Desert Hills Memory Care Center.

Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with Executive Director. Shannon Moore The LPA informed the Administrator of the purpose for the visit. The inspection included the following: The facility consists of two building structures for memory care clients. LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. LPA entered 10 randomly selected resident rooms and observed the required furnishing, lighting, bed and dressers. LPA observed a monthly Activities calendar and food menu posted in the dinning room. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Four Laundry rooms are present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility and no bodies of water observed. LPA began review of client records. Seven (7) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed client records to be available and complete. Continued 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 began review of employee records- Seven (7) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 08/03/2026. LPA observed personnel records to be available and complete. The kitchen has two secured entrances. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a location for sharps in the kitchen. Medications are centrally stored. There are two seperate rooms allocated for medication storage. Digital Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers were serviced on 5/2/2025. Emergency drills are conducted monthly at the facility with the last drill on 01/21/2026. Based on the information received during this visit today in the areas reviewed, there are no deficiencies that are being cited per Title 22, Division 6 of The California Code of Regulations. This LIC 809 report was reviewed with the facility representative, and a copy was provided.

Per Executive Director, the management team had concerns that had been brought up to them regarding communication from S1 towards others. However, it was the staff that resigned and was not fired. Per documents reviewed S1 provided a resignation letter to the facility on 1/3/24 and their last day of employment was 1/24/24. 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. Regarding allegation: Facility does not follow their plan of operation. It is alleged facility did not have a plan to provide training to staff to deal with residents that have behaviors. Interviews conducted with residents revealed facility’s staff provide adequate care to the residents. Interviews with staff revealed staff receive 40 hours of initial training and throughout the year they complete their additional training yearly, including behavioral response training. Documents reviewed revealed in 11/7/24, 12/3/24, and 12/18/24, staff received training in the following topics: Psychosocial Needs of the Elderly, Takes a Village Other Side of the Mirror, Positive Therapeutic Interventions and Activities. 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 . Exit interview was conducted with Shannon Moore and a copy of this report was provided.

Interviews with residents revealed 7 out of 9 interviewed revealed residents did not have bug bites in their skin, have not observed bed bugs at the facility, and stated bed sheets are change at least once a week. 1 out of 9 residents had skin lesions for which treatment was being applied and 1 out of 9 residents refused to be interviewed. Interviews with staff revealed staff have not observed bed bugs in the facility. Documents reviewed revealed facility received monthly pest control services between May and September of 2024. No notes on observations or services for bed bugs were noted. R1's notes note treatment for skin condition on 8/20/24. On 8/20/24 LPA Jeon observed facility clean, organized, and observed one resident with skin lesions. On 12/3/25 LPA Flores tour 5 resident rooms and observed their bed and bedding supplies, LPA did not observe bed bugs. 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 . Exit interview was conducted with Shannon Moore and a copy of this report was provided.

On 11/17/25 LPA Flores interviewed 2 staff over the phone and requested medication sheets for July-September 2023, for 9 residents. On 11/19/25 LPA Flores conducted a subsequent visit and interviewed 4 residents. The investigation revealed the following: Regarding allegation: Staff are not mitigating the spread of infectious outbreaks in the facility. It is alleged several residents have an infectious skin disease and facility administration is not providing proper mitigation. Interviews with staff revealed upon an infection outbreak staff follow their protocol. Per administrator and wellness director upon questionable scabies cases, residents may be sent to obtain a diagnosis with physician, the resident is isolated, linens are clean daily, treatment is given as directed, and staff are to use proper PPE which includes gloves and gown when providing care. Interviews with staff confirmed the facility’s protocol described by administrator during a scabies outbreak. Interviews with residents revealed staff have been observed using preventive measures to prevent the spread of an infectious disease. Document review revealed between July-August of 2023 there were 7 residents receiving treatment for scabies. Although there were several receiving treatment there is not enough evidence to say the facility had a scabies outbreak and staff were not using preventing measurements to prevent the spread. Therefore, the allegation is unsubstantiated. 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. Regarding allegation: Staff do not ensure sufficient supplies are available . It is alleged PPE supplies are not being provided for staff to provide care to residents with infection disease. Interviews with residents revealed staff have been observed using gloves while providing care and when necessary other PPE supplies. Interviews with staff revealed facility has not run out of PPE supplies during an outbreak. During today’s visit LPA reviewed PPE supplies and observed mask, gloves, some gowns. 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. (CONTINUED ON LIC 9099C) 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 Regarding allegation: Staff are drinking on the facility’s premises. It is alleged management team is consuming alcohol in the premises. Interviews with residents revealed staff have not been observed under the influence of alcohol. Interviews with staff revealed staff have not consumed alcoholic beverages during holiday parties. LPA did not observed or smell staff under the influence during the visit. 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 . Exit interview was conducted with Shannon Moore and a copy of this report was provided.

Regarding the allegation Staff handled resident in a rough manner , it was reported two unidentified women smashed R1 into the wall and caused a knee injury. Administrator denied this allegation. Information obtained from interview with Administrator advised R1 did not advise that facility staff handled R1 in a rough manner. Additionally, Administrator stated R1 was aggressive and abrasive towards staff. Information obtained from staff interviews denied they were rough with R1 or observed other staff being rough with R1. Information obtained from interviews with residents indicated there has not been a time when staff has handled them in a rough manner and they have not seen any staff miss handle any other residents. A review of the records did not document there were any disciplinary actions regarding personal rights violations. Regarding the allegation staff are overdosing resident, it was reported R1 had a prescription of a specific medication since 2021 and only 60 pills were given over the course of several months, but the facility managed to give R1 60 pills in a matter of 15-30 days. Wellness Director, Shannon Moore denied this allegation and stated that the medication was distributed as prescribed by R1’s Physician’s orders. Information obtained from interviews with staff stated medication was given as ordered. Staff also stated that R1’s medications were not re-evaluated during the 30-day respite stay. Information obtained from interview with Hospice Nurse indicated there were no concerns brought to the attention of the hospice team regarding R1’s medication. A review of the records, which included R1’s Medication Administration Record (MAR), and R1’s centrally stored medication report, indicated that the medication was provided to R1 as prescribed. 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 Regarding the allegation staff left resident in soiled clothing for extended period of time, it was reported that R1 was observed to be covered in feces. Executive Director denied this allegation and stated R1 was never left in soiled clothing for extended periods of time. Additional information indicated R1 was able to communicate and share when they needed to be changed. Information obtained from interview with additional staff indicated R1 was not ever covered in feces or left in soiled clothing for an extended amount of time. Staff advised the facility has a changing schedule, which would occur every 1.5 to 2 hours. Information obtained from interview with Hospice Nurse stated R1 was not observed to be covered in feces and did not mention to staff that there were any issues or concerns with linen or garments being changed in timely manner. Regarding the allegation staff did not safeguard resident’s personal belongings . It was reported R1’s necklace was missing for 72 hours. Information obtained from interview with Wellness Director stated the necklace was reported missing, but was found. It was advised that R1’s responsible party received and signed for the items. No further details were provided regarding where the necklace located. LPA’s review of Resident Personal Property and Valuables Report, along with a photo copy, and signed document indicating the item was removed from the facility. Interviews with additional staff corroborated the information. Interviews with additional residents indicated there are no concerns with their items being safeguarded. Based on interviews, record reviews, and observations, regarding the allegations that resident sustained injuries while in care, staff handled resident in a rough manner, staff are overdosing resident, staff left resident in soiled clothing for extended period of time, and staff did not safeguard resident’s personal belongings are unsubstantiated. Although the allegations may have occurred or be valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur due to the inability to interview R1. An exit interview was conducted. A copy of this report was provided to Administrator, Shannon Moore.

LPA attempted to conduct interview with R1, however they were unavailable. LPA conducted interviews with residents (2) residents who resided at the facility when the complaint was received. (1) of (2) residents revealed they recalled R1 but did not know if staff was preventing R1 from leaving the facility. Department staff conducted (2) administrative staff interviews which revealed R1 provided a copy of their new POA documents and moved out the same day 01/29/2024. R1’s file revealed the facility received a faxed letter from R1’s attorney dated 01/16/2024. Facility sign out sheets and SOC341 for R1 revealed that on 01/29/2024 R1’s attorney came to visit R1, and R1 moved out of the facility the same day. Therefore based on interviews and records review the allegation that R1 was not allowed to leave the facility is unsubstantiated. It was alleged “Staff do not ensure that resident's dental needs are being met.” It was alleged that Resident #1 (R1) was denied medical care to see a dentist for a broken tooth since May of 2023 by the facility. The Department received a photo showing a chipped tooth which allegedly belonged to R1. LPA attempted to conduct interview with R1, however they were unavailable. LPA conducted interviews with (2) residents who resided at the facility when the complaint was received. (1) of (2) resident’s recalled R1 and revealed they did not recall R1 mentioning they were being denied medical care. (2) of (2) residents revealed staff assists them in making doctor’s appointments when needed. Department staff conducted (4) staff interviews. (3) of (4) staff revealed no staff refused to make medical or dental appointments for R1. (3) of (4) staff revealed R1 would refuse to attend doctor’s appointments and refused to be taken out for medical treatment. R1’s file revealed R1 attended a dental appointment on 10/02/2023 for a broken tooth which revealed R1 refused care. Therefore based on interviews and records review the allegation that R1 was denied dental care while at the facility is unsubstantiated. 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 It was alleged “Resident's room is in disrepair.” It was alleged that R1’s room had a hole in the ceiling for (1) month in January 2024 and was not repaired. It was alleged the hole was observed on 01/05/2024 and again on 01/17/2024, with a plastic sheet over it. The Department received a photo of a hole in dry wall which was covered by a taped plastic sheet. It was alleged this was located in R1's room ceiling. LPA attempted to conduct interview with R1, however they were unavailable. LPA conducted interviews with (2) residents who resided at the facility when the complaint was received. (2) of (2) residents confirmed the facility ceiling had a leak which was repaired promptly. (1) of (2) residents revealed they would visit R1 in their room and revealed R1’s ceiling leak was repaired promptly. Department staff conducted (6) staff interviews. (5) of (6) staff revealed R1’s room had a leak and R1 and their roommate were provided an alternate room, but R1 refused to move out of the room. (4) of (6) staff revealed R1’s leak was repaired promptly, however R1 refused for staff repair the hole in the ceiling. Facility records revealed on 11/16/2023 a roofing company was hired for repair. (1) administrative staff revealed repairs continued until January of 2024, and R1's ceiling hole was able to be repaired when R1 moved out. Therefore, based on interviews and records review the allegation that R1’s room was in disrepair is unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.

proceeded to hit R1, causing R1 to fall to the ground. Per a record review of Unusual Incident/Injury report submitted to the department revealed that on 04/15/25 there was an incident involving R1 and R2 be ing involved in an incident where R1 was sent out due to a lump on the back of their head, and law enforcement being contacted. In addition regarding R2 due to their increased agitation, R2 followed up with their Primary Care Physician and the facility implemented and alert charting. Based on interviews and record review the allegation of staff did not prevent an unknown individual access to the facility resulting in a resident being physically attacked while in care 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, 9099C, LIC811-Confidential names list was reviewed and provided to Lavina Dubose, Memory Care.

Licensing Program Analyst (LPA) Seo Jeon made an unannounced visit to the facility to conduct a Case Management visit regarding an incident that took place on September 28, 2024. LPA spoke with Lorena Oropeza, interim executive director, and obtained pertinent documentation. LPA inspected the interior and exterior areas of the home. There were no health and safety concern at the time of inspection. 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 were provided to Lorena Oropeza.

Licensing Program Analyst (LPA) Ferrer Sabarias conducted a required annual visit. LPA was greeted and was granted entry and met with Business Office Manager Shelby Walker , who was informed of the purpose of the visit. The facility is comprised of (2) one story buildings with (28) resident rooms and (16) bathrooms, outdoor space and common areas. The facility does not have a pool or fire arms. The facility is designated as a residential care facility for the elderly for elderly ages 60 years and above. The facility is approved for delayed egress. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Infection Control: LPA observed the hand washing stations in the facility. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The dangerous items were observed to be locked and inaccessible to clients. LPA observed the operating facility signaling system. LPA observed activity areas for residents to engage in. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. 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 Record Review and Resident/Staff Files: LPA reviewed staff files and training that contained staff criminal clearance and updated training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork. Health Related Services/ Incidental Medical Services: All client medication were secured in a medication room. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. A planned fire drill was conducted during the time of the visit. LPA observed the smoke detectors and fire alarms were functional during the time of the visit. LPA observed all facility exits were clear from obstructions. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Business Office Manager Shelby Walker .

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to amend a complaint report. The LPA met with Interim-Executive Director, Lorena Oropeza , and informed her of the purpose for the visit.

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Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Executive Director, Shannon Moore, who was informed of the purpose of the visit. The facility is comprised of (2) one story buildings with (28) resident rooms and (14) bathrooms, outdoor space and common areas. The facility does not have a pool or fire arms. The facility is designated as a residential care facility for the elderly for elderly ages 60 years and above. The facility is approved for delayed egress. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Infection Control: LPA observed the hand washing stations in the facility. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The dangerous items were observed to be locked and inaccessible to clients. LPA observed the operating facility signaling system. LPA observed activity areas for residents to engage in. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. 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 Record Review and Resident/Staff Files: LPA reviewed staff files and training that contained staff criminal clearance and updated training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork. Health Related Services/ Incidental Medical Services: All client medication were secured in a medication room. LPA reviewed client medications and found all medication listed on MARS and all required labeling was found to be in place. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. A planned fire drill was conducted during the time of the visit. LPA observed the smoke detectors and fire alarms were functional during the time of the visit. LPA observed all facility exits were clear from obstructions. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Executive Director, Shannon Moore.

R1, and R2 were transported to the hospital for evaluation for minor medical care, and both residents returned to the facility without further incident. Through record review, LPA discovered that R1 has aggressive behaviors documented in their Physician’s Report, and R1’s care plan noted that R1 needs supervision for a multitude of reasons, including aggression. Staff schedule revealed that staff were present in the facility providing supervision to residents. Interviews with staff confirmed that staff were in the area, and further revealed that they responded quickly to the outburst of behaviors between the residents; thus, this allegation was Unsubstantiated. 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 a copy of this report was reviewed with and provided to Administrator Shannon Moore.