Kaego's Richman Gardens.

Licensing Prog ram Analyst (LPA) Nancy Guillen made an unannounced visit for the purpose of conducting a required annual Inspection. LPA was greeted and granted entry by staff after explaining the purpose of the visit. Administrator (AD) Susan Hidalgo was present and assisted with the visit. LPA observed the Administrator certificate was current with an expiration date of December 20, 2027. This is a Residential Care Facility for the Elderly (RCFE) licensed to twenty- six non-ambulatory residents, of which six may be bedridden, with a hospice waiver for eleven. This is a small commercial facility that consists six different buildings. Two buildings consists of the garage and additional storage space. The remaining four buildings contain thirteen bedrooms, seven bathrooms, kitchen, living areas, dinning room, medication room and multiple storage areas. During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following: LPA observed residents watching television in the living room and resting in their respective bedrooms. LPA was advised twenty two residents were in care and seven staff present . All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets with additional linens stored in the linen room located in Building 1. LPA observed bathrooms were clean and equipped with grab bars and non skid floor mats. LPA observed all windows were appropriately screened. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 103.2 and 110.4 degrees Fahrenheit. Continued on LIC809C 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 LPA toured the outside of the facility and observed outdoor passageways were free of obstruction. LPA observed the backyard had a shaded sitting area with furniture for resident use. LPA observed two emergency exits were locked without the proper fire clearance; a deficiency was cited on today's date. LPA observed the facility had a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. LPA reviewed the Fire Safety Inspection report and verified the annual fire alarm report was conducted and passed on January 2, 2026 and the carbon monoxide detectors are maintained monthly. Fire extinguishers were observed to be fully charged with a service date of March 31, 2026 and are located in each building. Gas stove, washer, and dryer were all inspected and observed to be operable. LPA observed knives and sharps to be locked and stored in the kitchen. The four car garage is used for storage which is kept locked and inaccessible to residents in care. Toxic chemicals, cleaning solutions, and disinfectants were observed to be stored in the garage. Medication is locked and centrally stored in a hallway closet in Building 1 however, Memantine was signed as administered to a resident, but pill was observed to be in the residents medication tray during medication review; a deficiency was cited on this date. LPA observed the First Aid Kit had all the required components. LPA observed the facility conducted their last emergency disaster drill on April 14, 2026. LPA began review of the records. LPA reviewed nine resident records. All the required documentation were present and current in the resident files reviewed. LPA reviewed six employee records. All employees present have a criminal record clearance and were associated to the facility. LPA observed records reviewed have a current First Aid certificate. Based on the observations made during today’s inspection, deficiencies are being cited and a civil penalty was assessed. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Magali Sanchez and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 10:30AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, storage areas, and medication room and observed the following: Structure: this is a small commercial facility. Facility is a 13-bedroom, 7-bathroom, 4-building small commercial facility with multiple storage areas, a kitchen, a dining room, a medication room, and multiple common areas. There is a large back yard with a patio cover for the residents. The entire facility is a memory care unit with a delayed egress alarmed exit at the front gate and exit alarms on the other three gates. LPA tested the delayed egress system, exit alarms, and the call button system. Resident Bedrooms: the 13 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 13 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 105 and 112 degrees F in the 7 resident bathrooms tested. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the housekeeping closets. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees are paid. 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 At about 11:30AM, LPA reviewed 6 resident files and 6 staff files, interviewed 6 residents and 4 staff, and inspected medications for 6 residents. Facility does not handle resident money. During the inspection, LPA and AD observed the following: based on documents, the licensee did not ensure Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5) had appraisals updated within the past year. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced plan of correction (POC) visit to follow up on citations issued on 10/17/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Citation issued on 10/17/2024 regarding Maintenance and Operation has been cleared. Delayed egress push lever has been removed. Licensee has complied with the POC. *Citation issued on 10/17/2024 regarding Fire Safety has NOT been cleared. Exit gates are secured with either a lock or keypad. CIVIL PENALTY ASSESSED. Based on the observations made during today's visit, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.

The liquor store manager confirmed seeing R1 walking outside of the facility the night of incident. Staff interviewed reported last seeing R1 at around 8 PM and did not see them again until approximately 9:20 PM when R1 was brought back by an unknown stranger. Staff had failed to notice R1 was missing during this time. One of two staff on duty that day admitted staff often turn off the auditory alarm to the emergency exit door located in the building and confirmed the alarm to the door was turned off at the time of R1’s elopement. One of two staff interviewed reported it being difficult to hear alarms due to the noise levels and location of R1’s bedroom. The facility is not approved for a locked perimeter exterior, however, two of two staff interviewed reported observing other staff propping the gates open for easy access in and out of the facility. R1’s family arrived at the facility at approximately 9:30 PM. Upon arriving R1’s family stated R1 had major bruising to their face, chest, hands and arms in addition to having a front right tooth completely knocked out, left front tooth loose and bottom teeth sore and cracked. After consulting with R1’s hospice nurse, 9-1-1 was called. R1 was taken to UCI Medical Center due to the severity of injuries sustained where they were admitted at 11:14 PM and diagnosed with bruising to the chin, tooth avulsion and maxillary ridge fracture of the mouth, blunt trauma to the torso, organ injury and cardiac contusion and a skull fracture. A meeting was held with facility management and R1’s family where it was disclosed that R1 had actually fallen outside of the facility grounds and an unknown man had brought them back to the facility despite initially saying the fall occurred at the facility. Two of two staff confirmed lying to R1’s family and that they were pressured to do so by the facility management. R1’s family reported management admitted to lying regarding the circumstances of R1’s fall during their meeting. Therefore, based on interviews conducted and records reviewed, the preponderance of evidence has been met. The allegations that staff did not provide adequate supervision resulting in resident wandering away from facility and causing resident to sustain multiple fractures and injuries; Staff did not provide resident’s authorized representative with the correct information of incident; Staff do not respond to facility alarm; and Staff does not securely lock facility's exterior gate has been Substantiated. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f) An exit interview was conducted, and a copy of this report, 9099-D Page, and appeal rights was left at the facility.

Licensing Program Analysts (LPAs) Kimberly Lyman and William Vanegas conducted an unannounced case management visit in conjunction with complaint visit #22-AS-20230906160954. LPAs were greeted and granted entry into the facility and explained the reason for the visit. Interim Administrator Wendy Cruz arrived during the visit. During the visit, LPAs toured the facility and observed the following: All exit gates are locked. The main exit gate is only accessed by a code. Auxiliary exit gates are secured with locks. Exit gate on north side of property has a delayed egress push lever that is broken. Facility fire clearance does not include delayed egress or locked perimeters. Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Wendy Cruz and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 12:30PM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following: Structure: this is a small commercial facility. Facility is a 13-bedroom, 5-bathroom, 4-building small commercial facility with multiple storage areas, a kitchen, a dining room, a medication room, and multiple common areas. There is a large back yard with a patio cover for the residents. The entire facility is a memory care unit with a delayed egress alarmed exit at the front gate. Resident Bedrooms: the 9 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 9 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 126, 138, 85, and 109 degrees F in the Tea Rose, Jasmine, Calla Lilly, and Apple Blossom buildings, respectively. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees are paid. At about 1:30PM, LPA reviewed 5 resident files and 5 staff files, interviewed 5 residents and 5 staff, and inspected medications for 5 residents. Facility does not handle resident money. CONTINUED 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 During the inspection, LPA and AD observed the following: based on observation, the hot water tested at 126, 138, 85, and 109 degrees F in the Tea Rose, Jasmine, Calla Lilly, and Apple Blossom buildings, respectively. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

Regarding the allegation that facility staff are not providing records to resident's responsible person(s): it was alleged that on December 28, 2023, R1’s Resident File was requested, the facility did not provide R1’s Resident File, facility staff were contacted by phone on January 31, 2024 and confirmed the request was mailed to the correct address, the request was sent again via certified mail, but as of June 12, 2024, the facility still had not provided R1’s Resident File. LPA reviewed a witness statement dated June 11, 2024, and a written request for R1’s Resident File dated December 28, 2023, which corroborated the allegation. LPA interviewed facility staff who corroborated that the facility had received the request on or before January 9, 2024, and had not provided R1’s Resident File by that date which is more than two business days from the request, but could not provide information on whether R1’s Resident File was ever provided. Based on the information obtained, the facility did not timely provide R1’s Resident File in response to the request. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.