Carmel Village Retirement Community.

On April 29, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced, for the purpose of conducting a Plan of Correction - Deficiencies inspection. This is a follow up to a deficiency issued during the annual inspection conducted on April 23, 2026. During today’s visit, LPA was greeted and granted entry after explaining the purpose of the visit to Executive Director (ED) Mandy Taylor. LPA conducted a tour of the facility with ED, and observed all delayed egress devices on exterior doors and perimeter fence gates were operational with all alarms working properly. The kitchen was observed with a sufficient amount of perishable and non-perishable food items. There was no sign of gnats in the main kitchen, dining room, and common areas observed during the tour. Based on observations, deficiencies are being cleared. An exit interview was conducted with Executive Director Mandy Taylor, and a copy of this report including the Letters of Deficiency Citations Cleared were provided at the end of the visit.

The investigation revealed the following: Regarding the allegation, Licensee did not properly address the infestation in the facility, it was alleged that Resident #1 (R1) was experiencing bites on his back and arms from an unidentified type of bug in his room. LPA toured the facility during the initial inspection visit conducted on October 31, 2025, and no immediate health and safety threats were identified. LPA did not observe any bugs in R1’s room and R1 confirmed no bites were visible at the time. A record review revealed R1 reported bugs in their room on September 29, 2025 and staff responded to the room on the same date. Staff #1 (S1) stated the room was inspected but no bugs were found. S1 stated R1 showed them zip lock bags of what R1 indicated were bugs, however S1 stated they were actually earwax and lint. Pictures were taken and provided. LPA interviewed R1 who reported the facility fumigated the room and the bugs were gone but returned shortly after. Resident stated they collected a bug in a zip lock bag and then stated it was later disposed of, therefore LPA was unable to observe the reported evidence. On September 30, 2025, R1 submitted a second request for service and a record review of a Pest Flex vendor invoice revealed the room was fumigated on October 4, 2025. Regarding the allegation, Staff did not communicate with resident’s representative in a timely manner, it is alleged that the facility did not respond to calls made to the resident’s representative regarding bugs and bites until two weeks after initial contact attempts. During an interview with Witness #1 (W1), it was reported that calls were made to staff and not immediately returned, however no evidence was provided during the investigation. Four out of four staff denied the allegation, stating call requests are returned in a timely manner and a record of all maintenance service requests are documented via LifeLoop software. Regarding the allegation, Staff did not safeguard residents’ personal belongings, it is alleged that resident’s shirts went missing during the first year of their residency and have not been returned. Four out of four staff interviewed and one witness denied the allegation, stating the resident’s laundry is done off site by family and returned weekly. This was corroborated during an interview with R1 and Witness #2 (W2). A record review of R1's Resident Property & Valuables form revealed the document was blank with no items listed and no evidence of missing items was provided during the investigation. Based on the observations made, interviews which were conducted, and the records that were reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are deemed UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided at exit.

LPA reviewed medication orders for R1. LPA observed orders for four different eye drops but was unable to review medication administration records. Due to the age of the complaint, facility was unable to access the resident's records in the electronic administration record. LPA attempted to interview staff employed during time of complaint but no staff were able to remember R1. Based on interviews conducted and record review, the allegations are found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is 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.

W1 states that all prescribed medications were administered to the resident. W1 does not recall specific medications due to the age of the complaint but denies facility wouldn't administer non-prescribed medication. Facility staff confirm physician orders are followed. LPA did not observe an order for Vitamin B on the resident's medication orders. Regarding the allegation that facility failed to provide supervision to resident resulting in resident pulling catheter out, the investigation revealed the following: Responsible Party and W1 confirm resident had a sitter at the facility as well as staff checking in every 2 hours. Once it was observed that the resident had pulled out the catheter, medical attention was sought immediately. The resident did not return to the facility after being sent out on this occasion due to declining health. Two out of two staff confirm residents on care are checked every 2 hours. Regarding the allegation that facility failed to properly store resident's medication, the investigation revealed the following: W1 states medications are delivered to the medication room and not to a resident's room. W1 does not recall an incident where insulin was observed to be in the resident's room especially since the resident was on med management. Two out of two staff confirm medications are not delivered to resident rooms. Regarding the allegation that facility staff failed to report resident's true condition to responsible party, the investigation revealed the following: W1 confirms sending condolences to the resident's family being inadvertently informed that the resident had passed. The hospital had mistakenly notified about the passing of the resident as the resident had not passed. The family was understandably upset but the notification came from the hospital and not the facility. W1 stated following what had been told to the witness. Due to the age of the complaint, LPA is unable to review parts of the resident's electronic medical record and staff interviewed do not remember the resident. Based on interviews conducted, the allegations are found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is 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.

Documents reviewed include the Carmel Village Retirement Community Service Plan dated January 8, 2025, for R1. Per Service Plan, it states R1 requires one person total assistance by staff members for all mobility/ambulation needs. During the interviews with residents, R2 reported that staff are helpful and attentive and stated that staff will respond quickly when he uses his call button. Per R2, staff work around the clock and reported that staff are meeting his needs. During the interviews with staff, Staff 1 (S1) reported that staff ensure the health and safety of the residents in Memory Care. S2 stated that staff are attentive and reported that the fall was not due to neglect. Per S3, staff do their best to ensure the health and safety of the residents in Memory Care. During the interviews, Witness 1 (W1) reported that she could not say if the fall was due to lack of care and supervision. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with ED Taylor, and a copy of this report was provided to the facility.

Based on interviews conducted, the allegations are found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is 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.

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint visits 22-AS-20220810143732, 22-AS-20221018074030, 22-AS-20221025101527, 22-AS-20230106135453, and 22-AS-20230112082829. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the visit, LPA requested documents from staff. Documents were unavailable during the visit. Please forward the following requested documents by close of business Wednesday March 18, 2026: Any documents pertaining to missing/ stolen items for Resident 1 and physician report. Physician report, pre-appraisal, care plan and any progress notes for 2022 for Resident 2. Physician report, pre-appraisal, care plan/ hospice notes and any progress notes for 2022 for Resident 3 Physician report, pre-appraisal, care plan and any progress notes for 2022 for Resident 4 Admission agreement for Resident 5. Exit interview conducted and a coy of this report was left at the facility.

However, ten out of the eleven residents interviewed denied the allegation and stated that they have not been treated roughly by any staff at the facility. LPA conducted six staff interviews. Three out of the six staff interviewed corroborated the allegation and stated that residents have complained to them about being treated roughly by S1. However, three out of the six staff interviewed denied the allegation and stated that they have not observed, or heard of any resident being treated roughly by staff. Due to conflicting information received during the investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Journey Care Director Rosa Avila and Resident Care Coordinator Ruby Molina. A copy of the report was provided.

On December 18, 2025, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for the purpose of conducting a case management health and safety check. The visit is a follow up to an Incident Report received by Orange County Regional Office on November 19, 2025. LPA introduced self to Executive Director (ED) Mandy Taylor, explained the reason for the visit, and was granted entry into the facility. LPA obtained copies of Resident/Staff Roster, Staff Schedules, and the following records for R1: Emergency Contact Info Sheet, Physician’s Report and Orders, Service Plans, Progress Notes, and Hospice records. During the inspection, LPA toured the facility with staff and observed no imminent health and safety issues. An exit interview was conducted with Executive Director Mandy Taylor, and a copy of this report was provided at exit.

On December 18, 2025, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for the purpose of conducting a case management health and safety check. The visit is a follow up to an SOC341 and Incident Report received by Orange County Regional Office on December 15, 2025. LPA introduced self to Executive Director (ED) Mandy Taylor, explained the reason for the visit, and was granted entry into the facility. LPA obtained copies of Resident/Staff Roster, Staff Schedules, and the following records for R1: Emergency Contact Info Sheet, Physician’s Report, Service Plans, Progress notes, and Hospital After Care Summary dated December 7, 2025. LPA also received written statements of four staff provided to the facility. During the inspection, LPA toured the facility with staff and observed no imminent health and safety issues. Interviews were conducted and records reviewed. An exit interview was conducted with Executive Director Mandy Taylor, and a copy of this report was provided at exit.

On November 25, 2025, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced case management visit to follow up on incident reports received by Orange County Regional Office on October 31, 2025 and November 6, 2025. LPA introduced self to Executive Director (ED) Mandy Taylor, explained the reason for the visit, and was granted entry into the facility. During the visit, LPA toured the facility and obtained copies of Resident/Staff Roster, Staff Schedules, and the following records for R1 and R2: Emergency Contact Sheet, Physician’s Report, Admissions Agreement, Service Plans, and Resident Personal Property and Valuables. LPA conducted interviews with residents and staff. The incident report submitted to the Department on October 31, 2025, stated that Resident #1 (R1) reported missing one hundred and seventeen dollars and R1's money clip on October 27, 2025. R1 reported last seeing the missing items on October 27, 2025. Facility staff reported incident to Fountain Valley Police Department, submitted a police report, and questioned staff who were scheduled to work on that date. Staff searched R1's apartment to attempt to locate the missing money and money clip and was unsuccessful. Facility reviewed camera footage and found internal investigation was inconclusive. LPA interviewed R1 who stated they are missing additional items and unhappy with the outcome of the investigation. Continue to LIC809-C.... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The incident report submitted to the Department on November 6, 2025, stated that Resident 2 (R2) reported missing thirty three dollars and R2's wallet on October 28, 2025. R2’s family reported last seeing the missing items on October 29, 2025, as indicated in emails dated November 6-14, 2025. Family reported incident to Fountain Valley Police Department (FVPD) and submitted a police report. Facility questioned staff who were scheduled to work on that date, reviewed camera footage, and found internal investigation was inconclusive. LPA interviewed R2 who stated they are dissatisfied with the status of the investigation. ED stated they will provide in-service training for all personnel regarding Mandated Reporting and the facility policy for Theft and Loss. ED stated they will follow up with FVPD and will provide an update to LPA on December 2, 2025, regarding any new developments. No deficiencies were cited during this visit. An exit interview was conducted with Executive Director Mandy Taylor, and a copy of this report was provided at exit.

and bathing. Staff stated it was common for R1 to hit them during attempts to provide care. Review of facility progress notes for R1 corroborated these accounts, documenting multiple incidents of staff being hit and noting additional episodes of aggressive behavior toward other residents. Staff further reported that R1’s family expressed concerns about neglect due to R1 often being observed in bed. However, caregivers’ notes confirmed that R1 routinely did not sleep through the night and was awake for extended periods. Staff stated that R1 would become upset, irritable, or resistant in the mornings when care was provided and would often prefer to remain in bed. All staff interviewed reported that memory care staff provided the best care possible to meet R1’s needs, noting that R1 was a physically large, heavy, and tall individual who required extensive assistance. Staff reported that R1’s health was declining and that the family requested one-to-one care at all times, which facility staff could not provide due to responsibilities for other residents in the memory care unit. Review of R1’s evaluation and needs assessment indicated that R1 required the highest level of assistance with mobility and ambulation, including the assistance of two staff members. R1 also required total assistance with bathing, dressing, and toileting. One staff member reported that at times a third staff member was needed due to R1’s size and behaviors, but staff stated they continued to provide care to the best of their ability. It was alleged that facility staff are forcing resident to receive unnecessary services. Per a witness alleged that the facility threatened to require approval of medications for R1 or require the family to hire a private caregiver to meet R1’s care needs. Interviews with four out of six staff confirmed that R1 was a high fall risk and that their overall health was declining during their stay. Staff reported R1 would attempt to stand up from their wheelchair or bed without assistance, necessitating close supervision. Due to these safety risks, staff stated they recommended that the family consider a private caregiver to ensure continuous supervision. LPA reviewed R1’s medication records and Outside Agency Documentation, which showed that medication changes were initiated by R1’s family in consultation with R1’s Physician Assistant. Four out of six staff confirmed that the facility followed medical orders as prescribed. No evidence was found indicating the facility forced or manipulated medication decisions. LPA also reviewed R1’s billing records and resident ledger. Records did not show additional charges, or rate increases throughout the year, aside from a standard rent increase at the beginning of the new year. No unexplained or forced charges for private caregiving or additional services were noted. (Complaint investigation report continued on LIC9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Therefore, based on LPA Tea's observations, interviews conducted, and records reviewed the allegations mentioned above have been determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with the facility. A copy of the report was provided to the facility.

the facility at the time of the alleged incident. All three residents stated they did not recall any residents sustaining an injury or experiencing a fall during that time. LPA Tea also interviewed two memory care staff members who were working during the period in question. Both staff members reported no knowledge or recollection of any resident sustaining an unexplained injury. Staff acknowledged that while falls are common among the residents’ population, they did not recall any specific incident matching the allegation. A previous LPA assigned to the complaint interviewed a former hospice staff member who provided care at the facility during the time of the alleged incident. The hospice staff reported they did not witness any injuries, falls, or inappropriate staff conduct. They stated they had never observed staff being rough or unkind to residents and described the allegation as a “he-said, she-said” situation without substantiating evidence. Based on LPA Tea’s observations, interviews conducted, and records reviewed, the allegation is determined to be UNFOUNDED. An unfounded finding indicates the allegation is false, could not have happened, and/or lacks a reasonable factual basis. No deficiencies cited at this time and an exit interview was conducted with the facility. A copy of the report was provided to the facility.

Concerning the allegation that "staff did not safeguard residents’ personal belongings," the investigation found that none of the three residents or three staff members interviewed supported this allegation. A review of Resident 1's (R1) file showed that the inventory intake sheet, signed and dated on May 10, 2019, listed no personal items. The file also contained email communication from April 5, 2021, between the resident's responsible party and the facility administrator. In this email, the responsible party provided a price list for items for which a refund was requested. Records show a check was issued to R1's responsible party on April 5, 2021, and cleared on May 11, 2021. As to the allegation that "staff left a resident in soiled clothing for extended periods," none of the three residents or three staff members interviewed corroborated this claim. Furthermore, staff interviews revealed that facility employees conduct routine checks on all incontinent residents at intervals ranging from every 20 minutes to two hours, and also assist residents whenever they request to be changed or refreshed. During the facility tour, LPA Haddadin did not observe any residents in soiled clothing or detect any related odors. Therefore, based on the preponderance of evidence gathered through interviews, documentation review, and observations conducted by LPA Haddadin, the allegations are deemed UNSUBSTANTIATED. This means that although the alleged events may have happened or are valid, there is not a preponderance of evidence to prove that the violations occurred. No deficiencies were cited during the visit. An exit interview was conducted, and a copy of this report was provided to the facility

During the investigation of a complaint received on 09/20/24, it was reported that the resident (Resident 1) pressed their pendant for assistance and when staff arrived the resident was observed on the floor lying on her back. It was stated that the resident independently tried to get out of her wheelchair and fell to the floor. The resident complained of back and hip pain and was sent by emergency services to the hospital. It was reported that the resident suffered a Lumbar Compression Fracture; however, it was not due to a lack of care and supervision. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated . Resident sustained multiple falls due to lack of supervision . During the interview process, the Resident Care Coordinator, the resident (Resident 1), and several staff persons were interviewed. In addition, documents were reviewed and obtained to include Personnel Report, Physicians Report, Emergency Information, Admission Agreement, Appraisal and Needs, Medication Administrative Record (MARs), Incident Reports and Medical Records. During the investigation of a complaint received on 09/20/24, it was reported that the resident (Resident 1) would independently page for assistance at times; however, other times, they would try and stand on their own and then fall. Documents reviewed, indicated that staff were available to assist the resident when they needed assistance or paged them. Falls were not due to a lack of supervision. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated . Licensee/health and wellness director was advised a copy of this report will be sent via certified mail. Two copies of the report will be sent. The licensee/health and wellness director is to sign and return a copy to the Orange County Regional Office.

On May 13, 2025, at 8:30am, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced, for the purpose of conducting a Plan of Correction - Deficiencies inspection. This is a follow up to a deficiency issued during the annual inspection conducted on April 22, 2025 by LPA Jessica Cho. During today’s visit, LPA Bentley was greeted and granted entry after explaining the purpose of the visit to Administrator/Executive Director Mandy Taylor. LPA inspected all common areas and inspected 16 resident apartment units which had all the required elements. The residents’ personal bathrooms were checked. Toilets and water faucets worked properly, and the grab bars were secure. Showers were free of mold/mildew, and the slip resistant mats were in place. Regarding, 87303(e)(2), Maintenance and Operation, regulation indicates that "the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F." Water temperature was measured today between 109.2 and 119.3 degrees Fahrenheit. Facility has complied with the terms of the Plan of Corrections (POC). An exit interview was conducted with Administrator Mandy Taylor, and a copy of this report including the Letter of Deficiency Citations Cleared were provided at the end of the visit.

Regarding the allegation of "Facility staff mismanaged resident's medications," it was reported that Resident 1 (R1)'s medication was not being administered promptly or in the correct dosages. LPA Haddadin conducted six staff interviews, three of whom were Medical Technicians. These interviews did not corroborate the allegation, and all staff members denied any mishandling of residents' medications. Six resident interviews also yielded denials of the allegations. Furthermore, LPA Haddadin interviewed R1, who stated they had previously experienced issues with the timely and correct administration of medications. However, R1 reported that the facility no longer manages their medications as R1 now self-administers. Additionally, LPA Haddadin observed a Medical Technician distributing medications to four randomly selected residents. The Medical Technician utilized electronic software that logs the time and date, and the software displays the medication name, resident's name, room number, and resident's picture, all of which staff verified before administering the medication. For the allegations: "Facility laundry room is not maintained clean," "Facility does not have adequate lighting," and "Facility is in disrepair," the investigation, through six staff interviews and six resident interviews, found no support for these claims. LPA Haddadin also conducted a walkthrough of the two laundry rooms and observed both to be clean, free of odors and debris. Both the washer and dryer were maintained and in working condition, and the trash bins were empty. Regarding the allegation of "Facility does not have adequate lighting," LPA Haddadin interviewed R1 in their room and observed an additional light stand, not present in other residents' rooms, which provided extra illumination. R1 indicated that the previous Executive Director had provided the light stand to address a lighting concern. For the allegations: "Facility does not provide a safe environment for residents," "Resident was not given their test results upon request," and "Resident's sleep is disturbed by staff slamming doors, conversations, and other activities," LPA Haddadin conducted six staff interviews and six resident interviews, all of whom denied the allegation that the "Facility does not provide a safe environment for residents." LPA Haddadin also reviewed the facility's required Annual Inspection report, conducted on April 19, 2022, by Community Care Licensing, and found no deficiencies to support this allegation. However, regarding the allegation that "Resident was not given their test results upon request," LPA Haddadin interviewed R1, who stated that the facility did provide the test results in January but could not recall the exact date. A review of records also showed that the test results were in R1's file and accessible to the resident. For the allegation that "Resident's sleep is disturbed by staff slamming doors, conversations, and other activities," LPA Haddadin conducted six resident interviews and six staff interviews, all of whom denied the allegations. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 For the allegations: "Facility does not have adequate staff to meet the needs of the residents" and "Facility staff are not adequately trained," LPA Haddadin interviewed six residents and three staff members. Six out of six residents stated that staff respond to their calls for assistance within twelve to twenty-five minutes. All three staff members stated that they respond to residents' calls within fifteen to twenty minutes. All interviewees indicated that staff respond to residents' calls in a timely manner. Regarding the allegation that "Facility staff are not adequately trained," a review of records showed that all Medical Technicians are mandated to complete an eight-hour refresher course every six months. Furthermore, a review of staff files for the three interviewed Medical Technicians showed that they had all been employed for at least two years and had completed the required training. Therefore, based on the preponderance of evidence gathered through interviews conducted by LPA Haddadin, the allegations: "Facility staff mismanaged resident's medications," "Facility staff are not adequately trained," "Facility laundry room is not maintained clean," "Resident's sleep is disturbed by staff slamming doors, conversations, and other activities," "Facility does not have adequate lighting," "Facility does not have adequate staff to meet the needs of the residents," "Resident was not given their test results upon request," "Facility is in disrepair," and "Facility does not provide a safe environment for residents" were found to be UNSUBSTANTIATED. This determination means that while the alleged incidents may have occurred or the concerns may be valid, there is not a preponderance of evidence to prove that the alleged violation took place. No deficiencies were cited during today's visit. An exit interview was conducted with the Administrator, and a copy of this report was provided.

(Continued from LIC 9099) Staff and residents interviewed by LPA Haddadin were asked if staff respond to residents calls for assistance in a timely manner. Six of six residents stated calls are answered between twelve and twenty five minutes. Three of three staff stated calls are answered within fifteen to twenty minutes. All interviewed stated staff respond to residents calls in a timely manner. Staff and residents interviewed by LPA Haddadin were asked if staff dropped a resident while assisting resident in the shower. All of the staff and residents interviewed were unaware of this and denied this allegation. Based on LPA Ruppert's record review and LPA Haddadin's interviews with residents and staff; although the allegations above may have happened or were valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Mandy Taylor, LVN, and a copy of this report was provided to the facility.

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced to follow-up on the death report and incident report. LPA met with Executive Director (ED) Justine Ortiz and explained the purpose of the visit. During the course of the visit, LPA interviewed two staff and reviewed pertinent documentation such as the Death & Incident Reports dated February 19, 2025 and Progress Notes dated February 19 - February 27, 2025. The incident is as follows: On February 25, 2025 at 3:11pm, the Department received the Incident Report (LIC624) and Death Report (LIC624A) for Resident #1 (R1). It was reported that R1 was discovered unresponsive in their room with food in their mouth by staff on February 25, 2025 at 9:37am. Per review of the Physician's Report dated January 1, 2025, R1 does have a special diet but is able to feed self. Staff performed CPR while on the 911 call. Fountain Valley Police Department and paramedics arrived to assist and transported resident to the hospital for further evaluation after detecting a pulse. R1 passed away at the hospital. There were no health and safety violations noted during today's visit. An exit interview was conducted with Executive Director Justine Ortiz, and a copy of this report was emailed during the visit.

LPA reviewed S1 record and observed that training on subject of Personal Rights was completed by S1 on March 28, 2021. Also training for Abuse and Neglect was completed by S1 on March 1, 2021. During residents’ interviews, LPA observed that three of three residents did not comprehend the questions asked due to their cognitive ability and mental awareness. Meaning, residents did not completely understand what the LPA was asking them. Therefore, based on the preponderance of evidence through interviews and documentation reviewed by LPA Haddadin, the allegation that the "staff intimated resident," is UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited during today's visit. An exit interview was conducted a copy of report was provided.

On 11/5/2024, LPAs Dwayne Mason Jr. and William Vanegas arrived at the facility for the purpose of conducting a Case Management visit for the purpose of following up on incident reports received by the Department. LPAs were greeted and granted entry by Front Desk/Receptionist Silvia Villalobos. LPAs met with Laura Foreman, Memory Care Director. LPAs obtained copies of the resident roster, staff roster, staff schedules and staff training logs. LPAs requested an electronic copy of the call button report from 10/21/2024 through 11/4/2024. LPAs conducted interviews with Memory Care Director, staff and residents. Based on staff interviews conducted, the majority of staff indicated that the facility is understaffed. However, based on interview with MCD, it was revealed that the facility utilizes a staffing agency called Pioneer Home Care to fill any call-outs from staff. MCD also showed LPA the job postings currently on the facility's website indicating the facility is currently hiring. Based on today's visit no deficiencies are being issued. This report was reviewed with facility staff and a copy was provided.

that they had not had an issue since then with vermin. File review of resident records revealed that R1 admission to the facility was March 25, 2023, about a year and 4 months ago. Interview with 13 of 13 residents revealed that residents have not ever had an issue with vermin in their food or have seen any vermin in the facility. Residents stated that they were very happy with the food quality of the facility. LPA obtained statements from the staff who stated that facility has had continuous pest control service from an outside vendor, which comes twice a month to do pest control maintenance. Records review reflect that facility has a contract with Pest Flex to services the facility. Copies of records obtained reflect that facility has a service agreement for pest control indicating facility had a previous pest company prior to contracting with them. Services instructions indicate to treat exterior and interior, focusing in kitchen areas, semi-monthly services, 2x month and service existing equipment. We have found the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. A copy of this report is being reviewed with the Executive Director and a copy furnished to the facility.

(Continued...) Per Needs and Service Plan dated May 6, 2024, R1 was assessed by the facility to be a high risk for falls. R1 sustained unwitnessed falls on April 2 and April 28, 2024. Facility spoke with R1's responsible party (RP) on April 28, 2024 regarding R1's change of condition. As a result facility spoke to RP about memory care placement and removed items from the apartment that could be potentially harmful. Following discussion with RP, R1 sustained falls on April 29th, 30th and May 1, 2024. Facility sought medical attention on April 30th and May 1st. RP was notified by facility of incidents after each fall. Upon return facility retained a private caregiver to provide additional supervision for R1 on May 2, 2024. Per email from Agape Home Care to facility on May 16, 2024, Agape Home Care was notified by RP on May 6, 2024 to stop service. RP advised facility that they would make arrangements for their own private caregiver for R1. On May 7, 2024 R1 sustained an unwitnessed fall. 911 was called and R1 was transported to the hospital. Health and Wellness Director notified RP of fall and the absence of a private caregiver. RP advised they were aware and was planning to provide supervision themselves and had been en route to the facility when the fall occurred. Following the fall, RP notified facility of intent to move R1 to a higher level of care. Shortly after moving on May 8, 2024 it was reported R1 passed away. Interviews with three of three staff members confirmed they were aware of R1's fall risk and that measures had been put in place to prevent falls from occurring. Two of the three staff members stated falls could have been prevented if a private caregiver was provided. Facility progress notes show staff were monitoring R1 continuously. Based on the preponderance of evidence, the allegation that staff do not prevent a resident from sustaining multiple falls while in care is unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. No deficiencies cited during today's visit. An exit interview was conducted with Administrator Justine Ortiz and a copy of this report was provided.

Licensing Program Analyst (LPA) Ruth Martinez made visit to this facility to conduct a case management visit. LPA arrived at facility was greeted and granted entry by receptionist. LPA met with Laura Sanchez, Resident Care Coordinator and Terrie Sherrell, Regional Director of Health and Wellness and explained the nature of the visit. LPA is conducting this visit as a follow up on an incident that was self reported an on October 24, 2023 regarding resident R1’s incident on October 20, 2023. During today’s visit, LPA interviewed staff and obtained copies pertinent documents. LPA toured the facility and observed R1 during activities with other residents. On October 20, 2023 at approximately 5:30pm staff received a call from R1's son notifying staff that R1 had called son from near by store. Staff immediately went to pick up resident and bring them back to the community. Upon return R1 was immediately evaluated by resident care coordinator, no injuries were noted. Primary care physician was notified and Health and Wellness Director. When R1 was interviews R1 was able to recall the whole process of the incident. Due to the nature of R1's recall the following was done out of protocol procedures: resident was assessed, 24 hour caregiver was put in place, all door codes were changed and place on a rotation for change of code, and an in-service training was conducted for all staff/all shift regarding elopement and code safety. Code safety measure are in place and continuous training is provided. This report was reviewed with facility representatives and a copy of the report was provided and left at the facility.

Regarding the allegation, "Resident's bedroom was left in unsanitary condition," the investigation revealed the following: On 11/3/2020 during a virtual Tele Assistance Partnership visit conducted along with AD Cash Benton and LPA Quiroz, LPA Quiroz virtually observed (R1s) bedroom area appearing to look clean as evidence by no trash on trash basin, (R1s) bed was made and no discoloration observed on (R1s) bed linen. (R1s) bathroom area was observed to be in sanitary conditions during virtual inspection conducted on 11/3/2020. Four of seven interviewees denied allegation indicating caregivers and housekeeping staff clean bedrooms according to housekeeping schedules and as needed due to sanitary and safety concerns. Three of Seven interviewees corroborated with allegation indicating (R1) prefers to only have two preferred caregivers clean their bedroom area. Therefore based on the preponderance of evidence through interviews conducted, documentation review and observations conducted by LPA Quiroz, the allegation that the "Facility failed to notify responsible party of medical emergency" and "Resident's bedroom was left in unsanitary condition" were found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited during today's visit. An exit interview was conducted with Terrie Sherrell Regional Director of Health and Wellness and a copy of this report along with LIC 811- Confidential Names were provided at exit.

LPA Quiroz was greeted by Front desk concierge and met with Administrator (AD) Charles Eusey and Health Wellness Director (HWD) Laura Sanchez, and explained the purpose of the inspection visit. This unannounced Case Management – Other inspection visit is being conducted by Licensing Program Analyst (LPA) Rosie Quiroz for the purpose of delivering amended findings for Complaint Control Numbers: 22-AS-20221011152147 and 22-AS-20220929163554 based on report corrections and complaint follow up investigation requiring interviews, review of supporting documents and facility observations for the following complaint control numbers: 22-AS-20201002130659 and 22-AS-20210324151302. During today's inspection, LPA Quiroz along with AD Eusey toured the memory care unit area consisting of resident's bedrooms, hallways and dining-room area. LPA Quiroz and AD Eusey discussed the previously delivered findings and the amended findings and LPA Quiroz delivered the amended reports. An exit interview was conducted and copy of this report and the amended reports were discussed with and provided to AD Eusey.