La Vida Real.

Licensing Program Analyst (LPA) Jose De La Cruz conducted an unannounced collateral visit to interview a resident in regards to an unrelated ongoing complaint investigation with another licensed facility. LPA gained access to the facility, identified himself, and met with Executive Director Kimberly Garcia to discuss purpose of today's visit. LPA's visit consisted on a safety check and interviewing resident. There were no deficiencies observed during today's visit. An exit interview was conducted with Executive Director Kimberly Garcia and a copy of this report along with Licensee/Appeal Rights (LIC9058) was provided to Executive Director Kimberly Garcia whose signature below confirms receipt of these rights.

It was also alleged that R1 was not being bathed or taken to dining room for lunch. Records collected revealed R1 was being taken to the dining room and provided some meals in room as requested by the resident. Interview with outside source could not confirm that R1 was not provided meals throughout the day. Interview with another outside source revealed that there was no evidence of no bathing such as body other. Lastly, it was alleged that R1 had a change in skin condition and it was not reported to responsible party. Records collected showed that as of April of 2022, R1’s responsible party and medical provider were notified of edema to the lower extremities. Records also show that the party responsible was present on July 6, 2022, when staff found four edemas to both lower extremities and R1 was treated with antibiotics later that day. Interview with outside source did not reveal any information that facility was not reporting changes to R1 with the party responsible. Based on interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058) were provided.

Facility surveillance reviewed revealed that at 6:49am on December 17, 2025, R1’s bedroom door was open and at 6:59am, R1 walked through going towards the common area without a walking aid and fell. At 7:01am, staff arrived to assist resident and assess. Interview with Executive Director revealed that R1 was sent out for a medical evaluation. Interview with outside source, established that they have no concern with the care R1 was and is currently receiving at the facility. Based on records and interviews there is not a preponderance of evidence to prove alleged violation occurred, therefore th e allegation is unsubstantiated. An exit interview was conducted with Executive Director, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. LPA conducted the visit with Executive Director, Kimberly Garcia and Business Office Manager, Kristin Molina. LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured between 106-118 degrees F.. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. The facility's pool is located in the Independent Living portion of the facility and locked. There is a water fountain in the main front courtyard, which was empty and did not contain water. Per the Executive Director, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. The reviewed files contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Executive Director, Kimberly Garcia to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

R1 resides in the Assisted Living portion of the facility. R1 was alert and oriented when interviewed and ambulating well without assistance. R1 explained they were independent with their activities of daily living but required standby assistance with showers and medication management. R1 explained they do not like to drink water. R1 will drink iced tea from the dining room and fill their cup up and bring it back to their apartment. R1 explained that their family member attached a cup holder to R1’s walker and provided flavored packets for water. However, R1 doesn’t want to drink water. R1 explained they have the right to drink water/fluids when they feel like it. Staff interviewed confirmed they witness R1 drinking fluids but aware R1 doesn’t like water. It was also alleged staff speak inappropriately to residents. It was reported Staff #1 (S1) was rude to R1 by commenting “where do you think you're going!" when R1 was taking their dog for a walk. S2 denied speaking inappropriately to R1 and explained they look out for R1 and their small dog. Additional interviews with staff and outside source’s confirmed they have not witnessed S1 speaking inappropriately R1 or residents. It was also alleged that staff did not ensure resident's room is clean and sanitary. It was reported R1’s trash is not being emptied. Staff interviews identified the trash is removed/emptied each shift. Outside source interview indicated the trash will sit in R1’s room from Wednesday thru Saturday and emits odors. R1’s interview indicated the trash is removed/emptied daily. However, the trash is not emptied every shift on the weekends, but it will be emptied at some point during the weekend. Lastly, it was alleged that staff did not provide notice of planned activities. It was reported that the monthly calendar was not printed and made available for individuals. An outside source reported it occurred in October 2025, and the facility only provided the weekly calendars. LPA observed the monthly calendars are on the facility televised showing throughout the day, as well as posted in some common areas. The Executive Director explained there was a mix up and the calendars were not delivered. Therefore, they provided many more options available for residents and visitors review. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Kimberly Garcia whose signature below confirms receipt of these rights.

It was also alleged that prior to the phone call mentioned above, R1 was visited in their room on two separate occasions by an unknown person and was asked for medical insurance documentation, making R1 feel like their privacy was violated. According to records collected, the unknown person was an employee of an outside source medical agency who was hired by the facility to provide rehabilitation services. Interview with outside source confirmed that outside source medical agency was only attempting to collect health insurance information to provide R1 with additional services. Based on interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Business Office Manager Kristin Molina, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced case management visit. LPA introduced herself and discussed the purpose of the visit with Executive Director Kimberly Garcia. On today's date, LPA Strong delivered an Immediate Exclusion letter for Staff 1. Executive Director states she understands. No deficiencies were cited on today's visit. An exit interview was conducted with Executive Director Kimberly Garcia to whom a copy of this report, LIC809-D and Licensee Appeal Rights (LIC 9058) were provided to.

According to records collected, R1 and R2 are a married couple. Interviews revealed that R2 reported the incident to staff who separated R1 and R2. Interview with an outside source confirmed that R1 and R2 were separated and put in different rooms after the incident. Interview with Executive Director revealed that responsible parties were not agreeable with the residents being separated. R1 and R2 were then returned to same bedroom and were later moved out of the facility by responsible parties. According to interviews with outside source, R1 did not have any history of aggressive behaviors. Based on interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Interview with S2 corroborated that S2 did have a discussion with S1 in the facility lobby regarding work shifts and incidents S2 had reported to management that had occurred at the facility. Also, interview with staff present established there were no other people in the lobby other than S1 and S2. Based on observations and interviews, S1 and S2 had the discussion in the unlicensed portion of the facility and the possible tenants present were from the independent living portion of the facility. It was also alleged that Staff 3 (S3) did not treat residents with dignity and respect as S3 made joking statements about resident’s incontinence needs, washed resident’s faces with cold water and rushed resident during care. During interview, S3 denied such allegations. Interview established that S3 was communicating resident needs to staff that were in training and incontinence information specific to a resident was necessary to provide proper care. S3 also stated that on one date, S3 could not get hot water to come out of one resident sink and wet a small corner of a washcloth into the water and used it to clean resident’s eyes. S3 states they did not wash the residents whole face with this water. S3 states that they do not rush residents during care. S3 revealed that residents in Memory Care require additional time and though S3 does not rush residents some residents do require prompting. Interview with other staff present on the date of the incident could not confirm that S3 made any of the statements or actions against residents. Interview with an outside source could not confirm that the alleged incidents occurred. B ased on multiple interviews and record reviews there is not a preponderance of evidence to prove alleged violations occurred , therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Kimberly Garcia to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Kimberly Garcia. According to the facility’s license, the facility has a maximum capacity of 177 non-ambulatory residents, of which 30 may be bedridden. The facility has an section of unlicensed independent living buildings on the west side of the property. LPA toured the interior and exterior of the facility and inspected seven rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Water temperature in residents rooms were measured all between 105 degrees F and 118 degrees F. Water temperature in common bathroom measured 115 degrees F. LPA toured and observed the commercial kitchen and walk-in freezer/refrigerator. Cooking/dining equipment and utensils were present. There was sufficient perishable food and at least two weeks worth of non-perishable food. LPA observed the medication room and first aids were complete and readily accessible. Medications were labeled, as required, and stored in locked medication carts. Resident records contained the required documentation. Staff records contained the required documentation. No pools or bodies of water on the licensed portion of the facility. Per Executive Director, no firearms or ammunition are kept at the facility. Fire extinguishers were readily accessible on each floor. No deficiencies were cited on todays visit. An exit interview was conducted with Executive Director Kimberly Garcia, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to during the visit.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced case management visit to follow-up on incidents reported to Community Care Licensing. LPA introduced herself and discussed the purpose of the visit with Assisted Living Director Yvonne Harmon . On September 30, 2024, Community Care Licensing received two self reported SOC341-Report of Suspected Dependent Adult/Elder Abuse forms in regards to two separate incidents involving Staff 1 (S1), Resident 1 (R1) and Resident 2 (R2). [Assisted Living Director was provided with an LIC811 Confidential Names list to identify individuals]. During today's visit, LPA conducted a health and safety check and collected records. An exit interview was conducted with Assisted Living Director Yvonne Harmon to whom a copy of this report and Licensee Appeal Rights (LIC 9058) were provided to.

Outside source also revealed that R1 does have redness on back side but not enough to be considered a pressure injury. Interview with additional outside source did not reveal any information to corroborate that R1 neglect by facility staff has resulted in pressure injury. It was also alleged that R1 neglect has resulted in multiple R1 falls. Records collected revealed that R1 does have a fall risk. Interview with staff revealed R1 tends to move self-off of bed and onto the floor but does not fall. Records also revealed that R1 is checked-on multiple time throughout the day. Interview with outside medical source also corroborated that R1 tends to have episodes of agitations and puts themselves on the floor. Records and interviews did not reveal R1 has sustained any injuries from these incidents. Lastly, it was alleged that R1 has been fearful of staff not providing meals to R1. Interview with staff revealed R1 receives three meals per day. Interview with outside source established that outside source has not been informed of R1 not receiving meals. Records reviewed revealed that R1 has received multiple meals on today’s visit, May 29, 2024. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

According to allegation, on February 6, 2024, R1 was observed to have a large bruise on the front left side of head and well as bruises/scrapes on hands and arms. Interview with Director of Assisted Living revealed R1 had an unwitnessed fall on February 6, 2024. Interview established that R1 received first aid from Licensed Vocational Nurse and was taken to the emergency room, on the same day, when bruise developed on left side of face and head. Records collected revealed that R1 moved into facility with multiple bruises on arms. Interview with staff present on February 6, 2024, corroborated that R1 had an unwitnessed fall and was assessed for injuries. Interview with outside source did not reveal any information to corroborate neglect resulted in injuries. Finally, records collected established R1 was diagnosed with hypoglycemia on the date of the incident. Based on Department’s interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director David Armour, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Plan Of Correction (POC) visit. The LPA introduced herself, and disclosed the purpose of the visit to Executive Director David Amour . During the visit, the LPA collected records, cleared POCs, and provided the administrator the Plan of Correction letter. An exit interview was conducted with Executive Director David Armour, to whom a copy of this report, and Applicant/Licensee Rights (LIC 9058), were provided.

[CONTINUED FROM LIC 9099] According to R1’s prescribed medication orders: During the time-frame of the complaint, R1’s had only one medication which was in suppository form. R1’s doctor determined that this suppository could be given “rectally every day as needed for constipation, not to exceed one dose per 24 hours.” The prescription limited only the maximum amount to be given in a day; it did not specify a maximum number of days R1 could go without a bowel movement (BM) before the suppository was required to be given. According to the facility’s Medication Administrator Records (MARs): During April 2021, R1 was given the suppository once on 04/05/2021 (resulting in a medium BM), and once on 04/24/2021 (resulting in a large BM). During May 2021, R1 was given the suppository once on 05/04/2021 (resulting in a large BM), and once on 05/16/2021 (resulting in an extra-large BM). According to the facility’s Bowel Movement Logs: During April 2021, R1 had a total of 28 BMs, of which 23 BMs occurred on days when no suppository was given. On the two days when the suppository was given, R1 had not had a BM during the preceding four days. On all other days in April 2021, R1 had at least one BM every two days. During May 2021, R1 had a total of 24 BMs, of which 20 BMs occurred on days when no suppository was given. On the first day the suppository was given, R1 had not had a BM in the preceding three days. On the second day the suppository was given, R1 had not had a BM in the preceding two days. On all other days in May 2021, R1 had at least one BM every day, or every other day. According to R1’s LIC602 Physician’s Report (dated 10/15/2020): R1 was diagnosed with Alzheimer’s Disease. R1’s hospice agency records and facility care records corroborated this. Due to their baseline memory loss, R1 was unable to be a reliable historian/interviewee for this investigation. Based on record reviewed and interviews, a preponderance of evidence does not exist to prove that licensee did not give R1’s suppository as it was prescribed and needed by R1. The allegation is therefore unsubstantiated. An exit interview was conducted with Armour, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Or about January 8th, 2022, Witness 1 (W1) noted that there was an injury to R1’s left index finger. R1 reported to W1 that they ran their wheelchair into a wall crushing their finger. W1 asked Staff Member 1 (S1) to check R1’s hand. S1, who is a Licensed Vocational Nurse, recalled noticing some light bruising on R1’s hand about 5:00 PM. S1 moved the hand lightly and R1 did not report any pain. S1 did not document their assessment or elevate any concerns regarding R1. S1 reported that R1 slept through to 11:00PM, the end of S1’s shift, without complaint of pain, even when receiving care. On or about January 9th, 2022, W1 noticed an injury to R1’s right hand. On January 10th Staff Member 2 (S2) was getting R1 up for breakfast and noticed the bruising on R1’s hands and R1 was complaining of pain. Witness 2 (W2) came to the room already aware that R1 had injured hands. W2 transported R1 to the hospital about 10:30 AM. At about 5:30 PM R1 returned to the facility with a soft cast and a diagnosis of a metacarpal fracture to the right ring finger. The physician that treated R1’s hand injuries did not report any suspicion of physical abuse. During the course of the investigation, it was revealed that R1 reported multiple and incompatible explanations for their injured hands. The investigation included interviews with staff members who provide care for R1 and all report training and practices that would protect R1 from injuries, specifically to R1’s hands. It is unclear how R1 sustained the injuries. It was further alleged that the call button was not assessable to R1. Based on observation and interviews, there are always three call buttons in R1’s room. One in the bathroom, one in the living room and a portable call button in a box, generally kept on a table. R1 became agitated when the box with the call button was moved to a location, thought to be more accessible to R1. The call button was returned to the table per R1’s preference. There is insufficient evidence to conclude that R1 did not have access to a call button. Based on inconsistent statements, and the lack of evidence or witnesses to corroborate or support the allegations, the findings are unsubstantiated. An exit interview was conducted and a copy of this report, and appeal rights were given to Administrator, David Armour.

(Continued from LIC9099) Records review confirmed that the outside contractor came to the facility on 10/4/2023, upgraded and tested the system, with no issues noted. LPA directly observed and tested the call button system, revealing it to be in working order with no errors or glitches. Resident interview revealed that while residents sometimes observed a delay in the response time from staff, the call system worked correctly. Outside source interviews did not corroborate the allegation, informing that no disrepair issues have been observed with the call button system. Regarding the allegation, "Staff did not meet resident(s) incontinence needs", it was alleged that staff did not assist residents with incontinence care in a timely manner. Staff interviews did not corroborate the allegation, revealing that staff checked residents every 1-2 hours, per protocol, and as needed depending on condition and requests for assistance. Resident interviews were inconsistent; some residents stated they waited too long for help, while other residents stated they receive toileting assistance timely, when requested. Outside source interviews did not corroborate the allegation, and did not express concern regarding the time in which residents wait for incontinence assistance. Records review did not give evidence to support the allegation. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director David Armour, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Continuation from LIC9099 Interview with staff also revealed that caregivers have assisted residents after falls after conducting a basic assessment themselves. Interview with outside source did not reveal any information to corroborate facility is not assessing residents after falls. It was also alleged that Resident 1 (R1) had hazardous nightstand in their room, causing them injury. Interview with R1 revealed that R1 had a fall and hit head on nightstand causing a cut on the forehead. LPA Strong observed a standard wooden nightstand with pointed corners. Interview with outside source revealed that the furniture piece was not hazardous, rather R1 fell and in doing so hit the nightstand. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director David Armour, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Other visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Human Resources Coordinator Tasha Smith. During today’s visit, LPA briefly toured the facility, interviewed staff, and reviewed written correspondence and personnel records. LPA also reviewed with licensee a signed/executed CDSS Decision and Order (D&O), which excluded Staff #1 (S1) from employment at the facility. [See LIC811 Confidential Names List for a description of S1.] Manager interview, corroborated by personnel records, showed: From 05/05/2023 through 09/09/2023, Licensee allowed S1 to work as a full-time employee of the facility, despite Licensee not receiving positive written confirmation from CCLD showing that S1 had received criminal record clearance. Licensee subsequently realized that S1 was not background-cleared, nor eligible for a criminal record exemption. Starting 09/09/2023, Licensee removed S1 from contact with residents. On 09/19/2023, Licensee administratively terminated S1’s employment. A preponderance of evidence exists to show that for a period of time, Licensee allowed S1 to work at the facility without either a California criminal record clearance or a criminal record exemption. One (1) deficiency was thus cited per California Code of Regulations, Title 22. An immediate civil penalty of $500 was assessed today for a Criminal Record Clearance violation (see attached LIC 421-BG). An exit interview was conducted with Smith, to whom a copy of this report, the LIC809-D, the LIC421-BG, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.