Palms Retirement Center.

Staff denied resident from receiving medical care Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff denied giving resident medication Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff denied resident a phone call Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff denied residents rights to choose a roommate Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 violation occurred. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.

The investigation into the allegation, staff neglected resident resulting in severe dehydration and hospitalization, revealed the following. It was reported that R1 was hospitalized on August 27, 2025, due to dehydration and a urinary tract infection (UTI) and subsequently sent to a Skilled Nursing Facility (SNF) because the facility failed to ensure R1 was properly fed and hydrated. A review of records shows that R1 moved to the facility on July 9, 2015. R1’s physician report dated September 12, 2024, shows R1 has been diagnosed with Parkinson’s Disease, Epilepsy, Hypothyroidism and Hypertension. R1 is able to leave the facility unassisted and handle their own cash resources. R1 is not conserved, has no power of attorney and makes all their own decisions. On August 27, 2025, staff noted R1 to be lethargic. Staff assessed R1 and decided to call 911. R1 was transported to the hospital and admitted for Acute cystitis without hematuria (UTI). R1 was at the hospital from August 27, 2025, to September 5, 2025. Hospital records dated August 27, 2025, to September 5, 2025, show R1 could be argumentative to staff and refused medication on August 28, 2025. Hospital notes for September 2, 2025, state patient (R1) has not been eating well, refusing most meals, does take medication. Hospital discharge paperwork for R1 shows R1 did not have adequate intake of food and water but does not meet the criteria for moderate or severe malnutrition. The recommendation is for R1 to drink Ensure Plus High Protein daily with meals and the goal is to eat 70% of all of their meals and snacks. R1 was discharged to a Skilled Nursing Facility (SNF) on September 5, 2025. R1 was at the SNF until October 1, 2025, when they returned to the facility. A review of records shows that R1 has refused food and water, and the facility documented those incidents. R1 did not eat or ate very little on August 5, 7, 10, 13 and 14, 2025. A review of records shows R1 was on home health visits from July 5, 2025, to October 24, 2025. The Home Health notes for August 27, 2025, state R1 has a poor appetite. The Administrator reported that after each incident R1’s primary care physician (PCP) and emergency contact were notified. R1’s emergency contact verified this report. R1 reported that they eat and drink when they feel like it and do not always eat three meals a day. R1 reported that they know how to get up and serve themselves water if need be. Staff reported that R1 was always encouraged to eat and drink and to let staff know if they needed anything. R1 verified this report. Based on the evidence gathered from interviews and a review of records, there is not enough evidence to prove that the staff failed to provide care or neglected R1, causing dehydration which resulted in hospitalization. Therefore, the allegation is deemed Unsubstantiated , meaning that, 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. 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 investigation into the allegation, staff did not address resident's change in condition, revealed the following. It was reported that prior to their hospitalization on August 27, 2025, R1 was not getting out of bed and lost 20 pounds from June 2025 to September 15, 2025. A review of records shows that according to R1’s physician report dated September 12, 2024, R1 weighed 195 pounds. R1 was weighed at the hospital when they were admitted on August 27, 2025, and at the time of their discharge to the Skilled Nursing Facility (SNF) on September 5, 2025. R1 weighed 149 pounds on both dates. No other documents gathered during the investigation listed R1’s weight. R1 lost 46 pounds from September 12, 2024, to September 5, 2025. That is an average of just under 4 pounds a month. It is unknown how much weight R1 lost from June 2025 to September 2025. A review of records shows that R1 has refused food and water, and the facility documented those incidents. R1 did not eat or ate very little on August 5, 7, 10, 13 and 14, 2025. A review of records shows R1 was on home health visits from July 5, 2025, to October 24, 2025. The Home Health notes for August 27, 2025, state R1 has a poor appetite. The Administrator reported that after each incident R1’s primary care physician (PCP) and emergency contact were notified. R1’s emergency contact verified this report. R1 reported that they eat and drink when they feel like it and do not always eat three meals a day. R1 reported that they know how to get up and serve themselves water if need be. Staff reported that R1 was always encouraged to eat and drink and to let staff know if they needed anything. R1 verified this report. No other issues were reported until R1 was observed to be lethargic on August 27, 2025. Staff called 911 and R1 was transported to the hospital and admitted for Acute cystitis without hematuria (UTI). R1 was at the hospital from August 27, 2025, to September 5, 2025, and then discharged to a SNF on September 5, 2025. R1 was at the SNF until October 1, 2025, when they returned to the facility. The Administrator reported that they were unaware of R1 not ambulating prior to their hospitalization in August 2025. 2 out of 2 staff interviewed reported that R1 was able to ambulate on their own prior to August 27, 2025. R1’s emergency contact reported they were notified when R1 was hospitalized. R1 reported that if they wanted to move around or stay in their room, they can do what suits them. None of the evidence gathered supports the allegation. Based on the evidence gathered through interviews and documents reviewed the allegation is deemed Unsubstantiated , meaning that, 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. An exit interview was conducted and a copy of the report provided. 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 first property list/inventory is dated January 1, 2024, and the property sheet dated September 21, 2025, showing what items R1’s emergency contact removed from the facility to take to R1 who was in at SNF at the time. R1’s emergency contact removed from the facility 2 pants, 2 shirts and 1 sweater. R1’s emergency contact signed and dated the form and there was a photocopy of their ID with the form. R1’s original property inventory sheet lists the following, 2 walkers, clothes, 5 jackets, bra, 3 socks and jogging pants. Nothing else is listed. The form is dated January 1, 2024. Dentures, shoes, personal effects and toiletries were not listed on the property inventory list. During the initial 10-day visit on September 25, 2025, the Administrator showed R1’s personal belongings box, which included dentures in their case, various clothing items, toiletries and 2 pairs of shoes and R1’s 2 walkers which were in their room, to LPA Alejandre. LPA observed all of R1's property in a box at the facility. The Administrator reported that they showed R1’s emergency contact R1’s property and they chose to only take clothing items. R1’s emergency contact reported they only took the items R1 requested and don’t remember seeing the other items. The Administrator reported that R1's items are kept secured at the facility. Based on evidence gathered the allegation, is 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 the report provided.

Based on a review of the personnel report, it appears that there is sufficient staff coverage to assist R1, and other residents, with their medication needs during all times of the day. LPA conducted an interview with R1. R1 denied any issues with his medication needs and denied any issues with requesting his as needed medications from staff. LPA conducted an additional five resident interviews. The five residents interviewed stated that they all receive assistance with their medications from the facility and they also denied any issues with their medication needs. LPA conducted four staff interviews. Four out of the four staff interviewed denied the allegation and reported that there is at least one staff on duty at all times during each day to assist residents with their medication needs. Regarding the allegation, staff did not provide requested document to resident's doctor, the following has been concluded: It was alleged that staff did not provide requested document to R1's doctor. LPA attempted to conduct an interview with R1's doctor, Witness #1 (W1). However, LPA was unable to make contact with W1 for an interview after multiple attempts. LPA conducted an interview with R1. R1 stated that he did not recall if staff provided him with a copy of his medication list to give to his doctor, W1. LPA conducted four staff interviews. Two staff were unable to provide any useful information for this allegation. However, the other two staff denied the allegation and stated that staff did provide R1's doctor with the document that they requested. Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the two allegations above are deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator Maria Dimacali and a copy of the report was provided at time of visit.

Staff are disclosing a resident's personal information Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are mishandling a resident's medications Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are interfering with a resident's medical decisions Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are not affording a resident privacy Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are stealing the resident's personal belongings Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are not following a licensed physician's orders Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are threatening a resident Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are unlawfully evicting a resident Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. **Continued on 9099-C2 page 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 Staff are falsifying and misplacing records of a resident Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff do not seek timely health and medical attention for a resident Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are overcharging a resident Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are not properly reporting incidents involving a resident Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff do not address a resident's change in medical condition Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are not providing adequate food service to a resident Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. A finding that a complaint allegation 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 violation occurred. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.

Per observation, during investigation visits, LPA observed resident had a supply of diapers and under pads piled high on side of television next to wall across from R1’s bed. LPA observed incontinent supplies throughout resident’s room. Resident was left in soiled bedding for extended amount of time Per staff interviews, five of five staff stated that they were not made aware of R1 being left in soiled bedding for period of time. Staff interviews stated that R1 did need assistance with toileting and would be changed 3 to 4 times a day as well as checked on every two hours. Per witness interview, witness is aware of R1 needing assistance but does not know how often it is given at facility. Per R1 interview, R1 stated that on one particular occasion a staff member made them pee inside diaper and was left in soiled diaper for two days. Per observations LPA observed R1 to be comfortable during visits and R1 stated that they were not having the soiled issues as before. Per records reviewed R1’s physicians reports dated 4/23/22, 6/21/24 & 3/5/26 stated that R1 needs assistance with bathing, dressing and toileting due to their physical condition. Needs and Service Plan dated 6/20/25 states that R1 is total assist with bathing, grooming, dressing and toileting. Staff handled Resident roughly Per interviews, five of five staff stated that R1 never mentioned to them about being handled roughly by staff at facility. One staff member stated they were aware that R1 always requested about being handled “gently” while staff were providing care. Interview with R1 stated that a Care giver whose first name was provided shoved R1 against bed roughly and was rude. Interview with witness stated that R1 denied the allegation regarding staff, stating that R1 claims they were never pushed by a staff member, there was no abuse happening and that they felt safe at facility. Per observations, staff member whom R1 mentioned was not available for interview on 8/15/22 and was informed Staff member no longer works at facility and left back in 2022. LPA did not observe staff member on roster on 3/25/26. Per information gathered from investigation, the allegations Staff mismanaged toileting supplies, Resident was left in soiled bedding for extending amount of time and staff handled resident roughly were deemed UNSUBSTANTIATED meaning that although the allegations may have happened or are valid, there is no preponderance of evidence to prove that the alleged violations occurred as reported. An exit interview was conducted with Administrator Kathleen Tamondong, copy of report was discussed and provided.

The investigation into the allegation, Staff are not properly reporting incidents to authorized representatives, revealed the following. It was reported that R1 sustained falls on June 9, 2025 and July 2, 2025 and R1's authorized representative/emergency contact was not notified. A review of records shows R1 sustained falls on June 21, 2025, and July 7, 2025. The Administrator reported there is no record of any falls for R1 on June 9 or July 2, 2025. R1 could not recall how many times or the dates of when they have suffered a fall. The Wellness Director reported that they have no record of falls for R1 on June 9 or July 2, 2025. 5 out of 5 staff members reported they are unaware of any falls for R1 on June 9 or July 2, 2025. R1's authorized representative/emergency contact reported that they were notified about the falls on June 21 and July 7, 2025. R1's authorized representative/emergency contact could provide any details about the falls reported to have taken place on June 9 or July 2, 2025. None of the evidence gathered supports the allegation, therefore the allegation is deemed Unsubstantiated , meaning that, 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. The investigation into the allegation, staff are leaving resident in soiled clothing for an extended period of time, revealed the following. It was reported that R1 was not properly assisted with incontinence issues and would be left in their soiled clothes for an hour before they were assisted and changed and this caused R1 to be hospitalized. No specific details were provided as to when or how many times this occurred. R1's physician reported that R1's hospitalization and diagnosis of Sepsis secondary to UTI could not be attributed to poor hygiene and was caused by their overall poor health. The Administrator and Wellness Director reported they were unaware of any issues assisting R1 with incontinence issues and have heard no reports of residents being left in soiled clothing. 5 out of 5 staff members reported that R1 was not neglected in any way, was never left in soiled clothing and they constantly checked on R1. R1 declined to comment when questioned about specific care provided by facility staff. R1 offered no explanation for this. None of the evidence gathered supports the allegation, therefore the allegation is deemed Unsubstantiated , meaning that, 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. An exit interview was conducted and a copy of the report provided. 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 investigation into the allegation, staff are not properly supervising residents who may be a fall risk, revealed the following. It was reported that R1 was known to fall risk and the facility failed to properly monitor R1 which led to numerous falls. R1 moved into the facility on May 13, 2025. R1 was diagnosed with polyneuropathy, Type II Diabetes, Chronic Obtrusive Pulmonary Disease (COPD), obesity, heart failure and chronic pain. R1’s psychiatric diagnosis includes bipolar disorder, depression, anxiety and psychotic disorder. R1 can communicate, is alert and oriented to time and place but experiences episodes of confusion. R1 can communicate their needs effectively and could follow instructions. According to the facility staff and R1’s physician R1 is a fall risk. According to R1’s physician R1 could walk 6 to 8 feet independently but required an assistive device or staff support for any distance beyond that. R1 was placed in a room near the medical technician’s office so they could be closer to staff and easier to monitor. R1’s physician reported that R1’s ability to communicate their needs and follow instructions meant one on one care was not clinically necessary. R1 utilized a motorized wheelchair and required assistance when transferring, bathing, dressing and incontinence care. R1 sustained fall on June 21, 2025, and July 7, 2025. The fall in June did not result in any injuries. A review of records shows R1 was on hourly safety checks. The Administrator, Wellness Director and 5 staff members reported that all staff members follow R1’s care plan that calls for hourly checks and for staff to assist with transferring, bathing, dressing and incontinence care. 5 out of 5 staff members reported that R1 was not neglected in any way and staff constantly checked on R1. R1 declined to comment when questioned about specific care provided by facility staff. R1 offered no explanation for this. R1’s physician reported that in their years attending and examining residents at the facility they have never witnessed any staff neglect. A Licensed Clinical Social Worker who had previously worked with R1 reported that staff attended R1 frequently and they did not observe anything that caused concern. Based on the evidence gathered through document review and interviews, the allegation is deemed Unsubstantiated , meaning that, 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. 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 investigation into the allegation, staff did not seek timely medical attention for resident in care, revealed the following. It was reported that after R1 fell on July 7, 2025, staff did not seek timely medical attention for R1. R1 moved into the facility on May 13, 2025. R1 was diagnosed with polyneuropathy, Type II Diabetes, Chronic Obtrusive Pulmonary Disease (COPD), obesity, heart failure and chronic pain. R1’s psychiatric diagnosis includes bipolar disorder, depression, anxiety and psychotic disorder. R1 can communicate, is alert and oriented to time and place but experiences episodes of confusion. R1 can communicate their needs effectively and could follow instructions. According to the facility staff and R1’s physician R1 is a fall risk. According to R1’s physician R1 could walk 6 to 8 feet independently but required an assistive device or staff support for any distance beyond that. R1 was placed in a room near the medical technician’s office so they could be closer to staff and easier to monitor. R1’s physician reported that R1’s ability to communicate their needs and follow instructions meant one on one care was not clinically necessary. R1 utilized a motorized wheelchair and required assistance when transferring, bathing, dressing and incontinence care. On July 7, 2025, R1 was discovered by staff on the floor of their room at approximately 7:00 am to 7:30 am. According to the special incident report dated July 8, 2025, for the fall incident on July 7, 2025, R1 suffered an unwitnessed fall and was in pain and 911 was called. R1 did not recall the time of the fall but reported they were not close to the call button to call for assistance. Staff reported seeing R1 in their bed around 6:00 am. R1 reported that they were transferring from their bed to their wheelchair unassisted when they fell. R1 did not have an explanation as to what caused the fall. R1 did report that they suffered memory loss following the fall on July 7, 2025, but did not provide any additional details. R1 declined to comment when questioned about specific care provided by facility staff. R1 offered no explanation for this. It was reported that the only reason 911 was called was because of R1’s insistence. A voicemail was provided to support this claim. A review of the voicemail shows facility staff (S1) called R1’s responsible party informing them R1 was sent to the hospital because they had a fall and R1 wanted to be sent to the hospital. S1 no longer works for the facility and never responded to a request for an interview. A review of hospital records shows that R1 was admitted to the hospital at 8:10 am on July 7, 2025. A review of facility records shows that R1 requested and received hospital transport several times for various reasons between their move in date, May 13, 2025, and the incident on July 7, 2025. It is unclear who prompted the 911 call. R1 was transported to the hospital shortly after their fall, therefore the allegation is deemed Unsubstantiated , meaning that, 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. 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 investigation into the allegation, resident sustained a fracture after an unwitnessed fall, revealed the following. It was reported that a lack of care and supervision resulted in R1 sustaining a fall that caused a fracture. R1 moved into the facility on May 13, 2025. R1 was diagnosed with polyneuropathy, Type II Diabetes, Chronic Obtrusive Pulmonary Disease (COPD), obesity, heart failure and chronic pain. R1’s psychiatric diagnosis includes bipolar disorder, depression, anxiety and psychotic disorder. R1 can communicate, is alert and oriented to time and place but experiences episodes of confusion. R1 can communicate their needs effectively and could follow instructions. According to the facility staff and R1’s physician R1 is a fall risk. According to R1’s physician R1 could walk 6 to 8 feet independently but required an assistive device or staff support for any distance beyond that. R1 was placed in a room near the medical technician’s office so they could be closer to staff and easier to monitor. R1’s physician reported that R1’s ability to communicate their needs and follow instructions meant one on one care was not clinically necessary. R1 sustained fall on June 21, 2025, and July 7, 2025. The fall in June did not result in any injuries. A review of records shows R1 was on hourly safety

Three of ten residents could not confirm or deny the allegation. LPA reviewed two resident files to try and identify R2. Upon review, LPA did not observe any incidents pertaining to sexual assault or a history of sexual abuse. It remains unclear as to R2’s identity. LPA reviewed staff files and 3 of 5 staff have updated training regarding resident abuse. 5 of 5 staff have signed abuse acknowledgement forms dated March 16, 2026. LPA contacted Fullerton Police Department to request potential police reports that could match the allegation under review. No reports provided were found to be pertaining to the complaint allegation. Regarding the facility allegation of staff not administering resident medications as prescribed revealed the following: LPA interviewed five current staff members of which four staff informed LPA that all medications are given as prescribed. The remaining staff interviewed does not handle the medications. In addition, two of ten former staff interviewed confirmed they gave all medications as prescribed. The remaining eight staff did not confirm or deny due to their position or not speaking to LPA. LPA interviewed residents in care regarding their medications, and seven of ten residents informed LPA that they get assistance with their medications and have no complaints. The remaining three residents were unable to confirm or deny the allegation. LPA reviewed eight resident medications and medication administration records and observed that all were being given as prescribed at the time of the investigation. LPA reviewed 5 staff training records on resident personal rights and observed them to be current. LPA reviewed three of five staff having medication technician certifications from Pharmacy vendors. The two remaining staff were observed to have medication training provided by the facility but do not perform medication technician duties. Based on the evidence gathered, the Department finds the allegation is unfounded. A finding that the complaint is unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was left at the facility.

Regarding Allegation Staff made inappropriate comments towards resident , Interview with Resident 1 (R1) stated that a staff member who they preferred not to name, made the following inappropriate comment after a witnessed fall “ you’re old and don’t need your knee’s. You are going to die”. R1 stated staff member made them feel shun for the incident occurring. Interviews with staff revealed that 5 of 6 staff members were not aware of inappropriate comments made and stated that R1 did not express concerns regarding staff. Regarding Allegation Facility not providing resident with requested documents , Interview with R1 stated that they needed personal records for upcoming doctors appointment, however when asked what records they needed and if they received such records, R1 could not recall the records requested and whether they received documents. Interview with Staff 1 (S1), revealed that R1 requested a copy of their Admission Agreement and S1 stated they provided document to R1. Regarding Allegation Staff not ensuring resident is bathed , based on documents received, R1’s Physician reports dated 10/28/22 under capacity for self care stated that R1 needs assistance with bathing. R1’s Functional capability assessment dated 9/30/22 also states R1 needs help with bathing and showering. No shower logs provided for R1. Interview with R1 revealed that they often wait to be showered. Interviews with staff members revealed that 3 of 6 staff stated that R1 was on a showering schedule. Interviews with staff revealed that 3 of 6 staff stated R1 had showers as needed 3 to 7 days a week. Regarding Allegation Facility failed to administer medications as prescribed, Record review revealed that R1 was on two medications for pain management (Hydrocodone Acetaminophen and Tramadol HCI) both meds prescribed as take one pill every six hours as needed for pain. Resident also on Trazodone for Insomnia. Medication logs from 11/5/22-11/7/22 show R1 received Pain medication Tramadol 6x for pain. Facility nurse notes state on 11/11/22 Doctors office contacted facility that they were not going to refill Norco pain med due to resident being referred to pain management doctor & resident was informed. Interview with R1 stated that they were not receiving their Norco (Hydrocodone Acetaminophen) medication and instead was given “Trazodone”. Interview with Staff 2 revealed that R1 is given medications as prescribed. Interview with Staff 1 stated that R1 always wanted PRN pain meds immediately after making request and wanted additional dosage immediately after an hour. Based on information provided in investigation, the preponderance of evidence has not been met, deeming the allegations Staff made inappropriate comments towards resident, Facility not providing resident with requested documents, Staff not ensuring resident is bathed and Facility failed to administer medications as prescribed to be Unsubstantiated meaning 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 as reported. An exit interview was conducted with Administrator and copy of report was discussed and provided.

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Khatera Bahadory and discussed the purpose of the visit. The facility is a two story building with seventy three resident bedrooms, three staff offices, two laundry rooms, two court yards, a medication room, dinning room, TV lounge, and kitchen. The facility appears clean, safe and sanitary. All resident bedrooms have the required components and furnishings. LPA observed resident bathrooms to have toilet paper, grab bars, paper towels and nonslip mats in the shower. LPA tested the water to be between 109.4-118.4 degrees Fahrenheit. LPA observed the laundry room on the first floor to be locked and made inaccessible when not in use. LPA observed the first floor medications cart and the memory care unit medications cart to be on the first floor and locked making them inaccessible to residents in care. LPA observed the laundry room on the second floor to be unlocked for assisted living residents to use. LPA observed the medication room to be on the second floor with medication carts locked and made inaccessible to residents in care. LPA observed the first aid kit to be in the medication room and has all the required components. LPA observed the memory unit doors to have operational delayed egress. LPA observed the kitchen to be clean and free of vermin. LPA observed a two day perishable and seven day nonperishable food supply on hand. LPA observed fire extinguishers in the kitchen and throughout the facility charged and with a service date of August 6, 2025. LPA observed the toxins and chemicals to be on the housekeeping carts and locked in the maintenance room behind the facility and made inaccessible to residents in care. LPA observed activities being conducted in the dining room during the inspection with residents. Continue on LIC 809-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 LPA observed two shaded seating areas outside for resident use that can be accessed through the memory care unit and the assisted living unit. LPA observed the emergency food and water supply to be stored in a shed in the memory care unit courtyard. LPA observed the outdoor areas to be free of debris and obstructions. LPA observed a fire inspection report from Thunder Fire Protection that was conducted on December 4, 2025 stating the facility fire alarms and smoke detectors were operational. LPA observed the last fire drill was conducted on December 12, 2025. LPA observed staff files and no discrepancies were observed. LPA reviewed resident files and no discrepancies were observed. LPA reviewed resident medications and no discrepancies were observed. Based on todays observations, no deficiencies are being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.

LPA did not observe any cockroaches in the hallway. LPA observed the housekeeping staff on shift and cleaning each unit and common areas. Two out of ten residents confirmed seeing cockroaches in the hallways and in their rooms while four out of four staff denied observing and receiving reports of cockroaches from residents. Four out of four staff confirmed that the facility receives monthly pest control services or as needed. In review of the pest control service reports, LPA confirmed the pest control services the facility on a monthly basis. The service reports dated November 25, 2025, December 29, 2025, and January 30, 2026, documents no signs of cockroach activity per the inspections or observed by staff. The investigation revealed that although two of ten residents confirmed observing cockroaches, there were no signs of activity in the ten units, hallway, and kitchen per LPA's inspection which was also confirmed on the service reports. It is determined that facility is actively addressing the issue by implementing proactive measures and utilizing professional pest control services. Therefore, due to conflicting information, the allegation is deemed UNSUBSTANTIATED. 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. An exit interview was conducted with Administrator Khatera Bahadory, and a copy of this report was provided at exit.

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced case management visit to amend Complaint Control Number 22-AS-20250701132137. Upon arrival, LPA Haddadin met with assistant AD Kathleen Tamondong, who granted entry to the facility. LPA explained the purpose of the visit. An exit interview was conducted with AD. At the conclusion of the visit, LPA Haddadin provided copies of all reports to assistant AD Kathleen Tamondong .

On the above noted date and time, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced case management visit to Amend a prior complaint. The complaint control number amended was 22-AS-20250701132137. Upon arrival, LPA Haddadin was greeted by Khatera Bahadory AD, who granted entry and was advised of the purpose of the visit An exit interview was conducted and a copy of this report and amended complaint reports were provided to AD.

LPA observed the resident census list with the shared room occupancies. The room where the mattresses were seen stacked has only one resident in care at this time. LPA observed a shared bedroom with one bed unoccupied and not being used. LPA observed a bed frame and box spring. LPA did not observe a mattress with an odor. Based on information gathered during the investigation the Department is unable to ascertain if the above 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, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with AD Khatera Bahadory and a copy of this report was left at the facility. 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 Upon interviews with Resident #1 (R1) it was revealed that the facility staff stacked the mattresses there for a short time while they were moving residents from the first floor to the second floor due to the construction that was taking place on the first level. R1 did not recall how long the mattresses and box springs were there but stated that they were not there for a long time and have since been removed. R1 informed LPA that no one slept on the stacked mattresses while they were in the room. Upon interviews with 2 of 2 staff revealed that they placed the mattresses and box springs in the room due to needing space while moving residents from the first floor to the second floor temporarily due to the construction that would be taking place. 2 of 2 staff informed LPA that the mattresses and box springs were removed out of the resident’s room and were not stored there. AD informed LPA that since they have been working at the facility, the bed in the room where the stacked mattresses were observed has remained unoccupied with no residents using the stacked beds. LPA observed AD's personnel record that states they started working at the facility on April 1, 2025. Based on observation, interviews and information gathered during the investigation the preponderance of evidence standard has not been met, therefore the above allegation is deemed UNFOUNDED. Meaning the allegation Facility failed to provide an appropriate bed was false, could not have happened and/or is without a reasonable basis. The department therefore dismissed the complaint. An exit interview was conducted with AD Khatera Bahadory and a copy of this report was left at the facility.

Per interviews, it was stated that the facility has a designated area located at the reception desk, where each resident has their own folder and that the receptionist will organize the mail and place mail in the corresponding resident folder. All resident and staff interviews also revealed that the facility will announce via intercom when mail has arrived to alert residents to retrieve their mail. During the tour of the facility, LPA Rodriguez observed the mail folders of residents and observed that all mail and packages were unopened and sealed. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, this allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with AD Bahadory. A copy of this report was explained and provided.

Per review of admission agreement, “Belongings Removal” section, In the event of a resident’s death or any way vacating of premises, facility will make responsible efforts to assist resident and/or responsible person with belonging removal. Facility requires all resident personal belongings to be removed within five days. Also, in the admission agreement the facility is not responsible for storing resident belongings. R1 has left the facility since April 30, 2025 to a new facility, and R1’s belongings has been here for almost a month, well past five days. The facility has been gracious to keep R1's belongings past the grace period. Per interviews with assistant administrator and Executive Director, the facility has never withheld R1’s belongings. R1 and their responsible party can pick up R1’s belongings anytime. The facility has also said they do not have contracts, promissory notes to arrange or pay for arrangements for belongings to be moved, it’s the sole responsibility of the resident or responsible party to move their belongings. Assistant Administrator and Executive Director said they have not touch R1’s belongings and left it the way R1 left it when they moved to the other facility. Based on LPA’s observations, LPA Tea toured R1’s former room and notice a closet full of miscellaneous items and several big plastic tubs and a lot of personal grooming items and fast-food drink cups on top of the facility dresser. All items are left untouched. R1 had also left a refrigerator. The facility hopes R1 and responsible party would pick up the items so they can have a bed available for a future resident. Out of respect for R1 they do not touch or move the items or throw it out. AA Tamongdong has said the facility has offered help to organize R1’s belongings. ED Bahadory also noted that when the other facility came to pick up R1, they said they would come back and pick up the rest of R1’s belongings. The facility has called and left several messages for R1’s primary responsible party and emailed. There has never been a response from them. Facility provided copies of emails sent to the responsible party of R1 prior and after R1 moving regarding facility placement and what to do with R1’s belonging. LPA did try to reach out R1’s primary responsible party and did not get any response as well. LPA did spoke to R1’s other brother who is not the primary responsible party and admitted that it was hard to get a hold or responses from the primary responsible party. And their other brother who lives in California does not have space permitted for R1’s belongings. They will try to reach out to R1 to see if they can arrange something or a possible solution. Report continued on LIC9099-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 Therefore, based on LPA Tea's observations and interviews conducted and records reviewed the allegation that facility staff are not giving resident’s belonging to resident after resident left the facility has been determined as UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies cited at this time and an exit interview was conducted with Executive Director Khatera Bahadory and Assistant Administrator Kathleen Tamondong. A copy of the report and confidential names list was provided to the facility.

out of 4 staff stated if the resident refuses the medication they will notate the refusal in the resident's chart. Interviews with staff indicated if a resident has a pattern of refusals they notify the resident's physician. Interviews also indicated staff would advise residents' of the side effects of refusals of certain medications. Staff stated they understand residents have the right to refuse medications and they honor that right. 6 out of 6 residents stated they are able to see a doctor of their choosing based on their own insurance. Facility manager stated they allow residents to choose their own physician based on their insurance. 4 out of 4 staff denied the allegation that facility is not allowing residents to see a physician of their own choosing. Therefore based on the preponderance of evidence through interviews and records reviewed the allegations staff are mismanaging residents medication and staff did not ensure resident was seen by their own physician are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies cited at this time and an exit interview was conducted and a copy of this report was provided.

Licensing Program Analysts (LPAs) Nancy Guillen and Ruth Martinez made an unannounced visit for the purpose of conducting a required annual Inspection. LPAs were greeted and granted entry by Facility Manager, John Garcia, after explaining the purpose of the visit. Administrator (AD) Eleanor P. Barrientos’s certificate was current and expires June 17, 2025. This is a Residential Care Facility for the Elderly (RCFE) licensed to one hundred forty-four non-ambulatory residents, of which thirty two may be bedridden, with a hospice waiver for ten. The facility is made up of two floors with seventy three resident bedrooms, two staff offices, two laundry rooms, two court yards, a Med room, dinning room, TV lounge, library, balcony, and kitchen. During the inspection, LPAs, Facility Manager,and Administrator Assistant conducted a tour of the inside and outside of the facility and observed the following: LPAs observed the See Something Say Something Poster (PUB 475) mounted on the wall by the facility entrance. LPA Guillen began inspection of resident rooms. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets with additional linens stored in the linen closet on the second floor. 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 105 and 114 degrees Fahrenheit. LPA Martinez toured the outside of the facility and observed outdoor passageways were free of obstruction. LPA observed the outdoor court yards had a shaded seating area with furniture for resident use. LIC-809C 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 Martinez observed the facility had a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide system was checked by Code Red Fire Inc on November 18, 2024 and inspection passed. Sprinkler system was inspected by State Fire Marshall on August 20,2024 and system passed. Egress doors were reportedly tested on February 17, 2025 and were tested throughout the facility by LPA. Fire extinguishers were mounted and located throughout the facility, fully charged with a service date of August 22, 2024. Toxic chemicals, cleaning solutions, and disinfectants were observed to be locked and inaccessible to residents in maintenance storage behind the building. Medication and First Aid kit was observed to be locked and centrally stored in the Med Room. First Aid Kit had all the required components. LPA Martinez observed the facility conducted their last emergency disaster drill on February 5, 2025 and is conducted monthly. LPA Martinez began review of the records. LPA reviewed eleven resident records. All the required documentation were present and current in the residents’ files reviewed. LPA reviewed nine employee records. All employee’s 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, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.

Per review of pest control maintenance paperwork and service logbook, facility currently has no bed bugs as shown in a recent service report from the facility’s pest maintenance company dated February 20, 2025. AA Tamondong said that pest control comes to inspect the facility quarterly and as needed. However there was a bed bug infestation reported on December 19, 2024 in which the facility was treated for. The following service report on January 2, 2025 shows that there are no evidence of bed bugs in the facility since December. Six out six staff interviewed said that there are no bed bugs currently and they react right away to contain and treat any infestation of bed bugs. All staff interviewed noted the facility check the rooms, gather clothes and bedding and wash and treat them. Afterwards facility maintenance staff clean and spray chemicals to treat for bed bugs. Then pest control comes out for prevention and maintenance. Per interviews, eight out twelve residents agree that the facility was doing a good job in preventing and acting upon bed bug infestations and pests. LPA Tea interviewed Resident 1 (R1) who felt there was no urgency or quick action when addressing a possible bed bug infestation. R1 said they felt itchy and the bites felt like goosebumps or “chill bumps.” R1 said the facility was slow to respond and check their room. While interviewing R1, LPA Tea was making observations and saw no visible bite marks on R1. LPA Tea inspected R1 and their roommate’s bed and the areas around and observed no bed bugs at the time. Per interviews, two out of two maintenance staff who checked R1’s room confirmed there were no bed bugs in the room. Maintenance staff checked and treated R1’s room upon report of possible bed bugs. AA Tamondong noted that pest control will do another inspection on February 24, 2025. Therefore, based on LPA Tea's observations and interviews conducted and records reviewed the allegation that facility staff is not acting to prevent a bed bug infestation has been determined to be unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies cited at this time and an exit interview was conducted with Administrator Eleanor Barrientos and Assistant Administrator Kathleen Tamondong. A copy of the report and confidential names list was provided to the facility.

paperwork confirms resident was discharged back to facility on 03/26/2024. Based on interviews conducted, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, 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 facility.

On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced Case Management visit to follow up on an Incident that occurred on March 14, 2024. LPA discussed purpose of visit with Administrator Erin Rehbein. On March 19, 2024 Department received a Self reported SOC 341 Report from Facility. Facility reported that an incident occurred between two residents on March 14, 2024. Staff reported to Administrator that in passing in facility hallway, Resident 1 (R1) approached Resident 2 (R2). Staff reported that R2 was rubbed by R1 on the right side thigh and butt area. Staff also reported that same incident occurred a second time on March 16, 2024. Upon learning of incident Administrator had staff member (S1) translate to R2 regarding incident. Based on translation S1 stated that they asked R2 if they were touched inappropriately to which R2 shook their head "no". S1 asked R2 if they were hurt and R2 stated "Ok" in Vietnamese. Based off interviews with staff, Administrator stated that they spoke to R1 regarding incident and R1 claimed they "did not know anything". Facility had sent out R1 to hospital for Psych Evaluation. R1's face sheet, Appraisal, and Emergency info all state that R1 has a health history of Dementia and Schizophrenia. R1's Physician's Report dated November 30, 2023 has diagnosis of Pneumonia, COPD and mild cognitive impairment. At time of visit R1 not present for interview. R1 has not returned to facility. Administrator states upon R1's discharge they plan to work with conservator regarding plan of care moving forward. During visit, with the help of staff 1, LPA attempted interviewing R2 regarding incident, upon attempt R2 nodded head "yes" when asked if they were okay. R2 was asked if they had been touched and R2 nodded "no". R2 was unable to verbally communicate due to a language barrier. LPA observed R2's Physician Report which has Schizophrenia listed as primary diagnosis and lists Cerebral Infarction as secondary diagnosis. R2's Resident's Appraisal dated 11/30/23 states R2 has a communication deficit and unable to communicate needs clearly. CONTINUED ON 809C 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 Administrator contacted responsible parties, Licensing, Ombudsman and Police regarding incident. LPA received copies of resident physician's reports and appraisals. An exit interview was conducted with Assistant Administrator Kathleen Tamondong and a copy of report was left at facility.

Based on interviews conducted and record review, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, 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 facility.

On this day Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit for the purpose of conducting a collateral visit in regards to an open complaint investigation unrelated to current licensee. LPA met with Administrator Erin Rehbein and explained reason for the visit On this day LPA conducted interviews related to complaint control number: 22-AS-20200925103558 During visit LPA conducted additional interviews and gathered records related with the following open complaints for Palms Retirement Center: 22-AS-20231009110307 22-AS-20230829083600 22-AS-20230802135409 22-AS-20230727154102 Exit interview conducted with Administrator and copy of report was provided to facility.

CONTINUED... and handling blood and other potential infectious materials following all safety precautionary measures. During the facility inspection visits conducted on 6/5/2023 and on today’s date, LPA Quiroz observed facility staff working at the facility to be wearing pertinent Personal Protective Equipment (PPE), conducting hand hygiene, cleaning and disinfecting with use of gloves in appropriate settings as evidence by observing staff utilizing gloves when disinfecting bathroom areas, transporting trash, serving meals and while washing dirty linen and resident’s clothing items in laundry area. Therefore, based on the preponderance of evidence gathered through interviews, observations conducted by LPA Quiroz and documentation review, the allegations that the " Staff are not following infectious control plan” is deemed UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint. No deficiencies cited during today's visit. An exit interview was conducted with (AD) Erin Rehbein and a copy of report was provided at exit.