Yorkshire Village

Allegation investigated: Pull cord is not operable Staff did not respond to resident timely Facility is understaffed

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Nicole Anguiano, Business Office Manager, 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 August 26, 2026, Community Care Licensing (The Department) received a complaint report with the following allegations. It was alleged that pull cord is not operable. Information received indicated that Resident #1’s (R1) emergency switch did not work in their room. The Department staff conducted an interview with R1, who stated that the pull cord was not working. R1 stated that the light goes off in Building A only. Continued on LIC9099-C.... Unsubstantiated LPA conducted interviews with three (3) residents, all of whom stated that they receive assistance whenever they use the pull cord for help. LPA conducted interviews six (6) staff members, all of whom stated that all pull cords were operational. LPA tested three (3) sample pull cords and confirmed that the pull cords were operating. There was a panel in the building that lights up on the corresponding room numbers when pull cords were pulled. Based on interviews conducted and observations, the evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated at this time. It was alleged that staff did not respond to resident timely. Information received indicated that Resident #1 (R1) waited for over one (1) hour for a nurse. The Department staff conducted an interview with R1, who stated that they have experienced delays of 30 minutes to one (1) hour when requesting assistance. LPA conducted interviews with three (3) residents, who reported waiting times from right away to 15 minutes, and the residents expressed that the waiting times were reasonable. LPA conducted interviews with six (6) staff members, all of whom confirmed the statements from the residents interviewed. Based on the interviews conducted, the evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated at this time. It was alleged that facility is understaffed. The Department did not receive any details on this allegation. LPA conducted a review of staff schedule for the month of August 2026 and observed that the facility was fully staffed in all four (4) buildings in the facility. LPA did not observe any lack of staff coverage. LPA conducted interviews with three (3) residents, none of whom expressed any concerns about staff coverage. LPA conducted interviews with six (6) staff members, all of whom stated that the facility was fully staffed, and there were no concerns about being short staffed. LPA toured all four (4) buildings of the facility and observed the same number of staff members in the staff schedule. Based on interviews conducted, records review and observation, the evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated at this time. 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. LPA obtained medication technicians' files and observed that all medication technicians had required qualifications. Based on record reviews and interviews, this allegation is Unfounded. A finding of Unfounded means the allegation could not have happened, is false, and/or is without a reasonable basis. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 11, 2026 · control 18-AS-20260826161753

Allegation investigated: Staff did not notice resident's change in condition Staff did not obtain timely medical attention for resident

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Nicole Anguiano, Business Office Manager, and informed them of the purpose of the LPA’s visit. The Department’s investigation involved interviews with staff and review of records. On August 18, 2026, Community Care Licensing (The Department) received a complaint report with the following allegation. It was alleged that staff did not notice resident’s change in condition. Information received indicated that staff did not test Resident #1’s (R1) glucose level regularly, and it was measured at 395 mg/dL on April 4, 2026, by R1’s relevant party (RP). R1 was subsequently transferred to an emergency hospital, where they were diagnosed with a Urinary Tract Infection (UTI). Continued on LIC9099-C.... Unsubstantiated LPA conducted R1’s records review. R1 was admitted on March 26, 2026, and moved out on April 6, 2026. According to the facility assessment dated March 31, 2026, R1 required maximum assistance with bathing, dressing, toileting, transferring, mobility, and special care needs, including assistance with glucose monitoring. However, because the relevant parties could not meet to finalize the details, R1’s formalized care plan was never executed. R1 was ultimately discharged from the facility before the care plan could be mutually agreed upon and signed. Regarding the glucose monitoring, the facility received a physician's order for blood sugar checks on March 31, 2026. The facility’s Medication Administration Records (MAR) demonstrate that staff performed these glucose checks twice daily from March 31, 2026, through April 4, 2026. All logged readings during this period remained within normal range. R1’s glucose level reading at 395 mg/dL was not performed by the facility staff and was not documented. Therefore, LPA could not verify the reading. Furthermore, a review of R1’s progress notes spanning March 27, 2026, to April 3, 2026, revealed no documentation of R1 expressing pain or exhibiting any clinical symptoms associated with a UTI. Based on records review, R1 did have UTI during their residency at the facility. However, the evidence found during the investigation did not meet the preponderance of evidence standard required to confirm staff neglect. Therefore, this allegation is unsubstantiated at this time. It was alleged that staff did not obtain timely medical attention for resident. Information received indicated that Resident #1’s (R1) glucose level reached 395 mg/dL on April 4, 2026, and R1’s relevant party called 911 to transport R1 to emergency room. LPA conducted R1’s records review. According to the facility assessment dated March 31, 2026, R1 required maximum assistance with bathing, dressing, toileting, transferring, mobility, and special care needs, including assistance with glucose monitoring. However, because the relevant parties could not meet to finalize the details, R1’s formalized care plan was never executed. R1 was ultimately discharged from the facility before the care plan could be mutually agreed upon and signed. The facility’s Medication Administration Records (MAR) demonstrate that staff performed these glucose checks twice daily from March 31, 2026, through April 4, 2026. All logged readings during this period remained within normal range. Continued on LIC9099-C.... Furthermore, a review of R1’s progress notes spanning March 27, 2026, to April 3, 2026, revealed no documentation of R1 expressing pain or exhibiting any symptoms associated with UTI. R1’s glucose level reading at 395 mg/dL was not performed by the facility staff and was not documented. It was performed by R1’s relevant party at 2:27 PM on April 4, 2026, which was not within prescribed time frame. Therefore, LPA could not verify the reading. Based on records review, R1 was transported to emergency room after high glucose level reading by R1’s relevant party. However, staff documented that R1 did not show any signs of illness that would cause staff to obtain medical attention. The evidence found during the investigation did not meet the preponderance of evidence standard required to confirm staff neglect. Therefore, this allegation is unsubstantiated at this time. 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, Aug 28, 2026 · control 18-AS-20260818123856

Allegation investigated: Staff refused to provide assistance resulting in resident being left on the floor for an extended period of time.

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with… who was informed of the purpose of the visit. During the visit, LPA conducted interviews, documented observations/conducted a walk through, and conducted records review. “Staff refused to provide assistance resulting in resident being left on the floor for an extended period of time.” Unsubstantiated It was alleged that on 08/12/2026, the Fire Department received a call for medical assistance after Resident #1 (R1) experienced a fall. It was alleged R1 reported having a fall in the bathroom and was down for 15 minutes. R1 yelled out to staff for help and staff refused to assist R1 up from the ground. R1 crawled to the bathroom sink and was able to lift themselves to their knees. It was alleged that staff reported per facility policy, staff cannot assist when a resident has a fall. R1 was transported to the hospital. LPA attempted to contact first responders on scene however, they were unavailable for interview. LPA attempted to conduct an interview with R1, however R1 was not oriented during the interview. LPA reviewed the facility incident report for 08/12/2026, which revealed S1 had assisted R1 on 08/12/2026 after experiencing an unwitnessed fall. S1 reported R1 experienced an unwitnessed fall in another residents room, Resident #2 (R2)’s room. S1 had gone into R2’s room to assist R2 and observed R1 was wandering in the hallway. S1 estimated 15 minutes later at around 9:15pm/ 9:10pm staff conducted their rounds and observed R1 lying flat on the floor on top of a fall mat. S1 stated R1 reported pain all over their body and back and reported hitting their toe on a dresser in R2’s room. S1 did not move R1 from the floor because S1 did not know if R1 was injured. S1 explained R1 is the type of resident to stub their toe and keep moving, and their expression of pain concerned them. S1 called 911 for R1. S1 denied that staff refused to provide assistance to R1. Regarding R1 being on their knees in a bathroom, S1 stated paramedics stayed with R1 in the room and when S1 returned they observed R1 was on their knees. S1 did not know how R1 got onto their knees. LPA reviewed facility video surveillance placed in the East Hallway outside of R2’s room on 08/12/2026. At 8:55 P.M. a staff member exits R2’s room. Approximately one minute later, R1 is seen entering R2’s bedroom. At 9:00 P.M. staff re-enters R2’s room and calls S1 for assistance. The video surveillance did not capture the interior of R2's room or fall. LPA reviewed the facility call logs for 08/12/2026 which confirmed a call was made to 911 on 08/12/2026 at 9:03 P.M. LPA attempted to interview R2, however they were not alert or oriented. Interview with S1 and (2) management staff reported the facility training instructs care staff to not move residents off the floor when they experience unwitnessed falls due to the possibly of injuring or worsening a resident’s injury. Staff will call 911 to assess the resident. LPA reviewed Procedure for Falls in-service training conducted on 05/20/2026 which stated “If a resident has a fall do not move the resident. Wait until 911 arrives to properly assess resident.” Based on interviews, and records reviewed the allegation was found to be unsubstantiated. Findings that are unsubstantiated mean the preponderance of the evidence standard has not been met. An exit interview was conducted where this report was reviewed and provided.the state’s words, verbatim · CDSS document, Aug 26, 2026 · control 18-AS-20260813162948

Type of visit: Case Management - Health Checks

Licensing Program Analysts (LPAs) Janira Arreola and Seo Jeon conducted an unannounced visit for the purpose of Health and Safety Check Case Management Visit. LPAs met with Business Office Manager, Nicole Kalacas who was informed of the purpose of the visit. During the time of the visit, LPAs conducted a walk through interviews and observations. During the time of the visit no immediate health or safety concerns were observed. No deficiencies were cited per California Code of Regulations Title 22. During the visit consultation was provided on emergency procedures and protocols when emergency services need to be contacted for residents on hospice. The Business Office Manger agreed to meet with the management team and provide an update on any changes to the emergency procedure for residents. An exit interview was conducted where this report and Technical Advisory Note were reviewed and provided.the state’s words, verbatim · CDSS document, Aug 20, 2026

Allegation investigated: Staff do not provide resident with toiletries Staff do not provide resident with linens

On 8/18/2026, Licensing Program Analyst's (LPA's) Valerie Flores and Janira Arreola conducted an unannounced visit to the facility for the purpose of delivering the investigative findings into the allegations listed above. LPA Flores met with Active Living Director Ashley Richardson and explained the purpose of the visit. The investigation is summarized as follows: On 8/12/2026, Community Care Licensing (CCL) received information alleging staff do not provide Resident #1 (R1) with toiletries. Interview conducted R1’s responsible person reports that they were advised by an unknown staff that prior to admittance, R1 must bring their own shampoo prior to arrival. R1 responsible person reports that they have to purchase R1 shampoo twice a month. It was further reported that R1’s responsible person was provided a list of items the residents may bring but reports that they were strictly advised that the items on the list were required to bring upon admittance. (Continue to LIC9099C...) Unsubstantiated (Continuation from LIC9099) An interview conducted with Staff #1 (S1) denied the allegation, explaining that the list is provided to all families and is a suggestion. S1 reports that some families prefer to bring a resident their own shampoo. If a family reports that they are unable to provide the resident with their own shampoo or choose not to provide the resident with shampoo, the facility will provide it to the resident. During the visit on 8/18/2026, LPA Flores observed a large order placed outside of housekeeping laundry storage. The order contained shampoos, toilet paper, lotions, and other personal care products. S1 reports that shipments are received once a week or as needed. LPA was unable to interview R1 as R1 was no longer residing at the facility during the time of visit. In addition, information received alleged staff did not provide R1 with linens. An interview with R1’s responsible person reports that R1 was unable to be admitted into the facility unless R1 was able to bring all the items listed on the paperwork. R1’s responsible person reports that it is noted to be a suggestion on the physical list but was verbally advised by an unknown staff that it was a requirement. Interview with Staff #1 (S1) reports that when they learn of a new residents admittance, they offer the residents to use linen that is supplied by the facility, but most families choose to bring their own linen and blankets. S1 denied the allegation of requiring R1 to bring their own linen. LPA observed additional supply of linen stored in the laundry room and supply closet. Therefore, the allegations of staff do not provide resident with toiletries and staff do not provide resident with linens are deemed unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the preponderance of the evidence has not been met. An exit interview was conducted, and a copy of the report was provided to Active Living Director Ashley Richardsonthe state’s words, verbatim · CDSS document, Aug 18, 2026 · control 18-AS-20260810131558

Allegation investigated: Staff did not ensure resident received medical care in a timely manner Resident sustained bruise due to staff neglect or physical abuse

Licensing Program Analyst (LPA) Abdoulaye Zerbo, conducted an unannounced visit to the facility in order to deliver findings on the above allegations. LPA met with Business Office Manager, Nicole Kalacas, who was informed of the purpose of the visit. It was alleged that staff did not ensure that Resident #1 (R1) received medical care in a timely manner. Information received indicated that facility staff did not promptly seek medical treatment for R1. LPA conducted multiple interviews with facility staff and with R1 to determine whether a delay in medical attention occurred on July 15, 2026. Interviews with several staff members indicated that R1 was observed to be lethargic, pale, slurring speech, and responding to verbal prompts by nodding. Staff reported that 911 was contacted immediately upon recognizing R1’s change in condition. (Continue to LIC9099C) Unsubstantiated LPA also reviewed the facility’s surveillance footage from July 15, 2026. At 12:21 p.m., R1 was observed scratching their hand while seated at the dining table and not eating the food provided. At 12:22 p.m., Staff #2 (S2) approached R1 after noticing that R1 was not eating. At 12:23 p.m., S2 notified Staff #3 (S3) of R1’s condition. At 12:24 p.m., S3 was observed calling 911. Between 12:24 p.m. and 12:35 p.m., staff remained with R1 and monitored their condition until paramedics arrived at 12:35 p.m. The video evidence corroborates staff statements that emergency medical services were contacted promptly and that R1 was continuously monitored until paramedics arrived. It was alleged that resident sustained bruise due to staff neglect or physical abuse. Information received indicated that a blackened bump on the left side of R1’s lip had been observed. LPA conducted multiple interviews and reviewed hospital records related to R1’s admission on July 15, 2026. Staff reported that R1 had vomited on themselves when they became lethargic, and stated the darkened area observed may have been food particles rather than a bruise. On July 30, 2026, LPA interviewed R1 at a skilled nursing facility. R1 was alert and oriented and denied any neglect or abuse by staff, stating that staff were careful and respectful. LPA also reviewed R1’s hospital records, which documented a physical examination noting multiple excoriated lesions over the trunk and extremities with generalized itchy skin. The hospital report did not document any blackened bump or bruising on the resident’s lip. Based on interviews conducted, review of surveillance footage, and examination of medical records, there is insufficient evidence to support the allegation that Staff did not ensure resident received medical care in a timely manner or that resident sustained bruise due to staff neglect or physical abuse. Therefore, these allegations are deemed unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the preponderance of the evidence has not been met. An exit interview was conducted, and a copy of the report was provided to the facility representative.the state’s words, verbatim · CDSS document, Aug 12, 2026 · control 18-AS-20260724102019

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility for the purpose of conducting a health and safety check and previously observed HVAC repairs needed which were identified during a visit on August 3, 2026. LPA met with Nicole Anguiano, Business Office Manager, and explained the purpose of the visit. LPA conducted a tour of Building A and B. Per Anguiano, new HVAC will be installed on August 12, 2026. During the visit, LPA observed additional portable fans were placed for the residents in the affected area of Building A. HVAC system in Building B was repaired already and fully operational. LPA conducted additional tour of Building C. LPA observed room #3 maintained comfortable temperature. LPA confirmed with the resident in room #3 regarding the room temperature. LPA did not observe any immediate health and safety concerns during the facility tour. An exit interview was conducted and a copy of this report was provided to the Business Office Manager.the state’s words, verbatim · CDSS document, Aug 11, 2026

Type of visit: Case Management - Health Checks

On 8/10/2026, Licensing Program Analysts (LPA) Valerie Flores made an unannounced visit to the facility for the purpose of conducting a health and safety check and previously observed HVAC repairs needed that were identified during a visit on August 3, 2026. LPA Flores met with Business Office Manager Nicole Anguiano and explained the purpose of the visit. The visit is summarized as follows: LPA Flores conducted a randomly selected tour of resident bedrooms in Building A and Building B. In addition, toured the common areas of Building A and B and did not observe any immediate health and safety concerns. LPA was informed that corporate maintenance is currently on-site assessing the air conditioning unit and possibly conducting the repair themselves. In addition, the facility is still awaiting for an estimate from the HVAC company to determine how much the repairs will be. During the visit, LPA Flores observed that additional portable fans were purchased and implemented in residents bedrooms. An exit interview was conducted and a copy of this report was provided to Business Office Manager Nicole Anguiano.the state’s words, verbatim · CDSS document, Aug 10, 2026

Allegation investigated: Staff do not ensure equipment is comfortable for resident

Licensing Program Analysts (LPA) Seo Jeon and Janira Arreola conducted an unannounced visit to the facility to deliver findings of the above allegation. LPA met with Nicole Anguiano, Business Office Manager, 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 26, 2026, Community Care Licensing (The Department) received a complaint report with the following allegation. It was alleged that staff do not ensure equipment is comfortable for resident. Information received indicated that Resident #1 (R1) refused to use the shower chair due to something sticking from the seat that caused pain. Continued on LIC9099-C..... Substantiated Per physician’s report dated November 3, 2025, and R1’s assessment, R1 uses wheelchair and required staff assistance for all activities of daily living (ADL), including transfer to and from wheelchair due to R1’s cognitive and physical condition. LPA conducted interviews with six (6) residents, all of whom denied experiencing pain from sitting on shower chairs. LPA conducted interviews with seven (7) staff members, none of whom heard about any complaints from residents about shower chairs. LPA conducted a tour of the facility and inspected all shower chairs but did not observe anything protruding from the sitting area. However, LPA observed one shower chair with torn back cushion with exposed sponge material that appeared to be in such condition for extended periods. Based on observation, the evidence found during the 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. Per physician’s report dated November 3, 2025, and R1’s assessment, R1 uses wheelchair and required staff assistance for all activities of daily living (ADL) due to R1’s cognitive and physical condition. LPA conducted R1’s medical records review. Both medical records dated June 10, 2026, and July 22, 2026, contained photos of multiple bruises on both R1’s legs. LPA conducted interviews with six (6) residents, all of whom denied being physically abused by staff. All residents interviewed stated that staff have been very careful when providing care. LPA conducted interviews with seven (7) staff members, all of whom denied pulling or dragging residents’ feet. R1 is currently admitted to a skilled nursing facility for rehabilitation. LPA conducted an interview with R1 at the skilled nursing facility. R1 had two (2) visitors at the time. R1 and both visitors did not suspect the bruises were from staff’s neglect or abuse. R1 stated that staff were very careful when providing assistance. R1 did not have any concerns regarding staff assistance with mobility. R1 and the visitors were not certain what or who caused the bruises on R1’s legs. There is insufficient evidence available to show that resident sustained multiple bruises due to staff neglect or physical abuse. The available documents are not sufficient to determine the cause of the bruises. Interviews conducted did not reveal any causes of the bruises. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated at this time. It was alleged that staff are not meeting resident’s hygiene needs. Information received indicated that there is inadequate staff assistance with Resident #1’s (R1) hygiene needs. R1 is currently admitted to a skilled nursing facility for rehabilitation. LPA conducted an interview with R1 at the skilled nursing facility. R1 had two (2) visitors at the time. R1 was brushing her teeth with some assistance from one of the visitors. LPA conducted an interview with R1, who stated that they did not remember when the facility staff members assisted with daily oral hygiene. LPA conducted interviews with six (6) residents, all of whom did not have any concerns with staff assistance with daily hygiene. LPA conducted R1’s records review. LPA reviewed the facility care logs from January 2026 through July 2026. LPA observed that staff had provided assistance with oral hygiene twice daily. LPA observed that staff had not missed any. Based on interviews conducted and records review, there is insufficient evidence to prove that staff are not meeting resident’s hygiene needs. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated at this time. Continued on LIC9099-C.... It was alleged that staff confine resident to wheelchair/bed. Information received indicated that Resident #1 (R1) was primarily kept in wheelchair or bed. Per physician’s report dated November 3, 2025, and R1’s assessment, R1 uses wheelchair and required staff assistance for all activities of daily living (ADL), including transfer to and from wheelchair due to R1’s cognitive and physical condition. LPA conducted interviews with six (6) residents, all of whom denied ever being confined to wheelchairs or beds. LPA conducted interviews with seven (7) staff members, all of whom denied ever witnessing residents confined to wheelchairs or beds. R1 is currently admitted to a skilled nursing facility for rehabilitation. LPA conducted an interview with R1 at the skilled nursing facility. R1 stated that R1 never said anything about being confined to wheelchair or bed. R1 was happy about staff members’ encouragement to get out of bed and participate in activities. Based on interviews conducted, there is insufficient evidence to prove that staff confine resident to wheelchair/bed. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated at this time. It was alleged that staff handled resident inappropriately. Information received indicated that staff grabbed Resident #1 (R1) by their feet and dragged out of bed. Per physician’s report dated November 3, 2025, and R1’s assessment, R1 uses wheelchair and required staff assistance for all activities of daily living (ADL), including transfer to and from wheelchair due to R1’s cognitive and physical condition. LPA conducted interviews with six (6) residents, all of whom denied ever being dragged out of beds. LPA conducted interviews with seven (7) staff members, all of whom denied ever witnessing staff dragging residents out of beds. R1 is currently admitted to a skilled nursing facility for rehabilitation. LPA conducted an interview with R1 at the skilled nursing facility. R1 stated that R1 never said anything about being grabbed by the feet and dragged out of bed by staff members. R1 had never experienced such incidents in the facility. R1 thought staff were polite and careful to residents in care. Based on interviews conducted, there is insufficient evidence to prove that staff handled resident inappropriately. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated at this time. Continued on LIC9099-C.... It was alleged that staff speak to resident inappropriately. Information received indicated that staff said, “Do you want to take shower or not?” when Resident #1 (R1) told staff that the shower chair was painful to sit on it. Per physician’s report dated November 3, 2025, and R1’s assessment, R1 uses wheelchair and required staff assistance for all activities of daily living (ADL) due to R1’s cognitive and physical condition. LPA conducted interviews with six (6) residents, all of whom denied experiencing staff speaking inappropriately to residents. LPA conducted interviews with seven (7) staff members, all of whom denied witnessing or speaking inappropriately to residents in care. R1 is currently admitted to a skilled nursing facility for rehabilitation. LPA conducted an interview with R1 at the skilled nursing facility. R1 denied telling anyone that the facility staff spoke inappropriately. R1 had never experienced such incidents in the facility. R1 thought staff were polite and careful to residents in care. Based on interviews conducted, there is insufficient evidence to prove that staff speak to resident inappropriately. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated at this time. It was alleged that staff withhold resident’s medication. Information received indicated that staff withheld Resident #1’s (R1) medication prescribed for their skin condition. LPA conducted interviews with six (6) residents, all of whom denied experiencing staff withholding their medication. LPA conducted interviews with seven (7) staff members, all of whom stated that staff strictly follow what is in residents’ prescriptions. All staff members interviewed stated that medication administration record (MAR) shows all residents’ records. LPA conducted R1’s records review. R1’s MAR shows the medication for skin condition were administered in May 2026 and June 2026 but not in July 2026. LPA conducted an interview with Anguiano, who stated that the medication for R1's skin condition was discontinued by R1's physician. LPA conducted review of R1's medication records which revealed that the medication ended on June 24, 2026. R1 is currently admitted to a skilled nursing facility for rehabilitation. LPA conducted an interview with R1 at the skilled nursing facility. R1 stated that staff stopped applying the prescribed medication for their skin condition but was not able to tell any time frame. Based on interviews conducted and records review, there is insufficient evidence to prove that staff withhold resident’s medication. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated at this time. Continued on LIC9099-C.... It was alleged that staff do not assist resident with mobility. Information received indicated that Resident #1 (R1) received inadequate staff assistance with mobility. Per physician’s report dated November 3, 2025, and R1’s assessment, R1 uses wheelchair and required staff assistance for all activities of daily living (ADL), including transfer to and from wheelchair due to R1’s cognitive and physical condition. R1 is currently admitted to a skilled nursing facility for rehabilitation. LPA conducted an interview with R1 at the skilled nursing facility. R1 stated that R1 never said anything about inadequate staff assistance with mobility. R1 was happy about staff members’ encouragement to get out of bed and participate in activities. R1 stated that staff had always provided good assistance with mobility while R1 resided at the facility. Based on interviews conducted, there is insufficient evidence to prove that staff do not assist resident with mobility. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated at this time. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, 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, Aug 7, 2026 · control 18-AS-20260726171118

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 7, 2026

Personal Rights of Residents in All Facilities, (a) (a) Residents in all residential care facilities for the elderly shall have... personal rights: (2) To be accorded safe, healthful and comfortable...furnishings and equipment. Above requirements were not met as evidenced by: Based on observation and interviews conducted, one (1) shower chair has torn back cushion that can cause discomfort for residents. This poses potential person rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 7, 2026

Plan of correction: Business office manager agreed to discuss this matter with the administrator and the licensees and send photo proof of replacement or repair via email by the POC due date.

Type of visit: Case Management - Other

Licensing Program Analysts (LPA) Seo Jeon and Janira Arreola conducted an unannounced visit to the facility to conduct a health and safety check and follow-up on the HVAC issues identified on August 3, 2026. LPAs met with Nicole Anguiano, Business Office Manager, and informed them of the purpose of the visit. LPAs conducted a tour of the facility and did not observe any immediate health and safety concerns. Anguiano provided documentation that showed their HVAC replacement in Building B. Anguiano informed that the management is waiting for an estimate for HVAC replacement in Building A. The estimated is expected on Monday, August 10, 2026. The management will then order the work to be scheduled. Anguiano agreed to inform The Department for any updates. An exit interview was conducted and a copy of this report was provided to Anguiano.the state’s words, verbatim · CDSS document, Aug 7, 2026

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Janira Arreola and Seo Jeon conducted an unannounced case management visit to the facility. LPAs met with Medication Technician Manager, Bianey Sandoval, who was informed on the purpose of the visit. LPAs conducted a walk through, interviews, and records review. During the time of the visit LPA Arreola delivered and reviewed an amended report with facility staff. During the time of the visit, LPAs conducted a walk through of the facility and measured the temperature of rooms previously identified to not have air flowing from the air conditioning vents. During the time of the visit LPAs observed the thermostats in the hallway by Rooms 1-5 in Building "A" measured 78F and 79F. LPAs also observed facility residents in Building "A" common area were the temperature read 71F. LPAs were provided with documentation on scheduled maintenance on the central air conditioning unit on 08/07/2026. An exit intervie was conducted where this report was reviewed and provided.the state’s words, verbatim · CDSS document, Aug 5, 2026

Type of visit: Case Management - Health Checks

On 08/03/2026, Licensing Program Analyst (LPA) Valerie Flores and Licensing Program Manager, Carolyn Tuba conducted an unannounced visit to the facility to conduct a health and safety check. LPA and LPM met with Executive Director, Teresa Mapilis and informed her the purpose of the visit. During the course of the visit, LPA and LPM consulted with Executive Director to confirm medication prescription for Resident 1 (R1). During an interview on 8/2/2026 it was disclosed to the LPM that R1 was not receiving the correct dosage. During today's visit LPA and LPM obtained documentation and reviewed records that states there will be no changes to R1's prescription per their physician. LPA and LPM consulted with Executive Director what procedures are in place for CCL to request documentation during a visit such as a physician's report when certain staff is not available. Executive Director stated that Medical Technician's are to contact Management such as Executive Director who has access to those documents during the visits conducted. LPA and LPM conducted a tour of random sampling of Building "A", Building "D" and Building "C" and observed no cool air or limited air coming out of the vents in residents rooms. Executive Director provided documentation from a local HVAC company who has made repairs prior to today's visit. (A technical violation was issued). An exit interview was conducted, and a copy of this report was reviewed and provided to Business Office Manager, Nicole Anguiano.the state’s words, verbatim · CDSS document, Aug 3, 2026

Type of visit: Case Management - Health Checks

On Sunday, 08/02/2026, Licensing Program Manager (LPM), Carolyn Tuba and Licensing Program Analyst (LPA), Jacqueline Shaw-Ross conducted an unannounced Case Management- Health Check visit to assess the facility for potential health and safety concerns. LPM/LPA met with Medical Technician, Latoya McVade and explained the purpose of today's visit. During the course of the visit, LPM/LPA toured building A, B, C and D and visited and spoke to random sample of residents. The bedrooms observed were clean and equipped with the required bedding, furnishings, and functional lighting. LPM/LPA also observed the lunch meal service, and residents appeared to be receiving lunch and dinner as scheduled. During the course of the visit Resident #1 (R1) brought up concerns about medication and the air vent and a window in their room. LPM/LPA did further investigation, interviews and observed medication logs and prescription for R1, however at this time did not find any health or safety concerns. Included in this report is an amended LIC809-D page that was issued on a previous visit of July 26, 2026. The reason for the amendment is to correct the section cited from Health and Safety Codes (HSC) to California Code of Regulation (CCR), as well as the description of the deficiency. Signatures were obtained during this visit. An exit interview was conducted with Medical Technician, Aileen Padilla, and a copy of this report was reviewed and provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 2, 2026

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Janira Arreola, Seo Jeon, and Abdoulaye Zerbo conducted an unannounced visit in order to conduct a case management and follow up of visit conducted on 07/23/2026. LPAs met with Medication Technician, Ligaya Carter, who was informed of the purpose of the visit. LPA Arreola conducted interviews, records review, and observations. The Department observed Resident #1 (R1) and Resident #2 (R2) were listed to be self responsible on their Face Sheet and Emergency Information Forms. LPA investigated R1 and R2’s ability to make medical decisions. R1 was interviewed at the time of the visit which revealed R1 is alert and oriented and indicated being able to make their own medical decisions. R1’s LIC602 Physician’s Report revealed R1 has a diagnosis of Mild Cognitive Impairment with no disorientation, and is able to communicate their care needs. Interview with (2) staff revealed R1 is alert and oriented, is able to communicate their care needs, and is able to make their own medical decisions. Therefore, based on interviews and records review no concerns were found on R1’s ability to make their own medical decisions at this time. R2 no longer resides at the facility and was unable to be interviewed. R2’s Face Sheet and Emergency Information Form listed R2 had a conservator. Interview with R2’s conservator revealed that R2 has been conserved since December of 2025 and was deemed by a medical professional to be able to make their own medical decisions and retained these powers. R2’s conservator stated they visited R2 at the facility regularly and observed R2 was able to communicate their needs and was making their own medical decisions. Interviews with (2) staff revealed R2 was alert, able to communicate their care needs, R2 was able to make their own medical decisions with assistance of their conservator and family. R2’s LIC602 Physician’s report revealed R2 has a diagnosis of Dementia, is able to communicate their needs, and is confused occasionally. Therefore, based on interviews and records review no concerns were identified on R2’s ability to make their own medical decisions. No violations of California Code of Regulations Title 22 were found at this time. Therefore, no deficiency were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided.the state’s words, verbatim · CDSS document, Jul 29, 2026

Type of visit: Case Management - Health Checks

On 07/29/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross arrived to the facility unannounced to assess for any health and safety concerns. LPA met with MedTech Manager, Vianey "Nani" Sandoval and the purpose of the visit was explained. LPA was informed that a scheduled power outage was taking place from 9:00 am to 3:00pm. Upon arrival, LPA observed a large generator positioned between Buildings A and B. Staff reported that residents from Building B, C, and D had temporarily relocated to Building A where the generator was supplying power. During a tour of Building A, LPA observed residents from all buildings gathered in the main activity room. The indoor temperature was observed to be cool and comfortable. Staff reported that temperatures in each building were monitored and documented every 30 minutes. LPA also observed hydration stations with water and cold beverages available to residents. Lunch was also being served and consisted of cold sandwiches, chips, fruit and cold beverages. During the visit, residents were observed actively participating in social activities, including playing games, listening to music, and dancing, and interacting with one another in a positive and engaging environment. During a tour of Building B, LPA observed three residents remaining in their rooms. Staff stated these residents chose to remain in place after verbal consent was obtained from their responsible parties/POAs and family members. Staff were in the process of completing documentation reflecting those decisions. During tours of Buildings C and D, LPA observed the indoor temperatures remained cool. Staff reported that residents from these builds had been temporarily relocated to Building B, with the exception of two residents who elected to remain in Building D. LPA observed staff making routine rounds throughout each building to ensure resident safety, monitor conditions, and remain available to help as needed. At 12:45pm, LPA was informed the power was back on in all buildings and residents were being transported back to their rooms. No health and safety concerns were observed during today's visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Vianey "Nani" Sandoval, Medtech Manager.the state’s words, verbatim · CDSS document, Jul 29, 2026

Type of visit: Case Management - Health Checks

On 07/26/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross, conducted an unannounced case management visit to the facility to assess for any health or safety concerns. LPA met with Daija Love, Medical Technician and the purpose of the visit was provided. LPA toured all residential buildings located on the facility grounds. During a tour of Building B, LPA observed that the laundry room in the West Hall of Building B was discovered to be unlocked, allowing resident access to cleaning chemicals and other potential hazards. LPA discussed this with the Medtech on duty and re-tested the lock. Upon observation it was discovered that the hole to the latch of the door had been plugged with tissue to prevent it from locking. Medtech stated they believed caregivers may have done this because they did not know the key code. Citation issued. While touring the East Hall Building B, LPA also noticed the laundry room door in that location was cracked open. LPA pulled the handle of the laundry and the door locked. Medtech stated this would be forwarded to management. Also during a tour of Building B, LPA observed crafting scissors inside a resident's bedroom with the bedroom door left wide open. Although the resident is authorized to possess crafting scissors, they were left in an area readily accessible to other residents. This concern was discussed with facility staff and citation issued. During a tour of Building A, LPA observed that several bedrooms in Building A were warm and noted that the air conditioning was not functioning in several bedrooms. Staff reported the air conditioning system was inoperable in select bedrooms and that management will be notified. LPA was unable to obtain a temperature reading; however, bedroom windows were open to promote ventilation. Residents occupying the affected rooms stated they were not experiencing discomfort at the time of the visit. Technical assistance was provided regarding maintaining a comfortable indoor temperature, and the Med Tech reported the issue had been elevated to management and will be scheduled for repair the following day. An exit interview was conducted and a copy of this report, LIC 809-D, LIC 9102 and the appeal rights were reviewed and provided to Daija Love, Medical Technician.the state’s words, verbatim · CDSS document, Jul 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 30, 2026

Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items... This requirement was not met as evidenced by: Based on observations, two laundry rooms located in building "B" (Memory Care) were found unlocked with detergent and bleach, as well as scissors were observed unattended and accessible. This posed an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Jul 26, 2026

Plan of correction: Facility will ensure hazardous items and sharp objects are inaccessible to residents by making sure that laundry doors stay locked and that scissors are picked up and put away as soon as the resident is finished using them. Medtechs will have meetings during each shift to remind care staff to keep the laundry doors locked and to keep scissors put away when not in use by the resident who is authorized to have scissors. Written proof of refresher training will be proved to the department by the POC date of 7/30/26.

Allegation investigated: Resident sustained unexplained injuries while in care

Licensing Program Analysts (LPA) Seo Jeon and Janira Arreola conducted an unannounced visit to the facility to deliver findings of the above allegation. LPA met with Bianey Sandoval, Medtech Manager, 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 April 2, 2025, Community Care Licensing (The Department) received a complaint report with the following allegation. It was alleged that resident sustained unexplained injuries while in care. Information received indicated that Resident #1 (R1) was observed with multiple bruises from unknown sources. The Department conducted record reviews. R1 was admitted to the facility in June 2022. R1 required staff assistance due to their physical and cognitive condition. R1 also required occasional staff assistance due to their disruptive and aggressive behavior. Continuned on LIC9099-C.... Substantiated R1 had history of falls from December 2024 through July 2025. R1 had total of seven (7) reported falls during that time. R1 was sent to Hospital #1 on March 31, 2025, by R1’s physician’s order for altered mental status and frequent falls. R1 was hospitalized until they were discharged to a skilled nursing facility on April 23, 2025. R1 was sent to Hospital #2 after being found unconscious on August 10, 2025. R1 passed away on August 10, 2025, while under hospice care. The Department’s review of medical records from Hospital #1 revealed that R1 was observed with bruises on left upper hip, right lower hip, and multiple bruises in upper and lower extremities in various stages of healing. R1 was also noted to be confused, not able to follow commands, frequently trying to get out of bed, pulling on IV lines, agitation, yelling and screaming. Those conditions required R1 to be put on soft restraints on upper and lower extremities. R1 remained restrained until they were discharged on April 23, 2025. The Department’s review of records revealed that staff did not conduct reassessment and update care plans after seven (7) recorded falls. Five (5) out of those (7) falls occurred in March 2025. R1’s bruises observed by medical staff at Hospital #1 were consistent with those five (5) falls that occurred in March 2025. Even after those falls, staff did not maintain updated assessments and care plans reflecting R1’s declining condition and increased fall risks. Based on records review, 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. A citation was issued. An exit interview was conducted where a copy of this report was provided, along with a copy of LIC9099-D and Appeal Rights.the state’s words, verbatim · CDSS document, Jul 23, 2026 · control 18-AS-20250402120100

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Aug 6, 2026

87463 Reappraisals, (a)The pre-admission appraisal, as specified in Section 87457..., shall be updated in writing as frequently as necessary..., the updated pre-admission..., the reappraisal. This requirement was not met as evidenced by: Based on records review, staff did not conduct reassessment on Resident #1 after multiple falls occurred in one month in 2025. This posed potential health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2026

Plan of correction: Medtech manager agreed to discuss the matter with the licensee and the administrator and send meeting notes involving resident wellness coordinator who is responsible for reassessment to LPA by the POC due date.

Type of visit: Case Management - Health Checks

On 07/23/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross conducted an unannounced Case Management- Health Check visit to assess the facility for potential health and safety concerns. LPA met with Marielle Figuero, Wellness Coordinator, and explained the purpose of the visit. During the course of the visit, LPA toured a random sample of resident bedrooms. The bedrooms observed were clean and equipped with the required bedding, furnishings, and functional lighting. LPA also observed the lunch meal service, and residents appeared to be receiving lunch as scheduled. No immediate health and safety concerns were observed during today's visit. An exit interview was conducted with Marielle Figuero, and a copy of this report was reviewed and provided at the conclusion of the visit. LPA was off premises from 12:00pm to 12:45pm.the state’s words, verbatim · CDSS document, Jul 23, 2026

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Janira Arreola and Seo Jeon conducted an unannounced case management visit. LPA met with Business Office Manager, Nicole Kalacas who was informed of the purpose of the visit. LPAs conducted a tour, interviews, and records review. LPA conducted a case management visit to conduct a health and safety check. No immediate health or safety issues were observed during the time of the visit. LPA also conducted interviews and records review to follow up on incidents and concerns at the facility. Additional information is being gathered for the case management. No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided.the state’s words, verbatim · CDSS document, Jul 23, 2026

Type of visit: Case Management - Health Checks

On Saturday, 07/18/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross conducted an unannounced case management visit to the facility to assess for any health or safety concerns. LPA met with Joselynn Martinez, Medical Technician and was informed of the purpose of the visit. Upon arrival, LPA observed residents participating in social activities in the main lobby. LPA conducted a tour of the facility in buildings A, B, C and D, including a random sample of residents' bedrooms across all facility buildings. Based on the observations made during today's visit LPA did not identify any health or safety concerns and no deficiencies were cited. An exit interview was conducted and a copy of this report was reviewed and provided to Joselynn Martinez, Medical Technician.the state’s words, verbatim · CDSS document, Jul 18, 2026

Type of visit: Case Management - Health Checks

On Wednesday, 07/15/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross and Licensing Program Manager (LPM) Jacob Garber, conducted an unannounced case management visit to assess the facility for compliance with health and safety requirements. LPA and LPM met with Ashley Richardson, Director of Active Living, who was informed of the purpose of the visit. Upon arrival, residents were observed participating in social activities in the dining area of Building B. Adequate staffing was observed to meet residents' care and supervision needs. A tour of the facility was conducted and a random sample of resident bedrooms throughout the facility was inspected. Based on observations made during today's visit, no immediate health or safety concerns were identified, and no deficiencies were cited. An exit interview was conducted and a copy of this report was reviewed with and provided to Ashley Richardson, Director of Active Living.the state’s words, verbatim · CDSS document, Jul 15, 2026

Type of visit: Case Management - Health Checks

On Saturday, 07/11/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross conducted an unannounced case management visit to the facility to assess for any health or safety concerns. LPA met with Daija Love, Medical Technician and was informed of the purpose of the visit. Upon arrival, LPA observed residents finishing their lunch and having dessert. LPA conducted a tour of the facility including a random sample of residents' bedrooms across all facility buildings. Based on the observations made during the visit LPA did not identify any health or safety concerns and no deficiencies were cited. An exit interview was conducted and a copy of this report was reviewed and provided to Daija Love, Medical Technician .the state’s words, verbatim · CDSS document, Jul 11, 2026

Allegation investigated: Staff does not provide adequate supervision to resident resulting in injuries. Staff does not ensure resident is being adequately fed. Staff are not safeguarding residents' personal belongings. Staff does not ensure resident has adequate toiletries. Staff does not ensure residents are provided activities. Staff does not ensure resident's furniture is in good repair.

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Marielle Figueroa, Resident Wellness Coordinator, 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 June 29, 2026, Community Care Licensing (The Department) received a complaint report with the following allegation. It was alleged that staff does not provide adequate supervision to resident resulting in injuries. Information received indicated that Resident #1 (R1) was observed in the front yard eating palm tree seeds from the ground. R1 was also observed with wearing blood stained shirt which may have been from a fall incident in the front yard. LPA’s records review revealed that R1 was admitted to the facility on November 24, 2025, and moved out on July 1, 2026. R1 had history of fall but did not require one-on-one assistance. Continued on LIC9099-C.... Unsubstantiated R1 did not have any fall incidents while residing at this facility. R1 did not require any assistance with mobility. R1 was once sent out to a hospital in March 2026 per R1’s physician’s order for health condition unrelated to fall incident. LPA conducted interviews with eight (8) residents, all of whom stated they do not require assistance or supervision when they go out in the front yard or back yard. LPA conducted interviews with Staff #1 (S1) and #2 (S2), both of whom stated that R1 liked to walk around the facility. R1 sometimes picked up palm tree seeds from the ground. Staff members tried to redirect R1 whenever R1 had the seeds. Neither S1 nor S2 remembered R1 wearing blood stained shirt. LPA conducted interviews with additional four (4) staff members, all of whom stated they redirected R1 from picking up anything from the ground. All staff members interviewed stated that none of the residents required one-on-one care. LPA’s attempted interview with R1 was unsuccessful due to lack of available information. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated. It was alleged that staff does not ensure resident is being adequately fed. Information received indicated that Resident #1 (R1) lost weight due to inadequate amount of food served. LPA conducted interviews with eight (8) residents, none of whom expressed any concerns about the amount of food served. LPA conducted interviews with six (6) staff members, all of whom stated all residents have been served with more than enough food. Two (2) out of six (6) staff members interviewed stated that R1 may have lost some weight due to constant wandering around the facility which has large buildings and outdoor areas. LPA’s attempted interview with R1 was unsuccessful due to lack of available information. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated. It was alleged that staff are not safeguarding residents’ personal belongings. Information received indicated that Resident #1 (R1) lost a hat and was observed wearing someone else’s shoes. LPA conducted interviews with Staff #1 (S1) and Staff #2 (S2), both of whom stated that R1 once did not have shoes. R1 told staff that they threw the shoes over the facility fences. Staff could not recover R1’s shoes. R1 came to the facility with only one pair of shoes, so staff provided a donated pair of shoes that were good fit for R1. R1’s hat was found within the facility and returned to R1 by a staff member. LPA conducted interviews with four (4) additional staff members, all of whom stated that residents sometimes lose their belongings due to their cognitive condition, but staff members always try to find rightful owners when anything is found in the facility. Continued on LIC9099-C.... LPA conducted interviews with eight (8) residents. Seven (7) residents interviewed stated that they have not lost anything in the facility. LPA’s attempted interview with R1 was unsuccessful due to lack of available information. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated. It was alleged that staff does not ensure resident has adequate toiletries. Information indicated that Resident #1 (R1) did not have any toiletries in their room. LPA conducted interviews with eight (8) residents, all of whom stated that they have all necessary toiletries in their rooms. LPA conducted interviews with six (6) staff members, all of whom confirmed the statements from the residents interviewed. LPA conducted a tour of the facility and observed that all rooms had necessary toiletries. LPA’s attempted interview with R1 was unsuccessful due to lack of available information. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated. It was alleged that staff does not ensure residents are provided activities. Information received indicated that there were no available resident activities. LPA conducted interviews with eight (8) residents, all of whom stated that staff provide daily resident activities. LPA conducted interviews with six (6) staff members, all of whom confirmed the statements from the residents interviewed. LPA toured the facility and observed a large calendar of daily activities posted on the wall in each building. LPA also observed several residents participating in activities provided by activities coordinators. LPA’s attempted interview with R1 was unsuccessful due to lack of available information. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated. It was alleged that staff does not ensure resident’s furniture is in good repair. Information received indicated that Resident #1 had broken furniture in their room. LPA conducted a tour of the facility and observed R1’s room had one (1) dresser that had one (1) missing handle out of two (2) in one (1) of four (4) drawers. The drawer was still functioning because it still had one (1) handle. LPA also observed a nightstand with a drawer that had one (1) handle with missing screw. The handle was hanging on the drawer by one screw, but the drawer was still functioning. LPA conducted an interview with Staff #1 (S1) who stated that the missing drawer handle was never reported. S1 stated that maintenance personnel could have fixed the problem within the same day if reported. LPA conducted interviews with five (5) additional staff members, all of whom confirmed the statement from S1. Continued on LIC9099-C.... LPA’s attempted interview with R1 was unsuccessful due to lack of available information. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, 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, Jul 8, 2026 · control 18-AS-20260629100334

Type of visit: Case Management - Health Checks

On 07/08/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross conducted an unannounced Case Management- Health Check visit to assess the facility for potential health and safety concerns. LPA met with Marielle Figueroa, Wellness Coordinator, and explained the purpose of the visit. During the course of the visit, LPA toured a random sample of resident bedrooms. The bedrooms observed were clean and equipped with the required bedding, furnishings, and functional lighting. LPA also observed activities taking place in the main building with staff engaging in recreational activities with residents. No immediate health and safety concerns were observed during today's visit. An exit interview was conducted with Marielle Figueroa, and a copy of this report was reviewed and provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 8, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced case management visit to the facility to assess for any health or safety concerns. LPA toured all residential buildings and random sample of resident rooms. LPA did not observe any immediate health and safety concerns. No deficiencies were cited at the time of this visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Marielle Figueroa, Resident Wellness Coordinator.the state’s words, verbatim · CDSS document, Jul 8, 2026

Allegation investigated: Staff did not provide resident records to the resident's authorized representative.

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to deliver findings for the above allegation. LPA met with Business Office Manager, Nicole Kalacas who was informed of the purpose of the visit. The investigation consisted of interviews and records review. Staff did not provide resident records to the resident's authorized representative. It was alleged that Resident #1's (R1) Responsible Party (RP) requested discharge records following R1's discharge from the facility on 06/15/2026 and had not received them. Unsubstantiated LPA interviewed RP, who stated she requested discharge paperwork from the facility on 06/15/2026 and again around 06/20/2026. RP alleged as of 07/02/2026, RP had not received documentation needed to verify R1's discharge date. LPA interviewed (3) staff members who stated RP was provided with requested discharge records such as a medications list and a refund check. (3) staff stated the facility had no record of a request for additional records prior to RP's email dated 06/29/2026. Email correspondence was reviewed and revealed facility staff responded on 06/29/2026 requesting clarification regarding the records being requested. (1) of (3) Staff stated that on 07/01/2026, following a telephone call from a county representative on behalf of RP, clarification was provided to facility staff on what records RP was requesting. (1) Facility staff stated additional information was provided to the county representative for relay to RP on how to request records with R1’s discharge date. Based on interviews and records reviewed, the allegation is Unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 6, 2026 · control 18-AS-20260626152157

Type of visit: Case Management - Health Checks

On 07/05/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross conducted an unannounced Case Management- Health Check visit to assess the facility for potential health and safety concerns. LPA met with Aileen Padilla, Lead Medical Technician, and explained the purpose of the visit. During the course of the visit, LPA toured a random sample of resident bedrooms. The bedrooms observed were clean and equipped with the required bedding, furnishings, and functional lighting. LPA also observed the lunch meal service, and residents appeared to be receiving lunch as scheduled. No immediate health and safety concerns were observed during today's visit. An exit interview was conducted with Aileen Padilla, and a copy of this report was reviewed and provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 5, 2026

Allegation investigated: Staff speak inappropriately to residents

On 7/2/2026, Licensing Program Analyst’s (LPA’s) Valerie Flores and Seo Jeon conducted an unannounced visit to the facility for the purpose of delivering the complaint findings into the allegations listed above. LPA Flores met with Business Office Manager Nicole Anguiano and explained to Nicole the purpose of the visit. The investigation is summarized as follows: On 1/10/2023, Community Care Licensing (CCL) received information alleging staff speak inappropriately to residents. An interview conducted with Staff #1 (S1) and Staff #5 (S5) reported that there was an incident involving Staff #6 (S6) where S6 was observed speaking to residents in an inappropriate tone. S5 reported observing S6 cursing at a resident but cannot recall what resident S6 was cursing at. (Continuation from LIC9099) Substantiated (Continuation from LIC9099) S1 reports that S6 was known to have poor attendance and when an unknown staff reported the incident involving S6, S6 was terminated. LPA Flores requested S6 files, but the file was unavailable for review. An interview conducted with Staff #7 (S7) reports observing a time when Staff #8 (S8) spoke to a resident in an aggressive manner. A records review conducted of the Unusual Incident Reports (UIR) reports an incident dating 1/15/2025 detailing a time when two staff overheard Staff #9 (S9) cursing at a resident. S1 was noted to have conducted an internal investigation where S6 was terminated as a result of the investigation. Therefore, the allegation of staff speak inappropriately to residents is deemed substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid as the preponderance of the evidence standard has been met. California Code of Regulations Title 22 is being cited on the attached LIC9099D. An exit interview was conducted and a copy of the LIC9099, LIC9099C, LIC9099D, and appeal rights were provided to Business Office Manager Nicole Anguiano. (Continuation from LIC9099A) Interviews conducted with (5) five residents report that staff have not dropped them during a transfer to and from their wheelchair. The residents report that staff handle them with care during wheelchair transfers. Interviews conducted with (7) seven staff report that they have not observed a time when residents were dropped on the floor during wheelchair transfers. Interviews with Staff #1 (S1) reported that if a resident was dropped during a wheelchair transfer, facility staff are required to complete an incident report to which are reported to CCL. Records review conducted of the Unusual Incident Reports received by the facility do not detail any incidents of any matter involving R1 and R2 from January of 2022 through January of 2023. Information received alleged that due to lack of supervision, Resident #3 (R3) was hit by Resident #4 (R4). Interviews conducted with (4) four staff report that they do not recall a specific incident involving R3 and R4. Staff further report that if a resident was involved in a verbal or physical altercation with another resident, staff will immediately intervene by redirecting the resident. Staff report that they will redirect the resident by offering the resident a snack and will elevate any concerns of change of behaviors to management so the resident can be properly assessed by their primary care physician. An interview was attempted with R3 but due to R3 cognitive ability, the interview was unsuccessful. LPA Flores conducted multiple interview attempts with R4 but R4 refused or was unresponsive to LPA Flores’ efforts. An interview conducted with S1 and S2 reported that R3 was known to have aggressive outburst towards staff but does not recall a specific incident involving R3 and R4. Records review conducted of the Unusual Incident Reports received by the facility do not detail any physical altercation between R3 and R4 from January of 2022 through January of 2023. Information received alleged staff are consuming drug and alcohol on the premises. Interviews conducted with (8) eight staff report that they did not have any knowledge of staff consuming drug or alcohol on the premises. Interviews with conducted with (6) six residents also report that they do not have knowledge of staff consuming drug or alcohol on the premises. Interviews conducted with Staff #3 (S3) and Staff #4 (S4) reports that they are aware of staff vaping outside at the designated smoking areas. Interviews conducted with Resident #5 (R5) and Resident #6 (R6) reports that they have observed staff smoking outside but do not know what the staff are smoking. (Continue to LIC9099AC2) Continuation from LIC9099AC2) Therefore, the allegations of staff are not properly transferring residents, due to lack of supervision resident hit resident, and staff members are consuming drugs and alcohol on the premises are deemed unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was provided to Business Office Manager Nicole Anguiano.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 18-AS-20230110153318

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jul 3, 2026

(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met with evidence by (3) three out of (3) three residents were not accorded dignity in their personal relationship with staff.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Business Office Manager Nicole Anguiano agreed to hold an in-service training for staff pertaining to Section 87468.1 Resident Personal Rights. Proof of training completion will be submitted to LPA by Close of Business on 7/16/2026. Licensee shall forward an email informing the contents

Type of visit: Case Management - Health Checks

On 7/2/2026, Licensing Program Analyst's (LPA's) Valerie Flores and Seo Jeon conducted an unannounced visit to the facility for the purpose of assessing any potential health and safety concerns. LPA Flores and Jeon met with Business Office Manager Nicole Anguiano and explained the purpose of the visit. The visit is summarized as follows: During the visit, LPA's toured a random sampling of resident bedrooms. Residents bedrooms were observe to be equipped with the required bedding, furniture, and functional lighting. LPA's observed lunch services being provided to the residents. No immediate health and safety concerns were observed. An exit interview was conducted, and a copy of this report was reviewed and provided to Business Office Manager, Nicole Anguiano.the state’s words, verbatim · CDSS document, Jul 2, 2026

Allegation investigated: Staff did not seek medical attention for resident’s injury

On 6/30/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering the investigative findings into the allegations listed above. LPA Flores met with Medication Technician Manager Bianey Sandoval and explained the purpose of the visit. The investigation is summarized as follows: On 5/28/2026, Community Care Licensing received information alleging staff did not seek medical attention for Resident #1’s (R1’s) after R1 sustained a hematoma to the back of the head as a result of a fall. Interviews conducted with (2) two out of (4) four staff reported that when R1 fell, Staff #1 (S1) contacted emergency services. Interview with S1 reported that they contacted emergency services on their personal cell phone but no longer has the call log showing a call was made on 5/27/2026. S1 reports that it took emergency services 20 minutes to respond the incident. (Continue to LIC9099C) Substantiated (Continuation from LIC9099) An interview conducted with Staff #3 (S3) reports that they do not recall emergency services being contacted. S3 stated that due to R1 receiving hospice care services, Yorkshire staff were instructed by Yorkshire management to contact the hospice provider if any incidents occur with a resident. Additional interviews conducted with S1 and Staff #2 (S2) confirmed that staff are instructed to contact the hospice provider if the resident is receiving hospice services as was alleged through past experience, emergency personnel have informed Yorkshire staff that the emergency services need prior approval to assist residents who are receiving hospice services. An interview was attempted with Staff #4 (S4) but was unsuccessful as S4 did not recall details of the incident dating on 5/27/2026. Interviews with (3) three of (4) four staff report R1 was not transported to the hospital as a result of R1’s injuries. LPA attempted (2) two additional staff interviews for staff that were reportedly present to the incident. LPA Flores concluded the interview attempts as the attempts were unsuccessful. An interview conducted with Relevant Party #1 (RP1) reports that they received a telephone call informing them that R1 experienced a fall and was requiring an evaluation. RP1 reports that the call was received at approximately 10AM on 5/27/2026 and RP1 did not arrive at the facility until approximately 1PM. RP1 explained that they have prior experience working at a Residential Care Facility for the Elderly and believed that the facility should have contacted emergency services regardless if R1 was receiving hospice care services. RP1 described the hematoma on the back of R1’s head to be the size of a golf ball and explained that an injury of that size at R1’s age can come with underlying issues that would require emergency services. A records request was submitted to the California Department of Forestry and Fire Protection for the incident dating on 5/27/2026. LPA Flores was informed that there are no records matching the R1’s name for that date. Therefore, the allegation of staff did not seek medical attention for resident’s injury is deemed substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid as the preponderance of the evidence standard has been met. Health and Safety Code is being cited on the attached LIC9099D. An exit interview was conducted and a copy of the LIC9099, LIC9099C, LIC9099D, and appeal rights were provided to Medication Technician Manager Bianey Sandoval. (Continuation from LIC9099A) R1’s responsible person reports that they were made aware of R1 receiving M1 by receiving a text message from R1’s hospice care provider explaining that R1 experienced a fall and M1 was administered for pain relief. R1’s responsible person reports that the staff did not contact R1’s responsible person to approve of M1 being administered to R1. R1’s responsible person reports that staff nor the prescribing physician never contacted R1’s responsible person explaining that M1 was being re-prescribed to R1. An interview conducted with Staff #1 (S1) reports that R1 was prescribed M1 by R1’s designated physician. S1 reports that M1 was previously discontinued for a brief period some time last year but does not know exactly when and how long M1 was discontinued. S1 reports that when a medication is re-prescribed at that level, it is the physicians responsibility to contact the resident’s responsible person advising the responsible person about the medication changes. S1 reports that they are unsure if there was a telephone between R1’s responsible person and the prescribing physician as they were not privy to the telephone call. A copy of a physician order was received for R1 details M1’s start date as 4/16/2025. LPA Flores contacted the prescribing physicians office to obtain clarification the prescription of M1 but an interview with an office representative reports that they do not have any records of there being an active order for M1. LPA Flores conducted serval attempt to interview Relevant Party #1 (RP1) and Relevant Party #2 (RP2) but attempts were unsuccessful. Additional information alleged that R1 was forced into enrolling with hospice services due to insufficient staffing. An interview conducted with R1 responsible person reports that they were not forced into enrolling with hospice services but feels tricked into hospice services instead. R1’s responsible person reports that R1 has experienced an increase in falls and was approached by the Administrator. R1’s responsible person reports that the Administrator stated that hospice can assist with providing additional care such as fall prevention and decrease the number of times R1 would be transported to the hospital. R1’s responsible person reports that at the time they believed hospice was a good choice as it may decrease any potential trauma R1 may endure by being transported to and from the doctors office. R1’s responsible person stated that they enrolled R1 into hospice and later did research on what hospice services are. R1 responsible person reports that they learned that hospice was an end-of-life treatment service and stated that R1 is nowhere near end-of-life. R1 responsible person reports that they removed R1 from receiving hospice care services only after a week. R1 responsible person reports that they were not specifically instructed to enroll with any specific hospice but were also not given suggestions other than the hospice care agency R1 was enrolled in. (Continue to LIC9099AC2) (Continuation from LIC9099AC) LPA attempted to speak with Relevant Party #3 (RP3) but attempts to interview RP3 were unsuccessful. Therefore, the allegations of staff provided an unauthorized medication to a resident and resident forced on hospice due to insufficient staffing are deemed unsubstantied. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was provided to Medication Technician Manager Bianey Sandoval.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 18-AS-20260528162825

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87469(c)(3) · Plan of correction due date: Jul 14, 2026

(c)If a resident who has an advance directive… facility staff shall do one of the following: (3) is experiencing a life-threatening emergency …directly related to the expected course of the resident’s terminal illness, the facility may immediately notify the resident’s hospice agency in lieu of calling emergency response (9-1-1). For emergencies not directly related … staff shall immediately telephone emergency response (9-1-1). This requirement was not met with evidence by: Emergency services were not contacted for R1 after R1 sustained a hematoma as a result of a fall.the state’s words, verbatim · CDSS document, Jun 30, 2026

Plan of correction: All staff will complete an outside vendor training will be conducted covering how to determine a life threatening emergency requiring emegency response (9-1-1). Proof will be submitted to LPA via email by Close of Business on 7/14/2026.

Allegation investigated: Staff did not seek timely medical care Facility did not provide care and supervision to resident Facility staff instructed staff to not report information to medical personnel

On 6/30/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering investigative findings into the allegations listed above. LPA Flores met with Medication Technician Manager Bianey Sandoval and explained the purpose of the visit. The investigation is summarized as follows: On 7/14/2025, Community Care Licensing (CCL) received information alleging staff did not seek timely medical care as Witness #1 (W1) suspected Resident #1 (R1) was experiencing a cerebrovascular accident. Interviews conducted with Administrator report that they recall an incident involving Resident #1 (R1) occurring some time in July of 2025. Administrator reports that R1 was demonstrating behaviors that were out of R1’s baseline. During a shift change, the oncoming shift staff observed R1 needing medical attention and addressed concerns to the managing staff. CCL received an incident report for R1 stating that on 7/8/2026 at 8:00AM, Staff #1 (S1) went to check on R1. (Continue to LIC9099C) Unsubstantiated (Continuation from LIC9099) R1 was found sitting on the floor in-between their walker and bed. R1 reported to S1 that they stood up and felt dizzy. R1 reportedly attempted to sit back down onto the bed and fell to the floor. Staff #2 (S2) assessed R1 where no injuries were observed but R1 complained of pain their low back region. Emergency services were reportedly contacted and transported R1 for further evaluation. A records request submitted to the California Department of Forestry and Fire Protection did not report receiving an emergency alert on 7/8/2026 but makes note of an incident involving R1 on 7/10/2026. A records request was submitted to American Medical Response on 6/5/2026. LPA conducted multiple follow-ups with no success. Discharge paperwork received for R1 from a visit at the hospital on 7/8/2025 reports that R1 was experiencing symptoms unrelated to a cerebrovascular accident. Discharge paperwork notes that R1 was admitted into the hospital at 9:00AM on 7/8/2025 and was later released back into the community on the same day with after-care instructions. An interview conducted with S1 reports that they do not recall specifics about the incident but denied the allegation of staff not seeking timely medical care for R1. LPA Flores conducted several interview attempts with S2, but attempts were unsuccessful. LPA conducted several interview attempts with R1, but interview attempts were unsuccessful as R1 refused or chose not to engage in conversation with LPA Flores. Witness #1 (W1) alleged staff did not provide care and supervision to Resident #1 (R1) leaving R1 in their room unattended all day. Interviews conducted with (6) six staff report that residents receive health check approximately every two hours. If a resident returned from the hospital or is experiencing a change of condition, residents will be placed on alert health checks which are conducted every 30 minutes. An interview was conducted with the Administrator whom vague recalls key information into the incident. The Administrator reports that during a shift change, the following shift reported concerns of R1 possibly not being checked on as needed but Administrator believes it to be a miscommunication. Administrator stated that staff are expected to conduct health checks on a regular basis that do not exceed a residents care plan or a two-hour time period. An interview conducted with S1 reports that they did not recall specific details of the incident but denied the allegation of staff not providing adequate care and supervision to R1. LPA Flores conducted several interview attempts with S2, but attempts were unsuccessful. LPA conducted several interview attempts with R1, but interview attempts were unsuccessful as R1 refused or chose not to engage in conversation with LPA Flores. (Continue to LIC9099C2) (Continuation from LIC9099C) Additional information alleged that a supervisor was instructing care staff not to report information to emergency personnel. Interviews conducted with (6) six staff deny any staff and/or supervisor instructing staff to withhold information from emergency personnel. Staff report that they are instructed to report any and all incidents that may affect the health and safety of any resident. An interview conducted with the Administrator denied ever instructing staff to withhold information from emergency personnel. Therefore, the allegation of staff did not seek timely medical care, facility did not provide care and supervision to resident and facility staff instructed staff to not report information to medical personnel are deemed unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was provided to Medication Technician Manager Bianey Sandoval.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 18-AS-20250714123651

Allegation investigated: Staff 1 did not treat Resident 1 with dignity

On 06/30/2026, Licensing Program Analysts (LPAs) Janette Romero and Seo Jeon conducted a joint visit at the facility. LPA Romero was delivering findings for the allegation listed above. LPA met with Medication Technician Manager (MTM) Bianey Sandoval and Business Office Manager Nicole Kalacas Anguiano who were informed of the purpose of the visit. Regarding the allegation, “Staff 1 did not treat Resident 1 with dignity” it was alleged that Staff 1 (S1) stated to Resident 1 (R1), “Go sit down” using a rude and sharp tone. It was further alleged that S1 speaks to R1 as if they were R1’s parent. This reportedly occurs every time R1 is in the dining room. A review of R1’s admission agreement indicates R1 was admitted to the facility on 12/31/2025. A review of R1’s physician’s report dated 12/25/2025 indicates that R1 exhibits memory loss. R1 was interviewed and corroborated the allegation. R1 was unable to provide specific incident dates or additional details and was not aware of any witnesses. Unsubstantiated S1 was interviewed and reported the following information. R1 requests that staff retain possession of their cigarettes and provide them at R1’s request in order to regulate their cigarette use. However, during multiple occasions while S1 is dispensing medications for the residents, R1 approaches S1’s medication cart to request cigarettes. S1 informs R1 that they are currently dispensing medications for the residents and will provide R1 with their requested cigarettes when S1 finishes their task, but R1 remains in front of S1’s medication cart. To avoid any medication errors, S1 kindly asks R1 to go sit down and R1 has stated, “Okay” and made a comment calling S1 their parent. S1 reported that R1 requests one cigarette every ten minutes and S1 has tried to mitigate reoccurring incidents by asking R1 how many cigarettes they would like to be provided before they begin dispensing medications. S1 provides R1 their requested cigarette quantity and ten minutes into dispensing medications, but R1 will continuously request additional cigarettes. S1 reported the incidents have never occurred in the dining room and was unable to provide specific incident dates. S1 reported that based on their cultural background, their communication style may be perceived as “sharp”. However, S1 denied speaking to R1 or any other resident in a rude, condescending, or disrespectful manner and reported they only redirect R1 when necessary. LPA conducted witness interviews with R1’s responsible person and an additional visitor. R1’s responsible person reported that due to R1’s diagnosis, R1 makes repetitive requests and requires frequent redirection which may be misinterpreted as rude. R1’s responsible person and the additional visitor interviewed reported they have never witnessed facility staff use a rude or sharp tone when speaking with R1 or any other facility resident and have no concerns with the care and supervision R1 receives in the facility. 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 and Confidential Names list (LIC 811) was provided to MTM Sandoval.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 18-AS-20260624134541

Allegation investigated: Staff did not provide medical attention to resident in a timely manner.

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced subsequent visit to the facility to deliver findings for the above allegation. LPA was greeted and granted entrance by Business Office Manager Nicole Kalacas. LPA identified himself and discussed the purpose of the visit. It was alleged that staff did not provide medical attention to resident in a timely manner. LPA Abdoulaye Zerbo interviewed Staff 1 (S1) regarding the above allegation. S1 reported that resident1 (R1) was on hospice services at the time of the reported concerns. S1 stated that the facility followed hospice protocols for both medical and non medical needs. S1 stated that the facility does not contact 911 for hospice residents unless directed to do so by hospice staff. Hospice residents must first be assessed by hospice, and 911 is called under hospice’s instruction or if the situation is life threatening, such as a head injury with active bleeding. Unsubstantiated S1 clarified that procedures differ for non hospice residents. Concerning the reported change in condition observed on 08 29 25, S1 explained that staff contacted R1’s physician for further instruction but did not receive a return call until 08- 31 -25. When R1’s physician contacted the facility staff on 08-31-25, they instructed the facility to contact 911 for R1 to be transported for further evaluation. On 06-09-26, LPA Zerbo attempted to interview R1; however, R1 did not respond to questions and was unable to provide any information regarding the allegation. LPA also attempted to contact R1’s physician but was unable to obtain an interview. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided Business Office Manager Nicole Kalacas.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 18-AS-20250908101108

Type of visit: Case Management - Health Checks

On 06/27/2026, Licensing Program Analyst (LPA) Aziz Faizi conducted an unannounced case management visit to the facility to assess for any health or safety concerns. LPA met with Manager on Duty Bianey Sandoval and was informed of the purpose of the visit. LPA conducted a tour of the facility including a random sample of residents' bedrooms across all facility buildings. LPA also observed residents having meal and snacks. Based on the observations made during the visit LPA did not identify any health or safety concerns and no deficiencies were cited. An exit interview was conducted and a copy of this report was reviewed and provided to Manager on Duty Bianey Sandoval.the state’s words, verbatim · CDSS document, Jun 27, 2026

Allegation investigated: Facility staff do not treat resident(s) with diginity and respect Facility staff failed to assist resident in a timely manner (within 15 minutes)

Licensing Program Analysts (LPA) Seo Jeon and Janira Arreola conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Nicole Anguiano, Business Office Manager, 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 June 5, 2025, Community Care Licensing (The Department) received a complaint report with the following allegations. It was alleged that facility staff do not treat resident(s) with dignity and respect. Information received indicated that a staff member yelled at Resident #1 (R1), saying “I don’t have time to keep coming in and changing you!” after R1 used the pull cord for staff assistance. Continued on LIC9099-C.... Unsubstantiated LPA conducted an interview with R1, who reported having a poor experience at the facility overall. R1 provided a timeline of their care: R1 was hospitalized in Temecula, California, in 2025, discharged to a skilled nursing facility (SNF), and subsequently moved to R1’s relevant party’s home. After experiencing another serious health condition, R1 was hospitalized again before being transferred to Yorkshire Village in May 2025. R1 resided at Yorkshire Village for approximately two months in a building consisting of two wings and roughly 60 residents. On July 1, 2025, R1 moved into an apartment and has lived independently since. During the interview, R1 could not recall the names of the staff members who allegedly treated them without respect and dignity, nor could they remember the specific disrespectful statements made. R1 did, however, recall the name of a nurse who used profane language during their previous stay at the skilled nursing facility. LPA conducted interviews with seven (7) residents, all of whom denied experiencing or witnessing disrespectful behaviors from staff members. LPA conducted interviews with six (6) staff members, all of whom denied treating residents disrespectfully. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated. It was alleged that facility staff failed to assist resident in a timely manner (within 15 minutes). Information received indicated that staff members took hours to assist Resident #1 (R1). LPA conducted an interview with R1, who stated that staff members would just come to turn off the flashing light and left without proving care when R1 used the pull cord. Staff members often told R1 that they would come back soon but came back much later than 30 minutes. LPA conducted interviews with seven (7) residents regarding the staff response time when their pull cords were used. All residents interviewed stated that staff response time was usually from right away to 15 minutes. All residents interviewed were satisfied with the staff response time. LPA conducted interviews with six (6) staff members, all of whom confirmed the residents’ statements. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, 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, Jun 26, 2026 · control 18-AS-20250605133201

Type of visit: Case Management - Health Checks

Licensing Program Analysts (LPA) Seo Jeon and Janira Arreola conducted an unannounced case management visit to the facility to assess for any health or safety concerns. Community Care Licensing staff toured all residential buildings and did not observe any immediate health and safety concerns. No deficiencies were cited at the time of this visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Nicole Anguiano, business office manager.the state’s words, verbatim · CDSS document, Jun 26, 2026

Allegation investigated: Staff did not provide a resident with their special diet, leading to the resident's death Staff are covering up violations at the facility

On 06/24/2026, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility to deliver findings for the allegations listed above. Upon arrival, LPA met with Medication Technician Gloria Sanchez and explained the purpose of the visit. Business Office Manager (BOM) Nicole Kalacas Anguiano was notified of the purpose of LPA's visit. Regarding the allegation, “Staff did not provide a resident with their special diet, leading to the resident’s death” it was alleged that Resident 1 (R1) was served solid food by Staff 1 (S1). The investigation consisted of records reviewed including video footage and interviews conducted. A review of R1’s Physician’s Report dated 09/03/2022 indicated the categories “Able to Communicate Needs” and “Special Diet” were marked “Yes”. The report documented that R1 required a soft diet. A review of R1’s Individual Service Plan dated 09/27/2023 noted R1 was admitted to the facility on 09/07/2022 and required a puree diet. Unsubstantiated A review of an Unusual Incident/Injury Report dated 10/19/2023 documented that R1 had a history of choking incidents. On 05/15/2023, R1’s diet was changed from regular to puree. On 08/27/2023, R1 was hospitalized following a choking incident, and on 09/05/2023, their diet was changed from puree to mechanical soft. On 09/26/2023, R1 experienced another choking incident and was assessed by paramedics but was not transported to the hospital. R1’s physician was notified and ordered a barium swallow test with the earliest availability being on 11/30/2023. On 10/18/2023, R1 choked while eating dinner but was able to cough up the food lodged in their throat. Emergency services were activated, and R1 was transported to the hospital for observation. R1 was discharged back to the facility on 10/19/2023 with a diagnosis of esophageal foreign body. Following the hospitalization, facility staff requested that R1’s physician change R1’s diet back to puree. R1’s physician was interviewed and reported that R1 was capable of eating independently and had been prescribed a soft diet. A review of a law enforcement incident report noted that S1 reported that at approximately 3:00 p.m. R1 was in the dining room and observed eating and interacting with staff. R1’s caregiver, Staff 2 (S2), later transported R1 to their room. Once back at the room, S2 noticed R1 unresponsive and immediately informed S1. Emergency services was contacted via 9-1-1. Interviews with facility staff were conducted and the following was reported. S1 reported that on 10/27/2023, R1 appeared to be at baseline. Later that day, S2 informed S1 that R1 was unresponsive. S1 responded to R1’s bedroom and observed R1 slumped over with their dentures slightly displaced. S1 denied serving R1 solid food and reported that their duties primarily involved medication management and documentation. S1 further reported that they did not observe any food particles around R1’s mouth. A review of a law enforcement incident report noted S2 stated to law enforcement that S2 gave R1 a snack at 3:00 p.m. At around 3:20 p.m., S2 observed R1 slumped in their wheelchair and appeared to be sleeping. S2 moved R1 to into their bedroom and asked if they (meaning R1) needed assistance lying on the bed. It was at this time, that S2 observed R1 unresponsive and immediately called S1 for help. A review of R1’s death certificate dated 11/07/2023 documented R1 passed away at the facility on 10/27/2023. The immediate cause of death is listed as cardiac arrest, with underlying causes of coronary artery disease and hypertension. A review of paramedic records did not reveal any findings of food particles or other evidence indicating that R1 passed away as a result of choking. During an interview, R1’s physician reported that an autopsy was not performed. Therefore, it could not be conclusively determined whether aspiration or choking contributed to R1’s death. Regarding the allegation, “Staff are covering up violations at the facility” it was alleged that staff moved R1 to their bedroom following an incident and S3 instructed staff to say R1 passed away in their bedroom which was incorrect. A review of video footage and interviews were conducted. The incident in question is the same incident noted above. During interviews the Department was given conflicting information on whether R1 had partially eaten their snack or had not eaten the snack provided at around 3pm. Interviews with various staff also revealed conflicting information regarding why R1 was moved from the common area. Multiple staff initially indicated they believed R1 to be sleeping and this is the reason for taking R1 to their bedroom. While a subsequent interview revealed a staff reported that R1 was taken to their bedroom to maintain their dignity and avoid other residents from seeing R1 in distress. S3 was interviewed and reported that on 10/27/2023, S3 was in a meeting when they received a call from S1 requesting their presence regarding an incident with R1. S1 directed S3 to R1’s room where R1 was observed unresponsive. Attempts to conduct a subsequent interview with S3 were not successful. S1 reported S3 never instructed staff to move R1 to their room. The allegations are unsubstantiated due to the evidence not meeting the preponderance of evidence standard. An exit interview was conducted and a copy of this report and Confidential Names list (LIC 811) was reviewed and provided to BOM. Note - LPA was off site from approximately 1:00 p.m. to 1:30 p.m. Interviews with facility staff were conducted and the following was reported. S2 reported that on 10/27/2023, they observed R1 in a wheelchair in the living room with their head slightly bowed. S2 reported that this did not initially appear concerning because R1 would occasionally fall asleep in their wheelchair while watching television. S2 reported placing a soft-food snack next to R1 and observed no signs of distress. At approximately 3:00 p.m., S2 checked on R1 again and observed that R1 appeared abnormal, with partially open watery eyes and drooling from the mouth. S2 called R1’s name but did not receive a response. S2 reported the snack had not been eaten and that they did not observe any food particles around or coming from R1’s mouth. A review of video footage was obtained. The video revealed S1 reported that at 3:02 p.m., they observed R1 interacting and speaking with S1’s son in the dining area. S2 provided R1 with a snack and R1 was eating their snack. S2 then reportedly observed R1 slumped and their snack was half eaten. S2 believed R1 was sleeping and wheeled to R1 to their bedroom to assist transferring them to bed. S2 then observed R1 to be unresponsive and contacted S1 for assistance. S1 observed R1 drooling from their mouth and reported the incident to their immediate supervisor, Staff 3 (S3). S3 checked R1’s pulse and emergency services were activated. S2 reported to local law enforcement that at approximately 3:00 p.m., staff served snacks to the residents. S2 observed what appeared to be R1 sleeping in their wheelchair in the living room and left a snack for them on the side. At approximately 3:20 p.m. S2 observed R1 slumping and wheeled them to their bedroom. S2 called R1 by their name and asked them if they wanted to lie down. However, R1 did not respond or move. S2 described lowering their torso and tilting their head to observe R1’s face and observed that R1 appeared pale, with halfway open eyes, and purple lips. S2 then ran to S1 to report R1’s state of condition. Responding ambulance personnel reported R1 was sitting in a wheelchair inside their bedroom upon their arrival. Ambulance personnel laid R1 on the floor and were presented with a Do-Not-Resuscitate order therefore life saving measures were not performed and they declared a time of death. The ambulance personnel are asked if they noticed anything by local law enforcement, to which the response was “No”. The coroner’s office is contacted by local law enforcement. The coroner’s office asks if there is any trauma, injuries, vomit, or anything suspicious to indicate R1 choked on anything, to which local law enforcement responds, “No”. Local law enforcement is advised the coroner’s office will not be responding to the facility.the state’s words, verbatim · CDSS document, Jun 24, 2026 · control 18-AS-20240206101016

Type of visit: Case Management - Health Checks

On 06/24/2026, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced case management visit to assess for any health and safety concerns. Upon arrival, LPA met with Medication Technician Gloria Sanchez and explained the purpose of the visit. Business Office Manager (BOM) Nicole Kalacas Anguiano was notified of the purpose of LPA's visit. LPA and Director of Active Living, Ashley Richardson toured a random sample of resident bedrooms and bathrooms in Buildings A, B, C, and D. LPA toured 8 resident bedrooms in Building A, 8 in Building B, 3 in Building C, and 4 in Building D. Resident bedrooms toured were equipped with the required bedding, furniture, and functional lighting. Call light cords were observed to be within arms reach from each resident's bed and the facility had operating utilities. LPA also observed the residents eating meals and snacks. During today's visit, LPA did not observe any health or safety concerns and no deficiencies were cited. An exit interview was conducted and a copy of this report was reviewed and provided to BOM. Note - LPA was off site from approximately 1:00 p.m. to 1:30 p.m.the state’s words, verbatim · CDSS document, Jun 24, 2026

Type of visit: Case Management - Health Checks

On 06/20/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross arrived at the facility unannounced to conduct a Case Management visit to the facility to assess for any health or safety concerns. LPA met with Medical Technician, Daija Love, and the purpose of the visit was explained. Ms.Love contacted Executive Director (E.D.), Teresa Mapilis by telephone to inform of the visit. E.D. was unable to attend the visit. LPA toured all four buildings inside and outside and requested copies of pertinent records via email. During today's visit, no deficiencies were cited. An exit interview was conducted and a copy of this report was reviewed and provided to Medical Technician Daija Love.the state’s words, verbatim · CDSS document, Jun 20, 2026

Allegation investigated: Staff are refusing to take resident back into care.

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced subsequent visit to the facility to deliver findings for the above allegation. LPA was greeted and granted entrance by Business Office Manager Nicole Kalacas. LPA identified himself and discussed the purpose of the visit. It was alleged that staff refused to take a resident back after a hospital stay. Confidential Witness 1 reported that the hospital could not reach the facility for discharge planning and later informed them that the Yorkshire Village had refused to accept the resident back. Confidential Witness 1 stated that the facility staff told them they did not have the appropriate level of care and that the hospital could locate a new placement faster. Confidential Witness 1 also reported that no facility staff came to the hospital to assist with assessment or discharge planning, and the resident remained hospitalized for approximately two weeks before being transferred to another facility. Confidential Witness 2 confirmed that their facility received the referral through third party agencies while the resident was already hospitalized. Confidential Witness 2 reported that Yorkshire Village staff informed them directly that they would not accept the resident back due to elopement concerns and inadequate security. Substantiated Yorkshire Village staff acknowledged that the resident had eloped twice and stated they told the hospital they needed time to coordinate an in-person assessment. Facility staff reported the hospital misinterpreted this as a refusal. Yorkshire Village staff reported that they never went to the hospital to completed a reassessment with the receiving facility. Interview with receiving facility reported that their assessment of the resident was completed at the hospital on 03/25/2026 however, the receiving facility denied Yorkshire Village staff conducted the assessment jointly with them. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies are cited according to the California Code of Regulations Title 22. An exit interview was conducted, and a copy of this report, the 9099-D and the appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 19, 2026 · control 18-AS-20260319112840

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(4) · Plan of correction due date: Jul 20, 2026

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph(5) (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement is not met as evidenced by: Based on interviews and record reviews, the licensee did not comply with the section cited above. Licensee did not follow the eviction procedure, which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 19, 2026

Plan of correction: Licensee agreed to conduct a training on eviction procedure by an outside vendor and submit proof of completion by POC due date.

Type of visit: Case Management - Health Checks

Licensing Program Analysts (LPA) Seo Jeon Abdoulaye Zerbo and Janira Arreola conducted an unannounced case management visit to the facility to assess for any health or safety concerns. Community Care Licensing staff toured all residential buildings and did not observe any immediate health and safety concerns. No deficiencies were cited at the time of this visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Nicole Anguiano, business office manager.the state’s words, verbatim · CDSS document, Jun 19, 2026

Allegation investigated: Resident sustained an injury due to staff neglect or physical abuse

On 6/17/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering the investigative findings into the allegation listed above. LPA Flores met with Business Office Manager Nicole Anguiano and explained the purpose of the visit. The investigation is summarized as follows: On 5/28/2026, Community Care Licensing (CCL) received a complaint alleging Resident #1 (R1) sustained an injury due to staff neglect or physical abuse. An interview conducted with Reporting Party (RP) reports that on 5/27/2026 R1 experience a fall in the facility, which was a result of neglect not caused directly by physical abuse. RP learned of the incident from R1’s responsible person. An interview conducted with R1’s responsible person reports that R1 is known to be a fall-risk and has experienced an increase in falls since residing in the facility. (Continue to LIC9099C) Unsubstantiated (Continuation from LIC9099) R1’s responsible person reports that if staff were properly supervising R1, R1 would never have fallen. R1’s responsible person reports that R1 does not need a one-on-one caregiver but believes that if staff were providing adequate supervision the fall could have been prevented. LPA requested and collected a copy of an incident report for the fall R1 experience on 5/27/2026. An incident report dated 5/27/2026 details that at 10:39AM, R1 was in the dining area, standing, and holding a chair when she fell back. An interview conducted with Staff #1(S1) reports that they were in the dining room ending an activity with the residents and began loading the activity cart. (S1) reports hearing a loud thump and immediately rushed towards the noise. S1 reports observing R1 lying on their back. S1 reportedly placed their hand under R1’s head to provide support. As S1 was providing support, S1 recalls feeling a lump forming on the back of R1’s head. Interviews with Staff #2 (S2) reports that they were assisting Staff #3 (S3) with the facility’s care track app while occasionally glancing back at the resident. S2 reports hearing a loud thud; S2 rushed towards R1 after observing R1 lying flat on their back. Interview with Staff #4 (S4) reports that they were in the Business Office when they heard a loud thump. S4 stated that they rushed out of the Business Office and into the dining room where R1 was observed lying flat on their back. Interviews with S2 and S4 confirmed that R1 sustained a lump on the back of the head, and no additional injuries were observed. LPA attempted to interview R1 but due to R1’s cognitive abilities, the interview attempt was unsuccessful. LPA attempted to conduct an interview with Staff #3 (S3) but S3 did not have a great recollection of the incident occurring on 5/27/2026. LPA Flores obtained a (22) twenty-two second clipped video footage of the incident. LPA observed R1 standing in the dining room, holding onto the back support of a chair. S1, S2, and S3 were observed holding onto a cellphone facing the opposite direction of R1. R1 was observed suddenly falling backwards pulling the chair onto the ground. S1 and S2 were observed immediately responding to the fall by rushing towards R1 then followed S3 and S4 just seconds after. The clipped video ended once staff approached R1. Therefore, the allegation of resident sustained an injury due to staff neglect or physical abuse is deemed unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was provided to Business Office Manager Nicole Anguiano.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 18-AS-20260528162825

Allegation investigated: Staff are mismanaging resident's medications Administrator is not appropriately managing the facility

On 06/17/2026, Licensing Program Analysts (LPAs) Janette Romero, Janira Arreola, and Valerie Flores made an unannounced joint visit to the facility to deliver complaint findings. LPAs met with Business Office Manager (BOM) Nicole Kalacas Anguiano who was informed of the purpose of the visit. Administrator Teresa Mapilis was informed of the purpose of LPAs visits. Regarding the allegation, “Staff are mismanaging resident’s medications” it was alleged that Staff 1 (S1) is covering up medication errors made by medication technicians. LPA made multiple unsuccessful attempts to contact S1 for an interview. No specific residents were identified as having been affected. Two of two staff were interviewed and refuted the allegations. Two of two staff interviews conducted described S1 as an individual that followed the facility’s policies and procedures without taking any shortcuts. One of two staff interviews conducted reported that S1 immediately reported any medication errors to the administrator and initiated corrective action. The staff further reported that they have received disciplinary action as a result of a medication error. Unsubstantiated Regarding the allegation, “Administrator is not appropriately managing the facility” it was alleged that staff report concerns to the administrator and business office manager and the administrator does not do anything about it. It was further reported once concerns are raised, the administrator and business office manager question staff about the incident and nothing is done. Specific incident details were not provided. Administrator Mapilis was interviewed and reported each time staff raise a concern, an internal investigation is conducted immediately to determine the root of the problem. Administrator Mapilis reported that corrective/disciplinary action is taken when warranted and an in-service training is also conducted to remind staff of the facility's staff expectations. BOM was also interviewed and corroborated the information provided by Administrator Mapilis. Three of three staff were interviewed and refuted the allegations. One of three staff interviewed reported that when staff raise concerns to the administrator, they are not informed of any corrective or disciplinary actions taken regarding an employee as a result of those concerns. The allegations are unsubstantiated as the evidence did not meet the preponderance of evidence standard.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 18-AS-20240206101016

Allegation investigated: Staff did not provide proper medication assistance to resident in care

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced subsequent visit to the facility to deliver findings for the above allegation. LPA was greeted and granted entrance by Business Office Manager Nicole Kalacas. LPA identified himself and discussed the purpose of the visit. It was alleged that staff did not provide proper medication assistance to resident in care. Resident 1 (R1) reported that during the previous year (2025), they believed they were receiving a lower dose of their psychotropic medication than prescribed and that their eye medication had not been administered correctly. However, R1 was not able to provide specific dates, or confirm which staff members were involved. LPA conducted staff interviews and the information obtained revealed that medications were administered as prescribed. LPA reviewed medication records, MARs, to corroborate the resident’s recollection of receiving incorrect dosages but did not find any discrepancies with the records. LPA could not corroborate the information with the confidential witness because no phone number was provided. Unsubstantiated LPA also called R1’s physician to verify R1’s statement but was unsuccessful. Additional interviews were conducted and the information obtained revealed that Staff reported that the only medication- related concern they recall involving R1 occurred when R1 was prescribed an antibiotic eye drop. Staff stated that when they informed R1 about the new medication and read the prescription label to them, R1 declined to take it, stating they were allergic to sulfates. Staff reported that they immediately notified the prescribing provider of R1’s allergy concern and requested the medication to be discontinued. Staff stated that the medication was discontinued within two days and confirmed that no doses were administered during that time. A review of R1's chart confirmed statement given by facility’s staff. Regarding R1’s psychotropic medication (M1), staff reported that R1 has always been prescribed 3 mg at bedtime, administered as one whole tablet, and not as a partial dose. LPA reviewed R1’s MAR and confirmed that M1 was dispensed at a consistent dosage of 3 mg. LPA also reviewed pictures provided by R1 and confirmed that pills were not cut. Based on the information obtained, the 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 and a copy of this report was provided to Business Office Manager Nicole Kalacas.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 18-AS-20250902101154

Allegation investigated: Staff did not assist resident with care needs.

Licensing Program Analysts (LPAs) Janira Arreola, Valerie Flores, and Janette Romero conducted an unannounced visit to the facility in order to investigate the above allegation. LPA met with, Nicole Anguiano, Business Office Manager, who was informed of the purpose of the visit. LPA Arreola conducted the investigation which consisted of interviews and observations. “Staff did not assist resident with care needs.” Unsubstantiated It was alleged that Resident #1 (R1) stated Resident #2 (R2) had made scratches on the wall of their bedroom due to staff not assisting R2 with care. It was alleged that R1’s and R2’s rooms share a common wall. LPA attempted to interview R2 however, R2 was not oriented during the time of the interview. LPA interviewed R1 who stated they had believed that R2 was scratching their shared wall due to a noise but no longer believes this is the case. R1 was unable to identify the origin of the noise coming from R2’s room. R1 stated that staff come to check on residents often when they are in their rooms and are responsive when they pull their call light cord. R2 stated they had no concerns about abuse or neglect for R2. LPA conducted interviews with (2) facility staff who stated that the marks on R2’s wall were caused by lowering and raising R2’s bed rails. Both staff stated they were unaware of R2 scratching their wall for assistance. Both staff stated all residents are checked on every (2) hours and additionally as needed. LPA observed R2’s room on 06/11/2026 at around 11:00 a.m. and observed R2’s bed had bedrails which were lowered and the bed was laid flat which exposed what appeared to be scratches or scrapes on the wall. LPA observed on 06/11/2026 at around 3:00 p.m. R2’s bed rails were raised and the head of the bed was raised which appeared to line up with the markings on R2’s wall. Therefore, based on interviews and observation the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 18-AS-20260611162435

Allegation investigated: Resident sustained multiple unexplained bruises while in care

On 6/17/2026, Licensing Program Analyst conducted an unannounced visit to the facility for the purpose of delivering the complaint findings into the allegation listed above. LPA Flores met with Business Office Manager Nicole Anguiano and explained the purpose of the visit. The investigation is summarized as follows: Information received alleged Resident #1 (R1) sustained multiple unexplained bruises while in care. Witness #1 (W1) and Witness #2 (W2) report that bruises were observed on various extremities of R1’s body. Bruises were described as being at different stages of healing which sparked concerns of possible physical abuse. Interviews conducted with (8) eight facility staff reported that on 1/27/2024, R1 experienced an unwitnessed fall in R1’s private bathroom. During a routine check, Staff #1 (S1) entered R1’s bedroom and did not immediately observe R1. (Continue to LIC9099C) Unsubstantiated (Continuation from LIC9099) S1 continued towards R1’s private bathroom where R1 was observed to be lying on the floor, flat on their back. S1 reportedly contacted S2 for additional assistance. Upon S2’s arrival, R1 was assessed and staff deemed it necessary to contact emergency personnel and R1’s responsible person. Interviews conducted with staff report that R1 did not sustain any visible bruising and were observed to have a minor lump to the back of the head. Interviews conducted with R1’s responsible person confirmed that they were contacted by facility staff to where staff informed R1’s responsible person that R1 was being transported to the hospital as R1 experienced an unwitnessed fall. R1’s responsible person provided photos to the Department of R1’s face. Photos received can be described as a 6-inch bruise on the left side of R1’s face. Interviews conducted with the (8) eight staff and Resident #2 (R2) report that R1 was not observed to have bruising until after R1 returned from the hospital after the fall incident. Records review conducted of R1’s Needs and Service Plan does not indicate R1 to be a fall risk. A review conducted of the facility’s Unusual Incident Reports did not reveal additional falls sustained by R1. A review conducted of R1 medication list revealed that R1 was receiving medication that would make R1 susceptible to bruising. Therefore, the allegations of resident sustained multiple unexplained bruises while in care is deemed unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was provided to Business Office Manager Nicole Anguiano.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 18-AS-20240130090510

Allegation investigated: Staff did not ensure resident's bed was appropriately scaled resulting in resident falling out of bed

Licensing Program Analysts (LPA) Seo Jeon and Abdoulaye Zerbo conducted an unannounced joint visit to the facility. LPA Jeon delivered findings for the above allegation. Community Care Licensing staff met with Nicole Anguiano, Business Office Manager, and informed them of the purpose of the visit. The Department’s investigation involved interviews with staff and review of records. On May 31, 2022, Community Care Licensing (The Department) received a complaint report with the following allegations. It was alleged that staff did not ensure resident's bed was appropriately scaled resulting in resident falling out of bed. Information received indicated that Resident #2 (R2) fell from their bed because the bed was adjusted too high. It was also alleged Staff #2 (S2) lowered R2’s bed before paramedics arrived to avoid questions from medical staff. Continued on LIC9099-C.... Unsubstantiated LPA conducted interviews with five (5) staff members, all of whom stated that any hospital beds can be adjusted quickly when providing care to the residents. Staff members then adjust the bed height back to normal when they are done with the residents. Staff members interviewed denied experiencing or witnessing any residents’ fall because of bed height. LPA conducted an interview with S2 who denied lowering R2’s or any residents’ beds to avoid being questioned by paramedics. LPA conducted interviews with 14 residents, none of whom expressed any concerns regarding height of their beds. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA’s attempted interview with R2 was unsuccessful because R2 was no longer a resident of the facility and lacked available contact information. LPA's attempted records review regarding R2's fall was unsuccessful due to lack of available records. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, 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, Jun 16, 2026 · control 18-AS-20220531102055

Type of visit: Case Management - Health Checks

On 06/13/2026, Licensing Program Analyst (LPA) Aziz Faizi conducted an unannounced case management visit to the facility to assess for any health or safety concerns. LPA toured all residential buildings and did not observe any immediate health and safety concerns. No deficiencies were cited at the time of this visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Zouri Holmes, Medication Technician.the state’s words, verbatim · CDSS document, Jun 13, 2026

Allegation investigated: Staff had physical altercation with resident resulting in injury to resident Facility did not report unusual incident to CCL Facility does not have enough food for residents daily nutritious needs resulting in weight loss Staff do not assist residents with incontinence needs Facility and residents bathroom has mold Staff do not shower residents Staff do not change residents clothing Facility does not have enough needed supplies for meet the residents needs Staff do not safeguard resident's person property

Licensing Program Analyst (LPA) Seo Jeon and Regional Manager (RM) Reyna Lacey conducted an unannounced joint visit to the facility to deliver findings of the above allegations. Community Care Licensing staff met with Nicole Anguiano, Business Office Manager and informed them of the purpose of the visit. The Department’s investigation involved interviews with staff and residents and review of records. On May 31, 2022, Community Care Licensing (The Department) received a complaint report with the following allegations. It was alleged that staff had physical altercation with resident resulting in injury to resident. Information received indicated that Staff #1 (S1) roughly pulled Resident #1’s (R1) arm while R1 was sitting on the toilet, causing it to break. The Department conducted an interview with a confidential witness (CW) who stated that S1’s rough handling caused a small scratch on R1’s arm. Continued on LIC9099-C.... Unsubstantiated CW denied witnessing S1 breaking R1’s arm, nor did they witness any staff member having a physical altercation with any resident in care. CW did not know the last name of S1. LPA’s subsequent interview with CW did not reveal any additional information about injuries caused by S1 to any residents in care. LPA’s records review revealed that R1 passed away on November 21, 2022. LPA conducted an interview with business office manager (BOM), who stated that S1 was never employed by the facility, past or present. LPA’s records review confirmed BOM’s statement regarding S1. LPA conducted interviews with five (5) staff members, all of whom denied knowing S1 as their coworker. LPA conducted interviews with 14 residents, none of whom experienced rough handling or physical altercation by staff. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that facility did not report unusual incident to CCL. The complaint report did not contain any relevant information. LPA conducted an interview with a confidential witness (CW) for additional information, but CW did not provide any relevant information. LPA conducted interviews with six (6) staff members, all of whom stated that any unusual incidents are reported to medication technicians who then report to the management. The management then reports to the Department and keeps the incident reports for their record keeping. LPA observed past incident reports provided by business office manager (BOM) and confirmed the statements from the staff members interviewed. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that facility does not have enough food for residents’ daily nutritious needs resulting in weight loss. Information received indicated that the facility regularly runs out of food, and residents are losing weight due to missed meals. LPA conducted five (5) unannounced tours of the facility within a span of 7 days and observed that the facility had sufficient supplies of food for residents in care. LPA conducted interviews with 14 residents, none of whom experienced missing any of the three (3) daily meals. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA conducted interviews with six (6) staff members, all of whom denied the facility running out of food for residents. One (1) of the six (6) staff members interviewed stated that they have never witnessed the facility running out of food in the past 14 years. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. Continued on LIC9099-C.... It was alleged that staff do not assist residents with incontinence needs. Information received indicated that Resident #1, 2, 3, 4, and 5 (R1, R2, R3, R4, R5) were frequently observed in urine-soaked briefs. LPA conducted interviews with 14 residents, all of whom expressed their satisfaction with staff assistance. Of the 5 residents named, only 1 could be interviewed and that resident could not provide information. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA conducted interviews with six (6) staff members, all of whom stated that all residents receive two (2) hour room checks or more often if requested or necessary. LPA conducted tours of the facility but did not observe any concerns of neglect in incontinence care. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that facility and residents bathroom has mold. Information received indicated that three (3) residents’ bathrooms had black mold. LPA conducted interviews with 14 residents, all of whom denied witnessing mold in their bathrooms. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA conducted interview with six (6) staff members, all of whom denied witnessing mold in residents’ or common bathrooms. LPA conducted tour of the facility and inspected all residents’ and common bathrooms but did not observe a substance that could be mold in any bathrooms. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that staff do not shower residents. Information received indicated that Resident #6 (R6) did not receive a shower for four (4) days. LPA conducted interviews with 14 residents, all of whom stated that they have received two (2) showers per week, and staff have not missed any. LPA’s interviews with six (6) staff members confirmed the statements from the residents interviewed. LPA’s attempted interviews with seven (7) additional residents but were unsuccessful due to their cognitive condition. LPA’s attempted interview with R6 was unsuccessful due to lack of contact information. Request for shower logs was unsuccessful. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that staff do not change residents clothing. Information received indicated that residents wore the same clothing for days. LPA conducted interviews with six (6) staff members, all of whom stated that staff assist residents with clothing change every day, but most residents receive assistance with clothing change multiple times throughout the day after each mealtime. Continued on LIC9099-C.... LPA conducted interviews with 14 residents. Eight (8) residents interviewed stated that they did not need assistance with clothing change. Six (6) residents interviewed stated that staff have assisted with clothing change every day. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA’s observation during the resident interviews did not reveal any concerns regarding residents’ clothing change. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that facility does not have enough needed supplies to meet the residents needs. Information received indicated that the facility did not have enough incontinent, shower, or bedding supplies to meet the residents’ needs. LPA conducted interviews with 14 residents, none of whom experienced shortage of supplies for their needs. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA conducted interviews with six (6) staff members, none of whom experienced shortage of supplies in the facility. LPA toured the facility and observed cleaning and incontinent supplies. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that staff do not safeguard resident's personal property. Information received indicated that staff members use Resident #3’s (R3) shower supplies for other residents. LPA conducted interviews with six (6) staff members, all of whom stated that every resident has their own shower supplies stored in a container. LPA’s interviews with 14 residents and facility tour confirmed the statements from the staff members interviewed. During the tour LPA observed shower supplies in each room for each resident. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, 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, Jun 12, 2026 · control 18-AS-20220531102055

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Health Checks

Regional Manager Reyna Lacey and Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced case management visit to the facility to assess for any health or safety concerns. Community Care Licensing staff toured all residential buildings and did not observe any immediate health and safety concerns. No deficiencies were cited at the time of this visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Nicole Anguiano, business office manager.the state’s words, verbatim · CDSS document, Jun 12, 2026

Allegation investigated: Staff are not meeting the resident's incontinence needs. Staff did not ensure resident receive scheduled showers.

The following report is an amended report: Regional Manager (RM) Reyna Lacey and Licensing Program Analysts (LPAs) Janira Arreola, Janette Romero, Seo Jeon, Valerie Flores and Abdoulaye Zerbo made a joint unannounced visit to the facility. LPA Arreola conducted the visit in order to investigate the above allegations. LPA met with Medical Technician, Ligaya Carter who was informed of the purpose of the visit. The investigation consisted of LPA conducted interviews and conducted records review. Substantiated “Resident sustained an injury due to staff neglect or physical abuse.” It was alleged Resident #1 (R1) was also observed with scratches on the inner part of their arm and a small bruise on their wrist. It is unknown how R1 sustained these injuries. There were no additional details or photos provided of the alleged injuries. LPA conducted (2) staff interviews with staff who work with R1 12/23/2025 and 12/25/2025. (2) of (2) staff revealed that they did not recalling seeing any injuries on R1’s arm or wrist. LPA attempted to conducted an interview with R1, however R1 was not alert or oriented during the interview. LPA conducted an interview with R1’s responsible person who reported that they had previously observed scratches on R1’s face. LPA conducted a random sampling of (6) additional residents who reside in the same building as R1. (6) of (6) residents stated they had no concerns about resident abuse or neglect, and were unaware of any residents being injured on their arms and wrist. LPA conducted records review of charting notes for R1 from 12/23/2025 to 12/25/2025 and found no charting notes for R1 on those dates. LPA conducted records review and staff interviews which revealed there were no incidents reported for R1 from 12/23/2025 to 12/25/2025. Therefore, the allegation that R1 had observed scratches and bruises was found to be unsubstantiated. “Resident left in soiled linens/bed for an extended period.” It was alleged that on 12/23/2025 and 12/25/2025, R1 was found lying in their bed which was saturated with urine. LPA conducted (2) staff interviews of staff who work with R1. (2) of (2) staff revealed that R1 would refuse to be changed when they were soiled with urine. Both staff stated that R1 would refuse to be changed and would conduct attempts to change R1 with different staff at different times. Both staff were unaware of a time when the bedding was saturated with R1’s urine. Both staff reported R1 is changed every (2) hours. LPA conducted an interview with R1’s responsible person who stated that they had observed R1’s bedding with urine on several occasions. R1’s responsible party stated it R1 had a large amount of urine which soaked their bedding. R1’s responsible party stated staff would report that R1 was changed (2) to (3) hours ago. LPA conducted observations of R1’s bedding and bed on 06/08/2026 and 06/11/2026 and observed R1’s bedding was dry and did not smell of urine. Therefore, based on interviews and observations the allegation that R1 was left in soiled linens for an extended period of time is unsubstantiated. “Staff did not ensure resident was accorded a comfortable room temperature.” It was alleged that on 12/23/2025 and 12/25/2025 R1’s window was left partially open which caused the room to be uncomfortably cold for R1. LPA conducted (2) staff interviews with staff who work with R1, who stated they did not recall a time when R1’s window was left open causing their room to be uncomfortably cold. Both staff reported staff open R1’s and other resident’s windows occasionally and will conduct checks on resident’s rooms to close the windows when necessary. LPA conducted an observation of R1’s room on 06/08/2026 and 06/11/2026 and did not observe R1’s window open. LPA attempted to conduct an interview with R1, however they were not alert or oriented. LPA conducted an interview with R1’s responsible party who revealed they were not aware of a time where R1’s room was uncomfortably cold. R1 does not have a roommate LPA conducted a random sampling of (6) additional residents who reside in the same building as R1. (6) of (6) residents stated their rooms are kept at comfortable temperatures. Therefore, the allegation that R1’s room was not kept at a comfortable temperature is unsubstantiated. “Staff are not providing adequate laundry service.” It was alleged that for a week prior to 12/23/2025 and 12/25/2025 R1’s clothing had not been laundered in over a week. LPA attempted to conduct an interview with R1, however they were not alert or oriented. LPA conducted an interview with R1’s responsible party who revealed they were not aware of a time where R1’s laundry was not done for over a week. R1 does not have a roommate LPA conducted a random sampling of (6) additional residents who reside in the same building as R1. (6) of (6) residents stated their laundry is conducted regularly by staff and is conducted once or twice a week. LPA conducted (2) staff interviews with staff who work with R1, who stated that resident laundry is conducted twice weekly and as needed. Both staff denied their was an instance where R1’s laundry was not conducted over a week. Therefore, the allegation that staff did not laundry R1’s clothing for a week is unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided. *LPA was offsite from 11:30am to 1:00pm. The following report is an amended report: “Staff are not meeting the resident's incontinence needs.” It was alleged that on 12/23/2025 and 12/25/2025, R1 was found lying saturated in their urine by a visitor. It was further alleged that a staff reported to the visitor that R1 refused to be changed. LPA made attempts to contact the visitor however, they were unavailable for interview. LPA conducted (6) resident interviews and (4) staff interviews which revealed that there is no staff matching the name provided by the visitor. LPA reviewed the staff roster and identified Staff #1 (S1) with a name similar to the staff name mentioned in the allegation. LPA conducted (4) staff interviews, including S1. Four (4) of four (4) staff revealed that S1 does not work with R1. Three (3) of four (4) staff revealed that R1 would refuse to be changed when they were soiled during the initial transition period after being admitted to the facility. Three (3) staff revealed they would conduct attempts to change R1 with different staff at different times, and also by calling R1’s responsible party to assist in changing or redirecting R1. Three (3) staff stated R1 was checked on every (2) hours and as needed to change their brief. Three (3) staff revealed that R1’s responsible party and doctor were notified of R1 refusing to be changed. Three (3) staff revealed that R1 is now receptive to staff changing R1’s brief and have no issues changing R1. LPA interviewed R1’s responsible person who stated staff would inform them of R1’s refusals when they first admitted to the facility, but have not been informed recently on R1’s refusals. R1’s responsible party stated that they have continued to observe R1 soiled in urine on different dates and different times when visiting R1 at the facility. R1’s responsible party stated staff would report that R1 was changed (2) to (3) hours ago. LPA made attempts to interview R1’s Physician and Physician’s Assistant, however they were unavailable for interview. LPA attempted to interview R1, however R1 was not alert or oriented. Therefore, based on interviews and records review the allegation is substantiated. The following report is an amended report: “Staff did not ensure resident receive scheduled showers.” It was alleged R1 had not taken a shower in over a week. LPA attempted to conduct an interview with R1, however they were not alert or oriented. LPA conducted an interview with R1’s responsible party who revealed they were not aware of a time where R1’s had not taken a shower in over a week. R1 does not have a roommate LPA conducted a random sampling of (6) additional residents who reside in the same building as R1. Six (6) of six (6) residents stated they receive showers twice a week and observe staff giving other residents showers. LPA conducted two (2) staff interviews with staff who work with R1. One (1) staff was unaware of a time where R1 was not showering for over a week. One (1) staff revealed that they recalled a time where R1 did not shower for a week due to them refusing to shower and notified R1’s responsible party and physician of the refusals. Staff revealed resident refusals to shower were not documented. LPA reviewed R1’s charting notes for December 2025 which revealed no documented refusal for showers. LPA conducted attempts to interview R1’s physician and physician’s assistant however they were unavailable for interview. Therefore, based on interviews and records review the allegations are substantiated. Based on LPA’s interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations Title 22 is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided. *LPA was offsite from 11:30am to 1:00pm.the state’s words, verbatim · CDSS document, Jun 11, 2026 · control 18-AS-20251229142236

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Jul 10, 2026

(b)…the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry…This requirement was not met as evidenced by: Based on interviews and records review staff did not ensure that R1 was clean and dry, and was observed soiled in urine on different dates and different times. This poses a potential health saftey or personal rights risk for residents in care.the state’s words, verbatim · CDSS document, Jun 11, 2026

Plan of correction: The POC is to conduct outside resource training regarding incontinence care and reporting/documenting resident self neglect. Proof of training for staff and administration is due by the POC due date. *The deficiency is part of an amended report.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Aug 26, 2026

(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident…with those activities of daily living such as…bathing and assistance…This requirement was not met as evidenced by: Based on interviews and records review facility did not ensure R1 was assisted in bathing for a week. This poses a potential health saftey or personal rights risk for residents in care.the state’s words, verbatim · CDSS document, Jun 11, 2026

Plan of correction: The POC is to conduct outside resource training regarding resident bathing and reporting/documenting resident self neglect. Proof of training for staff and administration is due by the POC due date. *The deficiency is part of an amended report.

Allegation investigated: Staff are not meeting the resident's incontinence needs. Staff did not ensure resident receive scheduled showers.

The following report is an amended report: Regional Manager (RM) Reyna Lacey and Licensing Program Analysts (LPAs) Janira Arreola, Janette Romero, Seo Jeon, Valerie Flores and Abdoulaye Zerbo made a joint unannounced visit to the facility. LPA Arreola conducted the visit in order to investigate the above allegations. LPA met with Medical Technician, Ligaya Carter who was informed of the purpose of the visit. The investigation consisted of LPA conducted interviews and conducted records review. Substantiated “Resident sustained an injury due to staff neglect or physical abuse.” It was alleged Resident #1 (R1) was also observed with scratches on the inner part of their arm and a small bruise on their wrist. It is unknown how R1 sustained these injuries. There were no additional details or photos provided of the alleged injuries. LPA conducted (2) staff interviews with staff who work with R1 12/23/2025 and 12/25/2025. (2) of (2) staff revealed that they did not recalling seeing any injuries on R1’s arm or wrist. LPA attempted to conducted an interview with R1, however R1 was not alert or oriented during the interview. LPA conducted an interview with R1’s responsible person who reported that they had previously observed scratches on R1’s face. LPA conducted a random sampling of (6) additional residents who reside in the same building as R1. (6) of (6) residents stated they had no concerns about resident abuse or neglect, and were unaware of any residents being injured on their arms and wrist. LPA conducted records review of charting notes for R1 from 12/23/2025 to 12/25/2025 and found no charting notes for R1 on those dates. LPA conducted records review and staff interviews which revealed there were no incidents reported for R1 from 12/23/2025 to 12/25/2025. Therefore, the allegation that R1 had observed scratches and bruises was found to be unsubstantiated. “Resident left in soiled linens/bed for an extended period.” It was alleged that on 12/23/2025 and 12/25/2025, R1 was found lying in their bed which was saturated with urine. LPA conducted (2) staff interviews of staff who work with R1. (2) of (2) staff revealed that R1 would refuse to be changed when they were soiled with urine. Both staff stated that R1 would refuse to be changed and would conduct attempts to change R1 with different staff at different times. Both staff were unaware of a time when the bedding was saturated with R1’s urine. Both staff reported R1 is changed every (2) hours. LPA conducted an interview with R1’s responsible person who stated that they had observed R1’s bedding with urine on several occasions. R1’s responsible party stated it R1 had a large amount of urine which soaked their bedding. R1’s responsible party stated staff would report that R1 was changed (2) to (3) hours ago. LPA conducted observations of R1’s bedding and bed on 06/08/2026 and 06/11/2026 and observed R1’s bedding was dry and did not smell of urine. Therefore, based on interviews and observations the allegation that R1 was left in soiled linens for an extended period of time is unsubstantiated. “Staff did not ensure resident was accorded a comfortable room temperature.” It was alleged that on 12/23/2025 and 12/25/2025 R1’s window was left partially open which caused the room to be uncomfortably cold for R1. LPA conducted (2) staff interviews with staff who work with R1, who stated they did not recall a time when R1’s window was left open causing their room to be uncomfortably cold. Both staff reported staff open R1’s and other resident’s windows occasionally and will conduct checks on resident’s rooms to close the windows when necessary. LPA conducted an observation of R1’s room on 06/08/2026 and 06/11/2026 and did not observe R1’s window open. LPA attempted to conduct an interview with R1, however they were not alert or oriented. LPA conducted an interview with R1’s responsible party who revealed they were not aware of a time where R1’s room was uncomfortably cold. R1 does not have a roommate LPA conducted a random sampling of (6) additional residents who reside in the same building as R1. (6) of (6) residents stated their rooms are kept at comfortable temperatures. Therefore, the allegation that R1’s room was not kept at a comfortable temperature is unsubstantiated. “Staff are not providing adequate laundry service.” It was alleged that for a week prior to 12/23/2025 and 12/25/2025 R1’s clothing had not been laundered in over a week. LPA attempted to conduct an interview with R1, however they were not alert or oriented. LPA conducted an interview with R1’s responsible party who revealed they were not aware of a time where R1’s laundry was not done for over a week. R1 does not have a roommate LPA conducted a random sampling of (6) additional residents who reside in the same building as R1. (6) of (6) residents stated their laundry is conducted regularly by staff and is conducted once or twice a week. LPA conducted (2) staff interviews with staff who work with R1, who stated that resident laundry is conducted twice weekly and as needed. Both staff denied their was an instance where R1’s laundry was not conducted over a week. Therefore, the allegation that staff did not laundry R1’s clothing for a week is unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided. *LPA was offsite from 11:30am to 1:00pm. The following report is an amended report: “Staff are not meeting the resident's incontinence needs.” It was alleged that on 12/23/2025 and 12/25/2025, R1 was found lying saturated in their urine by a visitor. It was further alleged that a staff reported to the visitor that R1 refused to be changed. LPA made attempts to contact the visitor however, they were unavailable for interview. LPA conducted (6) resident interviews and (4) staff interviews which revealed that there is no staff matching the name provided by the visitor. LPA reviewed the staff roster and identified Staff #1 (S1) with a name similar to the staff name mentioned in the allegation. LPA conducted (4) staff interviews, including S1. Four (4) of four (4) staff revealed that S1 does not work with R1. Three (3) of four (4) staff revealed that R1 would refuse to be changed when they were soiled during the initial transition period after being admitted to the facility. Three (3) staff revealed they would conduct attempts to change R1 with different staff at different times, and also by calling R1’s responsible party to assist in changing or redirecting R1. Three (3) staff stated R1 was checked on every (2) hours and as needed to change their brief. Three (3) staff revealed that R1’s responsible party and doctor were notified of R1 refusing to be changed. Three (3) staff revealed that R1 is now receptive to staff changing R1’s brief and have no issues changing R1. LPA interviewed R1’s responsible person who stated staff would inform them of R1’s refusals when they first admitted to the facility, but have not been informed recently on R1’s refusals. R1’s responsible party stated that they have continued to observe R1 soiled in urine on different dates and different times when visiting R1 at the facility. R1’s responsible party stated staff would report that R1 was changed (2) to (3) hours ago. LPA made attempts to interview R1’s Physician and Physician’s Assistant, however they were unavailable for interview. LPA attempted to interview R1, however R1 was not alert or oriented. Therefore, based on interviews and records review the allegation is substantiated. The following report is an amended report: “Staff did not ensure resident receive scheduled showers.” It was alleged R1 had not taken a shower in over a week. LPA attempted to conduct an interview with R1, however they were not alert or oriented. LPA conducted an interview with R1’s responsible party who revealed they were not aware of a time where R1’s had not taken a shower in over a week. R1 does not have a roommate LPA conducted a random sampling of (6) additional residents who reside in the same building as R1. Six (6) of six (6) residents stated they receive showers twice a week and observe staff giving other residents showers. LPA conducted two (2) staff interviews with staff who work with R1. One (1) staff was unaware of a time where R1 was not showering for over a week. One (1) staff revealed that they recalled a time where R1 did not shower for a week due to them refusing to shower and notified R1’s responsible party and physician of the refusals. Staff revealed resident refusals to shower were not documented. LPA reviewed R1’s charting notes for December 2025 which revealed no documented refusal for showers. LPA conducted attempts to interview R1’s physician and physician’s assistant however they were unavailable for interview. Therefore, based on interviews and records review the allegations are substantiated. Based on LPA’s interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations Title 22 is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided. *LPA was offsite from 11:30am to 1:00pm.the state’s words, verbatim · CDSS document, Jun 11, 2026 · control 18-AS-20251229142236

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Jul 10, 2026

(b)…the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry…This requirement was not met as evidenced by: Based on interviews and records review staff did not ensure that R1 was clean and dry, and was observed soiled in urine on different dates and different times. This poses a potential health saftey or personal rights risk for residents in care.the state’s words, verbatim · CDSS document, Jun 11, 2026

Plan of correction: The POC is to conduct outside resource training regarding incontinence care and reporting/documenting resident self neglect. Proof of training for staff and administration is due by the POC due date. *The deficiency is part of an amended report.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Aug 26, 2026

(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident…with those activities of daily living such as…bathing and assistance…This requirement was not met as evidenced by: Based on interviews and records review facility did not ensure R1 was assisted in bathing for a week. This poses a potential health saftey or personal rights risk for residents in care.the state’s words, verbatim · CDSS document, Jun 11, 2026

Plan of correction: The POC is to conduct outside resource training regarding resident bathing and reporting/documenting resident self neglect. Proof of training for staff and administration is due by the POC due date. *The deficiency is part of an amended report.

Allegation investigated: Licensee did not follow reporting requirements

On 6/11/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering the complaint findings into the allegation listed above. LPA Flores met with Medication Technician Ligaya Carter and explained the purpose of the visit. The investigation is summarized as follows: On 5/28/2026, Community Care Licensing (CCL) received a complaint alleging Licensee did not follow reporting requirements. An interview conducted with Resident #1’s (R1’s) responsible party reports that R1 experience a fall in the morning hours of 5/27/2026 and was not informed by staff. R1’s responsible person reports that they received a text message from Relevant Party #1 (RP1) on 5/27/2026 advising of a fall R1 experience which resulted in a hematoma to the back of the head that measure roughly the size of a golf ball. (Continue to LIC9099) Substantiated (Continuation from LIC9099) The interview conducted with RP1 corroborated R1’s responsible party’s account of contacting R1’s responsible party at approximately one o’clock in the afternoon informing them of a fall R1 experienced. Interviews with Administrator reported that they contacted R1’s responsible party via text message on 5/28/2026 to inform R1’s responsible party of the fall incident and a FAX was provided to the CCL on 5/28/2026. A records review conducted of CCL’s Unusual Incident Reports confirmed that an incident report was not received for the incident dating 5/27/2026. LPA requested a copy of the FAX transmittal receipt. An interview conducted with the Administrator reports that the facility does not maintain copies of the FAX transmittal receipt to confirm if the FAX was successful received by CCL. Therefore, the allegation of Licensee did not follow reporting requirements is deemed substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid as the preponderance of the evidence standard has been met. California Code of Regulations Title 22 is being cited on the attached LIC9099D. An exit interview was conducted with Medication Technician Ligaya Carter and a copy of the LIC9099, LIC9099C, LIC9099D, and appeal rights will be provided to the Business Office Manager Nicole Anguiano.the state’s words, verbatim · CDSS document, Jun 11, 2026 · control 18-AS-20260528162825

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 25, 2026

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence.. (D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met with evidence: Facility not maintaining proof of FAX transmittal receipt verifying the UIR was forwarded to CCL and CCL not having proof of receipt of the incident on 5/27/2026.the state’s words, verbatim · CDSS document, Jun 11, 2026

Plan of correction: Upper management is to review Reporting Requirements, Section 87211, and provide the department with a signed affidavit confirming that the section was read. The facility will maintain copies of FAX transmittal receipts and/or email copies of any incident reports sent to the Department.

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

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced subsequent visit to the facility to deliver findings for the above allegation. LPA was greeted and granted entrance by Medication Technician Manager Brianey Sandoval. LPA identified himself and discussed the purpose of the visit It was alleged that staff do not treat the resident with dignity and respect. R1 reported feeling that staff sometimes speak to them in a way that makes them feel like “nobody” and that their tone is occasionally disrespectful. R1 did not provide specific examples nor names of staff. Interviews with staff and management revealed no reported incidents or prior complaints involving disrespect toward R1. Staff described their interactions with R1 as positive and reported no concerns. R1 also reported staff generally treat them well, assist them with meals and medication, and are responsive to R1’s needs. R1 also indicated that staff are generally nice to them. Therefore, this allegation is unsubstantiated at this time. 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 and a copy of this report was provided to Medication Technician Ligaya Carter. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 11, 2026 · control 18-AS-20260403085429

Allegation investigated: Staff installed a camera in resident's room Staff placed a tag alarm on resident in an inconvenient place Staff are not providing a comfortable environment for resident

On 6/11/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering the complaint findings into the allegations listed above. LPA Flores met with Medication Technician Lead Aileen Padilla and explained the purpose of the visit. The investigation is summarized as follows: On 6/8/2026, Community Care Licensing (CCL) received a complaint alleging that staff installed a camera in Resident 1’s (R1) bedroom. Interviews with R1’s responsible party reported that the facility did not request prior approval from R1’s responsible party to install the camera. On 06/06/2026, CCL staff conducted an unannounced case management visit at the facility to assess for any health or safety concerns. During the health and safety visit, Licensing Program Analyst’s (LPA’s) Valerie Flores and Janira Arreola toured a random sampling of resident bedrooms which included R1’s bedroom. (Continue to LIC9099C) Unsubstantiated (Continuation from LIC9099) LPAs observed a white and black device, approximately four inches in length, mounted on a wall in R1’s bedroom. Interview with Staff #1 (S1) reported the facility requested family approval prior to installing a motion sensor device in the selected resident bedrooms. During a tour of R1’s bedroom, LPA observed the motion sensor device angled towards R1’s sleeping area. LPA Flores was granted access to the device’s notification system and discovered that the device did not capture audio or video footage. When activated, the device sends a notification to the tablet on what resident bedroom detected movement. Interview with S1 reports that the motion sensor is calibrated to identify the resident by weight and height. LPA inquired if consent records were obtained for the motion sensor device for R1. An interview conducted with S1 reported that S1 contacted R1’s responsible party to gain consent to install the motion sensor device in R1’s bedroom. S1 provided LPA Flores with their cellphone to view the text message chain. A text message sent to R1’s responsible party on 01/16/2026 by S1 revealed that S1 contacted R1’s responsible party requesting permission to install a sensor in R1’s bedroom. R1’s responsible party responded to the text messages agreeing to the installation of the motion sensor. LPA verified the text messages validity by comparing the telephone number from the text messages to R1’s responsible party telephone number listed on file. Additional interviews conducted with R1’s responsible party reported during a visit to the facility on 06/10/2026, R1’s responsible party learned that the device was a motion sensor device. R1’s responsible party reported that staff did not demonstrate how the motion detectors operate. R1’s responsible party reports that they did not recall the text exchange occurring. R1’s responsible party reports that there is a possibility prior text message exchanges were deleted with S1 and could not verify if prior authorization was given to install the sensors. LPA attempted to interview R1; due to R1’s cognitive ability, the interview attempt was unsuccessful. Information received alleged staff placed a tag alarm on R1 in an inconvenient place. An interview conducted with R1’s responsible party reported that during a visit with R1, R1 was observed to have a clip on the collar of their sweater along with a “garage remote” sized device clipped on the mid-left side of R1’s back. R1’s responsible party reports that the alarm was placed in a location where it may cause potential harm to R1 if R1 fell backwards and landed on the alarm. (Continue to LIC9099C2) (Continuation from LIC9099C1) An interview with S1 confirmed that R1 has a tag alarm that clips onto the clothing. S1 reported that due to R1’s frequent falls, the facility was attempting to reduce the potentiality of R1 falling by implementing the tag alarm. S1 stated that R1’s responsible party did not report concerns to facility staff utilizing the tag alarm. On 06/06/2026, LPA Flores observed R1 stand up from the rollator seat and began walking away from the rollator. When the tag alarm was activated, it triggered an alarm that nearby staff can hear. LPA observed Staff #2 (S2) approach R1 and encourage R1 to grab onto their rollator but R1 ignored S2’s attempts of redirection. (3) Three subsequent visits were conducted after the initial visit on 06/06/2026, where LPA did not observe R1 to be utilizing the tag alarm. LPA attempted to interview R1; due to R1’s cognitive ability, the interview attempt was unsuccessful. Information received alleged staff are not providing a comfortable environment to R1. An interview conducted with R1’s responsible party reported that facility staff never divulged to R1’s responsible party that staff of the opposite sex would assist R1 with dressing, bathing, or toileting. R1’s responsible party reports that on 5/31/2026, R1’s responsible party learned that Staff #3 (S3) assisted R1 with self-care needs and expressed feeling uncomfortable to managing staff. R1’s responsible party reports that staff have made accommodations since reporting concerns to staff but is not sure if the preferences are being enforced throughout every shift. Interview with (3) three staff report that since learning concerns from R1’s responsible party, the facility has made accommodations by providing selected residents to receive care from specific staff only. Interviews with Staff #4 (S4) reports that each care staff are assigned to set resident bedrooms and will rotate weekly. When the residents are known to have a specific staff preference, coordination will occur to switch off a resident to ensure the workload is equal. S4 reports that the accommodations are provided for every shift. LPA attempted to interview R1; due to R1’s cognitive ability, the interview attempt was unsuccessful. Therefore, the allegation of staff installed a camera in resident's room, staff placed a tag alarm on resident in an inconvenient place, and staff are not providing a comfortable environment for resident are deemed unsubstantiated. Unsubstantiated means the preponderance of evidence standard has not been met. An exit interview was conducted with Medication Technician Lead Aileen Padilla, and a copy of this report was provided to Business Office Manager Nicole Anguiano.the state’s words, verbatim · CDSS document, Jun 11, 2026 · control 18-AS-20260608144717

Type of visit: Case Management - Other

On 6/11/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced case management visit to the facility for the purpose of delivering an amended version of an original report for complaint control number 18-AS-20260528162825. LPA Flores met with Medication Technician Lead Aileen Padilla and explained the purpose of the visit. A deficiency was issued for complaint control number 18-AS-20260528162825. LPA Flores did not issue any additional deficiencies during the time of visit An exit interview was conducted was conducted with Medication Technician Lead Aileen Padilla and a copy of this report was provided to Business Office Manager Nicole Anguiano.the state’s words, verbatim · CDSS document, Jun 11, 2026

Type of visit: Case Management - Health Checks

On 06/10/2026, Regional Manager Reyna Lacey and Licensing Program Analysts (LPAs) Janette Romero, Janira Arreola, Valerie Flores, Seo Jeon, Abdoulaye Zerbo conducted an unannounced case management visit to the facility to assess for any health or safety concerns. Community Care Licensing staff toured the facility and obtained copies of records. During today's visit, no deficiencies were cited. An exit interview was conducted and a copy of this report was reviewed and provided to Medication Technician Manager, Bianey Sandoval. *This is an amended version of the original report to correct the end time of the visit to 6:30 p.m.the state’s words, verbatim · CDSS document, Jun 10, 2026

Type of visit: POC

Licensing Program Analysts (LPAs) Seo Jeon, Janira Arreola, Janette Romero, Valerie Flores, and Abdoulaye Zerbo conducted an unannounced visit to the facility to conduct a Plan of Correction (POC) Visit. The purpose of this report is to document the POC previously agreed upon. LPAs met with Business Office Manager Nicole Kalacas Anguiano who was informed of the purpose of the visit. Administrator Teresa Mapilis was also informed of the purpose of the visit. LPAs toured the facility, conducted interviews, and obtained copies of records. During a case management visit conducted on 06/08/2026, the facility was cited for California Code of Regulations (CCR) Title 22, regulation section 87468.1(a)(3) after LPAs observed four (4) residents in geriatric chairs with a tray table, and interviews conducted revealed none of the residents had the capacity to release the tray tables to exit the geriatric chairs. During the development of the plan of correction created on 06/08/2026, Business Office Manager Nicole Kalacas Anguiano agreed on behalf of the licensee to discontinue using geriatric chairs in the facility immediately and conduct a staff in service. During today's case management visit, LPAs observed two (2) additional residents in geriatric chairs with tray tables attached and both residents were also unable to release the tray tables to exit the geriatric chairs. Facility staff was unable to produce physician's orders for the geriatric chairs during the time of the visit. As a result, the POC has not been met and civil penalties will be assessed for failure to correct the deficiency. The POC shall include immediate discontinuation of the use of a geriatric chairs unless licensee obtains an exception granted by the Department along with a physician's order. The POC shall also include an in-service personal rights training for all staff conducted by outside source to be completed within 30 days and submission of verification that the training was completed. Per Administrator Mapilis, an exit interview was conducted with Medication Technician (MT) Ligaya Carter who was advised that civil penalties would continue to accrue until the plan of correction is met. During the exit interview, a copy of this report LIC 809-D, LIC 421FC, and Appeal Rights were reviewed and provided to MT Carter and emailed to Administrator Mapilis. Note - LPAs were off site from 4:10 p.m to 5:45 p.m.the state’s words, verbatim · CDSS document, Jun 9, 2026

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Seo Jeon and Janira Arreola made an unannounced case management visit to assess for any health and safety concerns. LPAs met with Business Office Manager (BOM) Nicole Anguiano who was informed of the purpose of the visit. LPAs toured the facility and did not observe any health or safety concerns. LPAs also conducted interviews with resident and staff members. LPAs observed four (4) residents in geriatric chairs during the facility tour. LPAs conducted interviews with those four (4) residents and observed that none of the four (4) residents knew how to release themselves out of their geriatric chairs. A citation was issued. One (1) deficiency was issued during today's visit. An exit interview was conducted and a copy of this report, LIC809-D and Appeal Rights were reviewed and provided.the state’s words, verbatim · CDSS document, Jun 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jun 9, 2026

Personal Rights of Residents in All Facilities, (a) Residents in all residential care facilities for the elderly.... (3) To be free from punishment...such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Based on observations, Residents 1, 2, 3, & 4 did not know how to release themselves from geriatric chair. This posed immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 8, 2026

Plan of correction: Licensee agreed to stop using the geriatric chairs until updated physicians' orders for the residents are obtained by the licensee. Licensee will send proof of in-service training to LPA via email by the POC date.

Type of visit: Case Management - Health Checks

On 6/6/2026, Licensing Program Analyst's (LPA's) Valerie Flores and Janira Arreola arrived unannounced to the facility for the purpose of conducting a health and safety visit. Upon arrival, LPA's met with Medication Technician Manager Bianey Sandoval and explained the purpose of the visit. The visit is summarized as followed: LPA's conducted a random sample of resident bedroom tours of building A, B, C, and D. LPA's conducted tours of (15) fifteen bedrooms in building A and Building B. In addition, LPA's conducted tours of (3) three bedrooms in Building C and Building D. Resident bedrooms that were toured were confirmed to be equipped with the required bedding, furniture, and functional lighting. LPA's observed pull cords that were easily reachable to residents. LPA's verified that the signal system was in operating-use; when activated, the pull cord sends a loud alarm that can be heard in all parts of the building. Random private and non-private bathrooms were observed to be sanitary and in good repair. During the tour, LPA's observed motion sensors in selected resident bedrooms. LPA also verified that all exit doors are equipped with operating alarms. LPA confirmed utilities where fully functioning and facility maintained running water. The facility prepares all meals in Building A. During the time of visit, LPA's observe residents being provided breakfast and lunch. Meals were observed to meet residents nutritional needs. The facility maintained a comfortable temperature for the residents measuring at 71-72 degrees Fahrenheit in Buildings A, B, C, and D. LPA's did not observe any health or safety concerns. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was reviewed and provided to Medication Technician Manager, Bianey Sandoval.the state’s words, verbatim · CDSS document, Jun 6, 2026

Type of visit: Case Management - Health Checks

On 06/04/2026, Licensing Program Analysts (LPAs) Janette Romero and Seo Jeon made an unannounced case management visit to assess for any health or safety concerns. LPAs met with Business Office Manager (BOM) Nicole Kalacas Anguiano who was informed of the purpose of the visit. Administrator Teresa Mapilis was also notified of the purpose of the visit. LPAs toured the facility and did not observe any health or safety concerns. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was reviewed and provided to BOM Kalacas Anguiano.the state’s words, verbatim · CDSS document, Jun 4, 2026

Type of visit: Case Management - Other

On 05/31/2026 at 01:55 PM, Licensing Program Analyst (LPA) Aziz Faizi arrived unannounced to the facility to conduct a case management / Health and Safety concern visit. LPA was greeted and granted entry by Medication Technician Ligaya Carter , who was informed of the purpose of the visit. Licensee/Administrator Teresa Mapilis arrived to the facility at a later time and was also informed of the purpose of the visit. LPA conducted an inside and outside tour of the facility including the kitchen. LPA also interviewed residents and staff, reviewed pertinent facility documents, including verification the of the administrator"s valid certificate. LPA oberved that the facility has sufficient staffing levels to meet the needs of the residents. The facility is equipped with adequate number of of call light systems throughout the facility rooms and common areas also functioning properly. LPA also verified that all exit doors are equipped with proper operational alarms and secured with keypad codes to ensure residents do not exit the facility unlawfully. No Health and Safety issues were observed, and no citations were issued during this visit. An exit interview was conducted, and this report was reviewed and a copy was provided to Medication Technician Ligaya Carter.the state’s words, verbatim · CDSS document, May 31, 2026

Type of visit: Required - 1 Year

On May 14, 2026 Licensing Program Analyst (LPA), Tremayne Barra arrived at the facility unannounced to conduct the Required Annual Inspection and met with Nicole Anguiano, Business Office Manager. LPA was later joined by Executive Director, Teresa Mapilis. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for 100 Elderly Adults and is currently operating at a capacity of 96 Elderly Adults. LPA toured the facility along with Nicole Anguiano and made observations pertaining to the annual visit. LPA inspected the facility inside and outside, there were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. There were no bodies of water currently on the premises. The facility is a multi building made up of four (4) seperate buildings. Building A and B are for memory care residents while building C and D consists of Assisted Living Waiver residents. Physical Plant: The facility phone number is (951) 658-1068 and it is operable. Observed a sampling of the residents’ bedrooms, and each was equipped with required furniture as per Title 22. Inspected facility bathrooms, and the hot water temperature tested within regulations. Bathrooms were clean, and appliances were operating appropriately. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. Observed required postings; "If you See Something, Say Something,” "Personal Rights," and PUB 475. Cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. Resident files are kept electronically. 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 that is locked and inaccessible to residents in care. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Eight (8) 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. Six (6) 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. Teresa Mapilis, Administrator’s certificate expiration date was 12/30/2026. Medications: Were locked and inaccessible to residents in care, and there were sufficient medications currently for residents. Overall the facility is clean, furniture is present and clean. Facility cooling system and other appliances were operable currently. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill met the department standards, and was conducted by the Office Manager. Infection Control: LPA observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures. No deficiencies were observed or cited per Title 22, Division 6 of the California Code of Regulations at this time. An exit interview was conducted where a copy of this report was discussed and given to Administrator, Teresa Mapilis.the state’s words, verbatim · CDSS document, May 14, 2026

Allegation investigated: Staff mismanaged residents’ medications Staff did not comply with reporting requirements Staff did not ensure hazardous items were inaccessible to residents

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Marielle Figueroa, Wellness Director, and informed them of the purpose of the visit. The Department’s investigation involved interviews with staff and residents and review of records. On 08-20-2024, Community Care Licensing (The Department) received a complaint report with the following allegations. It was alleged that staff mismanaged residents’ medications. Specifically, information indicated that Staff #1 (S1) dispensed Resident #2’s (R2) medication to Resident #1 (R1). During an interview with LPA, Staff #2 (S2) stated the error occurred in late July 2024. S2 clarified that while the medication and dosage were identical for both residents, the dose given to R1 was taken from R2’s container. Continued on LIC9099-C.... Substantiated An LPA’s records review confirmed that R1 and R2 had one same prescribed medication. Based on interviews conducted and records review, the Department’s investigation provided enough information to corroborate the allegation that staff mismanaged residents’ medications. This allegation is substantiated. It was alleged that staff did not comply with reporting requirements. Information received indicated that staff did not inform R1’s responsible person when the medication error occurred. LPA conducted an interview with R1’s relevant party, who stated that staff never informed about the medication incident. LPA’s records review revealed that staff had not reported the medication error to the Department. Based on interviews conducted and records review, the Department’s investigation provided enough information to corroborate the allegation that staff did not comply with reporting requirements. This allegation is substantiated. It was alleged that staff did not ensure hazardous items were inaccessible to residents. Information received indicated that Resident #3 (R3) took a knife from the facility kitchen while the door remained open. LPA’s record review revealed that R3 followed a staff member into the facility kitchen and took a knife on 07-21-2024. R3 waved the knife around and chased one of the staff members. 911 was called and R3 was placed under frequent check. Based on records review, the Department’s investigation provided enough information to corroborate the allegation that staff did not ensure hazardous items were inaccessible to residents. 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 LIC9099-D, and Appeal Rights. LPA obtained and reviewed pest control reports and invoices from June 2024 through August 2024 and observed that staff hired pest control company and treated all buildings in the facility every month. LPA toured the interior and exterior of the facility and did not observe any signs of pest infestation. Based on records review and observations, the Department’s investigation did not provide enough information to corroborate the allegation that staff are not properly addressing pest infestation in 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 7, 2026 · control 18-AS-20240820142126

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 14, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be..., (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Licensee did not ensure that staff dispense medication from correct resident's medication container. This posed potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 7, 2026

Plan of correction: Licensee agreed to provide in-service traning on medication management and send proof to LPA via email by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: May 14, 2026

87211 Reporting Requirements, (a) Each licensee shall furnish to the licensing agency such reports..., (1) A written report shall be submitted to the licensing agency..., (D) Any incident which threatens the welfare, safety or health of any resident.... This requirement was not met as evidenced by: Licensee did not report the incident involving medication error to all relevant parties. This posed potential health and safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 7, 2026

Plan of correction: Licensee agreed to provide in-service traning on reporting requiements and send proof to LPA via email by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: May 14, 2026

87309 Storage Space and Access, (a) Except as specified in subsection (b), the licensee shall ensure that ... knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by: Licensee did not ensure knives were inaccessible to R3 who followed a staff member into kitchen and took a knife. This posed immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 7, 2026

Plan of correction: Licensee stated that in-service training was already conducted immediately after the incident and locked storage was purchased so that sharp and dangerous items are double locked along with locked kitchen door.

Allegation investigated: Resident sustained multiple unexplained brusing while in care Facility staff are not addressing a change in the residents condition Facility staff left resident in urine soaked clothing for an extended period of time Facility staff impeding on third party's investigation

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to the facility to deliver findings for the above noted allegations. LPA Abdoulaye was greeted and granted entrance by Executive Director Teressa Mapilis. LPA Abdoulaye Zerbo identified himself and discussed the purpose of the visit. It was alleged Resident sustained multiple unexplained bruising while in care. Concerns were raised that bruises were discovered on the resident’s body, but no staff could explain what happened. LPA reviewed records, and information obtained from the Unusual Incident/Injury report did not reveal any bruises or injuries. LPA interviewed eight staff members, none of whom could corroborate the allegations. A confidential witness revealed that R1 fell almost every day, but information from interviews and records could not corroborate the allegation. Unsubstantiated It was alleged Facility staff are not addressing a change in the residents condition. Concerns were raised about staff members not addressing changes in condition. Interviews with multiple staff members revealed that changes in condition are reported to the medical technician, who will call paramedics in case of serious injuries. However, a confidential witness stated they were not informed of the resident's change in condition. Additional information indicated that the medical technician calls families and responsible parties whenever there is an incident or a change in condition. It was alleged that Facility staff left residents in urine-soaked clothing for an extended period of time. Concerns were made about staff not attending residents briefs in a timely manner. LPA interviewed multiple staff and residents, and information obtained revealed residents are being changed every 2 hours or sooner depending on the residents’ needs. Interviews obtained from 2 of 3 residents corroborated that residents are not left alone in their urine. It was alleged that Facility staff impeding on third party's investigation. Concerns were raised about facility staff refused to provide requested documentation to the Ombudsman. LPA conducted interviews with facility staff, and they do not recall documents requested by the Ombudsman. LPA attempted to contact the confidential witness for additional information but did not receive any information. Based on observations, interviews, and records review, the allegations listed above are unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to Executive Director Teressa Mapilisthe state’s words, verbatim · CDSS document, Apr 9, 2026 · control 18-AS-20240327103958

Type of visit: Case Management - Incident

On March 17, 2026, Licensee Program Analyst (LPA), Tremayne Barra made an unannounced case management incident visit. LPA was greeted and granted entry by facility staff. Executive Director, Teresa Mapilis met with LPA shortly after LPAs arrival. Teresa was informed of the purpose of the visit. Information received was pertaining to an elopement of Resident #1 (R1). During the investigation process LPA conducted interviews, record reviews, and made observations pertaining to the elopement. During the visit, LPA conducted an interview with Executive Director Mapilis, and obtained copies of pertinent records. Per Mapilis, camera footage shows Resident #1 eloped from the facility through the back door on 3/10/26 on or around 7:45PM unsupervised. Caregiver #1 (C1) noticed at or around 10PM that R1 was missing from the facility. Law enforcement was notified. R1 was found in the brush in the field owned by the facility on or around 11:20PM by law enforcement. Incident occurred again on 3/17/26. R1 eloped from the facility on or around 10:30PM. Caregiver #2 (C2) noticed R1 was missing from the facility. Notified law enforcement on or around 1:10AM. R1 was found in nearby brush in the field near the facility. The facility has 24/7 alarms on exit doors. Needs and service plan was updated on 3/11/2026. Plan states that frequent supervision and redirection would be given due to wondering on or off of the facility property. Exits would be monitored due to elopement risk. Facility did not provide sufficient staffing and supervision during 3/17/2026 incident per code 87463(J). R1 left the facility unnoticed for on or about 2 hours. As a result, the facility will be cited. An exit interview was conducted and a copy of this report, LIC 809-D, Confidential Names list (LIC 811), and Appeal Rights were reviewed and provided to Executive Director Mapilis.the state’s words, verbatim · CDSS document, Mar 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(j) · Plan of correction due date: Mar 17, 2026

(j) The licensee shall evaluate staffing needs to ensure that there is a sufficient number of direct care staff, as specified in Section 87411, Personnel Requirements - General, to support each residents physical, social, emotional, safety and health care needs, as identified in their current appraisal. This requirement was not met as evidenced by: Observing staff schedule and interview with Executive Director. Staff was unable to redirect or prevent unnoticed elopement of R1. R1 Went unnoticed for over 2 hours.the state’s words, verbatim · CDSS document, Mar 17, 2026

Plan of correction: Executive Director reported the facility will schedule an additional staff member for the noc shift to help monitor residents every 30 minutes and check facility exits. Training for elopement will be conducted with all staff. Proof of correction to be submitted to LPA by close of business on 03/18/2026.

Allegation investigated: Staff did not meet a resident's hygiene needs Staff did not meet a resident's dental needs Staff did not conduct a reassessment for a resident

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with Executive Director (ED), Teresa Mapilis, and explained both the purpose of the visit and the details of the allegations. The investigation included staff and witness interviews, as well as a review of records. On August 28, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that staff did not meet a resident's hygiene needs, staff did not meet a resident's dental needs, and staff did not conduct a reassessment for a resident. For the allegation that staff did not meet a resident’s hygiene needs, it was alleged that staff neglected R1’s hygiene. Continued on LIC 9099-C. Unfounded An interview with Additional Witness 1 (AW1) revealed that during a family visit with R1, relatives reported to AW1 that R1’s appearance and hygiene were poor. AW1 stated staff were informed that R1 had been refusing to bathe and staff were only able to encourage proper hygiene practices, but could not force R1 to comply. Interview with Executive Director Teresa Mipilis revealed that R1 began to refuse showers despite multiple attempts by various caregiver encouragement. ED reported that R1’s Responsible Party (RP) was notified verbally of the refusals and they acknowledged R1’s decline. ED noted that RP was informed that R1 was not maintaining hygiene and becoming increasingly withdrawn. An interview with Staff 1 (S1) revealed that R1 frequently refused assistance with showering or bathing, often insisting they could do it themselves or declining bathing entirely. S1 reported that each refusal prompts three separate attempts by staff to encourage R1 to maintain their hygiene. Interview with Staff 2 (S2) revealed that R1 refused to shave and did not allow staff to trim their beard for over two months. S2 reported that R1’s RP was informed of the ongoing hygiene refusals and acknowledged the concern. Interviews with three out of three residents corroborated that they receive sufficient hygiene assistance from facility staff. R2 added that they appreciate being allowed to bathe independently and upon request, assistance from staff. A review of records obtained revealed chart notes from 2023 through 2025 documented multiple instances in which R1 refused Activities of Daily Living (ADL’s) on various dates and times. Additionally, documents obtained revealed R1’s assessments and care plans were updated over time to gradually increase the level of staff assistance provided for hygiene care. A review of Title 22 under the California Code of Regulation was conducted, information obtained under Personal Rights revealed that Section 87468.2(a)(6) references the residents right to make choices concerning their daily lives at the facility. For the allegation that staff did not meet a resident’s dental needs, it was alleged that on December 10, 2024, the facility received an order for oral surgery for R1 and subsequently failed to ensure that R1 was sent to the scheduled dental procedure. An interview with AW1 revealed they were informed the facility had an in-house dentist. AW1 was unsure how many times R1 had been seen, due to staff not providing updates. An interview with Staff 3 (S3) revealed they assisted R1 with dental appointments and confirmed that R1 received seven dental treatments, including an oral surgery completed on December 10, 2024. A review of R1’s records showed documented dental treatments on the following dates: 10/20/2023, 03/27/2024, 05/29/2024, 08/17/2024, 11/20/2024, and 12/10/2024. Continued on LIC 9099-C. For the allegation that staff did not conduct a reassessment for a resident, it was alleged that R1 experienced a cognitive decline and the facility failed to complete appropriate reassessments in response to the change in condition. An interview with AW1 revealed concern regarding R1’s declining cognitive behaviors and noted that AW1 frequently requested that the facility perform a reassessment. AW1 added that the reassessment was necessary to obtain additional support services, such as home health. AW1 stated they were unaware whether reassessments had been completed, because the facility did not provide updates. An interview with the Executive Director confirmed that multiple reassessments and care plans for R1 was completed. An interview with Staff 4 (S4) further noted the facility conducted reassessments and provided updated care plans to RP, obtaining digital signatures acknowledging receipt on multiple care plans. A review of records showed that medical reassessments for R1 were completed on 7/26/2023, 9/20/2023, 3/27/2024, 11/6/2024, and 12/30/2024. Based on interviews, research, and record review, the allegations that facility staff did not meet a resident's hygiene needs, staff did not meet a resident's dental needs, and staff did not conduct a reassessment for a resident is unfounded. A finding that the allegation is unfounded meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. Therefore, this complaint is dismissed. An exit interview was conducted. A copy of this report was provided to Executive Director Teresa Mapilis.the state’s words, verbatim · CDSS document, Mar 5, 2026 · control 18-AS-20250828112158

Allegation investigated: Staff neglect resulted in a resident to be hospitalized Staff did not seek timely medical attention for a resident

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Executive Director (ED), Teresa Mapilis, and explained both the purpose of the visit and the details of the allegation. The investigation included staff and witness interviews, as well as a review of records. On August 28, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that staff neglect resulted in a resident to be hospitalized and staff did not seek timely medical attention for a resident. For the allegation that staff neglect resulted in a resident to be hospitalized, it was alleged that facility staff failed to address R1’s medical concerns leading to an infection. Interview with ED indicated that R1 received monthly medical evaluations at the facility. ED stated on February 5, 2025, R1’s Primary Care Provider (PCP) ordered laboratory work that revealed R1 had abnormal levels. ED reported that PCP instructed staff to send R1 to the hospital for further evaluation. Continued on LIC 9099-C. Unsubstantiated Interview with Additional Witness 1 (AW1) corroborated statements made by ED and reported that R1 would have monthly medical visits at the facility. AW1 added that visits were increased during the month if concerns were addressed. AW1 reported receiving notice of R1’s transfer to the hospital on February 5, 2025. Interviews with 3 of 3 staff members indicated that R1 tended to keep to themselves and did not typically complain about pain or medical concerns. S2 added that R1 often refused medical assistance and did not observe any concerns during interaction with R1. Interview with R1 revealed that R1 could not recall his experience at the facility or the reason for his hospital stay. Through record review, it was revealed that on February 5, 2025, R1’s Primary Care Provider ordered lab work during the assessment and results required further evaluation. For the allegation that staff did not seek timely medical attention for R1, it was reported that facility staff delayed medical intervention. During an interview, ED stated that on February 5, 2025, R1’s PCP contacted the facility and instructed staff to arrange medical transport due to abnormal lab results. ED reported that R1 was transported the same day as directed in a timely manner. An interview with AW1 confirmed that they were informed R1 had been transported to the hospital on February 5, 2025, due to concerning laboratory findings. R1 was unable to recall their experience at the facility or the reason for hospitalization. A review of records obtained revealed that R1 was admitted to Hemet Global Medical on February 5, 2025. Intake notes indicated that R1 reported only back pain at the time and did not express additional discomfort. Additionally, Community Care Licensing Division received a Special Incident Report stating that on February 5, 2025, at approximately 2:30 PM, R1’s physician instructed staff to arrange medical transport. The report further stated that instructions were followed in a timely manner and responsible parties were notified. Based on interviews and record reviews, the allegation that staff neglect resulted in a resident to be hospitalized and staff did not seek timely medical attention for a resident 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. A copy of this report was provided to ED, Teresa Mipilis.the state’s words, verbatim · CDSS document, Mar 3, 2026 · control 18-AS-20250828112158

Allegation investigated: Staff did not meet reporting requirements Staff did not comply with infection control requirements Staff did not provide adequate food service Staff did not provide a comfortable temperature Staff did not ensure that the call light was accessible to residents Staff did not ensure that the facility was kept clean Staff did not provide a safe and comfortable environment for residents Staff left resident unattended in direct sunlight without hydration Staff did not meet residents' medical needs

On 12/19/2025, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to deliver findings for the allegations listed above. LPA met with Business Office Manager (BOM) Nicole Anguiano and Administrator Teresa Mapilis who were informed of the purpose of the visit. Some allegations received identified the affected residents however, there were other allegations where the names of the residents were not disclosed. The LPA attempted to obtain the names of all affected residents but was unsuccessful. As a result, LPA interviewed a random sample of residents that resided in the respective areas of the facility at the time the complaint was received. The primary incident date is listed as 06/07/2024. Unsubstantiated Regarding the allegation, “Staff did not meet reporting requirements” it was alleged the facility failed to meet the mandated reporting requirements after a resident suffered a broken leg from a fall in the facility. It was further alleged that a different resident had falls on 06/13, 06/14, 06/16, 06/18 and multiple visits to the emergency room that were also unreported. The residents were identified by their room numbers. The resident identified in the allegation who allegedly had a broken leg was identified as Resident 1 (R1). There were a total of five (5) staff interviewed. One (1) of five (5) staff interviewed was unable to recall any resident breaking their leg in the facility. The remaining four (4) of five (5) staff interviewed reported, R1 never broke their leg in the facility. LPA attempted to conduct an interview with R1 to inquire whether they suffered a broken leg while at the facility. However, R1 was unable to participate in the interview. LPA also made attempts to contact R1’s responsible party but was unsuccessful. LPA reviewed Unusual Incident/Injury Reports (LIC 624s) regarding Resident 2’s (R2) unwitnessed incidents occurring on 06/01/2024, 06/13/2024, 06/14/2024, and 06/17/2024 which were reported to Community Care Licensing (CCL) timely. The reports documented 911 was called each time, and each time R2 was transported to the hospital for further evaluation. The reports also indicated R2’s responsible party and primary care physician were notified. LPA made contact with R2’s responsible party who reported R2 has since passed away. The responsible party reported that facility staff notified them of multiple falls R2 experienced in the facility and was aware R2 was sent to the hospital for evaluation. However, the responsible party was unable to recall exact incident dates and therefore was unable to confirm whether the facility reported every fall to them since R2 exhibited memory loss and RP was not always in the facility. Five (5) of five (5) staff interviewed reported the facility follows mandated reporting requirements and activates emergency services each time a resident has an unwitnessed fall or incident. Five (5) of five (5) staff interviewed added they have never suspected staff abuse or neglect led to the resident incidents and/or falls which include any incidents involving R1 and R2. It was reported that this is why the incidents were reported to CCL but not the Long-Term Care Ombudsman nor Law Enforcement. Mandated reporting requires reports to the local ombudsman, the corresponding licensing agency and local law enforcement when the mandated reporter reasonably suspects physical abuse, abandonment, abduction, isolation, financial abuse or neglect. However, five (5) of five (5) staff interviewed reported they did not reasonably suspect abuse or neglect regarding R2's unwitnessed incidents. BOM Anguiano also reported the facility is not aware of any other incidents involving R2 on the alleged dates. Regarding the allegation, “Staff did not comply with infection control requirements” it was alleged every resident was observed itching and scratching themselves and none of the staff was observed to have personal protective equipment donned such as gloves, masks, etc. A random sampling of 4 residents were interviewed. Two (2) of four (4) residents reported they did not have knowledge or recall the facility having an outbreak where multiple residents were observed to be scratching themselves. The remaining two residents were unable to provide information. Three (3) of three (3) staff interviewed reported the following information. Facility housekeepers are constantly cleaning, disinfecting the facility, and/or following universal precautions. They are unable to recall an incident where every or multiple residents were observed to be itching or scratching themselves. In June 2024, the facility did not experience any sort of outbreak or illness that would cause every resident to itch or scratch. Personal Protective Equipment (PPE) such as gloves, gowns, and masks is made available for staff use but there was no reason to encourage staff/residents to use PPE or isolate in June of 2024. Wellness Director was interviewed and reported that residents are seen by a dermatologist anytime they experience a skin condition. LPA toured the facility and observed PPE including gloves, face masks, gowns and hairnets available in the facility. LPA also observed a sign posted in the facility encouraging the use of masks and hand sanitizer for those experiencing flu like symptoms. Regarding the allegation, “Staff did not provide adequate food service” it was alleged residents were served a meal that was not nutritious. This meal consisted of a chili cheese hot dog on a bun with potato chips and Kool-Aid to drink. It was reported that residents were also given water. LPA reviewed the facility's menu for June 2024 noting on 06/07/2024 a chili cheese dog, zucchini fries, and dessert were on the menu for lunch. However, the chili cheese dog was on the menu only one day out of the month and the menu listed a variety of foods. LPA conducted a witness interview with a dietitian who confirmed reviewing the facility’s menu and providing menu guidelines and consultative services to the facility monthly in the year 2024. A random sampling of 4 residents were interviewed. Two (2) of four (4) residents reported the facility follows their menu, offers a variety of foods and drink options, or they can request alternative food options. The remaining two (2) residents were unable to provide information. Furthermore, it is not a requirement that the menu be posted in the facility. Regarding the allegation, “Staff did not provide a comfortable temperature” it was alleged a resident reported feeling warm and wanted the air to be on resulting in maintenance staff responding to the room to determine the issue. It was further alleged the vent in the resident’s room was observed to be closed, restricting the airflow. BOM Anguiano was interviewed and reported Resident 3 (R3) requests facility staff open and close the vent in their bedroom at various times. Therefore, the vent was closed at R3’s request and not due to facility staff malice or neglect. Administrator Mapilis was interviewed and reported R3 has complained about the temperature in their room and maintenance staff inspected the unit and reported there was nothing wrong with it. As a result, R3 has been offered to move to a different room or have a stand-up fan placed in their room. However, R3 has declined both offers. Mapilis reported that all thermostats are set to meet licensing regulations and maintain a comfortable temperature for all residents. R3 was interviewed and reported they instruct staff when to open and close their vent and staff have never opened or closed their vent without them asking. R3 was unable to recall an incident on 06/07/2024 regarding their vent. LPA toured R3s bedroom and observed all vents to be opened. LPA observed the hallway thermostat reportedly controlling R3s room set to 73-degrees Fahrenheit. Regarding the allegation, “Staff left resident unattended in direct sunlight without hydration” it was alleged a resident was left outside of the building in direct sunlight, unattended with no hydration. No further details were provided including the identification of the resident. BOM denied the allegations and it is believed the resident in question is Resident 4 (R4). R4 enjoys sitting in their wheelchair outside by the front door of the facility. However, R4 is always given a cup of water and facility staff constantly check on them. The Wellness Director reported that residents sitting outside are checked on after 30 minutes and encouraged to come inside. If they want to remain outside, the staff ensure they are appropriately dressed and provide fluids. An additional staff interview reported residents who choose to be outside are checked on at least every fifteen minutes. R4 was unable to participate in an interview. During a visit in September of 2025, this LPA observed R4 sitting in their wheelchair outside of the building, staff checking on R4 and encouraging R4 to drink from a cup that was provided. Regarding the allegation, “Staff did not meet resident’s medical needs” it was alleged a resident had a catheter. No additional details were obtained. The resident was only identified by their gender and the building they resided in. One (1) of five (5) staff interviewed reported they recall a resident with a catheter to reside in the respective building. However, they were unable to identify the resident. The remaining (4) of five (5) staff interviewed identified Resident 5 (R5) as the only resident to fit the description and use a catheter. They reported R5 receives home health assistance to change their catheter and have the capacity to independently empty it. R5 was interviewed and corroborated the information provided by the four (4) staff. LPA reviewed R5’s physician’s report dated 05/28/2024 noting they are ambulatory and do not exhibit memory loss. R5 did not report any issues or concerns with the catheter care. It was also alleged that R1 had a dirty and seeping bandage. Five (5) of five (5) staff interviewed reported that a dirty and seeping bandage never exited on any resident in the facility. The LPA was not able to interview all relevant parties which included a possible witness who may have observed any of the allegations during their visit. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report and Confidential Names list (LIC 811) were reviewed and provided to Administrator Mapilis. Regarding the allegation, “Staff did not ensure that the call light was accessible to residents” it was alleged residents are not aware of the call light or how to use it. It was further alleged the call lights were out of the resident’s reach and some were found behind the headboard of the bed. LPA toured several resident rooms and observed each call light to be accessible with the alarm pull cord lying on each resident’s bed. LPA observed some resident rooms with bed headboards. However, LPA did not observe any of the call lights behind the headboards. During the tour, a staff activated the call light and LPA observed it sounded an alarm at the resident’s front door, and the call light was manually turned off by staff. Three (3) of three (3) staff interviewed reported staff monitor all residents including those who are cognitively impaired and unable to use the call light system. Three (3) of three (3) staff interviewed reported facility staff added a small stuffed animal at the end of the pull cord so that the residents can easily locate the pull cord. One staff reported that caregivers check on all residents at least every two (2) hours to inquire if assistance is needed. A random sampling of 4 residents were interviewed. Two (2) of four (4) residents reported their call light is accessible. The remaining two residents were unable to provide information. Regarding the allegation, “Staff did not ensure that the facility was kept clean” it was alleged soiled diapers were found in rooms in the exposed trash can. LPA toured several resident rooms and did not observe any soiled diapers in exposed trash cans. A staff interview conducted reported that staff are trained to promptly remove and dispose of soiled diapers after providing incontinent care to maintain a sanitary and odor free environment. The staff interviewed added caregivers are trained to place wet/soiled diapers in a trash bag and immediately dispose of the bag by placing it in a trash bin outside of the facility. A random sampling of 4 residents were interviewed. Two (2) of four (4) residents qualified for an interview reported housekeeping staff is constantly cleaning the facility and they have not observed wet/soiled diapers in exposed trashcans. The remaining two residents were unable to provide information.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 18-AS-20240619104115

Type of visit: Case Management - Deficiencies

On 12/19/2025, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to address a deficiency found during a complaint investigation. LPA met with Business Office Manager Nicole Anguiano, Administrator Teresa Mapilis and Wellness Director Marielle Figueroa who were informed of the purpose of the visit. During investigation of complaint control 18-AS-20240619104115, LPA reviewed a Service Plan for Resident 1 (R1) dated 03/19/2024. LPA also reviewed Unusual Incident/Injury Reports (LIC 624s) reporting R1's unwitnessed incidents occurring on 06/01/2024, 06/13/2024, 06/14/2024, and 06/17/2024 where R1 was reportedly found on the floor inside and outside of the facility. The reports documented 911 was called each time, and each time R1 was transported to the hospital for further evaluation. The reports also indicated R1’s responsible party and primary care physician were notified, and LPA confirmed they were submitted to Community Care Licensing timely. BOM Anguiano reported she was unable to find documentation of an updated reappraisal noting a plan to address R1's unwitnessed incidents noted above to prevent future incidents. Per BOM, the only Service Plan for R1 on file is dated 03/19/2024. As a result, the facility will be cited. An exit interview was conducted and a copy of this report, LIC 809-D, Confidential Names list (LIC 811), and Appeal Rights were reviewed and provided to Wellness Director Figueroa.the state’s words, verbatim · CDSS document, Dec 19, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(b)(1)(C) · Plan of correction due date: Jan 2, 2026

(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. (1) Significant changes in condition, as defined in Section 87101, Definitions, include, but are not limited, to:(C)behavioral expression, as defined in Section 87101, Definitions, that may result in harm to self or others, such as unsafe wandering, elopement, hallucinations, lacking in hazard awareness, or lacking in impulse control. This requirement was not met as evidenced by: LPA also reviewed Unusual Incident/Injury Reports (LIC 624s) reporting R1's unwitnessed incidents occurring on 06/01/2024, 06/13/2024, 06/14/2024, and 06/17/2024 where R1 was reportedly found on the floor inside and outside of the facility. BOM Anguiano reported she was unable to find documentation of an updated reappraisal noting a plan to address R1's change of condition related to the unwitnessed incidents noted above. This poses a potential health/safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 19, 2025

Plan of correction: Wellness Director reported the facility will conduct an in-service staff training regarding resident reappraisals. Proof of correction to be submitted to LPA by close of business on 01/02/2026.

Allegation investigated: Staff are not addressing a scabies outbreak.

On December 18, 2025, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegations and to deliver findings. The Department was met by Nicole Anguiano, Office Manager, and the purpose of the visit was explained. Investigation consisted of the following: On May 22, 2024, the Department conducted an unannounced initial visit to the facility to investigate the complaint allegations mentioned above. During the visit, it was determined that the complaint required further investigation. On December 18, 2025, the Department requested and obtain the following documents: Staff schedule (dated: 12/18/25), client roster (dated 12/18/25) R1 Unusual Incident Report (UIR) dated 8/6/24 and 11/7/24, Dermatology visit notes (dated: 3/6/24), R1’s lab report (dated: 8/1/24), Physician Communication document (dated: 8/6/24), Medication order (dated: 8/2/24), Wound Care Progress notes (dated: 11/1/24), R1 Skilled Nursing Facility (SNF) admission document (dated: 7/25/24); R2 Physician visit and orders (dated: 6/5/24, 5/14/25), and R2 discharge document (dated; 5/22/24). The department conducted interviews with Administrator (A1), 5 staff (S1-S5). Page 1 of 3 Unsubstantiated The investigation revealed the following: Allegation: Staff are not addressing a scabies outbreak. The detail of the complaint alleges that multiple residents were covered in rashes and facility is not addressing the issue. On December 18, 2025, at 10:18am, the Department interviewed Nicole Anguiano (A1) who stated that there have been no reports of residents having a diagnosis of Scabies. However, A1 went on to state that a resident’s (R1) family member had a concern about a rash R1 had. This rash was not a diagnosis of scabies. R1 was diagnosed with another condition for which she was sent to a Skilled Nursing Facility (SNF) for care and subsequently returned to the facility. Lastly, A1 stated that Riverside County Public Health department was notified in addition to Community Care Licensing via Incident Report. Lastly, A1 stated that around the time of the complaint (May 2024) another resident (R2) was scratching, however when seen by a physician, the itching was a result of anxiety and not a diagnosis of Scabies; staff were instructed to treat with Neosporin. On December 18, 2025, between 11:45am and 12:30pm, the Department interviewed 5 staff (S1-S5) regarding the allegation. Of those interviewed, 5 out of 5 denied the allegation stating the facility has never had an outbreak of Scabies since they have been with the company. 5 out of 5 knew the protocol for an infectious disease outbreak. Page 2 of 3 On December 18, 2025, the Department made several attempts to interview the residents available in the memory care unit, however the Department was unable to interview residents due to their functioning level and their inability to understand the questions asked. On December 18, 2025, the Department reviewed and evaluated the following documents: R1 Unusual Incident Report (UIR) dated 8/6/24 and 11/7/24, Dermatology visit notes (dated: 3/6/24), R1’s lab report (dated: 8/1/24), Physician Communication document (dated: 8/6/24), Medication order (dated: 8/2/24), Wound Care Progress notes (dated: 11/1/24), R1 Skilled Nursing Facility (SNF) admission document (dated: 7/25/24); R2 Physician visit and orders (dated: 6/5/24, 5/14/25), and R2 discharge document (dated; 5/22/24). The review of documents reveals there was no outbreak of Scabies as indicated in the complaint. Additionally, the documents revealed that the facility followed protocol and reporting requirements to handle an infectious disease. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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. There were no deficiencies cited during today’s visit. Exit interview conducted with Administrator and copy of report provided. Page 3 of 3the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 18-AS-20240516103835

Allegation investigated: Staff handled resident in an inappropriate manner.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with Nicole Anguiano and explained the reason for the visit. The investigation consisted of the following: On 10/6/23 LPA Martinez conducted an initial complaint investigation visit and requested pertaining documents. On 10/30/25 LPA Flores conducted an interview with administrator and business office manager over the phone and requested resident #1(R1)’s physician report, needs and care plan, admission agreement, and face sheet. On 11/3/25 LPA Flores conducted interviews with 4 staff and 8 residents. LPA attempted to contact R1’s responsible party. The investigation revealed the following: Regarding allegation: Staff handled resident in an inappropriate manner. It is alleged staff mishandled a resident while outside the facility. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews with residents revealed 6 out of 8 residents stated staff are gentle and do not yell at residents in care. 2 out of 8 residents were unable to be interviewed due to cognitive skills. Interviews with staff revealed staff have not observed any staff mistreat or been rough to residents in care. Interview with Business Office Manager revealed the day of the allegation staff had taken R1 to a medical appointment. R1 had become agitated during the appointment and as they were leaving staff was guiding R1 to the vehicle by speaking louder due to R1’s listening skills. Staff did not put hands on R1 but put their hand up to avoid being hurt, as R1 was batting their hands due to their agitation. Per staff responsible party was notified via telephone. Documents review revealed in house incident report dated 9/29/23 notes the incident as described by staff above. 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 Nicole Anguiano and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 3, 2025 · control 18-AS-20231002082742

Allegation investigated: Staff did not report emergency to the Long-Term Care Ombudsman office Staff unable to provide emergency personnel with resident census Staff was unable to provide emergency personnel with residents' records Staff did not execute evacuation plan. Facility did not have adequate staff to meet the needs of the residents in care

On 09/17/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering investigative findings into the allegations listed above. LPA Flores identified herself and discussed the purpose of the visit with Wellness Director, Haley Logan. The investigation consisted of record reviews and interviews. The allegations stem from an emergency incident that occurred at the facility on 03/14/2025. Information received alleged staff did not report emergency to the Long-Term Care Ombudsman (LTCO). Community Care Licensing (CCL) is regulated by Title 22. Per Title 22 regulations, section 87211(c) Reporting Requirements requires a report to the LTCO for incidents of physical abuse, abandonment, abduction, isolation, financial abuse and neglect. The emergency occurring on 03/14/2025 was not for any of the above mentioned incidents. (Continue to LIC9099) Unfounded (Continuation from LIC9099) The report alleges staff were unable to provide emergency personnel with resident census. Interviews conducted with the Fire Department Representative and facility staff corroborate that Emergency Personnel were requesting a verbal head count of all residents to ensure all residents were accounted for. The Fire Department Representative reported the facility staff provided the Fire Department with a verbal head count when requested on 03/14/2025. The Fire Department Representative further explained facility staff provided a response to all of the Fire Department’s requests promptly and/or within a timely manner to the situation. It was alleged facility staff were unable to provide emergency personnel with resident records. Interviews conducted with the Fire Department Representative and facility staff corroborate that emergency personnel did not request resident records on 03/14/2025. Interviews with facility staff reported facility staff attempted to provide the Fire Department with the facility’s emergency disaster plan. Facility reported that Fire Department personnel declined to review the disaster plan. Interview with the Fire Department Representative revealed resident records are only requested when a resident may require medical attention. Facility staff and the Fire Department Representative corroborated that Emergency Medical Services were not requested and/or needed for any resident at the time of the incident on 03/14/2025. It was alleged staff did not execute evacuation plan. Record review revealed facility’s Emergency and Disaster plan outlines facility assembly point to be in the front of Building A by the flagpole and residents will be relocated to locations outside the facility as needed. Through interviews with facility staff and the Fire Department Representative, the facility staff evacuated all residents to the assembly point outside of Building A. The evacuation was a result of an incident that occurred on 03/14/2025 in Building B. Interviews with both facility staff and the Fire Department Representative revealed facility staff were instructed, by fire personnel, to relocate the residents from Building B into Building A. No additional relocations were required. It was alleged facility did not have adequate staff to meet the needs of the residents in care. It was reported the facility did not have enough staff to assist with the evacuation of residents. Interviews conducted with the Fire Department Representative, facility staff, and residents, corroborate that there was sufficient staffing on duty to assist with the evacuation of residents in Building B. Record review and interviews conducted for staff schedule verified (4) four staff were on shift during the evacuation. During the incident, an additional 2 staff arrived to assist in evacuating the 42 residents. These additional staff arrived prior to the arrival of the fire personnel. (Continue to LIC9099C) (Continuation from LIC9099C) A review of the fire department’s Incident Report dated 03/14/2025 revealed the alarm was activated at 6:49PM and they arrived at 6:59PM. Fire Department Representative indicated when fire personnel arrived almost all residents were evacuated. The representative could not provide the specific number of residents who still required evacuation when fire personnel arrived. The interview with the Fire Department Representative revealed there was a sufficient number of staff to evacuate the residents in care. Based on information obtained from interviews and record reviews, the evidence received pertaining to the allegations listed above, are deemed unfounded. A finding of unfounded means the allegations could not have happened or are without a reasonable basis. An exit interview was conducted where a copy of this report was discussed and given to Wellness Director, Haley Logan.the state’s words, verbatim · CDSS document, Sep 17, 2025 · control 18-AS-20250317191114

Type of visit: Case Management - Deficiencies

On 09/17/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced case management deficiencies visit. LPA met with Wellness Director, Haley Logan, and explained to her the purpose of the visit. Below is a summary of the purpose of visit: During the investigation conducted for complaint number 18-AS-20250317191114, information revealed that the facility had to evacuate residents in Building B due smoke breaking out in Building B on 3/14/2025. The facility staff did not report the incident of the fire evacuation of resident in Building B to Community Care Licensing until 3/17/2025. Per Title 22, section 87211(a)(3), reporting requirements, Fires or explosions which occur in or on the premises shall be reported no later than the next working day to the licensing agency. The licensee did not report to CCL the next working day. Therefore, a deficiency is being issued during today's visit. An exit interview was conducted where a copy of this report, 809D, and appeal rights were reviewed and provided to Wellness Director, Haley Logan.the state’s words, verbatim · CDSS document, Sep 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(3) · Plan of correction due date: Oct 3, 2025

(a)(3)Fires or explosions which occur in or on the premises shall be reported immediately to the local fire authority; in areas not having organized fire services, within 24 hours to the State Fire Marshal; and no later than the next working day to the licensing agency. This was not met with evidence by: Facility staff did not report fire evacuation in Building B's of the (42) forty-two residents the next working day as required. The facility submitted an incident report of the fire evacuation of Building B's for (42) forty-two residents on 3/17/2025.the state’s words, verbatim · CDSS document, Sep 17, 2025

Plan of correction: Wellness Director, Haley Logan, agreed to enroll in a training from an outside provider for all managing members regarding reporting requirement, section 87211. The POC will need all managing staff to submit proof of completion to LPA no later than close of business on 10/3/2025.

Allegation investigated: Staff mismanaging medication.

LPA Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Nicole Anguiano and explained the reason for the visit. The investigation consisted of the following: On 6/1/22 LPA George conducted an initial investigation visit. On 9/10/25 LPA Flores contacted administrator via telephone and requested a copy of staff/resident roster. On 9/12/25 LPA interviewed 6 staff over the phone. On 9/15/25 LPA Flores conducted an unrelated complaint investigaiton visit and reviewed medication for 9 residents and interviewed 9 residents. On 9/16/25 LPA delivered findings for above allegations. The investigation revealed the following: Regarding allegation: Staff are mismanaging medication. It is alleged that staff are mismanaging the residents medications. (CONTINUED ON LIC 9099C) Substantiated Interviews with residents revealed 6 out of 9 residents had no concerns regarding their medications. 3 out of 9 residents were aware the facility staff had run out of their medications a few times in the past. Interviews with staff revealed there have not been medication errors, missed medication, or mismanagement of the residents’ medications. Medication review for Resident #1-9 (R1-R9) revealed the following: 7 out of 9 residents were missing one or more of their prescribed and/or as needed medication(PRN). Missing medications were observed as follow; R1 was missing Tramadol. R2 was missing Vitamin D2, Loperamide 2mg, Milk of magnesium, Naproxen 500mg. R4 was missing Levothyroxine 50mg, Diclofenac gel, Anti-Acid and bubble pack for Oxcarbazepine 600mg was observed with the back popped/tear for 18 pills that were placed back into the pack. R6 was missing Enolose 10mg. R7 was missing Omeprazole, Acetaminophen 325mg, Milk of magnesium, Nystatin 100,000 solution. R8 was missing Acetaminophen 325mg, Docusate 100mg Loperamide 2mg, Albuterol HFA90 inhaler. R9 was missing milk of magnesium. Per wellness coordinator, they recently conducted an audit and have requested refills for the medications. LPA Flores contacted the pharmacy to verify orders were place per facility’s records dated 9/11/25 and 9/12/25. Interview with pharmacist revealed, orders have not been placed for refills for 5 residents. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted and a copy of this report, LIC 9099D, and appeal rights were provided. R1 is no longer at the facility and was not able to be interviewed. Interviews with staff revealed there have not been medication errors, missed medication, or mismanagement of the residents’ medications. Medication review of 9 residents revealed facility staff did not have some of the residents medications. However, per the review the medications available had been provided to the residents in care. 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 and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 16, 2025 · control 18-AS-20220531160519

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(6) · Plan of correction due date: Sep 17, 2025

87464 Basic Services: (f) Basic services shall at a minimum include:(6) Arrangements to meet health needs,... This requirement is not met as evidence by: Based on medication review and documents reviewed licensee did not ensure medications for R1,R2,R4,R6,R7,R8,R9 were available at the facility for the residents which poses an immediate risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: Administrator will certify in writing that will provide training to staff, will obtain all missing medication, and ensure that medication list is current by POC due date: 9/17/25. Administrator will submit a copy of training provided, and picutres of medication missing for R1,R2,R4,R6,R7,R8,R9 by 9/23/25.

Allegation investigated: Resident is being neglected

LPA Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Nicole Anguiano Office Manager and explained the reason for the visit. The investigation consisted of the following: On 11/30/22 LPA Nwogene conducted an initial investigation visit. On 9/10/25 LPA Flores contacted administrator via telephone and requested a copy of staff/resident roster and pertaining documents. On 9/12/22 LPA conducted interviews with 6 staff over the phone. On 9/15/25 LPA Flores conducted an unrelated complaint investigation visit at the facility and toured the facility and interviewed 9 residents. Regarding allegation: Resident is being neglected. It is alleged that resident #1(R1) was found on 11/28/22 not assisted with toileting needs. LPA was unable to interview R1, as R1 is no longer at the facility. Interviews with residents revealed 9 out of 9 residents stated staff provides care with toileting needs as needed. (CONTINUED ON LIC 9099C) Unsubstantiated Those residents that do not required assistance stated to have observed others around them receive assistance with toileting needs as needed. Interviews with staff revealed residents have not been found soiled in the morning or during any of the shifts. Per staff, residents are checked and cleaned at least every two hours and as needed for those that may need more frequent care. Documents reviewed revealed R1’s physician’s report dated: 9/1/22 notes R1 required assistance with toileting needs. During the tour of the facility LPA observed residents clean, no observations of residents being neglected were observed. 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 and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 16, 2025 · control 18-AS-20221128115055

Allegation investigated: Resident is being neglected while in care Resident is being left unattended in soaking wet clothing with feces for extended periods of time

LPA Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Nicole Anguiano and explained the reason for the visit. The investigation consisted of the following: On 12/21/22 LPA Arreola conducted an initial investigation visit. On 9/10/25 LPA Flores contacted administrator via telephone, requested a copy of staff/resident roster, and requested pertinent documents. On 9/12/25 LPA interviewed 6 staff over the phone. On 9/15/25 LPA Flores conducted a visit and interviewed 9 residents. On 9/16/25 LPA Flores delivered findings. Regarding allegation: Resident is being neglected while in care. It is alleged residents are being left unattended. Interviews with residents revealed 9 out of 9 residents stated staff provide residents with care and respond when they call for assistance. Residents stated to use the call light cord, phone, or walk to staff when in need of assistance. Resident #1(R1) was unable to be interviewed as R1 is no longer at the faciltiy. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews with staff revealed residents are not left without care. Staff provide assistance with showers, change of clothes, incontinence care, etc. During the facility’s tour LPA Flores observed 9 resident’s rooms had a call light cord accessible to them, which can be pull to request assistance from staff. Most residents were observed in the common area and staff were observed assisting or responding to the residents’ needs. 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: Resident is being left unattended in soaking wet clothing with feces for extended periods of time. It is alleged resident #1(R1) is being left in clothes with feces and wet. Interviews conducted with staff revealed residents have not been found in soaking clothes or feces. Per staff residents are checked at least every two hours. Those that may soil themselves more often are checked every 30 minutes and change as needed. Per documents reviewed, needs and care plan dated: 8/15/23 R1 required maximum assistance with toileting needs and was needed to be assisted with frequent or unscheduled changes. 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 and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 16, 2025 · control 18-AS-20221214131706

Allegation investigated: Staff speaks inappropriately to residents in care Staff are not answering residents call bells timely

LPA Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Nicole Anguiano Office Manager and explained the reason for the visit. The investigation consisted of the following: On 11/17/22 LPA Danielson conducted an initial investigation visit. On 9/10/25 LPA Flores contacted administrator via telephone and requested a copy of staff/resident roster. On 9/12/25 LPA Flores interviewed 6 staff over the phone. On 9/15/25 LPA Flores conducted a tour of 9 resident rooms with Bianey Sandoval Wellness Coordinator and interviewed 9 residents. Regarding allegation: Staff speaks inappropriately to residents in care. It is alleged staff members curses at the residents.Interviews conducted with residents revealed staff are respectful when communicating with the residents and do not use foul language. Unsubstantiated Interviews conducted with staff revealed 5 out of 6 staff stated they have not witnessed residents spoken inappropriately by staff. 1 out of 6 staff stated that there was a staff at the time of the allegation that made inappropriate jokes with residents. Per executive director, there are no write ups for the staff in question and or no reports for any of the staff being disrespectful. 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 are not answering residents’ call bells timely. It is alleged staff are ignoring the residents’ calls when using the call light. Interviews with residents revealed 9 out of 9 residents stated the staff respond to their call in a timely manner when using the call light. Interviews with staff revealed 6 out of 6 staff stated that when a resident uses the call light cord, a board that is visible to all staff in the dining room turns on for the room calling. Also, once the cord is pulled the staff see the light and hear the sound that turns on. Per staff, they respond to the residents' calls within 3-5 minutes. During the tour of the facility LPA tested 3 call light cords in residents' rooms which when pulled a loud sound that can be heard in the building is heard and a green light outside the residents’ room turned on. Staff responded to the call light calls within 2 minutes. LPA observed staff in each buildings. 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 Teresa Mapilis Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 15, 2025 · control 18-AS-20221109082654

Allegation investigated: Staff neglect/lack of supervision resulted in resident's death.

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Abdoulaye met with Office Manager Nicole Aguiano and explained the reason for the visit. On 12/01/2023, the Riverside Adult and Senior Care Regional Office (RO) received a complaint of an allegation of staff neglect/lack of supervision resulted in resident’s death. When Resident #1 (R1) arrived at the hospital on 08/02/2023, R1 was found to have bilateral skull fractures and brain bleeds, along with aspiration pneumonia. R1’s condition progressively worsened, and R1 died at the hospital on 08/11/2023. It was alleged the death of R1 from bilateral head bleeds was inconsistent with the single unwitnessed ground level fall that the facility reported. A review of the Unusual Incident/Injury Report submitted by the facility documented on 08/02/2023, at around 12:15pm, Staff #1 (S1) heard a stomp sound coming from R1’s room and found R1 on the floor by R1’s bed, bleeding from the back of head. R1 was unable to say how they ended up on the floor. Staff called 911 at 12:18pm, and the ambulance arrived at 12:25pm. R1 was transported to the hospital. Unsubstantiated A review of R1’s falls while residing at the facility revealed the following: on 01/21/2021, R1 reported R1 lost balance and fell back, R1 declined hospitalization; on 06/25/2021, R1 sustained a fall which resulted in a brain bleed, and R1 was admitted to a skilled nursing facility from 06/28/2021 to 07/17/2021; on 03/19/2023, during a home visit, R1 fell and sustained a split in ear, requiring stitches; and for the incident in question: on 08/02/2023, R1 was found on the bedroom floor bleeding from the back of head, and was hospitalized. Once at the hospital, R1 was found to have sustained bilateral skull fractures with bleeding in multiple areas, which required emergency surgery. R1 died in the hospital on 08/11/2023. R1’s cause of death was intercranial hemorrhage complicated by cerebral edema and acute respiratory failure. There was no autopsy performed. Information obtained from interviews with medical personnel revealed that the 08/02/2023 CT scans showed that R1’s fractures were all acute, without indication of healing in progress. R1’s injuries might be explained if R1 had fallen multiple times within a short period of time, but the facility did not report multiple falls; only a single fall was reported. R1 was confused upon AMR’s arrival and could not provide an explanation about what had taken place. A review of R1’s death certificate documented R1 died at 6:31pm on 08/11/2023. The cause of death was subdural hematoma from blunt force head trauma with pneumonia as a contributing condition. The manner of death was listed as an accident from an unwitnessed mechanical fall in R1’s facility bedroom at 12:22pm on 08/02/2023. Upon facility admission on 01/16/2021, R1 was ambulatory with a walker due to balance issues and was a known fall risk. Despite this, R1 was deemed independent with all activities of daily living and did not require special or overnight supervision. R1 sustained two documented falls before 08/02/2023 while residing at the facility. In response to R1’s 06/25/2021 fall, during which R1 was admitted to a skilled nursing facility from 06/28/2021 to 07/17/2021, the facility was unable to produce an updated service plan or reassessment indicating how R1’s fall risk would be addressed, and the facility’s Wellness Director at that time could not recall what the facility did to address it. The facility informed R1’s primary care physician (PCP) on 07/17/2021 that R1 returned to the facility with new medications, and and the PCP replied on 07/20/2021 with medication reconciliation. Similarly, following R1’s 03/19/2023 fall while on a home visit that resulted in a split ear, the facility did not provide proof of reassessment, but the facility did fax R1’s hospital discharge records to the PCP, who instructed the facility to continue with R1’s current plan of Continued 9099 C... care and directed R1 to increase fluid intake and decrease ambulation when feeling weak. An interview with the PCP revealed they had no new recommendations for R1. The PCP reported physical therapy was last ordered in 2016, and while R1’s facility falls were known, R1 was stable and was walking 2-3 miles a day at the facility. The Department’s investigation revealed that R1’s bedroom laminate flooring was in disrepair and that the facility was aware of it at least two months before the present incident. Interviews with resident and staff revealed some areas between laminate planks in the center of R1’s bedroom had lifted, and that R1 complained about it. The facility Maintenance Director acknowledged R1 had asked for the floor to be repaired, but the repair did not occur until after R1 left the facility. The official work order for the repair was not put in until 08/14/2023. While it is possible R1 tripped over the damaged laminate floor on 08/02/2023, there is insufficient evidence to prove that the floor, or the absence of reappraisals, contributed to R1’s 08/02/2023 fall. Based on the assessment made by medical personnel R1 would have sustained at least two points of impact to cause these injuries. R1’s assigned facility caregiver (S1) heard one single thump sound from R1’s bedroom on the afternoon of 08/02/2023. Another resident witnessed the fall and reported they saw R1 fall back from a standing position onto R1’s bedroom floor. The Wellness Director, the resident witness and the AMR Paramedic and EMT stated there was blood on the footboard or bedpost of R1’s bed. R1 also told a hospital staff member that their injuries were the result of a fall. Based on this information, the allegation that R1’s injuries and subsequent death were the result of something other than a ground level fall is therefore deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued to Office Manager Nicole Aguianothe state’s words, verbatim · CDSS document, Sep 11, 2025 · control 18-AS-20231201143530

Allegation investigated: Staff did not report incidents to licensing.

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted a subsequent complaint visit to deliver findings for the above noted allegation. LPA Abdoulaye was greeted and granted entrance by Office Manager Nicole Aguiano. LPA Abdoulaye Zerbo identified himself and discussed the purpose of the visit. It was alleged that staff did not report incidents to licensing. Concerns were raised that the incidents mentioned in the eviction notice were not reported to licensing and the Ombudsman. LPA conducted a records review, and the information obtained revealed that the eviction notice listed 23 incidents involving R1, but only 2 out of the 23 incidents were reported to licensing. Based on records review, the allegation that staff did not report an incident to licensing was determined to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Pursuant to the California Code of Regulations, Title 22, Division 6, Health and Safety Code, a deficiency is cited on the attached LIC 9099-D. An exit interview was conducted where this report, LIC9099D and appeal rights were discussed and provided to Office Manager Nicole Aguiano. Substantiated It was alleged that staff retaliated against resident. It was reported that a facility representative retaliated against the resident by issuing an eviction notice. The eviction notice issued on 01/23/2024 was reviewed. The notice contained all required Title 22 regulation requirements including the reason for the eviction with specific facts regarding the date, place and circumstances concerning the reason for the eviction. R1 was unavailable to be interviewed as they no longer reside at the facility. Attempts to contact R1 were not successful. Based on interviews and records review, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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 at this time. An exit interview was conducted where this report, LIC9099 was discussed and provided to Office Manager Nicole Aguianothe state’s words, verbatim · CDSS document, Sep 11, 2025 · control 18-AS-20240207131041

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 10, 2025

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case (D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on records review, Licensee only reported to the Department 2 out of 23 incidents that occurred with R1, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 11, 2025

Plan of correction: Licensee stated they will schedule training for themselves and all staff on mandated reporting requirements. Proof of training and materials used will be submitted to the Department by the POC due date

Type of visit: Case Management - Deficiencies

During the Department’s investigation of Complaint # 18-AS-20231201143530 the following deficiencies were observed: The Department’s investigation revealed that R1’s floor was lifted between laminate planks in the center of R1’s bedroom. The facility was aware of the disrepair at least two months before 08/02/2023, the day of R1’s fall, but did not repair it. There is a possibility that R1 fell and hit R1’s head as a result of tripping on this floor. R1’s Residence and Care Agreement was reviewed and states “The Maintenance Department is responsible for performing preventive, routine, and emergency maintenance throughout the Community and upkeep of the grounds.” The Americans with Disabilities Act of 1990 defines a “trip hazard” as a surface for walking with a vertical change of ¼ inch or more at any joint or crack. It does not appear that the facility completed a reappraisal of R1 following R1’s hospitalizations for falls on 06/25/2021 and 03/19/2023. Citations were issued, an exit interview was conducted and a copy of this report, the 809D and the appeal rights were provided to Office Manager Nicole Aguianothe state’s words, verbatim · CDSS document, Sep 11, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Oct 10, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above when they were aware of the disrepair of R1’s floor at least two months before 08/02/2023, but did not repair the floor, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 11, 2025

Plan of correction: During today's visit, LPA observed the floor to have been repaired.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Oct 10, 2025

87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above when they did not complete a reappraisal of R1 following R1’s hospitalizations for falls on 06/25/2021 and 03/19/2023, which posed a potential health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Sep 11, 2025

Plan of correction: The licensee will conduct training on Reappraisals requirements and provide proof of training and materials used by POC due date

Type of visit: Case Management - Incident

On 09/09/2025, Licensing Program Analyst (LPA) Javina George made an unannounced case management incident visit. LPA was greeted and granted entry by Nicole Anguiano, Business Office Manager who was informed of the purpose of the visit. Administrator, Teresa Mapilis arrived at the facility and met with LPA shortly after LPAs arrival. On 09/05/25 the department received a death report, reporting that Resident #1 (R1) passed away on 09/03/25. During the visit, LPA conducted an interview with Executive Director Mapilis, and obtained copies of pertinent records both physically as well as electronically. Per Mapilis, the official death certificate has not been issued at this time, nor has a preliminary cause of death been provided. LPA advised Executive Director to send a copy of the death certificate to the Department as soon as it is available. Additionally, there were no health or safety concerns, observed during today's visit. An exit interview was conducted, where a copy of this report, and LIC811- Confidential Names list was reviewed and provided to Teresa Mapilis, Executive Director.the state’s words, verbatim · CDSS document, Sep 9, 2025

Allegation investigated: Staff do not ensure residents are provided nutritious meals. Staff did not safeguard resident's personal belongings.

On 5/21/2025, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to deliver findings regarding the allegation listed above. LPA met with Office Manager, Nicole Anguiano who was informed of the purpose of the visit. Regarding the allegation, “Staff do not ensure residents are provided nutritious meals” it was alleged staff do not ensure Resident 1 (R1) receives a nutritious meal. LPA reviewed R1’s Identification and Emergency Information (LIC 601) dated 1/5/2024 noting R1 was admitted to the facility on 1/8/2024 and had a responsible person. LPA reviewed R1’s signed physician’s report dated 5/28/24 indicating R1 does not require a special diet and has a capacity to feed themselves. LPA reviewed the facility’s menu, which meets the Department’s general food service requirements. LPA conducted an interview with R1’s responsible person who corroborated the allegation and reported the facility frequently served a tuna sandwich or hot dog with chips for lunch. Administrator, Teresa Mapilis was interviewed and reported the following information. The facility hosts a birthday party for the residents every month and serves hot dogs, pizza, hamburgers, and sandwiches with fries or potato chips for lunch, which the residents really seem to enjoy. Unsubstantiated Fruits, vegetables, and salads are always available as side dishes during special celebrations. While residents may occasionally have hot dogs, pizza, hamburgers, or sandwiches for lunch, this should not be taken as indicative of residents’ overall nutritional intake at the facility. The facility follows their menu and serves balanced and nutritious meals unless a resident requests an alternative option. Residents with dietary requirements prescribed by their physician including gluten free, high protein, and low sodium are always accommodated to. Four (4) staff interviews conducted corroborated the information provided by Administrator Mapilis and added residents receive additional food and alternative menu options when requested. Regarding the allegation, “Staff did not safeguard resident's personal belongings” it was alleged three (3) of R1’s bracelets have gone missing while residing in the facility. LPA reviewed R1’s Client/Resident Personal Property and Valuables (LIC 621) dated 1/5/2024 stating, “At the present time I decline to track personal property. I understand that I have the right to request a new copy of this form to start tracking personal property at any time.” The LIC 621 dated 1/5/2024 appeared to be electronically signed by R1’s responsible person and Administrator Mapilis. Administrator Mapilis reported R1’s responsible person did not request a new LIC 621 to request the facility begin tracking R1’s personal property. R1’s responsible person was interviewed and was unable to recall signing the LIC 621 requesting the facility to not track R1’s property. R1’s responsible person reported R1 wore three (3) bracelets that went missing while they resided in the facility. R1’s responsible person added only one (1) of three (3) bracelets were found. LPA reviewed an incident report dated 5/29/2024 noting one (1) bracelet was found and placed on R1 in the presence of their responsible person. The incident report also notes R1’s responsible person stated they felt bad taking the jewelry because it was R1’s identity. LPA reviewed a second incident report dated 6/2/2024 noting medical personnel provided the facility with a hospital bag which included the “jewelries” inside. The incident report notes R1’s responsible person was called to pick the “jewelries” and stated they would do so at a later time. OM Anguiano reported R1’s responsible person later picked up the two (2) missing bracelets. Three (3) of four (4) staff interviewed reported having knowledge R1’s bracelets were misplaced. Three (3) of four (4) staff interviewed reported the following information. A resident’s jewelry is removed before they shower to help protect it from damage that may be caused by soap or water. Care staff providing shower assistance to the resident is responsible for placing the jewelry back on the resident immediately after the shower. One (1) of three (3) of R1’s missing bracelets was found in R1’s drawer and provided to management due to reports of it missing. The two (2) remaining bracelets were provided in a bag by paramedics when R1 returned to the facility following a hospital stay. During the initial complaint visit, LPA attempted to conduct an interview with R1 and was informed R1 was not present in the facility. R1’s responsible person reported R1 was removed from the facility sometime in 2024 and is not available for an interview. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to OM Anguiano.the state’s words, verbatim · CDSS document, May 21, 2025 · control 18-AS-20240531131008

Allegation investigated: Staff yelled at a visitor in front of residents

On 09/11/2025, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to deliver an amended version of the original report in regard to the allegation listed above. LPA met with Office Manager (OM), Nicole Anguiano who was informed of the purpose of the visit. Regarding the allegation, “Staff yelled at a visitor in front of residents” it was alleged Administrator Teresa Mapilis yelled at a visitor near OM Anguiano’s office. It was further alleged the incident occurred in the presence of approximately 20 to 25 residents and OM Anguiano. The reporting party was unable to identify the identities of any of the alleged resident witnesses. As a result, LPA attempted to conduct an interview with a random sample of the population. Five (5) residents were unqualified for an interview as LPA determined them to be unreliable historians. *This is an amended version of the original report. Unsubstantiated OM Anguiano was interviewed and reported although there was an incident due to a verbal disagreement between Administrator Mapilis and a visitor, Administrator Mapilis did not yell at the visitor. OM reported her office door was closed, and none of the residents witnessed the incident. Administrator Mapilis was interviewed and denied ever yelling at the visitor or any staff/resident in the facility. Three (3) staff were interviewed of which two (2) recalled the incident. Two (2) of three (3) staff interviewed were unable to recall if residents were present during the incident between Administrator Mapilis and the visitor. Three (3) of three (3) staff interviewed reported Administrator Mapilis has never yelled or disrespected them or any other staff/resident in the facility. 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 reviewed and provided to OM Anguiano. *This is an amended version of the original report.the state’s words, verbatim · CDSS document, May 21, 2025 · control 18-AS-20240606081652

Allegation investigated: Staff did not safeguard a resident while in care Staff did not follow appropriate reporting requirements

On May 13, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced and met with Administrator, Teresa Mapilis. LPA explained the purpose for the visit was to provide findings for the complaint investigation. On November 15, 2022, Community Care Licensing received a complaint alleging staff did not safeguard a resident while in care and staff did not follow appropriate reporting requirements. During the investigation LPA conducted interviews and record reviews. Regarding the allegation staff did not safeguard a resident while in care, it was reported on August 09,2022, family members abducted Resident from the facility and placed Resident in another assisted living facility. Information obtained from interview with Administrator denied the allegation. Additional information obtained from interview with Administrator stated Resident was removed from the facility on July 1, 2022. An exit interview was conducted and a copy of this report was provided to Administrator, Teresa Mapilis. Unfounded Administrator stated there was no incident involving Resident being removed from the facility inappropriately. Administrator indicated that the facility did safeguard Resident while in care and ensured plans of care was followed. Information obtained from interviews stated there were no issues or concerns regarding Resident’s placement. Additional information obtained from staff interviews corroborated that Resident was removed in July 2022. Interviews with additional residents indicated they have no concerns regarding their safety. Interview with witness indicated Resident was receiving the best care while residing at the facility. Witness denied that Resident was kidnapped from the facility and corroborated that Resident was removed from the facility in July 2022. Due to the death of Resident, LPA is unable to interview Resident to obtain any additional information regarding the allegations. Regarding the allegation that staff did not follow appropriate reporting requirements it was reported facility staff did not notify law enforcement of the removal of the resident because there were no issues or concerns. Administrator denied the allegation and stated Resident was not residing at the facility on the date of the reported incident; therefore, there was no need to report. Administrator stated the facility ensures all incident reports are submitted in a timely manner. LPA conducted a review of the incident reports submitted and no issues or concerns regarding reporting were observed. Based on interviews and record reviews, the allegations that staff did not safeguard a resident while in care and staff did not follow appropriate reporting requirements are deemed as unfounded due to Resident not being placed at the facility when the alleged incident occurred. An allegation finding of unfounded means the allegation was false, could not have happened and/or is without a reasonable basis.the state’s words, verbatim · CDSS document, May 13, 2025 · control 18-AS-20221115152403

Type of visit: Required - 1 Year

On May 13, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with Teresa Mapilis, Administrator. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for 100 Elderly Adults and is currently operating at a capacity of 87 Elderly Adults (740). LPA Mixson toured the facility along with Administrator, Teresa Mapilis and made observations pertaining to the annual visit. LPA inspected the facility inside and outside there were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. There were no bodies of water currently on the premises. The facility is a multi building made up of four located at 26933 Cornell Street Hemet CA. 92544. Physical Plant: The facility phone number is (951) 658-1068 and it is operable. LPA Mixson observed a sampling of the residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and the hot water temperature tested within regulations. Bathrooms were clean, and appliances were operating appropriately currently. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings; "If you See Something, Say Something,” "Personal Rights," and PUB 475. Cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. Designated storage space was observed for personal and resident files, and it was locked and inaccessible to residents in care currently. Resident files are kept electronically. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. Care & Supervision/Administration: Adequate staff are present for the care and supervision of resident in care. "Personal rights," telephone numbers, and floor plans were observed posted throughout the facility currently. The listed Administrator possesses a current administrator’s certificate with an expiration date of 12/30/2026. Records Reviewed and Resident/Staff Files: LPA reviewed a sampling of personnel files and reviewed the facility's staff schedule. Personnel files reviewed had criminal clearance and updated training along with First Aid Certification. A sample of resident files was reviewed and possessed all required paperwork. Medications: Were locked and inaccessible to residents in care, and there were sufficient medications currently for residents. Overall the facility is clean, furniture is present and clean. Facility cooling system and other appliances were operable currently. Administrator informed LPA there are safety lights for night throughout the facility. Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill met the department standards, and was conducted by the Office Manager 03/12/2025. Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures. No TA deficiencies were observed or cited per Title 22, Division 6 of the California Code of Regulations at this time. An exit interview was conducted where a copy of this report was discussed and given to Administrator, Teresa Mapilis.the state’s words, verbatim · CDSS document, May 13, 2025

Allegation investigated: Staff mismanaged resident's medication Staff restrained resident in care

On May 13, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced and met with Teresa Mapilis, Administrator. LPA explained the reason for the visit was to provide findings for the complaint investigation. On March 11, 2025, Community Care Licensing received a complaint alleging staff mismanaged resident’s medication and staff restrained resident in care. During the investigation, LPA conducted interviews, record reviews, and made observations. It was reported facility staff was giving Resident 300 mg of a medication when their physician's order stated 200mg. Additionally it was reported on March 7, 2025, a Geri chair was observed to be pushed up against Resident’s bed to deter Resident from exiting or falling out of the bed. Regarding the allegation staff mismanaged resident’s medication, it was reported facility staff was giving Resident 300 mg of a medication when Resident’s Physician's Order prescribed only 200mg. Information obtained from interview with Administrator stated Resident #1 was receiving hospice services through Hope. Administrator stated all of Resident #1’s medication was prescribed and ordered through their hospice services. It was further explained Resident’s medication was in bubble packs that were identified as morning and evening medication and it was only one pill for each distribution. Administrator did state that Resident had a previous prescription for 200 mg, but on March 8, 2025, the prescription was discontinued. Unsubstantiated Administrator stated a new prescription of 100 mg was issued and was ordered to start on March 9, 2025. It was advised that Resident #1 died on March 9, 2025. Information obtained from interviews with additional staff advised Resident’s Physician’s Order for the 200mg was 14 days and then a new prescription was initiated. Staff indicated there were no concerns advised regarding the mismanagement of Resident #1’s medication. Information obtained from interviews with additional staff indicated there was no information provided regarding R1’s medications being mismanaged. Information obtained from interviews with Hospice Nurses advised the medications were provided to the facility labeled and in bubble packs. It was confirmed Resident was prescribed 200 mg. Additional information obtained indicated when Hospice Nurses are not available, facility staff will distribute medication. Interviews with additional residents did not indicate any issues or concerns regarding medication management. A review of Resident #1’s Physician Order dated February 11, 2025 indicated Resident was prescribed 200 mg of the medication for 14 days and then a prescription of 100 mg was initiated. Medication Administration Record dated from March 1 to March 31, 2025 indicated Resident was prescribed 200 mg of the medication until March 8, 2025. No additional documentation is recorded due to Resident’s death. The last dosage of 200 mg was given on March 8, 2025. A review of additional records revealed there were no documentation of errors or missed medications. Due to the passing of Resident, LPA was unable to obtain additional information regarding the distribution of medication. LPA also attempted to interview additional witnesses regarding the allegations, but was unsuccessful in their attempts. Regarding the allegation that staff restrained resident in care. Additionally, it was reported resident was slouched in the bed with their head against bed. Information obtained from interview with Administrator denied this allegation. Administrator stated Resident #1 does require total assistance for transferring from chair to bed. Administrator stated staff are aware and trained to assist in transfer. Interviews with additional staff acknowledged Resident #1 was a total assist. It was indicated Resident #1 was on Hospice and required a hospital bed with rails. Staff denied utilizing a Geri chair to keep Resident #1 restrained. Interviews with additional residents indicated staff do not use Geri Chair to restrain residents and there are no additional concerns. LPA was unable to interview Resident #1 due to their death. Based on interviews, record reviews, and observations, the allegations that staff mismanaged resident’s medication and staff restrained resident in care may have happened or is valid, but there is not a preponderance of the evidence to prove the alleged violations did or did not occur. Therefore, the allegations have been determined unsubstantiated. An exit interview was conducted and a copy of this report was provided to Administrator, Teresa Mapilis.the state’s words, verbatim · CDSS document, May 12, 2025 · control 18-AS-20250311133731

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to re-deliver amended findings. Upon entry, LPA met with Nicole Anguiano, business office director, and informed them of the purpose of the visit. LPA delivered the amended LIC9099 and LIC9099-C along with this report.the state’s words, verbatim · CDSS document, May 8, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Seo Jeon, conducted an unannounced visit to the facility for a case management visit. The LPA was allowed entrance into the facility and met with Nicole Anguiano, Business Office Manager. The LPA informed them of the purpose for the visit. A report was received by the Department from the facility on 10-31-2024 regarding an incident between Resident #1 (R1) and Resident #2 (R2). LPA toured the facility and observed all facility utilities to be on and operating without issue. LPA did not observe any immediate health and safety concerns. LPA spoke to Anguiano about the incident report received on 10-31-2024. Anguiano informed LPA that a staff member was present during the entire incident pointing that there was enough staff coverage for residents in care. The staff member immediately redirected both R1 and R2. Anguiano informed LPA that R2 was relocated to Building A 2 weeks after the incident for safety of both residents. LPA did not observe any health and safety concerns at this time. There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22. An exit interview was conducted, a copy of this report were provided to Nicole Anguiano, business office manager.the state’s words, verbatim · CDSS document, Jan 15, 2025

Allegation investigated: Staff member physically abused resident in care.

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced subsequent visit to the facility to investigate the above allegation. LPA met with business office director, Nicole Anguiano, who was informed of the purpose of the visit. Throughout the investigation, LPA conducted a walk through, interviews and records review. The complaint alleged that staff member physically abused residents in care. On August 22, 2024, LPA and Wellness Director, Eloisa Mireles, discussed about the allegations. Eloisa stated that it was indeed one resident's aggressive act on another resident, not staff abusing residents. LPA's review of residents' files revealed both individuals were residents at this facility. Eloisa sent SOC341 and incident report as usual but did not know how the complaint was filed as staff abusing residents. Continued on LIC9099-C Unfounded Therefore, based on interviews and records review, the allegation is unfounded at this time. Allegations that are UNFOUNDED, mean that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Nicole Anguiano where this report was reviewed and provided to them. Therefore, based on interviews and records review, the allegation is unfounded at this time. Allegations that are UNFOUNDED, mean that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Nicole Anguiano where this report was reviewed and provided to them.the state’s words, verbatim · CDSS document, Oct 25, 2024 · control 18-AS-20240815102419

Allegation investigated: Due to lack of supervision, resident got into a physical altercation with another resident

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced subsequent complaint visit to the facility and met with the Business Office Director, Nicole Anguiano, informing them of the purpose of the visit. Throughout the investigation, LPA interviewed staff and residents, reviewed files, and obtained supporting documentation to aid in determining the findings of the noted allegation. On August 29, 2024, Community Care Licensing received a complaint report alleging that due to lack of supervision, a resident got into a physical altercation with another resident. During LPA’s initial 10-day visit on August 30, 2024, a review of resident files revealed both Resident #1 (R1) and Resident #2 (R2) were residents at the facility. Continued on LIC9099-C.... Unsubstantiated Per review of monthly staff schedule, LPA verified the facility had sufficient staff coverage to meet the care and supervision needs of each resident. The facility had four (4) caregivers and one (1) med/tech to 36 residents at the time of the incident. LPA conducted an interview with R1 regarding the alleged incident. During the interview, R1 recounted while they were walking through the hallway carrying their lunch plate, R2 suddenly and unexpectedly launched an aggressive attack on R1. R1 expressed surprise and confusion, noting they had no prior familiarity or interactions with R2. The commotion created by the incident drew the attention of two caregivers who were providing care to other residents nearby. The caregivers intervened and managed to re-directed R2, successfully preventing any further harm to R1. LPA also attempted to interview R2; however, R2 was unable to communicate due to their health condition. LPA reviewed supportive documentation which detailed the resident-on-resident altercation and confirmed the incident was self-reported by the facility as per regulatory requirements. A review of the staff schedule confirmed there was sufficient staffing in numbers to provide care and supervision necessary to meet residents’ needs at the time of the incident. Based on the interviews conducted, record reviews, and the verification of staff schedules, LPA determined the allegation that due to lack of supervision, a resident got into physical altercation with another resident is Unsubstantiated. A finding of Unsubstantiated means that the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report was provided. ***This is an amended version of the report created on 10-25-2024.the state’s words, verbatim · CDSS document, Oct 25, 2024 · control 18-AS-20240829145120

Allegation investigated: Staff are not showering resdients regularly Staff was rough with a resident in care Staff is rude to residents in care

Licensing Program Analysts (LPAs), Stephanie Martinez and Ferrer Sabarias, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegations. The LPAs met with Business Office Manager, Nicole Anguiano, and informed her of the purpose for the visit. The investigation included resident and staff interviews, a review of records, and collection of relevant documentation. A report was received by the Department alleging facility staff are failing to provide residents with showers that are scheduled to be provided two (2) times per week. Ten (10) interviews were conducted with residents who receive assistance to bathe; of the ten (10), three (3) residents reported showers are received regularly, five (5) residents reported being able to shower on their own or not knowing if they receive assistance to shower, and two (2) residents reported shower assistance is insufficient. One of the two (2) residents interviewed one reported they have not spoken with staff to request additional showers. Two (2) staff interviews were Unsubstantiated conducted; one staff reported there was no knowledge of residents not being showered regularly, while the second interview reported residents are not showered regularly. Rounding Logs, where showers can be documented, did not provide definitive information. Therefore, due to inconsistent information, this allegation is deemed UNSUBSTANTIATED at this time. A second report was also received alleging Staff One (S1) was rough with Resident One (R1) when the staff roughly removed the resident's sweater and roughly transferred the resident to their wheelchair. S1 was interviewed and denied the allegation. R1 was interviewed and denied the allegation. R1; however, is diagnosed with a condition which might affect their ability to recall. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. Another report was received by the Department alleging a staff member, Staff One (S1), is rude and will make inappropriate statements to residents in care. S1 was interviewed and denied the allegation. Ten (10) resident interviews were conducted; nine (9) residents denied the allegation. One resident who reported that staff are rude refused to provide additional information regarding the matter. Two (2) staff interviews were conducted; one (1) staff reported having no knowledge of staff being rude, while the other staff reported only hearing a complaint from a resident of an unknown staff member being rude to the resident. The resident identified was questioned and denied the allegation. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. This report was reviewed with Business Office Manager Anguiano and a copy was provided.the state’s words, verbatim · CDSS document, Aug 22, 2024 · control 18-AS-20240206101016

Allegation investigated: Staff verbally abuse resident Staff physically abused resident

Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to conclude the investigation into the allegation listed above. LPA met with Wellness Director Eloisa Mireles and explained the purpose of the visit. The 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 verbally abuse resident” it was reported staff was verbally aggressive to Resident One (R1). Interview with R1 reveled it was not staff who was being verbally aggressive to R1 but Resident Two (R2). Interviews with staff and residents denied staff being verbally aggressive to residents and denied witnessing staff being verbally aggressive to R1 while in care. Regarding the allegation “Staff physically abused resident” it was reported staff had grabbed R1 by the arm and pulled R1. Interview with R1 revealed it was not staff who had grabbed and pulled R1 but R2. Unfounded Interviews with staff and residents denied staff being physically abusive to residents and denied witnessing staff being physically abusive to R1 while in care. This agency has investigated the complaint alleging “Staff verbally abuse resident “ and “Staff physically abused resident”. 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, and a copy of this report was provided to Wellness Director Eloisa Mireles. Interview with two (2) out of four (4) residents revealed they were aware of a former resident who lived in building D who had allegedly stolen R1’s belongings. Interview with Resident Two (R2) reported they had their a few of their personal belongings and their tablet stolen by the former resident. Interview with five (5) out of five (5) staff revealed they were not aware of R1’s personal belongings being stolen. Interview with Staff One (S1) revealed R1 did not report to S1 they had their personal belongings stolen after their hospitalization in September 2023. Therefore due to insufficient information available, 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 did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Wellness Director Eloisa Mireles.the state’s words, verbatim · CDSS document, Aug 12, 2024 · control 18-AS-20240308165256

Type of visit: Case Management - Annual Continuation

Regional Manager, Reyna Lacey, and Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was greeted and allowed to enter the facility to conduct the inspection. On today’s visit the LPA met with Administrator, Teresa Mapilis, and Business Office Manager (BOM), Nicole Anguiano. They were notified of the purpose for the visit. PHYSICAL PLANT: The Licensee appears to be operating the facility within the conditions and limitations specified on the license. Residents appear to be protected against immediate hazards. Outdoor and indoor passageways are kept free of obstruction. No pool or body of water was observed on the property. According to the Administrator, there are no weapons kept on the property. Disinfectants, cleaning solutions, and poisons were inaccessible to residents in care. A comfortable temperature was being maintained in each building on the property. There was sufficient lighting in resident bedrooms to ensure the comfort and safety of residents. The hot water was tested in several resident bedrooms and observed to be within regulatory requirements. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. Additional equipment for physically handicapped clients is available. The smoke and carbon monoxide alarms are being monitored by alarm central and recently inspected by the county fire department. Corrections requested by the fire department were completed on 07/08/24 and 07/09/24. The interior and exterior areas of the facility were observed to be clean and safe. FOOD SERVICE: There was a variety of food which appeared to be selected and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient. Sufficient supplies for resident's dinning use was observed to be available. RECORD REVIEW: Staff files had required training; including, but not limited to, First Aid/CPR, Reporting Requirements, and Emergency and Disaster Training. Training on special health conditions was observed on file. Hospice Care Plan was observed on file for resident in care. Staff present had the required criminal record clearances. Admission Agreement, Medical Assessment (Physician's Report), Assessments, and Service Plans were observed on file for residents in care. Administrator Mapilis has an active Administrator's certificate, which expires on 12/30/2024. A fire drill was completed on 06/05/2024. The facility currently has 18 residents in care receiving hospice services; which is within their Hospice Waiver limit. The Licensee corporation is active with the California Secretary of State and proof of current Limited Liability Insurance was observed to be in place. MEDICATION: Two of four medication carts were inspected. Medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be safe, locked, and inaccessible to residents in care. No deficiencies have been cited at this time. This report was reviewed with Administrator Mapilis and a copy was provided. NOTE: LPA left the facility at 1:00 PM and returned at 1:30 PM.the state’s words, verbatim · CDSS document, Jul 12, 2024

Allegation investigated: Staff are administering medication to resident not consented by POA. Staff are not meeting resident's hygiene needs. Staff did not ensure resident used her walking device.

On June 21, 2024, Licensing Program Analyst (LPA), Venus Mixson conducted an unannounced visit and met with the Administrator, Teresa Mapilis. The visit was conducted to provide the findings for the investigation pertaining to the listed allegations. LPA interviewed staff, residents, and witness and conducted record reviews. LPA was unable to interview Resident Number 1 (R1) due to Resident refusing to speak with department staff. On January 17, 2024, Community Care Licensing (CCL) received a complaint that Staff are administering medication to resident not consented by POA, Staff are not meeting resident's hygiene needs, and Staff did not ensure resident used their walking device. Regarding the allegation of Staff are not meeting resident's hygiene needs, it was reported that R1 was brought into the doctor’s office and was observed to be dirty, smelled like urine. On another occasion it was reported that R1's diaper was observed to be on the outside of their clothes, R1's skin was dry and cracked and R1's was reported to have dirt on their face. Information obtained from interviews stated the facility staff are instructed to give R1 reminders and to assist R1, but at no time are the staff to force R1 to practice the daily hygiene. A review of documentation indicated that R1 refuses to participate in hygiene practices regularly. Regarding the allegation of Staff are administering medication to resident not consented by POA, it was reported that Staff are administering medication to resident not consented by POA. CONTINUED ON LIC 9099-C Unsubstantiated CONTINUED FROM 9099 It was advised that the primary care doctor prescribed R1 two specific medications. Information obtained from interviews with facility staff stated staff follow R1's plan of care, service plan as well as the Physicians orders. The records review indicated that there were no medications being administered to R1 that were not prescribed by the attending doctor. Regarding the allegation of Staff did not ensure resident used their walking device, it was reported that R1 was taken to the doctors without their walking device. Information obtained from interview with the Administrator and facility staff advised that R1 is supposed to use their walker when ambulating. It was stated that there was an incident where R1 was transported to see their primary doctor and R1 was trying to hit Staff Member with their walker. Staff Member was able to calm R1 down and properly use their walker to assist with ambulating. Upon arrival to the doctor’s office, R1 refused to use the walker. The driver, which was also a staff member, escorted R1 into the doctor’s office. Information obtained from additional witness stated that R1's walker was present and available for use. Based on interviews, reviews of the documents, observations, and the inability to interview R1, the allegations of Staff are administering medication to resident not consented by POA, Staff are not meeting resident's hygiene needs, and Staff did not ensure resident used a walking device have been deemed "Unsubstantiated." An allegation finding of "unsubstantiated" means although the allegations may have happened or are valid, there is not a preponderance of evidence strand to prove the alleged violation(s), did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted, a copy of this report, along with the appeal rights were provided to the Administrator, Teresa Mapilis.the state’s words, verbatim · CDSS document, Jun 21, 2024 · control 18-AS-20240117092257

Allegation investigated: Illegal eviction

Licensing Program Analyst (LPA), Yolanda Delgado made an unannounced visit to the facility to investigate a complaint regarding the allegation listed above. LPA met with Administrator, Teresa Mapilis and explained the purpose of the visit and the elements of the allegation. LPA Delgado conducted the investigation which consisted of interview with staff member and record review. On May 14, 2024, Community Care Licensing received a complaint stating illegal eviction. The allegation stated that the facility wrongfully evicted Resident #1 (R1), facility accused R1 of incorrect information, R1 threatened and harassed the other residents, R1 received a 30-day written notice. During the LPA’s investigation, LPA attempted 3 times to contact R1 with no return calls received. (Continued on Page 2) Unfounded (Continued from Page 1) LPA reviewed R1’s face sheet, LIC602, Needs and Services plan, admission packet, assessment forms, progress notes, documentation of incidents that involved R1’s behavior with Administrator, staff and residents on separate dates from February 4, 2023 through January 4, 2024 with physical and verbal abuse towards other residents and staff. During the LPA’s interview with Administrator, it was concluded that Administrator hand delivered and mailed the eviction notice with a 30-Day notice along with several resources to help find alternate housing. Based on LPAs observations, records review, and staff interview, this agency has investigated the complaint alleging “illegal eviction” 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, and a copy of this report, LIC811 was provided to facility representative. *LPA was away from the facility from 12:25-1:25PMthe state’s words, verbatim · CDSS document, May 22, 2024 · control 18-AS-20240514110222

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility staff with LPA identification and business card. LPA was able to complete one (1) domain, due to time constraint, LPA will need to return to complete the Annual Inspection. LPA allocated time to prepare this report for delivery. Based on the information received during this visit today, there are no deficiency that is being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with and a copy provided to the facility representative at the time of the exit interview.the state’s words, verbatim · CDSS document, May 22, 2024

Allegation investigated: Staff did not notify responsible party of change of resident's health condition.

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Administrator, Teresa Mapilis, and informed her of the purpose for her visit. A report was received by the Department alleging the facility did not notify family members of residents currently experiencing rashes. On this visit the LPA conducted staff and resident interviews, reviewed records and obtained copies of pertinent documentation. Nine resident interviews were conducted; of the nine, four residents reported they currently had a rash on their body. According to Administrator, Teresa Mapilis, there about seven residents in building B who currently have a rash. One third party interview revealed the responsible party of Resident One (R1) was not notified of the resident's rash. An interview with Administrator Mapilis revealed the responsible party of R1 was not notified by the facility due to the resident receiving services from a hospice agency. Administrator Mapilis reported the hospice agency would have reached out to R1's responsible party to notify them of the health condition. Therefore, based on interviews, this allegation Substantiated is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. This violation poses a potential threat to the health, safety, and personal rights of residents in care. A citation will be issued. An exit interview was conducted with Business Office Manager (BOM), Nicole Anguiano. This report was reviewed, and a copy was provided, along with the LIC 811, and instructions on appeal rights.the state’s words, verbatim · CDSS document, Apr 22, 2024 · control 18-AS-20240417082812

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Apr 29, 2024

Personal Rights of Residents in All Facilities: (a) Residents in all RCFEs shall have all of the following...rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services...This requirement was not met, as evidenced by: Based on interviews, the licensee did not ensure R1's right to have their representative informed of activities related to care was met. Admin. revealed the responsible party of R1 wasn't notified due to R1 receiving services from a hospice agency, who would have reached out to the responsible party for notification.the state’s words, verbatim · CDSS document, Apr 22, 2024

Plan of correction: The Administrator stated in-service training will be provided to staff regarding notifying family members of hospice residents of any health changes.

Allegation investigated: Staff did not ensure facility is kept free of bed bugs.

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Administrator, Teresa Mapilis, and informed her of the purpose for her visit. A report was received by the Department alleging there are residents in care who have rashes, all over their bodies, which appear to be bed bug bites for which the facility has not provided treatment. On this visit the LPA conducted staff and resident interviews, reviewed records and obtained copies of pertinent documentation. Nine resident interviews were conducted; of the nine, four residents reported they currently had a rash on their body. One of the four residents reported the facility is treating the rash; another resident reported the facility was not treating the rash; and the remaining two residents could not provide any information on whether their rash was being treated. According to Administrator, Teresa Mapilis, there are about seven residents in building B who currently have a rash. She reported there is only one resident, Resident Two (R2) who has been Unfounded diagnosed with an infectious condition. According to the Administrator, infection control policies are being followed for R2, including environmental cleaning and frequent showers. Staff interviews confirmed environmental cleaning and frequent showers are being completed. Documentation, including medical records and discharge paperwork, revealed the remaining residents have not been diagnosed with the contagious disease and are currently receiving treatment for the rash they were diagnosed with. Additionally, an Attendance Log revealed care staff were provided with training relating to skin issues on 04/18/2024. No information was received to indicate there is a bed bug infestation at the facility. Therefore, based on interviews and records, this allegation is deemed UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Business Office Manager (BOM), Nicole Anguiano. This report was reviewed, and a copy was provided, along with the LIC 811.the state’s words, verbatim · CDSS document, Apr 22, 2024 · control 18-AS-20240417082812

Allegation investigated: Resident was physically assaulted by another resident which resulted in injuries due to lack of supervision.

Licensing Program Analyst (LPA), Jacqueline Shaw Ross made an unannounced visit to deliver findings for the allegations noted above. LPA met with Nicole Anguiano, Business Office Manager, and explained the purpose of the visit and the elements of the allegations. The investigation consisted of observations, interviews, and records review. On 1/5/2024, Community Care Licensing received an allegation that a resident was physically assaulted by another resident that resulted in injuries. It was reported that R2 became agitated with R1 over a comment that was made by R1. R2 began yelling at R1 and grabbed R1's left arm, leaving a bruise. R1 called the police, and police arrived however no charges were filed. LPA interviewed staff who corroborated that the incident did occur. The assault was witnessed by a newly hired staff member who was taking a video training course. LPA interviewed R1 who stated there was concern there was not enough supervision which led to the assault. Substantiated Staff indicated no other staff were around during the assault except for the newly hired staff member. LPA interviewed R2 but was unable to finish the interview due to R2 became verbally aggressive to LPA. LPA reviewed documents pertinent to the investigation that included facility incident reports, client records and photos of the injury. Based on LPA’s observations, interviews conducted, and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. An exit interview was conducted and a copy of this report was provided along with Appeal Rights. Based on LPA’s observation, interview(s) conducted and record review(s), the preponderance of evidence shows that the allegations 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. An exit interview was conducted, a copy of this report, appeal rights was provided to Nicole Anguiano, Business Office Manager.the state’s words, verbatim · CDSS document, Feb 23, 2024 · control 18-AS-20240105081727

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(A) · Plan of correction due date: Mar 22, 2024

87411 Personnel Requirements- General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not ensure facility personnel to be sufficient in numbers and competent to provide the services necessary to meet resident needs.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: Facility agrees to revisit the schedule for the assisted living building that may include increasing more staff or have more frequent checks to ensure there is consistent supervision, as well as provide additional training on supervision and safety of residents. Facility will provide training log and revised staffing schedule to the Department by POC date of 3/22/2024.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived unannounced to the facility to conduct additional interviews with witnesses regarding complaint 18-AS-20240105081727. LPA was granted entry into the facility and met with Executive Director Teresa Mapilis. LPA explained the purpose of the visit. LPA was informed that the additional staff witness was scheduled to begin work at 2:00pm but called out due to a family emergency. LPA conducted an interview with Executive Director and documented the information on a LIC 812. No additional interviews were conducted. A copy of this document was provided to Executive Director Teresa Mapilis.the state’s words, verbatim · CDSS document, Jan 9, 2024