Scott Villa

During the course of investigation, LPA obtained copies of resident roster and staff schedule. LPA reviewed residents' files and obtained copies of including but not limited to the following documents: LIC601 Identification and Emergency Information; LIC602A Physician's Report; LIC625 Appraisal/Needs and Services Plan. LPA interviewed the following: R1, staff (S1) and administrator (ADM) on October 30, 2025; R2 and R5 on January 28, 2026 and obtained additional information from ADM. R1 stated the incident happened inside the facility in the hallway when R1 was going to the bathroom. During interview, LPA didn't observe any bruise in R1's face but scratches on left arm which R1 stated he scratched because his arm was itching. R2 stated R1 was messing up his coffee and his legs so he slapped R1's hand and it happened on the common area inside the facility. R2 was not able to provide the date nor names of staff or other residents who witnessed the incident. R5 stated the incident happened outside in the smoking area of the facility when R1 confronted another resident and R2 intervened. R5 futher stated that R2 turned around to R1 and flailed his hands toward R2 and R2 pushed and slapped R1 on the cheek. R5 stated the facility van arrived and the driver separated R1 and R2. S1 stated not observing any incident between R1 and R2. ADM stated the van driver didn't report the incident. ADM further stated that R1 and R2 came to her on separate occasions regarding R1 staring at R2 and R2 spreading rumor about R1. ADM stated after the report, ADM transferred R1 and R2 to rooms far away from each other. LPA reviewed the f acility's camera footage for October 22, 2025 with ADM which covers the inside common areas. LPA didn't observed any incident between R1 and R2 on the alleged date. ADM indicated, and LPA observed the smoking area obstructed from the camera. Based on information gathered, the allegation is unsubstantiated. A finding that the complaint 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. No deficiency cited. Exit interview conducted and copy of this report provided.

While at the facility for a complaint (Control # 15-AS-20230125080856), Licensing Program Analyst (LPA) Delmundo observed the administrator's signatures on the block designated for the resident and/or responsible person to be signed on resident's (R1) LIC601 Identification and Emergency Contact Information,and LIC625 Appraisal/Needs and Services Plan. LPA asked, and Jonabelle Tolentino, administrator, confirmed it's her signature. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with Jonabelle Tolentino. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

Page 2 Copies of including but not limited to R1’s following documents were also obtained: Admission Agreement; LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; Pre-placement Appraisal; LIC9172 Functional Capability Assessment; LIC625 Appraisal/Needs and Services Plan; Unusual Incident Reports; facility notes; doctor's visit notes. Local law enforcement was also involved in the investigation and copy of police report was obtained and reviewed. The following were interviewed: hospice nurse (RN) on February 11, 2025; R1’s family member (FM) on February 11, 2025; R1’s roommate (R2) on June 5, 2025; staff (S1, S2, S3, S4) on June 5, 2025 and June 30, 2025. Documents showed R1 was on hospice, has major neuro cognitive disorder, required full assistance, and was non-verbal. Pre-placement Appraisal indicated R1 needed special observation/night supervision. RN confirmed RP’s statement that the facility called hospice agency on January 20, 2025, and that R1 had a cut on the forehead. RN further stated that RN came to visit on January 21, 2025, and the cut was deeper than what the facility described. The cut did not require hospitalization, but it was red and about two centimeters long, and there was bruising forming around R1’s eyes. RN asked the care staff for an explanation. The care staff believed the incident occurred around Sunday night, January 19, 2025, going into Monday morning, January 20, 2025, but the staff provided no specific time, or explanation for the cause of the unexplained injuries. FM visited R1 at the facility on January 23, 2025 and was informed by the staff that R1 had a cut on forehead and two black eyes. The staff told FM that they think R1 did it to self but when FM saw R1’s condition, FM felt it was unlikely that R1 could have caused the injuries to thyself. .....continued on 9099C (page 3) 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 Page 3 Staff initially believed R1’s injuries were self-inflicted due to R1’s history of restlessness, and staff speculated that R1 may have rolled over and bumped self on the bed rails. R1’s roommate, R2, was also suspected by staff and by the local law enforcement of causing the injuries; however, R2 was interviewed by the Department and police officer and R2 denied any involvement and claimed not to have witnessed anything. Overnight shift staff are supposed to check on residents every one to two hours but based on law enforcement’s review of the facilities’ camera footage, no checks were made by care staff between 0325 to 0723 hours. Staff (S2) was seen entering R1 and R2’s room at 0544 with a broom and again at 0710 with tray of food, but the injury was not discovered until about 0723 hours. Two of the staff (S2 and S3) were inconsistent in their statements. S3 initially reported to the police that she cared for R1 the night of the incident and saw no injuries. However, S3 later recanted and admitted not on duty and later confirmed that it was S1 was the only staff working the overnight shift on the night of the incident. S1 was interviewed by the Department. S1 stated she conducted her rounds every hour during the overnight shift despite camera footage showing no checks were completed between 0325 to 0723 hours. Therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. A $500.00 immediate civil penalty is assessed and will continue for $100.00/day until corrected. An additional civil penalty may be assessed. Deficiency, plan and proof of correction and civil penalty were discussed with the administrator. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.

While at the facility conducting an investigation of a complaint (Control # 15-AS-20250204131826) and upon review of resident's (R1) file, LPA observed R1's medications on the medication bottles were discarded to a container. R1 was discharged from the facility effective 1/29/25. The Medication Destruction page of the LIC622 Centrally Stored Medication and Destruction Record was not completed. Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D . Failure to submit proof of correction by plan of correction due date may result civil penalty. Deficiency and plan and proof of correction were discussed with Lulin 'Lucy' Wu, back-up administrator. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

LPA obtained copies of LIC9020 Register of Facility Residents for 10/14/24, 12/31/24 and 2/07/25. LPA reviewed and compared the 3 LIC9020s and observed 4 residents (R1, R2, R3, R4) listed on 10/14/24 LIC9020 were no longer on the 2/07/25 LIC9020. LPA reviewed these residents' records and obtained copies of including but not limited to the following: Admission Agreement; LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; Pre-placement Appraisal; LIC625 Appraisal/Needs and Services Plan; facility notes; doctor's orders of medications; Medication Administration Records (MARs); LIC622 Centrally Stored Medication and Destruction Records. Out of these 4 residents, only R1 has seizure medications. The other 3 did not have seizure disorder diagnosis nor seizure medications. LPA interviewed S1, S2 and BUA. S1 and S2 denied receiving calls for R1, R2, R3 and R4 pertaining to medications. BUA stated when Jonabelle Tolentino (administrator) went on vacation, S3 took over the administration of medications from around 12/28/24 through 1/08/25, 1/09/25. BUA also stated that S1 took over the administration of medications when S3 went on vacation up until this day, 2/12/25, which LPA confirmed with S1. LPA reviewed the doctor's order of medications and compared with LIC622 and MAR. Review of records showed S1 has medication training and R1's MAR were properly filled-up. Based on records review and interviews, the allegation of 'Staff are not distributing a resident's medication as prescribed' is closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

R1 was interviewed and stated when he was at the dining room on 8/12/23 and asked S3 if S3 has seen his salt and salad dressing in his room , S1 yelled at him. One of the other 4 residents interviewed stated she was yelled at by S1. . Four staff including S1 and S3 were interviewed. Three of the staff denied yelling any residents including R1. One of these staff stated she must be in the laundry room when the incident in the dining room happened. The other staff stated not observing the incident but have observed S1 raising voice on other residents including R1. Although S1 denied yelling at R1, video camera footage of the alleged day of incident was reviewed by LPA and administrator and observed R1 talking to S3 and S1 came to the scene. S1 was observed pointing fingers and moving her hands while talking to R1. Hand movements and facial expressions seemed S1 raising voice which administrator agreed. Based on information gathered, the preponderance of evidence standard has been met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations. and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the administrator. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this 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 Four staff who were present on the day of the alleged incident were interviewed. Two of the staff denied throwing any of the residents personal belongings. The other 2 staff who did the cleaning stated they threw away only the food items that were expired, rotten and with mold and told R1 they are throwing them away. Four other residents were interviewed including R1's roommate. R1's roommate confirmed that the 2 staff who did the cleaning of their room only threw away the food items that were expired, rotten and with mold and the items that were not expired were not thrown away. LPA observed some food items in the room when LPA conducted inspection on 8/17/23. The other 3 residents stated that none of their personal belongings were thrown away. Based on information gathered, the allegation is closed as unsubstantiated. A finding that the complaint 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. No deficiency cited. Exit interview conducted and copy of this report provided to the administrator.

On this day, 06/05/2025 at 9:00 AM, Licensing Program Analysts (LPAs) David Doidge and Andrew Christy arrived unannounced to conduct an annual required inspection LPAs met with Jonabelle Tolentino, administrator, and informed the reason for visit. LPAs toured the facility including but not limited to common areas, bathrooms, shower room, living/activity room, kitchen, dining area, front, side and backyard. Facility has adequate food supplies for 7 days of non-perishables and 2 days of perishables. Fire extinguishers were observed fully charge with tags showed serviced 02/25/2025. Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in a common bathroom measured at 116 degrees Fahrenheit. Facility conducts fire drills every 3 months, and records showed last conducted 04/28/2025. Emergency Disaster Plan last updated 03/24/2025. LPAs reviewed five (5) residents and five (5) staff files; all were complete. Medications were checked and compared with doctor's orders on file and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources. No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.

R1 acknowledgedm and stated she knows RP and RRP, but indicated she has to stay away from them. R2 stated the staff allow him to receive and make phone calls using the facility telephone, while R3 indicated he does not want to make phone calls. R1’s family members (FM1 and FM2) stated they gave instruction to the facility not to give the phone to R1 when RP amd RRP call because of the alleged abuse and that an investigation is still on-going for the complaint they filled to another agency for the abuse. Information was received by LPA from the said agency. S1 confirmed FM1 and FM2 statements that the facility was told not to give the phone to R1 when RP called. S2 indicated that she didn’t give the phone and hung up when RP called the facility. Based on the information gathered, and R1’s family members and facility's intent to protect R1, and R1's statement she has to stay from RP and RRP, the allegation is closed as unsubstantiated. A finding that the complaint 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. No deficiency cited. Exit interview conducted and copy of this report provided to the administrator.

On this day, January 29, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 2 complaint (Complaint #15-AS-20250127122838). LPA met with Lulin 'Lucy' Wu, back-up administrator (BUA), and informed the reason for visit. LPA obtained copies of LIC9020 Register of Facility Residents. When verified for total number of residents on LIC9020, BUA stated resident (R1) passed away on 1/15/25 in the hospital; however, review of documents and LPA's efaxed folder for the facility revealed no Death Report submitted. LPA also observed Unusual Incident Reports and SOC341 on resident's (R2) file but these documents were not submitted nor received by the Department. Facility did not report to the Department within 2 hours upon knowledge of the suspected abuse. LPA toured the facility inside out with the BUA. LPA inspected the common areas, activity room, dining room, kitchen, ensuite toilets, shower room. LPA randomly selected 6 residents rooms for inspection. LPA observed the following: -at 2:19 pm to 2:21 pm, auditory signal on the exit door in one of the resident's rooms not in working condition. LPA also observed extra hospital bed sideways against the wall and detached baseboard and wall moulding with protruding nail in this room. .....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 Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation of section 87303(a) within 12 month period. Failure to submit proof of correction by plan of correction due date, may result in additional civil penalties. Deficiencies and plan and proof of corrections were discussed with the BUA. Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.

Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with Jonabelle Tolentino, administrator, and informed the purpose of visit. Facility has an approved LIC808 Mitigation Plan on file. LPA toured the facility inside out with Jonabelle Tolentino. LPA inspected the living room, dining area, kitchen, hallways, side and backyard. LPA randomly selected 9 bedrooms for inspection. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days. LPA observed screening station by the front entrance with hand sanitizer, no touch temperature probe and Visitor's Log. Visitor's temperature and symptom checks are done at entrance. Residents and staff are screened for COVID-19 symptoms, and temperature checked and recorded daily. Facility keeps record of proof of vaccination of residents and staff. Supplies of PPEs were checked and observed adequate for 30 days, and antigen test kits are readily available. Staff were fit tested for N95 respirator, and copy of record was requested by LPA which LPA received on May 12, 2022. Fire extinguishers checked and observed fully charge with tags showed serviced January 19, 2022. Hot water temperature in one of the common bathrooms was tested and measured at 112.6 degrees Fahrenheit. . .....continued next 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 Administrator to submit copies of the following updated documents by June 24, 2022: 1. LIC308 Designation of Facility Responsibility 2, LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan 4. Proof of $3M liability insurance. LPA reminded that new Infection Control Plan should be submitted by June 30. 2022. No deficiency cited during today's visit. Exit interview conducted and copy of this report provided.