Citrus Gardens.

Allegation #1: Staff will not return residents' belongings. The complaint alleged that the resident left Citrus Gardens and currently resides at Helping Hands Room and Board, where the resident is having difficulty retrieving the resident's (R1) belongings. On June 6, 2024, the department interviewed the former Executive Director (ED1), who stated that they helped R1 pack most of their belongings, medications, and all items given to the Helping Hands Room and Board (HHRB). ED1 also stated they went back a second time to bring R1 the remaining belongings. On April 20, 2026, the department interviewed the Executive Director (ED), who denied the allegation. The ED stated that when a resident moved out of the facility, staff ensured that all belongings and medications were given to the resident and to the HHRB. The department also interviewed the Administrator (A1), who denied the allegation. A1 explained that before any resident leaves the facility, we must ensure that all medications, the doctor's orders, and the resident's belongings are given to the resident or their family members. Additionally, the department interviewed four staff members (S1-S4), all of whom denied the allegation. They also stated that the facility would ensure residents took their belongings. They further stated that even when a resident goes out over the weekend, the facility would ensure the resident's medications are with them, so they don’t miss any. The department also interviewed six residents (R2-R7), all of whom said they like living here. 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 On April 21, 2026, the department interviewed the representative of (HHRB), who stated that the facility gave R1 all of R1's belongings. However, after R1's medications were almost running out, the HHRB called the facility to ask about refilling them, and the facility stated that R1 needed to see the doctor and call the pharmacy for a refill. The department was unable to interview R1 because R1 moved out of HHRB in December 2024. On April 20, 2026, the department reviewed the facility's admission agreement dated 09/30/2023, which stated that all resident personal property would be removed from their rooms within fifteen (15) days. And the facility shall have the right to dispose of such abandoned property in accordance with California Law. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An Exit interview was conducted, and a copy of this report was provided to Administrator Liliana Moreno.

Allegation #1: Staff did not prevent resident from causing injuries to another resident in care. The complaint alleged that the resident was physically assaulted by another resident and sustained injuries to the resident's eyes. On April 16, 2026, the department interviewed the Executive Director (ED) and the Administrator (A1), both of whom stated that they try to have more staff around residents who are aggressive toward other residents. The Administrator noted that the caregivers are aware of which residents require more supervision and who are likely to act aggressively. Additionally, four staff members (S1-S4) were interviewed, all of whom denied the allegation. They also stated that they are very alert and proactive around residents to prevent any residents from causing injuries to others. The department then interviewed six residents (R3-R8). 6 out of the six residents denied ever being hurt by other residents. However, the department was unable to interview R1 and R2 because they no longer reside at the facility. On April 16, 2026, the department reviewed the facility's notes dated 09/06/24 through 09/13/24, which documented that the facility assigned a one-on-one caregiver to R1 due to aggressive behavior and altercations with others. On 09/11/24, during the incident, the caregiver intervened and called Medical Emergency Services (MES), which transported residents R1 and R2 to the hospital. R2 was placed on a 51/50 hold. Both were discharged on 09/12/24. The department also reviewed the Unusual Incident Report dated 09/12/24, which was sent to Community Care Licensing and the Ombudsman. 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 Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to Administrator Liliana Moreno.

Allegation #1: Staff do not meet residents’ incontinence needs. The complaint alleged that residents' briefs were changed late and that this caused rashes. On April 16, 2026, the department interviewed the Executive Director (ED), who denied the allegation and stated that the caregiver changed residents' diapers every two hours and as needed. At the same time, the department interviewed the Administrator (A1), who also denied the allegation and stated that caregivers changed residents' diapers every two hours and as needed. A1 also stated that if a resident needed to be changed sooner, the caregiver or any staff member would do so. The department interviewed four staff members (S1-S4), all of whom denied the allegation and stated that they know their residents and how often they need to be changed. Additionally, the department interviewed 6 residents (R1-R6), 4 of whom wear diapers, and none reported that the caregiver took too long to change them. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. Report Continue on LIC9099C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation #2: Staff do not ensure residents are bathed. The complaint also alleged insufficient time for showers and that residents are not receiving them when they should. On April 16, 2026, the department interviewed the Executive Director (ED), who denied the allegation and stated that the facility maintains a shower schedule for all residents, including those in hospice. At the same time, the department interviewed the Administrator (A1), who also denied the allegation and stated that residents are showered three times a week, with some showering every day if they choose. The department interviewed four staff members (S1-S4), all of whom denied the allegation and stated that residents have scheduled showers, with some showering three times a week or every day. Additionally, the department interviewed 6 residents (R1-R6), all of whom reported showering regularly but sometimes not wanting to shower. On April 16, 2026, the department reviewed the facility’s residents' weekly shower schedules, which showed that most residents are scheduled three times a week, and hospice residents are scheduled three times a week as well. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. Report Continued on LIC9099C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation #3: Staff do not maintain the facility in clean and sanitary condition. The complaint alleged that there are no housekeeping services on weekends and that, upon arrival, visitors often report that the facility is generally not clean. On April 16, 2026, the department interviewed the Executive Director (ED), who denied the allegation and stated that the facility has caregivers and housekeepers on weekends. At the same time, the department interviewed the Administrator (A1), who also denied the allegation and stated that the facility schedules three to four housekeepers on weekends. The department interviewed four staff members (S1-S4), all of whom denied the allegation and stated that the facility schedules housekeepers on weekends because residents' rooms need to be cleaned then. Additionally, the department interviewed 6 residents (R1-R6), all of whom stated that their rooms are cleaned on weekends as well. They also stated that if they spill something, the housekeeper cleans it right away. On April 16, 2026, the department toured the facility and some residents' rooms. The rooms were clean, and the facility did not appear to be in disrepair. The department observed that the housekeeper was mapping the residents' floor while the residents were outside. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An Exit interview was conducted, and a copy of this report was provided to the Executive Director, Valerie Garcia.

Allegation #1: Staff do not ensure residents are provided feeding assistance. The complaint alleged that residents in memory care are not fed because staff are slacking off. During lunch, three residents returned their full plates to the kitchen because the staff did not assist. On April 16, 2026, the department conducted interviews regarding an allegation about meal assistance. The Executive Director (ED) and the Administrator (A1) denied the allegation. The Administrator noted that the caregiver is aware of which residents require meal assistance and is present to help during mealtimes. Additionally, four staff members (S1-S4) were interviewed, all of whom also denied the allegation. They stated that only two residents need help with feeding, and that the caregiver is consistently available at every meal to assist them. The department then interviewed six residents (R1-R6). Four of the six residents denied the need for assistance with feeding. Although the department attempted to interview R1, R1 was unable to answer the questions. R2, another resident, confirmed that they had not been unassisted during mealtimes and stated that staff assisted R2 with feeding at all times. Report Continue on LIC9099C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Finally, the department reviewed the facility's resident Physician Report LIC602A, which indicated that only two residents needed assistance with feeding. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to the Executive Director, Valerie Garcia.

On Wednesday April 8, 2026 at 1:25PM Licensing Program Analyst (LPA) Tremayne Barra made an unannounced visit to the facility and met with Executive Director, Valeria Garcia and Administrator, Liliana Moreno, to conduct a case management incident. LPA informed them of the purpose of the visit. During the visit, LPA toured the facility and made observations pertaining to the incident. LPA conducted staff interviews, requested and received pertinent documents and conducted record reviews . LPA observed resident Joy McCarroll in her room in villa #5 laying in her bed with an oxygen machine connected to her nose. Joy granted permission to speak with her. LPA conducted a health, safety and welfare check of the resident in care. LPA did not observe any health and safety concerns at the time of the visit. An exit interview was conducted, a copy of this report was provided to the Executive Director.

Licensing Program Analysts (LPAs) Tremayne Barra and Armando Perez conducted an unannounced visit for the purpose of confirming the recent changes to the capacity of the facility. LPA received an updated approved fire clearance and updated facility sketch. The facility has applied to go from a licensed capacity of Fifty Nine (59) Non-Ambulatory of which 5 may be Bedridden, to the new requested capacity at Sixty Four (64) Non-Ambulatory in which 5 may be bedridden. LPAs were greeted and granted entry by Executive Director; Valeria Garcia. LPAs conducted a tour of the interior and exterior of the compound that consists of 5 structures. Each structure is labeled as such on the submitted facility sketch. LPAs observed changes in the structures to accommodate the additional clearance. According to Administrator, no new structures were added, the request was to reflect the new approved capacity of Sixty Four (64) Non-Ambulatory in which 5 may be bedridden. On March 17 2026, the Riverside County Fire Department approved the capacity change. LPA observed each resident bedroom to have the required furnishing. LPA observed the facility to be clean and in good repair. All outdoor and indoor passageways are free of obstruction. No health and safety concerns were observed during today's visit. An exit interview was conducted, and a copy of this report was provided to facility representative.

Interview with ED reported that R1 was identified as a fall risk and staff were made aware to provide increased and sufficient supervision. ED noted R1 began to have a cognitive and communication decline, contributing to the falls. Interview with Staff 1 (S1) reported R1 had a care plan that included the use of a Geriatric Chair and bed railings to help prevent falls. Interview with R1’s responsible party confirmed facility staff communicated fall incidents and when R1 was transported to the hospital in a timely manner. A review of medical hospital records obtained did not reference injuries resulting from falls. Additionally, a review of incident reports submitted to Community Care Licensing identified four fall-related incidents involving R1. Facility staff appropriately documented responses, such as arranging medical transport and notifying responsible parties and hospice agencies. Regarding the allegation of lack of supervision/neglect resulting in Resident 1 (R1) developing a wound with an infection, it was alleged that R1 was not receiving adequate wound care which caused the condition of the wound to worsen. Interview with AW1 indicated that R1 appeared to have a severe infection and AW1 was unsure how often wound care was being provided. AW1 stated that their observations of R1’s condition, were the result of inadequate care by staff. Interview with S1 revealed that R1 was on hospice and experiencing a decline in health. S1 reported that R1 had a diagnosis of cognitive impairment and a form of cancer that resulted in a wound on R1’s left hand. S1 emphasized that a body check completed during admission on February 26, 2026, documented a skin tear and a bump on R1’s left hand. A review of R1’s medical records confirmed a cancerous growth on the left hand. Additionally, the growth was described as an open wound; however, it was noted on the medical record to be non-infected and did not develop while R1 was in care at the facility. Interview with Resident 2 (R2) indicated that staff attended to R1 daily and R2 observed the bandage on R1’s left arm changed regularly. Interview with Responsible Party (RP), reported visiting R1 a couple times a week and reported staff provided good care for R1. RP emphasized they had no concerns neglect or abuse had occurred at the facility. A police report dated June 24, 2025 was obtained and revealed a case related to the allegations regarding neglect and abuse of R1 at the facility was investigated and closed with no evidence of suspected abuse or neglect by facility staff. Regarding the allegation that staff do not maintain residents’ hygiene, it was reported that on June 18, 2025, R1 was observed to have a foul odor, with maggots and flies on R1's left arm. An interview with Additional Witness 1 (AW1) indicated they were visiting R2 when they noticed a foul odor coming from R1. AW1 stated that upon approaching R1, they observed a maggot on R1’s left arm. Interview with ED reported that they had not seen or been made aware of maggots on R1. 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 ED denied the allegation and noted a bathing log was maintained by hospice and staff would assist with cleaning the bandage in between hospice visits. Interview with AW2 reported that staff often attended to R1 and maintained the cleanliness of R1’s room. It was also denied that AW2 observed maggots on R1. Interview with 5 of 5 staff corroborated denying observing maggots on R1. Interview with R1’s Responsible Party reported they had no concerns regarding R1’s care and observed R1’s room to be clean and organized during visits. A review of June and July 2025 hospice records revealed R1 was bathed on 6/5, 6/10, 6/12, 6/17, 6/19, 6/24, 6/26, 7/1, 7/3, 7/8, 7/15 and 7/17. Additionally, documentation showed that multiple wound care visits had been completed. Based on interviews, record reviews, and observations, the allegations of lack of supervision and neglect resulting in R1 sustaining injuries and a wound infection, and staff do not maintain resident’s hygiene has been deemed UNSUBSTANTIATED. A finding that the 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. An exit interview was conducted. A copy of this report was provided to Executive Director Valeria Garcia.

Interviews with six of six staff members corroborated that no observations of a broken bed had been reported. On June 4th, 2025, LPA toured the facility documenting observations. LPA inspected 14 rooms, noting that no inadequate sleeping arrangements were observed. LPA noted proper bed accommodation in 14 of 14 rooms with proper bed frames and mattresses. Through resident interviews, 3 of 3 revealed no issues with their sleeping accommodation or aware of any reported broken beds. Multiple interview attempts were made with Additional Witness 1 (AW1) to gather further information, however, AW1 did not respond to the interview request. Through record review, no special incident reports or maintenance orders documenting a broken bed were reported. In response to the allegation that the Facility Administrator is not present on the premises for a sufficient number of hours, it was reported that AW1 attempted to speak with management regarding a resident’s inadequate sleeping accommodations, but management was unavailable. Information obtained from an  interview with ED, stated they are regularly on-site Monday through Friday from 8:00 AM to 5:00 PM. It was also advised that an additional Administrator is present during similar hours to provide support.  Interviews with all six staff members corroborated that both the ED and Administrator are consistently available in person to assist staff and visitors. Staff further indicated that both administrators are accessible by phone when not physically present at the facility. Information obtained from interviews with residents stated that Administrator is available during weekday hours. A review of records confirmed that both the ED and Administrator hold valid Administrator certificates. Additionally, Title 22 regulations do not specify a required number of on-site hours, but indicated the importance of fulfilling the responsibilities associated with the role. The regulations also permit the use of designated substitutes who possess adequate qualifications to be responsible and accountable for the facility’s management and administration. Staff schedules reviewed, verified that both the ED and Administrator are scheduled to be on-site Monday through Friday, from 8:00 AM to 5:00 PM documenting compliance with regulation. Continued on LIC 9099-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 Based on interviews, record reviews, and observations the allegations staff did not ensure resident had adequate sleeping accommodation and Facility’s Administrator is not on the premises a sufficient number of hours has been deemed UNSUBSTANTIATED. A finding that the 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. An exit interview was conducted. A copy of this report was provided to Executive Director Valeria Garcia and Business Office Manager Judine Ramirez.

Information obtained from interview with R1 indicated that they experienced a financial issue, resulting in a delay in their monthly rent payment. It was confirmed that no eviction procedures had been initiated and that an arrangement was made to accept payment upon receipt of the new bank card. Despite these challenges, R1 stated they had no issues with the treatment provided by the staff and expressed overall satisfaction with living at the facility. Interview with Witness (W1), stated they visited R1 approximately once a week, reported observing no abusive behavior from staff. W1 noted that staff treated R1 well and stated that R1 had not mentioned any mistreatment. A review of facility records, including incident reports, revealed no documented incidents of staff abuse involving R1. Additionally, there was no documentation of an eviction notice, as no such action had been initiated. Based on interviews, research, and record review, the allegation that facility staff are abusive to resident in care is unfounded. A finding that the allegation is unfounded meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. Therefore, this complaint is dismissed. An exit interview was conducted. A copy of this report was provided to Executive Director Valeria Garcia.

Licensing Program Analyst (LPA) Seo Jeon made an unannounced visit to the facility to conduct a Case Management visit regarding a complaint report number 18-AS-20250303133359 . LPA spoke with the Executive Director, Valeria Garcia, and informed them of the purpose of the LPA's visit. LPA conducted a health, safety and welfare check of residents in care. LPA did not observe any health and safety concerns at the time of the visit. There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22. An exit interview was conducted, a copy of this report was provided to the Executive Director.

Licensing Program Analyst (LPA) Armando Perez conducted an unannounced visit for the purpose of confirming the recent changes to the capacity of the facility. LPA received an updated approved fire clearance and updated facility sketch. The facility has applied to go from a licensed capacity of Fifty Five (55) Non-Ambulatory of which 5 may be Bedridden, to the new requested capacity at Fifty Nine (59) Non-Ambulatory in which 5 may be bedridden. LPA was greeted and granted entry by Administrator; Valeria Garcia, who also has a current administrator certificate that expires on 12/12/2026. LPA conducted a tour of the interior and exterior of the compound that consists of 5 structures. Each structure is referred to as a Villa and is labeled as such on the submitted facility sketch. According to Administrator, no new structures were added, the request was to reflect the new approved capacity of Fifty Nine (59) Non-Ambulatory in which 5 may be bedridden. On August 1 2025, the Riverside County Fire Department approved the capacity change. LPA observed each resident bedroom to have the required furnishing. LPA observed the facility to be clean and in good repair. All outdoor and indoor passageways are free of obstruction. LPA observed for the facility food supply to meet the minimum requirements of having a 2-day supply of perishable and 7 day supply of non-perishable food items. LPA reviewed the storage and dispensing of medications and observed for them to be locked and inaccessible to residents. No health and safety concerns were observed during today's visit. An exit interview was conducted, and a copy of this report was provided to facility representative. .

Information obtained from staff corroborated that C1 was upset regarding the change in supervision. Information obtained from interview with S1 stated denied threatening clients with evictions or that the facility was their home. Additional interviews conducted with staff denied that they heard S1 make any inappropriate statement regarding eviction or that the facility was their home. Additional witnesses were interviews and it was stated they never observed any staff being verbally threatening to residents. Based on observations, record reviews, and interviews with clients and staff, this allegation is deemed Unsubstantiated. A finding of "Unsubstantiated" means that the allegation may have occurred or is valid, but there is insufficient evidence to prove the alleged violation. An exit interview was conducted, and a copy of this report was provided to the Administrator.

Based on records review and observation the allegation of the facility doesn't have a qualified administrator is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to Valerie Garcia Administrator.

Reporting Party (RP) stated they tried multiple times to contact R1 via telephone and whenever RP called the facility requesting to speak to R1, a staff member would inform RP that Theus was not available and to call back later in the day when Theus is at the facility so they could speak to R1. Interview with R1 revealed if they requested a telephone to make or receive a phone call, staff would make a telephone accessible for R1. During LPA’s initial visit on 12/27/23, LPA observed a working telephone accessible to residents in each villa and a telephone available for use in the front office. LPA called the facility on 01/03/2024 and LPA spoke to Executive Director Diana Ramirez. LPA requested to speak to R1 and Ramirez informed LPA that R1 is bedridden and LPA would need to call Ramirez’s cellphone to communicate with R1. Ramirez gave LPA their cellphone number so R1 could have access to a telephone while in care. Therefore, based on interviews, record review, and observations, the allegation “Facility staff are not ensuring that resident has access to a phone while in care” has been deemed UNSUBSTANTIATED at this time. A finding that the allegation(s) are 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(s) occurred. An exit interview was conducted where a copy of this report was discussed and provided to Theus, along with a copy of LIC811-Confidential Names.

Department staff interview with the Executive Director revealed that they are not aware of a fall occurring with C1 around the time frame alleged by the RP. LPA Nickolas was unable to interview C1 because they are deceased. LPA Nickolas' facility file review revealed that the facility's in-house notes document a fall with C1 several months before. LPA Nickolas' file review also revealed that C2 never resided at the facility. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #2 “Resident sustained pressure ulcers while in care”. The allegation alleged that C1 had bed sores on two (2) areas of their body. The allegation alleged that the stage of the sores was unknown. Department staff interview with S1 revealed that S1 acknowledged the sores, and hospice provided the facility instructions on rotating C1. Department staff interview with the Executive Director revealed that a hospice nurse noted the pressure wounds on July 21, 2020, but it was too early to stage them. The Executive Director stated that the hospice agency advised them that the pressure wounds were healing nicely. LPA Nickolas' interview with C1 revealed they could not be interviewed because they are deceased. LPA Nickolas' file review revealed that C1's hospice agency treated their pressure wounds with wound care specialists and nurses. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #3: “Resident sustained unexplained bruising while in care”. The allegation alleged that numerous clients had bruises on their bodies. LPA Nickolas’ interview with the Business Office Manager revealed that although they worked at the facility when this allegation was made, they do not remember. LPA Nickolas’ interview with several clients in care revealed that they could not provide any information about this allegation. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #4 "Staff did not provide water to residents". The allegation alleged that clients were observed sitting outside in the heat, and there was no water or cups for clients to have water. LPA Nickolas' interview with the Business Office Manager revealed that they denied this allegation. LPA Nickolas interviewed several clients in care. However, the clients interviewed were unable to provide answers to questions asked about this allegation. LPA Nickolas observed pitchers of ice water and cups outside when clients were outside and in the common areas of all five (5) Villas. LPA Nickolas also reviewed the facility's hydration policy and confirmed that the facility's staff are trained according to the hydration policy. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. 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 Allegation #5 “Staff did not provided resident with their own hygiene supplies”. The allegation alleged that the facility staff has one (1) hairbrush for eight (8) residents. The allegation alleged that the Executive Director needed to go and buy supplies. Department staff interview with the Executive Director revealed that the facility cannot order supplies due to billing issues with the vendor. The Executive Director stated that supplies are ordered through the sister company, and the facility had yet to go without supplies. Department staff interview with S2 revealed that the facility is having trouble with the supplier delivering supplies; therefore, the Executive Director is buying supplies. S2 stated the facility has enough supplies to care for residents. Department staff interview with staff #3 (S3) revealed that S3 confirmed the allegation. During a facility tour on August 7, 2023, LPA Nickolas’ observed that the facility has sufficient hygiene supplies to care for the residents in care. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #6 "Staff not meeting resident's needs". The allegation alleged that the facility cannot meet the needs of the clients because they are understaffed. LPA Nickolas' interview with the Wellness Coordinator revealed one (1) caregiver in every Villa, except the largest Villa has two (2) caregivers. LPA Nickolas' interview with the Business Office Manager revealed that although there are assigned caregivers to each Villa, the staff working at the facility is expected to assist the clients when needed. LPA Nickolas' interviews with clients in care revealed that some clients could participate in the interview process while others could not. The clients who participated in the interview expressed no concerns about residing at the facility. LPA Nickolas visited the facility three (3) times and conducted tours during each visit. LPA Nickolas' observed sufficient staffing to meet the client's needs. A finding of Unsubstantiated means that 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 and copy of this report was provided.

Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to investigate complaint control numbers 18-AS-20220503163805, 18-AS-20200820153416, and 18-AS-20200820154620. LPA Nickolas met with Wellness Coordinator Monica Quinones and explained the purpose of the visit. The Executive Director, Diana Molina Ramirez, later arrived at the facility. During today’s visit, LPA Nickolas toured the facility, interviewed clients and staff, reviewed and collected copies of documents. LPA advised Molina Ramirez that, at this time, the complaints requires further investigation. Possible follow-up telephone calls, requests for copies of relevant documents, and visits are necessary before reaching investigative findings . No deficiencies were cited during this visit. An exit interview was conducted with Molina Ramirez, and a copy of this report was provided.

LPA Nickolas' file reviews also revealed that the facility notified C1's relative 30 minutes after C1 was discovered missing and reported the incident to the Community Care Licensing Division (CCLD) within the regulatory timeframe. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. A finding of Unsubstantiated means 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 and copy of this report was provided.

On August 7, 2023, at 5:34 p.m., Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to investigate complaint control numbers 18-AS-20220908145705, 18-AS-20220503163805, 18-AS-20200820153416, and 18-AS-20200820154620. LPA Nickolas met with Med Tech Rebecca Rodriguez and explained the purpose of the visit. During today’s visit LPA Nickolas toured the facility with Rodriguez. The Executive Director Diana Molina Ramirez later arrived at the facility. LPA advised Molina Ramirez that, at this time, the complaints requires further investigation. Possible follow-up telephone calls, requests for copies of relevant documents, and visits are necessary before reaching investigative findings . No deficiencies were cited during this visit. An exit interview was conducted with Molina Ramirez, and a copy of this report was provided.