-20230818125146

Allegation investigated: Staff did not provide adequate supervision resulting in resident suffering a fall and sustaining injuries. Facility did not seek medical attention for a resident in care. Staff left resident soiled for a long period of time. Staff did not replace resident's bedding. Staff did not dispose of resident's trash. Staff refused to assist a resident in care.

Licensing Program Analyst (LPA) Kathleen Banrasavong made an unannounced visit to the facility to commence a complaint investigation regarding the allegation(s) listed above. LPA met with Administrator, Aurelien Fruit, where LPA explained the purpose of the visit and the elements of the allegation(s). The allegation(s) were investigated, the investigation consisted of observation, interviews with five (5) staff members and five (5) residents, and record review. On 08/07/2023, Community Care Licensing received a complaint stating that the following allegations: Staff did not provide adequate supervision resulting in resident suffering a fall and sustaining injuries, Facility did not seek medical attention for a resident in care, Staff left resident soiled for a long period of time, Staff did not replace resident's bedding, Staff did not dispose of resident's trash, Staff refused to assist a resident in care. (Continued on 9099-C) Unsubstantiated (Continuation from 9099) In regards to the allegation that staff did not provide adequate supervision resulting in residents suffering a fall and sustaining injuries, information obtained stated facility staff did not provide adequate supervision for the residents. It was also reported that the facility did not seek medical attention. Information obtained from interviews stated that residents are able to request assistance from facility staff when needed and obtain assistance within a reasonable time period. Through interviews obtained, the residents stated that they are able to get and receive medical attention if needed and no issues or concerns were advised. It was also reported that staff left resident soiled for a long period of time and staff did not replace resident’s bedding. It was reported that an additional witness observed Resident #1 (R1) to be covered in feces while they were sleeping on separate occasions. It was reported that Resident’s bedding had vomit stains. It was also reported that staff did not dispose of residents’ trash. LPA observed resident’s bedding, trash, and room and deemed that it met the regulatory requirements. Through record reviews and staff interviews, LPA learned that there is a schedule where the staff changed bedding and takes out the trash. Residents can request to have it done more frequently, as needed. Interviews with residents corroborated the information obtained from staff. Information obtained from residents stated they can get assistance with changing briefs and bedding, in a reasonable. No issues or concerns were advised. (Continued on 9099-C) (Continuation from 9099) In regards to staff refusing to assist a resident in care, it was reported that staff refused to help residents get around the facility. During the LPA visit on 08/08/2023, residents indicated that they are able to ask for assistance and receive it. Based on LPA’s observation, interview conducted and record review(s), the preponderance of evidence shows that the allegations of staff did not provide adequate supervision resulting in resident suffering a fall and sustaining injuries, facility did not seek medical attention for a resident in care, staff left resident soiled for a long period of time, staff did not replace resident's bedding, staff did not dispose of resident's trash, staff refused to assist a resident in care may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, a copy of this report, appeal rights was provided to the Administrator, Aurelien Fruit as evidenced by his signature.the state’s words, verbatim · CDSS document, Oct 4, 2023 · control 18-AS-20230807114540

Allegation investigated: Staff did not prevent a resident from kicking another resident while in care Staff did not prevent a resident from engaging in inappropriate sexual interactions with another resident Staff are mishandling a resident's medical needs while in care

Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an unannounced visit to commence a complaint with the above allegations. LPA met with Administrator, Aurelien Fruit, where LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of observation, interviews with staff members and residents, and record review. On 08/15/2023, Community Care Licensing received a complaint alleging that staff did not prevent a resident from kicking another resident while in care, staff did not prevent a resident from engaging in inappropriate sexual interactions with another resident while in care, staff do not repair the facility's elevators, and staff are mishandling a resident's medical needs while in care. In regards to the allegation that staff mishandling the resident’s medical needs while in care. It was reported that staff missed medication distribution for Resident #1. Residents indicated that they have their medical needs met and if medical needs were requested, the request was fulfilled by the facility within a reasonable time period. LPA reviewed medication and record of the MARS log which appeared to have been distributed and logged correctly. No issues or concerns were advised. (Continued on 9099-C) Unsubstantiated (Continuation from 9099) In regards to the allegation that staff did not prevent resident from kicking another resident in care. It was also reported that facility staff did not prevent a resident from engaging in inappropriate sexual interactions with another resident while in care. Information obtained from interviews indicated that the residents can report any health and safety concerns to the Administrator and have their issues resolved by the facility. LPA reviewed documents in relation to the allegation, which revealed that the facility took active measures to switch out roommates due to incidents. Based on interviews, the allegations that staff did not prevent a resident from kicking another resident while in care, staff did not prevent a resident from engaging in inappropriate sexual interactions with another resident while in care, staff do not repair the facility's elevators, and staff are mishandling a resident's medical needs while in care., may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report, appeal rights were discussed with and provided to the Administrator, Aurelien Fruit.the state’s words, verbatim · CDSS document, Oct 4, 2023 · control 18-AS-20230815144142