Yorkshire Village.

Licensing Program Analysts (LPAs) Janira Arreola and Seo Jeon conducted an unannounced visit for the purpose of Health and Safety Check Case Management Visit. LPAs met with Business Office Manager, Nicole Kalacas who was informed of the purpose of the visit. During the time of the visit, LPAs conducted a walk through interviews and observations. During the time of the visit no immediate health or safety concerns were observed. No deficiencies were cited per California Code of Regulations Title 22. During the visit consultation was provided on emergency procedures and protocols when emergency services need to be contacted for residents on hospice. The Business Office Manger agreed to meet with the management team and provide an update on any changes to the emergency procedure for residents. An exit interview was conducted where this report and Technical Advisory Note were reviewed and provided.

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility for the purpose of conducting a health and safety check and previously observed HVAC repairs needed which were identified during a visit on August 3, 2026. LPA met with Nicole Anguiano, Business Office Manager, and explained the purpose of the visit. LPA conducted a tour of Building A and B. Per Anguiano, new HVAC will be installed on August 12, 2026. During the visit, LPA observed additional portable fans were placed for the residents in the affected area of Building A. HVAC system in Building B was repaired already and fully operational. LPA conducted additional tour of Building C. LPA observed room #3 maintained comfortable temperature. LPA confirmed with the resident in room #3 regarding the room temperature. LPA did not observe any immediate health and safety concerns during the facility tour. An exit interview was conducted and a copy of this report was provided to the Business Office Manager.

On 8/10/2026, Licensing Program Analysts (LPA) Valerie Flores made an unannounced visit to the facility for the purpose of conducting a health and safety check and previously observed HVAC repairs needed that were identified during a visit on August 3, 2026. LPA Flores met with Business Office Manager Nicole Anguiano and explained the purpose of the visit. The visit is summarized as follows: LPA Flores conducted a randomly selected tour of resident bedrooms in Building A and Building B. In addition, toured the common areas of Building A and B and did not observe any immediate health and safety concerns. LPA was informed that corporate maintenance is currently on-site assessing the air conditioning unit and possibly conducting the repair themselves. In addition, the facility is still awaiting for an estimate from the HVAC company to determine how much the repairs will be. During the visit, LPA Flores observed that additional portable fans were purchased and implemented in residents bedrooms. An exit interview was conducted and a copy of this report was provided to Business Office Manager Nicole Anguiano.

Licensing Program Analysts (LPA) Seo Jeon and Janira Arreola conducted an unannounced visit to the facility to conduct a health and safety check and follow-up on the HVAC issues identified on August 3, 2026. LPAs met with Nicole Anguiano, Business Office Manager, and informed them of the purpose of the visit. LPAs conducted a tour of the facility and did not observe any immediate health and safety concerns. Anguiano provided documentation that showed their HVAC replacement in Building B. Anguiano informed that the management is waiting for an estimate for HVAC replacement in Building A. The estimated is expected on Monday, August 10, 2026. The management will then order the work to be scheduled. Anguiano agreed to inform The Department for any updates. An exit interview was conducted and a copy of this report was provided to Anguiano.

Licensing Program Analysts (LPAs) Janira Arreola and Seo Jeon conducted an unannounced case management visit to the facility. LPAs met with Medication Technician Manager, Bianey Sandoval, who was informed on the purpose of the visit. LPAs conducted a walk through, interviews, and records review. During the time of the visit LPA Arreola delivered and reviewed an amended report with facility staff. During the time of the visit, LPAs conducted a walk through of the facility and measured the temperature of rooms previously identified to not have air flowing from the air conditioning vents. During the time of the visit LPAs observed the thermostats in the hallway by Rooms 1-5 in Building "A" measured 78F and 79F. LPAs also observed facility residents in Building "A" common area were the temperature read 71F. LPAs were provided with documentation on scheduled maintenance on the central air conditioning unit on 08/07/2026. An exit intervie was conducted where this report was reviewed and provided.

On 08/03/2026, Licensing Program Analyst (LPA) Valerie Flores and Licensing Program Manager, Carolyn Tuba conducted an unannounced visit to the facility to conduct a health and safety check. LPA and LPM met with Executive Director, Teresa Mapilis and informed her the purpose of the visit. During the course of the visit, LPA and LPM consulted with Executive Director to confirm medication prescription for Resident 1 (R1). During an interview on 8/2/2026 it was disclosed to the LPM that R1 was not receiving the correct dosage. During today's visit LPA and LPM obtained documentation and reviewed records that states there will be no changes to R1's prescription per their physician. LPA and LPM consulted with Executive Director what procedures are in place for CCL to request documentation during a visit such as a physician's report when certain staff is not available. Executive Director stated that Medical Technician's are to contact Management such as Executive Director who has access to those documents during the visits conducted. LPA and LPM conducted a tour of random sampling of Building "A", Building "D" and Building "C" and observed no cool air or limited air coming out of the vents in residents rooms. Executive Director provided documentation from a local HVAC company who has made repairs prior to today's visit. (A technical violation was issued). An exit interview was conducted, and a copy of this report was reviewed and provided to Business Office Manager, Nicole Anguiano.

On Sunday, 08/02/2026, Licensing Program Manager (LPM), Carolyn Tuba and Licensing Program Analyst (LPA), Jacqueline Shaw-Ross conducted an unannounced Case Management- Health Check visit to assess the facility for potential health and safety concerns. LPM/LPA met with Medical Technician, Latoya McVade and explained the purpose of today's visit. During the course of the visit, LPM/LPA toured building A, B, C and D and visited and spoke to random sample of residents. The bedrooms observed were clean and equipped with the required bedding, furnishings, and functional lighting. LPM/LPA also observed the lunch meal service, and residents appeared to be receiving lunch and dinner as scheduled. During the course of the visit Resident #1 (R1) brought up concerns about medication and the air vent and a window in their room. LPM/LPA did further investigation, interviews and observed medication logs and prescription for R1, however at this time did not find any health or safety concerns. Included in this report is an amended LIC809-D page that was issued on a previous visit of July 26, 2026. The reason for the amendment is to correct the section cited from Health and Safety Codes (HSC) to California Code of Regulation (CCR), as well as the description of the deficiency. Signatures were obtained during this visit. An exit interview was conducted with Medical Technician, Aileen Padilla, and a copy of this report was reviewed and provided at the conclusion of the visit.

On 07/29/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross arrived to the facility unannounced to assess for any health and safety concerns. LPA met with MedTech Manager, Vianey "Nani" Sandoval and the purpose of the visit was explained. LPA was informed that a scheduled power outage was taking place from 9:00 am to 3:00pm. Upon arrival, LPA observed a large generator positioned between Buildings A and B. Staff reported that residents from Building B, C, and D had temporarily relocated to Building A where the generator was supplying power. During a tour of Building A, LPA observed residents from all buildings gathered in the main activity room. The indoor temperature was observed to be cool and comfortable. Staff reported that temperatures in each building were monitored and documented every 30 minutes. LPA also observed hydration stations with water and cold beverages available to residents. Lunch was also being served and consisted of cold sandwiches, chips, fruit and cold beverages. During the visit, residents were observed actively participating in social activities, including playing games, listening to music, and dancing, and interacting with one another in a positive and engaging environment. During a tour of Building B, LPA observed three residents remaining in their rooms. Staff stated these residents chose to remain in place after verbal consent was obtained from their responsible parties/POAs and family members. Staff were in the process of completing documentation reflecting those decisions. During tours of Buildings C and D, LPA observed the indoor temperatures remained cool. Staff reported that residents from these builds had been temporarily relocated to Building B, with the exception of two residents who elected to remain in Building D. LPA observed staff making routine rounds throughout each building to ensure resident safety, monitor conditions, and remain available to help as needed. At 12:45pm, LPA was informed the power was back on in all buildings and residents were being transported back to their rooms. No health and safety concerns were observed during today's visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Vianey "Nani" Sandoval, Medtech Manager.

Licensing Program Analysts (LPAs) Janira Arreola and Seo Jeon conducted an unannounced case management visit. LPA met with Business Office Manager, Nicole Kalacas who was informed of the purpose of the visit. LPAs conducted a tour, interviews, and records review. LPA conducted a case management visit to conduct a health and safety check. No immediate health or safety issues were observed during the time of the visit. LPA also conducted interviews and records review to follow up on incidents and concerns at the facility. Additional information is being gathered for the case management. No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided.

On Saturday, 07/18/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross conducted an unannounced case management visit to the facility to assess for any health or safety concerns. LPA met with Joselynn Martinez, Medical Technician and was informed of the purpose of the visit. Upon arrival, LPA observed residents participating in social activities in the main lobby. LPA conducted a tour of the facility in buildings A, B, C and D, including a random sample of residents' bedrooms across all facility buildings. Based on the observations made during today's visit LPA did not identify any health or safety concerns and no deficiencies were cited. An exit interview was conducted and a copy of this report was reviewed and provided to Joselynn Martinez, Medical Technician.

On Wednesday, 07/15/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross and Licensing Program Manager (LPM) Jacob Garber, conducted an unannounced case management visit to assess the facility for compliance with health and safety requirements. LPA and LPM met with Ashley Richardson, Director of Active Living, who was informed of the purpose of the visit. Upon arrival, residents were observed participating in social activities in the dining area of Building B. Adequate staffing was observed to meet residents' care and supervision needs. A tour of the facility was conducted and a random sample of resident bedrooms throughout the facility was inspected. Based on observations made during today's visit, no immediate health or safety concerns were identified, and no deficiencies were cited. An exit interview was conducted and a copy of this report was reviewed with and provided to Ashley Richardson, Director of Active Living.

On Saturday, 07/11/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross conducted an unannounced case management visit to the facility to assess for any health or safety concerns. LPA met with Daija Love, Medical Technician and was informed of the purpose of the visit. Upon arrival, LPA observed residents finishing their lunch and having dessert. LPA conducted a tour of the facility including a random sample of residents' bedrooms across all facility buildings. Based on the observations made during the visit LPA did not identify any health or safety concerns and no deficiencies were cited. An exit interview was conducted and a copy of this report was reviewed and provided to Daija Love, Medical Technician .

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced case management visit to the facility to assess for any health or safety concerns. LPA toured all residential buildings and random sample of resident rooms. LPA did not observe any immediate health and safety concerns. No deficiencies were cited at the time of this visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Marielle Figueroa, Resident Wellness Coordinator.

R1 did not have any fall incidents while residing at this facility. R1 did not require any assistance with mobility. R1 was once sent out to a hospital in March 2026 per R1’s physician’s order for health condition unrelated to fall incident. LPA conducted interviews with eight (8) residents, all of whom stated they do not require assistance or supervision when they go out in the front yard or back yard. LPA conducted interviews with Staff #1 (S1) and #2 (S2), both of whom stated that R1 liked to walk around the facility. R1 sometimes picked up palm tree seeds from the ground. Staff members tried to redirect R1 whenever R1 had the seeds. Neither S1 nor S2 remembered R1 wearing blood stained shirt. LPA conducted interviews with additional four (4) staff members, all of whom stated they redirected R1 from picking up anything from the ground. All staff members interviewed stated that none of the residents required one-on-one care. LPA’s attempted interview with R1 was unsuccessful due to lack of available information. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated. It was alleged that staff does not ensure resident is being adequately fed. Information received indicated that Resident #1 (R1) lost weight due to inadequate amount of food served. LPA conducted interviews with eight (8) residents, none of whom expressed any concerns about the amount of food served. LPA conducted interviews with six (6) staff members, all of whom stated all residents have been served with more than enough food. Two (2) out of six (6) staff members interviewed stated that R1 may have lost some weight due to constant wandering around the facility which has large buildings and outdoor areas. LPA’s attempted interview with R1 was unsuccessful due to lack of available information. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated. It was alleged that staff are not safeguarding residents’ personal belongings. Information received indicated that Resident #1 (R1) lost a hat and was observed wearing someone else’s shoes. LPA conducted interviews with Staff #1 (S1) and Staff #2 (S2), both of whom stated that R1 once did not have shoes. R1 told staff that they threw the shoes over the facility fences. Staff could not recover R1’s shoes. R1 came to the facility with only one pair of shoes, so staff provided a donated pair of shoes that were good fit for R1. R1’s hat was found within the facility and returned to R1 by a staff member. LPA conducted interviews with four (4) additional staff members, all of whom stated that residents sometimes lose their belongings due to their cognitive condition, but staff members always try to find rightful owners when anything is found in the facility. Continued on LIC9099-C.... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA conducted interviews with eight (8) residents. Seven (7) residents interviewed stated that they have not lost anything in the facility. LPA’s attempted interview with R1 was unsuccessful due to lack of available information. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated. It was alleged that staff does not ensure resident has adequate toiletries. Information indicated that Resident #1 (R1) did not have any toiletries in their room. LPA conducted interviews with eight (8) residents, all of whom stated that they have all necessary toiletries in their rooms. LPA conducted interviews with six (6) staff members, all of whom confirmed the statements from the residents interviewed. LPA conducted a tour of the facility and observed that all rooms had necessary toiletries. LPA’s attempted interview with R1 was unsuccessful due to lack of available information. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated. It was alleged that staff does not ensure residents are provided activities. Information received indicated that there were no available resident activities. LPA conducted interviews with eight (8) residents, all of whom stated that staff provide daily resident activities. LPA conducted interviews with six (6) staff members, all of whom confirmed the statements from the residents interviewed. LPA toured the facility and observed a large calendar of daily activities posted on the wall in each building. LPA also observed several residents participating in activities provided by activities coordinators. LPA’s attempted interview with R1 was unsuccessful due to lack of available information. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated. It was alleged that staff does not ensure resident’s furniture is in good repair. Information received indicated that Resident #1 had broken furniture in their room. LPA conducted a tour of the facility and observed R1’s room had one (1) dresser that had one (1) missing handle out of two (2) in one (1) of four (4) drawers. The drawer was still functioning because it still had one (1) handle. LPA also observed a nightstand with a drawer that had one (1) handle with missing screw. The handle was hanging on the drawer by one screw, but the drawer was still functioning. LPA conducted an interview with Staff #1 (S1) who stated that the missing drawer handle was never reported. S1 stated that maintenance personnel could have fixed the problem within the same day if reported. LPA conducted interviews with five (5) additional staff members, all of whom confirmed the statement from S1. Continued on LIC9099-C.... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA’s attempted interview with R1 was unsuccessful due to lack of available information. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.

LPA interviewed RP, who stated she requested discharge paperwork from the facility on 06/15/2026 and again around 06/20/2026. RP alleged as of 07/02/2026, RP had not received documentation needed to verify R1's discharge date. LPA interviewed (3) staff members who stated RP was provided with requested discharge records such as a medications list and a refund check. (3) staff stated the facility had no record of a request for additional records prior to RP's email dated 06/29/2026. Email correspondence was reviewed and revealed facility staff responded on 06/29/2026 requesting clarification regarding the records being requested. (1) of (3) Staff stated that on 07/01/2026, following a telephone call from a county representative on behalf of RP, clarification was provided to facility staff on what records RP was requesting. (1) Facility staff stated additional information was provided to the county representative for relay to RP on how to request records with R1’s discharge date. Based on interviews and records reviewed, the allegation is Unsubstantiated . Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.

On 07/05/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross conducted an unannounced Case Management- Health Check visit to assess the facility for potential health and safety concerns. LPA met with Aileen Padilla, Lead Medical Technician, and explained the purpose of the visit. During the course of the visit, LPA toured a random sample of resident bedrooms. The bedrooms observed were clean and equipped with the required bedding, furnishings, and functional lighting. LPA also observed the lunch meal service, and residents appeared to be receiving lunch as scheduled. No immediate health and safety concerns were observed during today's visit. An exit interview was conducted with Aileen Padilla, and a copy of this report was reviewed and provided at the conclusion of the visit.

On 7/2/2026, Licensing Program Analyst's (LPA's) Valerie Flores and Seo Jeon conducted an unannounced visit to the facility for the purpose of assessing any potential health and safety concerns. LPA Flores and Jeon met with Business Office Manager Nicole Anguiano and explained the purpose of the visit. The visit is summarized as follows: During the visit, LPA's toured a random sampling of resident bedrooms. Residents bedrooms were observe to be equipped with the required bedding, furniture, and functional lighting. LPA's observed lunch services being provided to the residents. No immediate health and safety concerns were observed. An exit interview was conducted, and a copy of this report was reviewed and provided to Business Office Manager, Nicole Anguiano.

S1 clarified that procedures differ for non hospice residents. Concerning the reported change in condition observed on 08 29 25, S1 explained that staff contacted R1’s physician for further instruction but did not receive a return call until 08- 31 -25. When R1’s physician contacted the facility staff on 08-31-25, they instructed the facility to contact 911 for R1 to be transported for further evaluation. On 06-09-26, LPA Zerbo attempted to interview R1; however, R1 did not respond to questions and was unable to provide any information regarding the allegation. LPA also attempted to contact R1’s physician but was unable to obtain an interview. Although the allegation may have happened or is 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 Business Office Manager Nicole Kalacas.

On 06/27/2026, Licensing Program Analyst (LPA) Aziz Faizi conducted an unannounced case management visit to the facility to assess for any health or safety concerns. LPA met with Manager on Duty Bianey Sandoval and was informed of the purpose of the visit. LPA conducted a tour of the facility including a random sample of residents' bedrooms across all facility buildings. LPA also observed residents having meal and snacks. Based on the observations made during the visit LPA did not identify any health or safety concerns and no deficiencies were cited. An exit interview was conducted and a copy of this report was reviewed and provided to Manager on Duty Bianey Sandoval.

Licensing Program Analysts (LPA) Seo Jeon and Janira Arreola conducted an unannounced case management visit to the facility to assess for any health or safety concerns. Community Care Licensing staff toured all residential buildings and did not observe any immediate health and safety concerns. No deficiencies were cited at the time of this visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Nicole Anguiano, business office manager.

On 06/24/2026, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced case management visit to assess for any health and safety concerns. Upon arrival, LPA met with Medication Technician Gloria Sanchez and explained the purpose of the visit. Business Office Manager (BOM) Nicole Kalacas Anguiano was notified of the purpose of LPA's visit. LPA and Director of Active Living, Ashley Richardson toured a random sample of resident bedrooms and bathrooms in Buildings A, B, C, and D. LPA toured 8 resident bedrooms in Building A, 8 in Building B, 3 in Building C, and 4 in Building D. Resident bedrooms toured were equipped with the required bedding, furniture, and functional lighting. Call light cords were observed to be within arms reach from each resident's bed and the facility had operating utilities. LPA also observed the residents eating meals and snacks. During today's visit, LPA did not observe any health or safety concerns and no deficiencies were cited. An exit interview was conducted and a copy of this report was reviewed and provided to BOM. Note - LPA was off site from approximately 1:00 p.m. to 1:30 p.m.

A review of an Unusual Incident/Injury Report dated 10/19/2023 documented that R1 had a history of choking incidents. On 05/15/2023, R1’s diet was changed from regular to puree. On 08/27/2023, R1 was hospitalized following a choking incident, and on 09/05/2023, their diet was changed from puree to mechanical soft. On 09/26/2023, R1 experienced another choking incident and was assessed by paramedics but was not transported to the hospital. R1’s physician was notified and ordered a barium swallow test with the earliest availability being on 11/30/2023. On 10/18/2023, R1 choked while eating dinner but was able to cough up the food lodged in their throat. Emergency services were activated, and R1 was transported to the hospital for observation. R1 was discharged back to the facility on 10/19/2023 with a diagnosis of esophageal foreign body. Following the hospitalization, facility staff requested that R1’s physician change R1’s diet back to puree. R1’s physician was interviewed and reported that R1 was capable of eating independently and had been prescribed a soft diet. A review of a law enforcement incident report noted that S1 reported that at approximately 3:00 p.m. R1 was in the dining room and observed eating and interacting with staff. R1’s caregiver, Staff 2 (S2), later transported R1 to their room. Once back at the room, S2 noticed R1 unresponsive and immediately informed S1. Emergency services was contacted via 9-1-1. Interviews with facility staff were conducted and the following was reported. S1 reported that on 10/27/2023, R1 appeared to be at baseline. Later that day, S2 informed S1 that R1 was unresponsive. S1 responded to R1’s bedroom and observed R1 slumped over with their dentures slightly displaced. S1 denied serving R1 solid food and reported that their duties primarily involved medication management and documentation. S1 further reported that they did not observe any food particles around R1’s mouth. A review of a law enforcement incident report noted S2 stated to law enforcement that S2 gave R1 a snack at 3:00 p.m. At around 3:20 p.m., S2 observed R1 slumped in their wheelchair and appeared to be sleeping. S2 moved R1 to into their bedroom and asked if they (meaning R1) needed assistance lying on the bed. It was at this time, that S2 observed R1 unresponsive and immediately called S1 for help. 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 A review of R1’s death certificate dated 11/07/2023 documented R1 passed away at the facility on 10/27/2023. The immediate cause of death is listed as cardiac arrest, with underlying causes of coronary artery disease and hypertension. A review of paramedic records did not reveal any findings of food particles or other evidence indicating that R1 passed away as a result of choking. During an interview, R1’s physician reported that an autopsy was not performed. Therefore, it could not be conclusively determined whether aspiration or choking contributed to R1’s death. Regarding the allegation, “Staff are covering up violations at the facility” it was alleged that staff moved R1 to their bedroom following an incident and S3 instructed staff to say R1 passed away in their bedroom which was incorrect. A review of video footage and interviews were conducted. The incident in question is the same incident noted above. During interviews the Department was given conflicting information on whether R1 had partially eaten their snack or had not eaten the snack provided at around 3pm. Interviews with various staff also revealed conflicting information regarding why R1 was moved from the common area. Multiple staff initially indicated they believed R1 to be sleeping and this is the reason for taking R1 to their bedroom. While a subsequent interview revealed a staff reported that R1 was taken to their bedroom to maintain their dignity and avoid other residents from seeing R1 in distress. S3 was interviewed and reported that on 10/27/2023, S3 was in a meeting when they received a call from S1 requesting their presence regarding an incident with R1. S1 directed S3 to R1’s room where R1 was observed unresponsive. Attempts to conduct a subsequent interview with S3 were not successful. S1 reported S3 never instructed staff to move R1 to their room. The allegations are unsubstantiated due to the evidence not meeting the preponderance of evidence standard. An exit interview was conducted and a copy of this report and Confidential Names list (LIC 811) was reviewed and provided to BOM. Note - LPA was off site from approximately 1:00 p.m. to 1:30 p.m. 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 Interviews with facility staff were conducted and the following was reported. S2 reported that on 10/27/2023, they observed R1 in a wheelchair in the living room with their head slightly bowed. S2 reported that this did not initially appear concerning because R1 would occasionally fall asleep in their wheelchair while watching television. S2 reported placing a soft-food snack next to R1 and observed no signs of distress. At approximately 3:00 p.m., S2 checked on R1 again and observed that R1 appeared abnormal, with partially open watery eyes and drooling from the mouth. S2 called R1’s name but did not receive a response. S2 reported the snack had not been eaten and that they did not observe any food particles around or coming from R1’s mouth. A review of video footage was obtained. The video revealed S1 reported that at 3:02 p.m., they observed R1 interacting and speaking with S1’s son in the dining area. S2 provided R1 with a snack and R1 was eating their snack. S2 then reportedly observed R1 slumped and their snack was half eaten. S2 believed R1 was sleeping and wheeled to R1 to their bedroom to assist transferring them to bed. S2 then observed R1 to be unresponsive and contacted S1 for assistance. S1 observed R1 drooling from their mouth and reported the incident to their immediate supervisor, Staff 3 (S3). S3 checked R1’s pulse and emergency services were activated. S2 reported to local law enforcement that at approximately 3:00 p.m., staff served snacks to the residents. S2 observed what appeared to be R1 sleeping in their wheelchair in the living room and left a snack for them on the side. At approximately 3:20 p.m. S2 observed R1 slumping and wheeled them to their bedroom. S2 called R1 by their name and asked them if they wanted to lie down. However, R1 did not respond or move. S2 described lowering their torso and tilting their head to observe R1’s face and observed that R1 appeared pale, with halfway open eyes, and purple lips. S2 then ran to S1 to report R1’s state of condition. Responding ambulance personnel reported R1 was sitting in a wheelchair inside their bedroom upon their arrival. Ambulance personnel laid R1 on the floor and were presented with a Do-Not-Resuscitate order therefore life saving measures were not performed and they declared a time of death. The ambulance personnel are asked if they noticed anything by local law enforcement, to which the response was “No”. The coroner’s office is contacted by local law enforcement. The coroner’s office asks if there is any trauma, injuries, vomit, or anything suspicious to indicate R1 choked on anything, to which local law enforcement responds, “No”. Local law enforcement is advised the coroner’s office will not be responding to the facility.

On 06/20/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross arrived at the facility unannounced to conduct a Case Management visit to the facility to assess for any health or safety concerns. LPA met with Medical Technician, Daija Love, and the purpose of the visit was explained. Ms.Love contacted Executive Director (E.D.), Teresa Mapilis by telephone to inform of the visit. E.D. was unable to attend the visit. LPA toured all four buildings inside and outside and requested copies of pertinent records via email. During today's visit, no deficiencies were cited. An exit interview was conducted and a copy of this report was reviewed and provided to Medical Technician Daija Love.

Licensing Program Analysts (LPA) Seo Jeon Abdoulaye Zerbo and Janira Arreola conducted an unannounced case management visit to the facility to assess for any health or safety concerns. Community Care Licensing staff toured all residential buildings and did not observe any immediate health and safety concerns. No deficiencies were cited at the time of this visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Nicole Anguiano, business office manager.

(Continuation from LIC9099) S1 continued towards R1’s private bathroom where R1 was observed to be lying on the floor, flat on their back. S1 reportedly contacted S2 for additional assistance. Upon S2’s arrival, R1 was assessed and staff deemed it necessary to contact emergency personnel and R1’s responsible person. Interviews conducted with staff report that R1 did not sustain any visible bruising and were observed to have a minor lump to the back of the head. Interviews conducted with R1’s responsible person confirmed that they were contacted by facility staff to where staff informed R1’s responsible person that R1 was being transported to the hospital as R1 experienced an unwitnessed fall. R1’s responsible person provided photos to the Department of R1’s face. Photos received can be described as a 6-inch bruise on the left side of R1’s face. Interviews conducted with the (8) eight staff and Resident #2 (R2) report that R1 was not observed to have bruising until after R1 returned from the hospital after the fall incident. Records review conducted of R1’s Needs and Service Plan does not indicate R1 to be a fall risk. A review conducted of the facility’s Unusual Incident Reports did not reveal additional falls sustained by R1. A review conducted of R1 medication list revealed that R1 was receiving medication that would make R1 susceptible to bruising. Therefore, the allegations of resident sustained multiple unexplained bruises while in care is deemed unsubstantiated. A finding that the complaint is 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, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was provided to Business Office Manager Nicole Anguiano.

LPA conducted interviews with five (5) staff members, all of whom stated that any hospital beds can be adjusted quickly when providing care to the residents. Staff members then adjust the bed height back to normal when they are done with the residents. Staff members interviewed denied experiencing or witnessing any residents’ fall because of bed height. LPA conducted an interview with S2 who denied lowering R2’s or any residents’ beds to avoid being questioned by paramedics. LPA conducted interviews with 14 residents, none of whom expressed any concerns regarding height of their beds. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA’s attempted interview with R2 was unsuccessful because R2 was no longer a resident of the facility and lacked available contact information. LPA's attempted records review regarding R2's fall was unsuccessful due to lack of available records. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.

On 06/13/2026, Licensing Program Analyst (LPA) Aziz Faizi conducted an unannounced case management visit to the facility to assess for any health or safety concerns. LPA toured all residential buildings and did not observe any immediate health and safety concerns. No deficiencies were cited at the time of this visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Zouri Holmes, Medication Technician.

Regional Manager Reyna Lacey and Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced case management visit to the facility to assess for any health or safety concerns. Community Care Licensing staff toured all residential buildings and did not observe any immediate health and safety concerns. No deficiencies were cited at the time of this visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Nicole Anguiano, business office manager.

CW denied witnessing S1 breaking R1’s arm, nor did they witness any staff member having a physical altercation with any resident in care. CW did not know the last name of S1. LPA’s subsequent interview with CW did not reveal any additional information about injuries caused by S1 to any residents in care. LPA’s records review revealed that R1 passed away on November 21, 2022. LPA conducted an interview with business office manager (BOM), who stated that S1 was never employed by the facility, past or present. LPA’s records review confirmed BOM’s statement regarding S1. LPA conducted interviews with five (5) staff members, all of whom denied knowing S1 as their coworker. LPA conducted interviews with 14 residents, none of whom experienced rough handling or physical altercation by staff. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that facility did not report unusual incident to CCL. The complaint report did not contain any relevant information. LPA conducted an interview with a confidential witness (CW) for additional information, but CW did not provide any relevant information. LPA conducted interviews with six (6) staff members, all of whom stated that any unusual incidents are reported to medication technicians who then report to the management. The management then reports to the Department and keeps the incident reports for their record keeping. LPA observed past incident reports provided by business office manager (BOM) and confirmed the statements from the staff members interviewed. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that facility does not have enough food for residents’ daily nutritious needs resulting in weight loss. Information received indicated that the facility regularly runs out of food, and residents are losing weight due to missed meals. LPA conducted five (5) unannounced tours of the facility within a span of 7 days and observed that the facility had sufficient supplies of food for residents in care. LPA conducted interviews with 14 residents, none of whom experienced missing any of the three (3) daily meals. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA conducted interviews with six (6) staff members, all of whom denied the facility running out of food for residents. One (1) of the six (6) staff members interviewed stated that they have never witnessed the facility running out of food in the past 14 years. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. Continued on LIC9099-C.... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 It was alleged that staff do not assist residents with incontinence needs. Information received indicated that Resident #1, 2, 3, 4, and 5 (R1, R2, R3, R4, R5) were frequently observed in urine-soaked briefs. LPA conducted interviews with 14 residents, all of whom expressed their satisfaction with staff assistance. Of the 5 residents named, only 1 could be interviewed and that resident could not provide information. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA conducted interviews with six (6) staff members, all of whom stated that all residents receive two (2) hour room checks or more often if requested or necessary. LPA conducted tours of the facility but did not observe any concerns of neglect in incontinence care. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that facility and residents bathroom has mold. Information received indicated that three (3) residents’ bathrooms had black mold. LPA conducted interviews with 14 residents, all of whom denied witnessing mold in their bathrooms. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA conducted interview with six (6) staff members, all of whom denied witnessing mold in residents’ or common bathrooms. LPA conducted tour of the facility and inspected all residents’ and common bathrooms but did not observe a substance that could be mold in any bathrooms. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that staff do not shower residents. Information received indicated that Resident #6 (R6) did not receive a shower for four (4) days. LPA conducted interviews with 14 residents, all of whom stated that they have received two (2) showers per week, and staff have not missed any. LPA’s interviews with six (6) staff members confirmed the statements from the residents interviewed. LPA’s attempted interviews with seven (7) additional residents but were unsuccessful due to their cognitive condition. LPA’s attempted interview with R6 was unsuccessful due to lack of contact information. Request for shower logs was unsuccessful. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that staff do not change residents clothing. Information received indicated that residents wore the same clothing for days. LPA conducted interviews with six (6) staff members, all of whom stated that staff assist residents with clothing change every day, but most residents receive assistance with clothing change multiple times throughout the day after each mealtime. Continued on LIC9099-C.... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA conducted interviews with 14 residents. Eight (8) residents interviewed stated that they did not need assistance with clothing change. Six (6) residents interviewed stated that staff have assisted with clothing change every day. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA’s observation during the resident interviews did not reveal any concerns regarding residents’ clothing change. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that facility does not have enough needed supplies to meet the residents needs. Information received indicated that the facility did not have enough incontinent, shower, or bedding supplies to meet the residents’ needs. LPA conducted interviews with 14 residents, none of whom experienced shortage of supplies for their needs. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA conducted interviews with six (6) staff members, none of whom experienced shortage of supplies in the facility. LPA toured the facility and observed cleaning and incontinent supplies. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that staff do not safeguard resident's personal property. Information received indicated that staff members use Resident #3’s (R3) shower supplies for other residents. LPA conducted interviews with six (6) staff members, all of whom stated that every resident has their own shower supplies stored in a container. LPA’s interviews with 14 residents and facility tour confirmed the statements from the staff members interviewed. During the tour LPA observed shower supplies in each room for each resident. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.

On 6/11/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced case management visit to the facility for the purpose of delivering an amended version of an original report for complaint control number 18-AS-20260528162825. LPA Flores met with Medication Technician Lead Aileen Padilla and explained the purpose of the visit. A deficiency was issued for complaint control number 18-AS-20260528162825. LPA Flores did not issue any additional deficiencies during the time of visit An exit interview was conducted was conducted with Medication Technician Lead Aileen Padilla and a copy of this report was provided to Business Office Manager Nicole Anguiano.

On 06/10/2026, Regional Manager Reyna Lacey and Licensing Program Analysts (LPAs) Janette Romero, Janira Arreola, Valerie Flores, Seo Jeon, Abdoulaye Zerbo conducted an unannounced case management visit to the facility to assess for any health or safety concerns. Community Care Licensing staff toured the facility and obtained copies of records. During today's visit, no deficiencies were cited. An exit interview was conducted and a copy of this report was reviewed and provided to Medication Technician Manager, Bianey Sandoval. *This is an amended version of the original report to correct the end time of the visit to 6:30 p.m.

Licensing Program Analysts (LPAs) Seo Jeon, Janira Arreola, Janette Romero, Valerie Flores, and Abdoulaye Zerbo conducted an unannounced visit to the facility to conduct a Plan of Correction (POC) Visit. The purpose of this report is to document the POC previously agreed upon. LPAs met with Business Office Manager Nicole Kalacas Anguiano who was informed of the purpose of the visit. Administrator Teresa Mapilis was also informed of the purpose of the visit. LPAs toured the facility, conducted interviews, and obtained copies of records. During a case management visit conducted on 06/08/2026, the facility was cited for California Code of Regulations (CCR) Title 22, regulation section 87468.1(a)(3) after LPAs observed four (4) residents in geriatric chairs with a tray table, and interviews conducted revealed none of the residents had the capacity to release the tray tables to exit the geriatric chairs. During the development of the plan of correction created on 06/08/2026, Business Office Manager Nicole Kalacas Anguiano agreed on behalf of the licensee to discontinue using geriatric chairs in the facility immediately and conduct a staff in service. During today's case management visit, LPAs observed two (2) additional residents in geriatric chairs with tray tables attached and both residents were also unable to release the tray tables to exit the geriatric chairs. Facility staff was unable to produce physician's orders for the geriatric chairs during the time of the visit. As a result, the POC has not been met and civil penalties will be assessed for failure to correct the deficiency. The POC shall include immediate discontinuation of the use of a geriatric chairs unless licensee obtains an exception granted by the Department along with a physician's order. The POC shall also include an in-service personal rights training for all staff conducted by outside source to be completed within 30 days and submission of verification that the training was completed. Per Administrator Mapilis, an exit interview was conducted with Medication Technician (MT) Ligaya Carter who was advised that civil penalties would continue to accrue until the plan of correction is met. During the exit interview, a copy of this report LIC 809-D, LIC 421FC, and Appeal Rights were reviewed and provided to MT Carter and emailed to Administrator Mapilis. Note - LPAs were off site from 4:10 p.m to 5:45 p.m.

On 6/6/2026, Licensing Program Analyst's (LPA's) Valerie Flores and Janira Arreola arrived unannounced to the facility for the purpose of conducting a health and safety visit. Upon arrival, LPA's met with Medication Technician Manager Bianey Sandoval and explained the purpose of the visit. The visit is summarized as followed: LPA's conducted a random sample of resident bedroom tours of building A, B, C, and D. LPA's conducted tours of (15) fifteen bedrooms in building A and Building B. In addition, LPA's conducted tours of (3) three bedrooms in Building C and Building D. Resident bedrooms that were toured were confirmed to be equipped with the required bedding, furniture, and functional lighting. LPA's observed pull cords that were easily reachable to residents. LPA's verified that the signal system was in operating-use; when activated, the pull cord sends a loud alarm that can be heard in all parts of the building. Random private and non-private bathrooms were observed to be sanitary and in good repair. During the tour, LPA's observed motion sensors in selected resident bedrooms. LPA also verified that all exit doors are equipped with operating alarms. LPA confirmed utilities where fully functioning and facility maintained running water. The facility prepares all meals in Building A. During the time of visit, LPA's observe residents being provided breakfast and lunch. Meals were observed to meet residents nutritional needs. The facility maintained a comfortable temperature for the residents measuring at 71-72 degrees Fahrenheit in Buildings A, B, C, and D. LPA's did not observe any health or safety concerns. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was reviewed and provided to Medication Technician Manager, Bianey Sandoval.

On 06/04/2026, Licensing Program Analysts (LPAs) Janette Romero and Seo Jeon made an unannounced case management visit to assess for any health or safety concerns. LPAs met with Business Office Manager (BOM) Nicole Kalacas Anguiano who was informed of the purpose of the visit. Administrator Teresa Mapilis was also notified of the purpose of the visit. LPAs toured the facility and did not observe any health or safety concerns. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was reviewed and provided to BOM Kalacas Anguiano.

On 05/31/2026 at 01:55 PM, Licensing Program Analyst (LPA) Aziz Faizi arrived unannounced to the facility to conduct a case management / Health and Safety concern visit. LPA was greeted and granted entry by Medication Technician Ligaya Carter , who was informed of the purpose of the visit. Licensee/Administrator Teresa Mapilis arrived to the facility at a later time and was also informed of the purpose of the visit. LPA conducted an inside and outside tour of the facility including the kitchen. LPA also interviewed residents and staff, reviewed pertinent facility documents, including verification the of the administrator"s valid certificate. LPA oberved that the facility has sufficient staffing levels to meet the needs of the residents. The facility is equipped with adequate number of of call light systems throughout the facility rooms and common areas also functioning properly. LPA also verified that all exit doors are equipped with proper operational alarms and secured with keypad codes to ensure residents do not exit the facility unlawfully. No Health and Safety issues were observed, and no citations were issued during this visit. An exit interview was conducted, and this report was reviewed and a copy was provided to Medication Technician Ligaya Carter.

On May 14, 2026 Licensing Program Analyst (LPA), Tremayne Barra arrived at the facility unannounced to conduct the Required Annual Inspection and met with Nicole Anguiano, Business Office Manager. LPA was later joined by Executive Director, Teresa Mapilis. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for 100 Elderly Adults and is currently operating at a capacity of 96 Elderly Adults. LPA toured the facility along with Nicole Anguiano and made observations pertaining to the annual visit. LPA inspected the facility inside and outside, there were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. There were no bodies of water currently on the premises. The facility is a multi building made up of four (4) seperate buildings. Building A and B are for memory care residents while building C and D consists of Assisted Living Waiver residents. Physical Plant: The facility phone number is (951) 658-1068 and it is operable. Observed a sampling of the residents’ bedrooms, and each was equipped with required furniture as per Title 22. Inspected facility bathrooms, and the hot water temperature tested within regulations. Bathrooms were clean, and appliances were operating appropriately. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. Observed required postings; "If you See Something, Say Something,” "Personal Rights," and PUB 475. Cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. Resident files are kept electronically. 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 Food Service : Food prep areas are clean and organized. 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 that is locked and inaccessible to residents in care. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Eight (8) 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. Personnel Records/Training/ Staffing/ Administration : LPA reviewed employee records. Six (6) 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 administrative organization. Teresa Mapilis, Administrator’s certificate expiration date was 12/30/2026. Medications : Were locked and inaccessible to residents in care, and there were sufficient medications currently for residents. Overall the facility is clean, furniture is present and clean. Facility cooling system and other appliances were operable currently. Disaster preparedness : LPA reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill met the department standards, and was conducted by the Office Manager. Infection Control: LPA observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures. No deficiencies were observed or cited per Title 22, Division 6 of the California Code of Regulations at this time. An exit interview was conducted where a copy of this report was discussed and given to Administrator, Teresa Mapilis.