Glen Terra Assisted Living.

Regarding the allegation: Staff did not prevent resident from being physically harmed by another resident. It is being alleged that Resident #1 (R1) was physically and verbally abused as they were being transported in the van back to the assisted living facility where R1 lives by Resident #2 (R2). During LPA’s interview with R1, R1 stated, “R2 told them to shut up then R2 hit them on the arm and facial area with a newspaper and their glasses fell.” LPA asked in what van did this happen and R1 stated, “it was in the day program van.” During LPA’s interview with R2, R2 stated, “they don’t remember hitting R1.” Furthermore, LPA interviewed Staff #1 (S1) whom stated, “that R2 hit R1 during the transport back to the facility.” LPA asked if the transportation van belonged to the facility and S1 stated, “no, it was from PACE WElBEHEALTH van.” Let it be noted, R2 did hit R1 but it did not happen at the assisted living facility, and it did not happen in the assisted living facility van. Therefore, based on the interviews conducted the allegation is UNFOUNDED at this time. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis. Exit interview conducted and a copy of this report issued to the Executive Director .

Cont. from LIC 9099 11:30a.m. – 3:45p.m., LPA interviewed ED, other staff and four (04) out of one hundred one (101) residents including R1, R2 and other residents that have knowledge of the incident. ED and other staff revealed that staff did not witness any incident of verb altercation between R1 and R2. R2 came and reported to staff that while R2 and three (3) other residents were sitting outside having a conversation, R1 walked towards them and accused R2 of talking about R1. R2 denied the accusation and told R1 to leave them alone and continue talking with R3. R1 walked away. Staff never received any complaints from R1 regarding the incident. R1 did not want to talk to staff about it. During interviews R1 revealed inconsistent statements regarding the incident. R2 and other residents present during incident verified the information received from staff. A review of residents’ records and other internal documents did not reveal any pertinent information to verify the allegation. Overall investigation revealed that although there was an incident involving R1 and R2, there is no sufficient information and/or evidence to verify that R2 threatened R1. Therefore, based on interviews and record review, the allegation is UNSUBSTANTIATED at this time. No health and safety hazard noted during this visit. Exit interview was conducted and a copy of report was issued.

Cont. from LIC 9099-C Therefore, to verify if facility had appropriate coverage for staff shortages during night shift, LPA requested a revised staff schedule for the month of June and July 2025 to determine appropriate staff coverage. On 11/04/25 between 11:30a.m. – 3:45p.m., LPA interviewed additional three (03) residents and on 01/06/26 LPA interviewed three (03) more residents via -phone. Prior to this visit on 12/20/25, LPA Alvizar-Ettima reviewed the documentation previously obtained from the facility Insufficient staffing to meet resident needs It was alleged that there are insufficient staff members to provide for care and supervision for all residents residing in the facility. There are only two (02) night shift caregivers for the entire facility. During mealtime in the dining room, residents’ food is served by the caregivers instead of kitchen staff. Interview with Executive Director revealed that for night shift there are always no less than two (02) staff and no more than three (03) staff working. Plus, five (05) evening shift staff may work double shifts to cover shortage of night shift staff. Executive Director also stated that caregivers are trained in Dining Room procedures and permitted to assist with meal service as part of their job duties. Four (04) facility staff (S1-S4) interviewed during investigation, confirmed the information provided by Executive Director. Staff confirmed that evening shift staff work double shifts to assist night shift if needed. As a part of their job duties, caregivers also assist residents in the dining room. Meal service duties are not compromising resident supervision or care. Residents did not address any concerns regarding staff shortages. During facility visits, residents were observed to be appropriately supervised, and staff were present and engaged in resident care activities. LPA observed caregivers present in resident areas, responsive to resident requests, and assisting them as needed. A review of documents provided by Executive Director verified the information revealed from staff interviews. No information or evidence was obtained to corroborate with the allegation. Based on observation, interviews and records review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Cont. from LIC 9099 During subsequent visits on 11/04/25 between 11:30a.m. – 3:45p.m., LPA interviewed additional three (03) out of one hundred one (101) residents and on 01/06/26 LPA interviewed three (03) additional residents via -phone. Prior to this visit on 12/20/25 LPA Alvizar-Ettima reviewed records and other documentation obtained during the initial visit. Facility staff hit client with an object, resulting in bruising It was alleged that during nighttime hours, a staff member became upset because Resident #1 (R1) was out of bed. R1 reported that staff folded R1's walker and began swinging toward R1. R1 states they blocked the walker with the back of their hand, resulting in bruising to the back of both hands. During interviews with R1 revealed inconsistent statements regarding the incident. R1 appeared confused and was unable to clearly describe the events. R1 later stated they may have hurt themselves but could not provide specific details. Staff #1 (S1) and Staff #2 (S2) denied hitting R1. Both staff reported R1 was confused, attempting to leave the facility at night, throwing personal belongings, yelling, and exhibiting agitated behavior. Staff reported attempts to redirect R1 back to bed. S2 reported hearing R1 state, “Oh, I hurt myself,” but did not witness an injury occur. The Executive Director reported R1 has a history of nighttime confusion and behavioral episodes and denied staff misconduct. During interviews with residents, ten (10) out of one hundred one (101) residents reveal staff has not hit them and did not observed staff hitting R1. Resident #2 (R2) reported R1 is outspoken and has a history of agitation but R2 did not witness the incident. During facility visits, LPA observed staff present in resident areas, engaged in resident care activities, and responsive to resident needs. No inappropriate staff conduct was observed. Facility records indicated R1 has mild cognitive impairment and is not permitted to leave the facility unassisted. Based on interviews, observation and review records, there is insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazard noted during this visit. Exit interview was conducted and a copy of report was issued.

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced One (1) year Required visit at this facility. LPA met with Executive Director Carlos Lara and explained the reason for the visit. At 9:23 AM, with the assistance of the Executive Director, LPA toured the facility inside and out and the following was observed: The facility is a four (4) storey building fire cleared for 155 non-ambulatory residents, four (4) of which may be bedridden and has hospice waiver for twenty (20) residents. The facility had submitted and approved Mitigation and Infection Control plan. The facility's smoke alarms are hard wired and interconnected. Last testing, which includes the sprinklers, fire door, alarms and exit light was completed on 12/12/24. Fire/earthquake and emergency evacuation drill is conducted on monthly basis for different shift and the last one was conducted ton 08/13/25. The fire extinguishers throughout the facility hallways are on all four (4) floors, all extinguishers were last serviced on 05/20/25. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperatures. There was a sufficient amount of perishable and non-perishable food at the facility and properly stored. Residents do not have access to the kitchen. Listing for residents that require a special diet is posted on the kitchen wall. There were no pesticides or poisons observed near any food areas. Kitchen/food service staff observed with gloves and proper hair cover. Bedrooms: Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms. Emergency push button was tested for proper function. 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 Bathrooms: Resident bathrooms were properly supplied and had functional fixtures. Hot water temperature in random resident bathrooms on all floors were checked and measured at a range of 113.0°F to 117.5°F. Common Areas : Common areas, including the lobby, activity rooms, dining rooms, and reading room appeared clean and were properly furnished. There is a coffee/hot beverage station at the reading room. Salon was closed and locked during the day of the visit. Surrounding Grounds : Entry/exits were free of obstruction. The outdoor/patio areas are located at the front and beside the dining room. There is no body of water in the facility Laundry: Each floor has it's own designated laundry area for personal clothing of residents. The main laundry area is located on the 1st floor beside the employees' lounge. All the laundry areas were locked during the day of the visit. Staff Office/Work Station: Administrator's office is located on the first floor, by the entrance. Medication room and nurses' office on the second floor. Resident Files : LPA conducted a file review of resident records. Residents records observed to be complete and updated. Staff Files : LPA also conducted a file review of staff records. Staff records observed to be complete and updated. Medications : There are medication carts stationed at the medication/nurses' room. There is a refrigerator, with lock, in the medication room to store medicine that requires cooler temperature. Medication room is also locked at all times. Medication documentation and implementation appeared to be complete. There is a First aid kit on each medication cart and another by the reception area. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of this Report Issued.

A review of the facility’s maintenance records show that facility’s most recent fumigation was 04/01/2025. During interviews with staff, Staff #1 (S1) stated they have had cockroaches in the past and every now and then a water bug might find its way in, but facility gets regular pest control and have not had any issues lately. S1 added that nothing has been reported in recent days. All other staff stated they have not witnessed cockroaches on the third floor or anywhere in the facility. During interviews with residents, one (01) out of ten (10) residents stated they saw cockroaches in the facility recently. All other residents stated they did not observe cockroaches in the facility. Based on observations, record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.

It was alleged that staff does not ensure resident receives adequate incontinence care. It was reported that R1 was left in a wet diaper for an extended period of time. To investigate this allegation on 08/20/2024 between 10:30am and 11:30am, staff interviews were initiated. Interviews revealed that staff change residents diapers every two hours or as often as needed. R1 is checked on more often by staff since they have a history of skin breakdown and due to their diagnosis of diaper dermatitis. Between 11:30am and 12pm, LPA reviewed facility records. Records confirmed what staff told LPA. LPA attempted to interview R1, but they were not able to answer any questions. Based on interviews and records review there is not sufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. It was reported that staff allowed resident to sleep in a wheelchair overnight. To investigate this allegation between 10:30am and 11:30am, staff interviews were initiated. Interviews revealed that night staff constantly check on residents throughout the night and do not allow residents to sleep in their wheelchairs. In addition, staff indicated that R1 has a history of making up stories in order to get attention. Based on interviews there is not sufficient information to support the allegation. Thus, the allegation is UNSUBSTANTIATED at this time. No health and safety issues noted at this time. Exit interview conducted and a copy of the report was issued.

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced annual inspection visit. LPA met with Administrator Carlos Lara. The purpose of the visit was explained. Facility is licensed to served 155 non - ambulatory residents, of which 4 may be bedridden and has a hospice waiver for 20 residents. Facility is a 4 story building, with a lobby, dining room, 2 activity rooms, a kitchen, a small outdoor shaded patio, medication room is on the second floor, and a salon in the third floor. Fire alarm sprinkle system was observed throughout the facility. There are no large bodies of water on the premises. LPA Valenzuela conducted a walk through with the Administrator and observed the following: Facility is clean and free of odors in common areas. Elevators are in working condition. All bedrooms have the proper bedding, and furniture. The facility maintains a comfortable temperature at 78 degrees. The smoke detectors are hardwired and interconnected and observed to be operational. There are carbon monoxide detectors in the facility. Fire extinguishers are located throughout the facility and were last serviced in May of 2024. The bathrooms were checked for cleanliness and proper operation. LPAs observed the appropriate grab bars in the showers and toilets. The hot water temperature was measured at 115.6 degrees. LPA observed seven days worth of perishable and non-perishable food. There are three complete first aid kits. Exit interview conducted. A copy of this report was issued and signature obtained. No deficiencies were issued at this time.

(continued from LIC 9099) Regarding the allegation that Staff are not responding to residents’ call buttons in a timely manner, it was alleged that R1 waited for 45 minutes to an hour before someone respond to R1's call. LPA's interview with R1 today revealed that whenever R1 pushed own call button, staff respond within ten (10) minutes at most. LPA's interview with three (3) residents on 03/27/24 at 12:00 PM to 1:30 PM and eight (8) residents today between 12:00 PM to 2:00 with a total of eleven (11) total residents interviewed, six (6) of which are incontinent, revealed that ten (10) out of eleven (11) residents stated that staff respond to call button within reasonable time or within three (3) minutes to a maximum of fifteen (15) minutes. One (1) out of eleven (11) resident interviewed did not use the call button while living at the facility. Based on the information gathered during this and prior visit, these allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.

(continued from LIC 90990 Further, LPA’s interview with the Kitchen supervisor and the Executive director today between 12:00 PM to 1:30 PM also revealed that kitchen is being fumigated/treated by their contracted pest control once a month or more during summer to avoid any infestation in the kitchen. LPA's record review confirmed that the facility has a contracted pest control company that visits the facility once a month to treat/fumigate reported rooms, common areas and random rooms to avoid any kind of infestation. LPA's interview with nine (9) residents or 10% of the current census between 12:00 PM to 1:30 PM revealed that nine (9) out of nine (9) residents did not see any roaches in their room or any common areas of the facility. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.

LPA observed R1 to be clean, well nourished, and in good spirits. Based on interviews, records review, and observation, there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.

Based on interviews and record review there is not sufficient information to verify this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. It was alleged that staff do not ensure residents personal property is adequately disinfected. It was reported that the all the residents clothes are washed together and not separated from those that have scabies. To investigate this allegation between 1:00pm and 2:00pm, staff interviews were initiated. Interviews revealed that residents clothes are washed separately, but the linens and towels are not. The washing machines and dryers are pre-set to hot temperatures to make sure everything gets disinfected. In addition, if the towels or linens are white, bleach is also added to the wash. There are six washing machines and there is a schedule that each resident has as to when their clothes gets washed. Currently, the facility does not have any residents with an active case of scabies. Between 3:15pm and 3:30pm, LPA went to inspect one of the laundry rooms. LPA observed more that one washing machine and staff washing residents clothes separately. Based on interviews and observation, there is not sufficient information to support this allegation. Thus, this allegation is UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced inspection visit. LPA met with Administrator Carlos Lara. The purpose of the visit was explained. Facility is licensed to served 155 non - ambulatory residents, of which 4 may be bedridden and has a hospice waiver for 20 residents. Facility is a 4 story building, with a lobby, dining room, 2 activity rooms, a kitchen, a small outdoor shaded patio, medication room is on the second floor, and a salon in the third floor. Fire alarm sprinkle system was observed throughout the facility. There are no large bodies of water in the property. LPA Valenzuela conducted a walk through with and observed the following: Facility is clean and free of odors in common areas. Elevators are in working condition. All bedrooms have the proper bedding, and furniture. The facility maintains a comfortable temperature at 78 degrees. The smoke detectors are hardwired and interconnected and observed to be operational. There are carbon monoxide detectors in the facility. Fire extinguishers are located throughout the facility and were last serviced in May of 2023. The bathrooms were checked for cleanliness and proper operation. LPAs observed the appropriate grab bars in the showers and toilets. The hot water temperature was measured at 111.5 degrees. LPA observed seven days worth of perishable and non-perishable food. Exit interview conducted. A copy of this report was issued and signature obtained. No deficiencies were issued at this time 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