Yorkshire Village.

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.

It was alleged Facility staff are not addressing a change in the residents condition. Concerns were raised about staff members not addressing changes in condition. Interviews with multiple staff members revealed that changes in condition are reported to the medical technician, who will call paramedics in case of serious injuries. However, a confidential witness stated they were not informed of the resident's change in condition. Additional information indicated that the medical technician calls families and responsible parties whenever there is an incident or a change in condition. It was alleged that Facility staff left residents in urine-soaked clothing for an extended period of time. Concerns were made about staff not attending residents briefs in a timely manner. LPA interviewed multiple staff and residents, and information obtained revealed residents are being changed every 2 hours or sooner depending on the residents’ needs. Interviews obtained from 2 of 3 residents corroborated that residents are not left alone in their urine. It was alleged that Facility staff impeding on third party's investigation. Concerns were raised about facility staff refused to provide requested documentation to the Ombudsman. LPA conducted interviews with facility staff, and they do not recall documents requested by the Ombudsman. LPA attempted to contact the confidential witness for additional information but did not receive any information. Based on observations, interviews, and records review, the allegations listed above are unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to Executive Director Teressa Mapilis

An interview with Additional Witness 1 (AW1) revealed that during a family visit with R1, relatives reported to AW1 that R1’s appearance and hygiene were poor. AW1 stated staff were informed that R1 had been refusing to bathe and staff were only able to encourage proper hygiene practices, but could not force R1 to comply. Interview with Executive Director Teresa Mipilis revealed that R1 began to refuse showers despite multiple attempts by various caregiver encouragement. ED reported that R1’s Responsible Party (RP) was notified verbally of the refusals and they acknowledged R1’s decline. ED noted that RP was informed that R1 was not maintaining hygiene and becoming increasingly withdrawn. An interview with Staff 1 (S1) revealed that R1 frequently refused assistance with showering or bathing, often insisting they could do it themselves or declining bathing entirely. S1 reported that each refusal prompts three separate attempts by staff to encourage R1 to maintain their hygiene. Interview with Staff 2 (S2) revealed that R1 refused to shave and did not allow staff to trim their beard for over two months. S2 reported that R1’s RP was informed of the ongoing hygiene refusals and acknowledged the concern. Interviews with three out of three residents corroborated that they receive sufficient hygiene assistance from facility staff. R2 added that they appreciate being allowed to bathe independently and upon request, assistance from staff. A review of records obtained revealed chart notes from 2023 through 2025 documented multiple instances in which R1 refused Activities of Daily Living (ADL’s) on various dates and times. Additionally, documents obtained revealed R1’s assessments and care plans were updated over time to gradually increase the level of staff assistance provided for hygiene care. A review of Title 22 under the California Code of Regulation was conducted, information obtained under Personal Rights revealed that Section 87468.2(a)(6) references the residents right to make choices concerning their daily lives at the facility. For the allegation that staff did not meet a resident’s dental needs, it was alleged that on December 10, 2024, the facility received an order for oral surgery for R1 and subsequently failed to ensure that R1 was sent to the scheduled dental procedure. An interview with AW1 revealed they were informed the facility had an in-house dentist. AW1 was unsure how many times R1 had been seen, due to staff not providing updates. An interview with Staff 3 (S3) revealed they assisted R1 with dental appointments and confirmed that R1 received seven dental treatments, including an oral surgery completed on December 10, 2024. A review of R1’s records showed documented dental treatments on the following dates: 10/20/2023, 03/27/2024, 05/29/2024, 08/17/2024, 11/20/2024, and 12/10/2024. 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 For the allegation that staff did not conduct a reassessment for a resident, it was alleged that R1 experienced a cognitive decline and the facility failed to complete appropriate reassessments in response to the change in condition. An interview with AW1 revealed concern regarding R1’s declining cognitive behaviors and noted that AW1 frequently requested that the facility perform a reassessment. AW1 added that the reassessment was necessary to obtain additional support services, such as home health. AW1 stated they were unaware whether reassessments had been completed, because the facility did not provide updates. An interview with the Executive Director confirmed that multiple reassessments and care plans for R1 was completed. An interview with Staff 4 (S4) further noted the facility conducted reassessments and provided updated care plans to RP, obtaining digital signatures acknowledging receipt on multiple care plans. A review of records showed that medical reassessments for R1 were completed on 7/26/2023, 9/20/2023, 3/27/2024, 11/6/2024, and 12/30/2024. Based on interviews, research, and record review, the allegations that facility staff did not meet a resident's hygiene needs, staff did not meet a resident's dental needs, and staff did not conduct a reassessment for a resident 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 Teresa Mapilis.

Interview with Additional Witness 1 (AW1) corroborated statements made by ED and reported that R1 would have monthly medical visits at the facility. AW1 added that visits were increased during the month if concerns were addressed. AW1 reported receiving notice of R1’s transfer to the hospital on February 5, 2025. Interviews with 3 of 3 staff members indicated that R1 tended to keep to themselves and did not typically complain about pain or medical concerns. S2 added that R1 often refused medical assistance and did not observe any concerns during interaction with R1. Interview with R1 revealed that R1 could not recall his experience at the facility or the reason for his hospital stay. Through record review, it was revealed that on February 5, 2025, R1’s Primary Care Provider ordered lab work during the assessment and results required further evaluation. For the allegation that staff did not seek timely medical attention for R1, it was reported that facility staff delayed medical intervention. During an interview, ED stated that on February 5, 2025, R1’s PCP contacted the facility and instructed staff to arrange medical transport due to abnormal lab results. ED reported that R1 was transported the same day as directed in a timely manner. An interview with AW1 confirmed that they were informed R1 had been transported to the hospital on February 5, 2025, due to concerning laboratory findings. R1 was unable to recall their experience at the facility or the reason for hospitalization. A review of records obtained revealed that R1 was admitted to Hemet Global Medical on February 5, 2025. Intake notes indicated that R1 reported only back pain at the time and did not express additional discomfort. Additionally, Community Care Licensing Division received a Special Incident Report stating that on February 5, 2025, at approximately 2:30 PM, R1’s physician instructed staff to arrange medical transport. The report further stated that instructions were followed in a timely manner and responsible parties were notified. Based on interviews and record reviews, the allegation that staff neglect resulted in a resident to be hospitalized and staff did not seek timely medical attention for a resident 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. A copy of this report was provided to ED, Teresa Mipilis.

Regarding the allegation, “Staff did not meet reporting requirements” it was alleged the facility failed to meet the mandated reporting requirements after a resident suffered a broken leg from a fall in the facility. It was further alleged that a different resident had falls on 06/13, 06/14, 06/16, 06/18 and multiple visits to the emergency room that were also unreported. The residents were identified by their room numbers. The resident identified in the allegation who allegedly had a broken leg was identified as Resident 1 (R1). There were a total of five (5) staff interviewed. One (1) of five (5) staff interviewed was unable to recall any resident breaking their leg in the facility. The remaining four (4) of five (5) staff interviewed reported, R1 never broke their leg in the facility. LPA attempted to conduct an interview with R1 to inquire whether they suffered a broken leg while at the facility. However, R1 was unable to participate in the interview. LPA also made attempts to contact R1’s responsible party but was unsuccessful. LPA reviewed Unusual Incident/Injury Reports (LIC 624s) regarding Resident 2’s (R2) unwitnessed incidents occurring on 06/01/2024, 06/13/2024, 06/14/2024, and 06/17/2024 which were reported to Community Care Licensing (CCL) timely. The reports documented 911 was called each time, and each time R2 was transported to the hospital for further evaluation. The reports also indicated R2’s responsible party and primary care physician were notified. LPA made contact with R2’s responsible party who reported R2 has since passed away. The responsible party reported that facility staff notified them of multiple falls R2 experienced in the facility and was aware R2 was sent to the hospital for evaluation. However, the responsible party was unable to recall exact incident dates and therefore was unable to confirm whether the facility reported every fall to them since R2 exhibited memory loss and RP was not always in the facility. Five (5) of five (5) staff interviewed reported the facility follows mandated reporting requirements and activates emergency services each time a resident has an unwitnessed fall or incident. Five (5) of five (5) staff interviewed added they have never suspected staff abuse or neglect led to the resident incidents and/or falls which include any incidents involving R1 and R2. It was reported that this is why the incidents were reported to CCL but not the Long-Term Care Ombudsman nor Law Enforcement. 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 Mandated reporting requires reports to the local ombudsman, the corresponding licensing agency and local law enforcement when the mandated reporter reasonably suspects physical abuse, abandonment, abduction, isolation, financial abuse or neglect. However, five (5) of five (5) staff interviewed reported they did not reasonably suspect abuse or neglect regarding R2's unwitnessed incidents. BOM Anguiano also reported the facility is not aware of any other incidents involving R2 on the alleged dates. Regarding the allegation, “Staff did not comply with infection control requirements” it was alleged every resident was observed itching and scratching themselves and none of the staff was observed to have personal protective equipment donned such as gloves, masks, etc. A random sampling of 4 residents were interviewed. Two (2) of four (4) residents reported they did not have knowledge or recall the facility having an outbreak where multiple residents were observed to be scratching themselves. The remaining two residents were unable to provide information. Three (3) of three (3) staff interviewed reported the following information. Facility housekeepers are constantly cleaning, disinfecting the facility, and/or following universal precautions. They are unable to recall an incident where every or multiple residents were observed to be itching or scratching themselves. In June 2024, the facility did not experience any sort of outbreak or illness that would cause every resident to itch or scratch. Personal Protective Equipment (PPE) such as gloves, gowns, and masks is made available for staff use but there was no reason to encourage staff/residents to use PPE or isolate in June of 2024. Wellness Director was interviewed and reported that residents are seen by a dermatologist anytime they experience a skin condition. LPA toured the facility and observed PPE including gloves, face masks, gowns and hairnets available in the facility. LPA also observed a sign posted in the facility encouraging the use of masks and hand sanitizer for those experiencing flu like symptoms. 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 did not provide adequate food service” it was alleged residents were served a meal that was not nutritious. This meal consisted of a chili cheese hot dog on a bun with potato chips and Kool-Aid to drink. It was reported that residents were also given water. LPA reviewed the facility's menu for June 2024 noting on 06/07/2024 a chili cheese dog, zucchini fries, and dessert were on the menu for lunch. However, the chili cheese dog was on the menu only one day out of the month and the menu listed a variety of foods. LPA conducted a witness interview with a dietitian who confirmed reviewing the facility’s menu and providing menu guidelines and consultative services to the facility monthly in the year 2024. A random sampling of 4 residents were interviewed. Two (2) of four (4) residents reported the facility follows their menu, offers a variety of foods and drink options, or they can request alternative food options. The remaining two (2) residents were unable to provide information. Furthermore, it is not a requirement that the menu be posted in the facility. Regarding the allegation, “Staff did not provide a comfortable temperature” it was alleged a resident reported feeling warm and wanted the air to be on resulting in maintenance staff responding to the room to determine the issue. It was further alleged the vent in the resident’s room was observed to be closed, restricting the airflow. BOM Anguiano was interviewed and reported Resident 3 (R3) requests facility staff open and close the vent in their bedroom at various times. Therefore, the vent was closed at R3’s request and not due to facility staff malice or neglect. Administrator Mapilis was interviewed and reported R3 has complained about the temperature in their room and maintenance staff inspected the unit and reported there was nothing wrong with it. As a result, R3 has been offered to move to a different room or have a stand-up fan placed in their room. However, R3 has declined both offers. Mapilis reported that all thermostats are set to meet licensing regulations and maintain a comfortable temperature for all residents. R3 was interviewed and reported they instruct staff when to open and close their vent and staff have never opened or closed their vent without them asking. R3 was unable to recall an incident on 06/07/2024 regarding their vent. LPA toured R3s bedroom and observed all vents to be opened. LPA observed the hallway thermostat reportedly controlling R3s room set to 73-degrees Fahrenheit. 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 unattended in direct sunlight without hydration” it was alleged a resident was left outside of the building in direct sunlight, unattended with no hydration. No further details were provided including the identification of the resident. BOM denied the allegations and it is believed the resident in question is Resident 4 (R4). R4 enjoys sitting in their wheelchair outside by the front door of the facility. However, R4 is always given a cup of water and facility staff constantly check on them. The Wellness Director reported that residents sitting outside are checked on after 30 minutes and encouraged to come inside. If they want to remain outside, the staff ensure they are appropriately dressed and provide fluids. An additional staff interview reported residents who choose to be outside are checked on at least every fifteen minutes. R4 was unable to participate in an interview. During a visit in September of 2025, this LPA observed R4 sitting in their wheelchair outside of the building, staff checking on R4 and encouraging R4 to drink from a cup that was provided. Regarding the allegation, “Staff did not meet resident’s medical needs” it was alleged a resident had a catheter. No additional details were obtained. The resident was only identified by their gender and the building they resided in. One (1) of five (5) staff interviewed reported they recall a resident with a catheter to reside in the respective building. However, they were unable to identify the resident. The remaining (4) of five (5) staff interviewed identified Resident 5 (R5) as the only resident to fit the description and use a catheter. They reported R5 receives home health assistance to change their catheter and have the capacity to independently empty it. R5 was interviewed and corroborated the information provided by the four (4) staff. LPA reviewed R5’s physician’s report dated 05/28/2024 noting they are ambulatory and do not exhibit memory loss. R5 did not report any issues or concerns with the catheter care. It was also alleged that R1 had a dirty and seeping bandage. Five (5) of five (5) staff interviewed reported that a dirty and seeping bandage never exited on any resident in the facility. The LPA was not able to interview all relevant parties which included a possible witness who may have observed any of the allegations during their visit. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did no

The investigation revealed the following: Allegation: Staff are not addressing a scabies outbreak. The detail of the complaint alleges that multiple residents were covered in rashes and facility is not addressing the issue. On December 18, 2025, at 10:18am, the Department interviewed Nicole Anguiano (A1) who stated that there have been no reports of residents having a diagnosis of Scabies. However, A1 went on to state that a resident’s (R1) family member had a concern about a rash R1 had. This rash was not a diagnosis of scabies. R1 was diagnosed with another condition for which she was sent to a Skilled Nursing Facility (SNF) for care and subsequently returned to the facility. Lastly, A1 stated that Riverside County Public Health department was notified in addition to Community Care Licensing via Incident Report. Lastly, A1 stated that around the time of the complaint (May 2024) another resident (R2) was scratching, however when seen by a physician, the itching was a result of anxiety and not a diagnosis of Scabies; staff were instructed to treat with Neosporin. On December 18, 2025, between 11:45am and 12:30pm, the Department interviewed 5 staff (S1-S5) regarding the allegation. Of those interviewed, 5 out of 5 denied the allegation stating the facility has never had an outbreak of Scabies since they have been with the company. 5 out of 5 knew the protocol for an infectious disease outbreak. Page 2 of 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On December 18, 2025, the Department made several attempts to interview the residents available in the memory care unit, however the Department was unable to interview residents due to their functioning level and their inability to understand the questions asked. On December 18, 2025, the Department reviewed and evaluated the following documents: R1 Unusual Incident Report (UIR) dated 8/6/24 and 11/7/24, Dermatology visit notes (dated: 3/6/24), R1’s lab report (dated: 8/1/24), Physician Communication document (dated: 8/6/24), Medication order (dated: 8/2/24), Wound Care Progress notes (dated: 11/1/24), R1 Skilled Nursing Facility (SNF) admission document (dated: 7/25/24); R2 Physician visit and orders (dated: 6/5/24, 5/14/25), and R2 discharge document (dated; 5/22/24). The review of documents reveals there was no outbreak of Scabies as indicated in the complaint. Additionally, the documents revealed that the facility followed protocol and reporting requirements to handle an infectious disease. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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 allegation is UNSUBSTANTIATED. There were no deficiencies cited during today’s visit. Exit interview conducted with Administrator and copy of report provided. Page 3 of 3

Interviews with residents revealed 6 out of 8 residents stated staff are gentle and do not yell at residents in care. 2 out of 8 residents were unable to be interviewed due to cognitive skills. Interviews with staff revealed staff have not observed any staff mistreat or been rough to residents in care. Interview with Business Office Manager revealed the day of the allegation staff had taken R1 to a medical appointment. R1 had become agitated during the appointment and as they were leaving staff was guiding R1 to the vehicle by speaking louder due to R1’s listening skills. Staff did not put hands on R1 but put their hand up to avoid being hurt, as R1 was batting their hands due to their agitation. Per staff responsible party was notified via telephone. Documents review revealed in house incident report dated 9/29/23 notes the incident as described by staff above. 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 Nicole Anguiano and a copy of this report was provided.

(Continuation from LIC9099) The report alleges staff were unable to provide emergency personnel with resident census. Interviews conducted with the Fire Department Representative and facility staff corroborate that Emergency Personnel were requesting a verbal head count of all residents to ensure all residents were accounted for. The Fire Department Representative reported the facility staff provided the Fire Department with a verbal head count when requested on 03/14/2025. The Fire Department Representative further explained facility staff provided a response to all of the Fire Department’s requests promptly and/or within a timely manner to the situation. It was alleged facility staff were unable to provide emergency personnel with resident records. Interviews conducted with the Fire Department Representative and facility staff corroborate that emergency personnel did not request resident records on 03/14/2025. Interviews with facility staff reported facility staff attempted to provide the Fire Department with the facility’s emergency disaster plan. Facility reported that Fire Department personnel declined to review the disaster plan. Interview with the Fire Department Representative revealed resident records are only requested when a resident may require medical attention. Facility staff and the Fire Department Representative corroborated that Emergency Medical Services were not requested and/or needed for any resident at the time of the incident on 03/14/2025. It was alleged staff did not execute evacuation plan. Record review revealed facility’s Emergency and Disaster plan outlines facility assembly point to be in the front of Building A by the flagpole and residents will be relocated to locations outside the facility as needed. Through interviews with facility staff and the Fire Department Representative, the facility staff evacuated all residents to the assembly point outside of Building A. The evacuation was a result of an incident that occurred on 03/14/2025 in Building B. Interviews with both facility staff and the Fire Department Representative revealed facility staff were instructed, by fire personnel, to relocate the residents from Building B into Building A. No additional relocations were required. It was alleged facility did not have adequate staff to meet the needs of the residents in care. It was reported the facility did not have enough staff to assist with the evacuation of residents. Interviews conducted with the Fire Department Representative, facility staff, and residents, corroborate that there was sufficient staffing on duty to assist with the evacuation of residents in Building B. Record review and interviews conducted for staff schedule verified (4) four staff were on shift during the evacuation. During the incident, an additional 2 staff arrived to assist in evacuating the 42 residents. These additional staff arrived prior to the arrival of the fire personnel. (Continue to 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 (Continuation from LIC9099C) A review of the fire department’s Incident Report dated 03/14/2025 revealed the alarm was activated at 6:49PM and they arrived at 6:59PM. Fire Department Representative indicated when fire personnel arrived almost all residents were evacuated. The representative could not provide the specific number of residents who still required evacuation when fire personnel arrived. The interview with the Fire Department Representative revealed there was a sufficient number of staff to evacuate the residents in care. Based on information obtained from interviews and record reviews, the evidence received pertaining to the allegations listed above, are deemed unfounded. A finding of unfounded means the allegations could not have happened or are without a reasonable basis. An exit interview was conducted where a copy of this report was discussed and given to Wellness Director, Haley Logan.

Interviews conducted with staff revealed 5 out of 6 staff stated they have not witnessed residents spoken inappropriately by staff. 1 out of 6 staff stated that there was a staff at the time of the allegation that made inappropriate jokes with residents. Per executive director, there are no write ups for the staff in question and or no reports for any of the staff being disrespectful. 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 are not answering residents’ call bells timely . It is alleged staff are ignoring the residents’ calls when using the call light. Interviews with residents revealed 9 out of 9 residents stated the staff respond to their call in a timely manner when using the call light. Interviews with staff revealed 6 out of 6 staff stated that when a resident uses the call light cord, a board that is visible to all staff in the dining room turns on for the room calling. Also, once the cord is pulled the staff see the light and hear the sound that turns on. Per staff, they respond to the residents' calls within 3-5 minutes. During the tour of the facility LPA tested 3 call light cords in residents' rooms which when pulled a loud sound that can be heard in the building is heard and a green light outside the residents’ room turned on. Staff responded to the call light calls within 2 minutes. LPA observed staff in each buildings. 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 Teresa Mapilis Administrator and a copy of this report was provided.

On 09/09/2025, Licensing Program Analyst (LPA) Javina George made an unannounced case management incident visit. LPA was greeted and granted entry by Nicole Anguiano, Business Office Manager who was informed of the purpose of the visit. Administrator, Teresa Mapilis arrived at the facility and met with LPA shortly after LPAs arrival. On 09/05/25 the department received a death report, reporting that Resident #1 (R1) passed away on 09/03/25. During the visit, LPA conducted an interview with Executive Director Mapilis, and obtained copies of pertinent records both physically as well as electronically. Per Mapilis, the official death certificate has not been issued at this time, nor has a preliminary cause of death been provided. LPA advised Executive Director to send a copy of the death certificate to the Department as soon as it is available. Additionally, there were no health or safety concerns, observed during today's visit. An exit interview was conducted, where a copy of this report, and LIC811- Confidential Names list was reviewed and provided to Teresa Mapilis, Executive Director.

OM Anguiano was interviewed and reported although there was an incident due to a verbal disagreement between Administrator Mapilis and a visitor, Administrator Mapilis did not yell at the visitor. OM reported her office door was closed, and none of the residents witnessed the incident. Administrator Mapilis was interviewed and denied ever yelling at the visitor or any staff/resident in the facility. Three (3) staff were interviewed of which two (2) recalled the incident. Two (2) of three (3) staff interviewed were unable to recall if residents were present during the incident between Administrator Mapilis and the visitor. Three (3) of three (3) staff interviewed reported Administrator Mapilis has never yelled or disrespected them or any other staff/resident in the facility. 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 reviewed and provided to OM Anguiano. *This is an amended version of the original report.

On May 13, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with Teresa Mapilis, Administrator. 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 87 Elderly Adults (740). LPA Mixson toured the facility along with Administrator, Teresa Mapilis 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 located at 26933 Cornell Street Hemet CA. 92544. Physical Plant: The facility phone number is (951) 658-1068 and it is operable. LPA Mixson observed a sampling of the residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and the hot water temperature tested within regulations. Bathrooms were clean, and appliances were operating appropriately currently. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson 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. Designated storage space was observed for personal and resident files, and it was locked and inaccessible to residents in care currently. 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: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. Care & Supervision / Administration: Adequate staff are present for the care and supervision of resident in care. "Personal rights," telephone numbers, and floor plans were observed posted throughout the facility currently. The listed Administrator possesses a current administrator’s certificate with an expiration date of 12/30/2026. Records Reviewed and Resident/Staff Files: LPA reviewed a sampling of personnel files and reviewed the facility's staff schedule. Personnel files reviewed had criminal clearance and updated training along with First Aid Certification. A sample of resident files was reviewed and possessed all required paperwork. 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. Administrator informed LPA there are safety lights for night throughout the facility. Disaster preparedness: LPA Mixson 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 03/12/2025. Infection Control: LPA Mixson 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 TA 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.

Administrator stated there was no incident involving Resident being removed from the facility inappropriately. Administrator indicated that the facility did safeguard Resident while in care and ensured plans of care was followed. Information obtained from interviews stated there were no issues or concerns regarding Resident’s placement. Additional information obtained from staff interviews corroborated that Resident was removed in July 2022. Interviews with additional residents indicated they have no concerns regarding their safety. Interview with witness indicated Resident was receiving the best care while residing at the facility. Witness denied that Resident was kidnapped from the facility and corroborated that Resident was removed from the facility in July 2022. Due to the death of Resident, LPA is unable to interview Resident to obtain any additional information regarding the allegations. Regarding the allegation that staff did not follow appropriate reporting requirements it was reported facility staff did not notify law enforcement of the removal of the resident because there were no issues or concerns. Administrator denied the allegation and stated Resident was not residing at the facility on the date of the reported incident; therefore, there was no need to report. Administrator stated the facility ensures all incident reports are submitted in a timely manner. LPA conducted a review of the incident reports submitted and no issues or concerns regarding reporting were observed. Based on interviews and record reviews, the allegations that staff did not safeguard a resident while in care and staff did not follow appropriate reporting requirements are deemed as unfounded due to Resident not being placed at the facility when the alleged incident occurred. An allegation finding of unfounded means the allegation was false, could not have happened and/or is without a reasonable basis.

Administrator stated a new prescription of 100 mg was issued and was ordered to start on March 9, 2025. It was advised that Resident #1 died on March 9, 2025. Information obtained from interviews with additional staff advised Resident’s Physician’s Order for the 200mg was 14 days and then a new prescription was initiated. Staff indicated there were no concerns advised regarding the mismanagement of Resident #1’s medication. Information obtained from interviews with additional staff indicated there was no information provided regarding R1’s medications being mismanaged. Information obtained from interviews with Hospice Nurses advised the medications were provided to the facility labeled and in bubble packs. It was confirmed Resident was prescribed 200 mg. Additional information obtained indicated when Hospice Nurses are not available, facility staff will distribute medication. Interviews with additional residents did not indicate any issues or concerns regarding medication management. A review of Resident #1’s Physician Order dated February 11, 2025 indicated Resident was prescribed 200 mg of the medication for 14 days and then a prescription of 100 mg was initiated. Medication Administration Record dated from March 1 to March 31, 2025 indicated Resident was prescribed 200 mg of the medication until March 8, 2025. No additional documentation is recorded due to Resident’s death. The last dosage of 200 mg was given on March 8, 2025. A review of additional records revealed there were no documentation of errors or missed medications. Due to the passing of Resident, LPA was unable to obtain additional information regarding the distribution of medication. LPA also attempted to interview additional witnesses regarding the allegations, but was unsuccessful in their attempts. Regarding the allegation that staff restrained resident in care. Additionally, it was reported resident was slouched in the bed with their head against bed. Information obtained from interview with Administrator denied this allegation. Administrator stated Resident #1 does require total assistance for transferring from chair to bed. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Administrator stated staff are aware and trained to assist in transfer. Interviews with additional staff acknowledged Resident #1 was a total assist. It was indicated Resident #1 was on Hospice and required a hospital bed with rails. Staff denied utilizing a Geri chair to keep Resident #1 restrained. Interviews with additional residents indicated staff do not use Geri Chair to restrain residents and there are no additional concerns. LPA was unable to interview Resident #1 due to their death. Based on interviews, record reviews, and observations, the allegations that staff mismanaged resident’s medication and staff restrained resident in care may have happened or is valid, but there is not a preponderance of the evidence to prove the alleged violations did or did not occur. Therefore, the allegations have been determined unsubstantiated. An exit interview was conducted and a copy of this report was provided to Administrator, Teresa Mapilis.

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to re-deliver amended findings. Upon entry, LPA met with Nicole Anguiano, business office director, and informed them of the purpose of the visit. LPA delivered the amended LIC9099 and LIC9099-C along with this report.

Licensing Program Analyst (LPA), Seo Jeon, conducted an unannounced visit to the facility for a case management visit. The LPA was allowed entrance into the facility and met with Nicole Anguiano, Business Office Manager. The LPA informed them of the purpose for the visit. A report was received by the Department from the facility on 10-31-2024 regarding an incident between Resident #1 (R1) and Resident #2 (R2). LPA toured the facility and observed all facility utilities to be on and operating without issue. LPA did not observe any immediate health and safety concerns. LPA spoke to Anguiano about the incident report received on 10-31-2024. Anguiano informed LPA that a staff member was present during the entire incident pointing that there was enough staff coverage for residents in care. The staff member immediately redirected both R1 and R2. Anguiano informed LPA that R2 was relocated to Building A 2 weeks after the incident for safety of both residents. LPA did not observe any health and safety concerns at this time. 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 Nicole Anguiano, business office manager.

Therefore, based on interviews and records review, the allegation is unfounded at this time. Allegations that are UNFOUNDED, mean that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Nicole Anguiano where this report was reviewed and provided to them. 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 Therefore, based on interviews and records review, the allegation is unfounded at this time. Allegations that are UNFOUNDED, mean that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Nicole Anguiano where this report was reviewed and provided to them.

Interviews with staff and residents denied staff being physically abusive to residents and denied witnessing staff being physically abusive to R1 while in care. This agency has investigated the complaint alleging “Staff verbally abuse resident “ and “Staff physically abused resident”. We have found that the complaint was unfounded, meaning that the allegation was 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 Wellness Director Eloisa Mireles. 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 Interview with two (2) out of four (4) residents revealed they were aware of a former resident who lived in building D who had allegedly stolen R1’s belongings. Interview with Resident Two (R2) reported they had their a few of their personal belongings and their tablet stolen by the former resident. Interview with five (5) out of five (5) staff revealed they were not aware of R1’s personal belongings being stolen. Interview with Staff One (S1) revealed R1 did not report to S1 they had their personal belongings stolen after their hospitalization in September 2023. Therefore due to insufficient information available, the allegation has been deemed unsubstantiated at this time. 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 to Wellness Director Eloisa Mireles.

Regional Manager, Reyna Lacey, and Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was greeted and allowed to enter the facility to conduct the inspection. On today’s visit the LPA met with Administrator, Teresa Mapilis, and Business Office Manager (BOM), Nicole Anguiano. They were notified of the purpose for the visit. PHYSICAL PLANT: The Licensee appears to be operating the facility within the conditions and limitations specified on the license. Residents appear to be protected against immediate hazards. Outdoor and indoor passageways are kept free of obstruction. No pool or body of water was observed on the property. According to the Administrator, there are no weapons kept on the property. Disinfectants, cleaning solutions, and poisons were inaccessible to residents in care. A comfortable temperature was being maintained in each building on the property. There was sufficient lighting in resident bedrooms to ensure the comfort and safety of residents. The hot water was tested in several resident bedrooms and observed to be within regulatory requirements. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. Additional equipment for physically handicapped clients is available. The smoke and carbon monoxide alarms are being monitored by alarm central and recently inspected by the county fire department. Corrections requested by the fire department were completed on 07/08/24 and 07/09/24. The interior and exterior areas of the facility were observed to be clean and safe. FOOD SERVICE: There was a variety of food which appeared to be selected and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient. Sufficient supplies for resident's dinning use was observed to be available. RECORD REVIEW: Staff files had required training; including, but not limited to, First Aid/CPR, Reporting 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 Requirements, and Emergency and Disaster Training. Training on special health conditions was observed on file. Hospice Care Plan was observed on file for resident in care. Staff present had the required criminal record clearances. Admission Agreement, Medical Assessment (Physician's Report), Assessments, and Service Plans were observed on file for residents in care. Administrator Mapilis has an active Administrator's certificate, which expires on 12/30/2024. A fire drill was completed on 06/05/2024. The facility currently has 18 residents in care receiving hospice services; which is within their Hospice Waiver limit. The Licensee corporation is active with the California Secretary of State and proof of current Limited Liability Insurance was observed to be in place. MEDICATION: Two of four medication carts were inspected. Medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be safe, locked, and inaccessible to residents in care. No deficiencies have been cited at this time. This report was reviewed with Administrator Mapilis and a copy was provided. NOTE: LPA left the facility at 1:00 PM and returned at 1:30 PM.

CONTINUED FROM 9099 It was advised that the primary care doctor prescribed R1 two specific medications. Information obtained from interviews with facility staff stated staff follow R1's plan of care, service plan as well as the Physicians orders. The records review indicated that there were no medications being administered to R1 that were not prescribed by the attending doctor. Regarding the allegation of Staff did not ensure resident used their walking device, it was reported that R1 was taken to the doctors without their walking device. Information obtained from interview with the Administrator and facility staff advised that R1 is supposed to use their walker when ambulating. It was stated that there was an incident where R1 was transported to see their primary doctor and R1 was trying to hit Staff Member with their walker. Staff Member was able to calm R1 down and properly use their walker to assist with ambulating. Upon arrival to the doctor’s office, R1 refused to use the walker. The driver, which was also a staff member, escorted R1 into the doctor’s office. Information obtained from additional witness stated that R1's walker was present and available for use. Based on interviews, reviews of the documents, observations, and the inability to interview R1, the allegations of Staff are administering medication to resident not consented by POA, Staff are not meeting resident's hygiene needs, and Staff did not ensure resident used a walking device have been deemed "Unsubstantiated." An allegation finding of "unsubstantiated" means although the allegations may have happened or are valid, there is not a preponderance of evidence strand to prove the alleged violation(s), did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted, a copy of this report, along with the appeal rights were provided to the Administrator, Teresa Mapilis.

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility staff with LPA identification and business card. LPA was able to complete one (1) domain, due to time constraint, LPA will need to return to complete the Annual Inspection. LPA allocated time to prepare this report for delivery. Based on the information received during this visit today, there are no deficiency that is being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with and a copy provided to the facility representative at the time of the exit interview.

(Continued from Page 1) LPA reviewed R1’s face sheet, LIC602, Needs and Services plan, admission packet, assessment forms, progress notes, documentation of incidents that involved R1’s behavior with Administrator, staff and residents on separate dates from February 4, 2023 through January 4, 2024 with physical and verbal abuse towards other residents and staff. During the LPA’s interview with Administrator, it was concluded that Administrator hand delivered and mailed the eviction notice with a 30-Day notice along with several resources to help find alternate housing. Based on LPAs observations, records review, and staff interview, this agency has investigated the complaint alleging “illegal eviction” and we have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report, LIC811 was provided to facility representative. *LPA was away from the facility from 12:25-1:25PM

diagnosed with an infectious condition. According to the Administrator, infection control policies are being followed for R2, including environmental cleaning and frequent showers. Staff interviews confirmed environmental cleaning and frequent showers are being completed. Documentation, including medical records and discharge paperwork, revealed the remaining residents have not been diagnosed with the contagious disease and are currently receiving treatment for the rash they were diagnosed with. Additionally, an Attendance Log revealed care staff were provided with training relating to skin issues on 04/18/2024. No information was received to indicate there is a bed bug infestation at the facility. Therefore, based on interviews and records, this allegation is deemed 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 with Business Office Manager (BOM), Nicole Anguiano. This report was reviewed, and a copy was provided, along with the LIC 811.

Staff indicated no other staff were around during the assault except for the newly hired staff member. LPA interviewed R2 but was unable to finish the interview due to R2 became verbally aggressive to LPA. LPA reviewed documents pertinent to the investigation that included facility incident reports, client records and photos of the injury. Based on LPA’s observations, interviews conducted, and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. An exit interview was conducted and a copy of this report was provided along with Appeal Rights. 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 LPA’s observation, interview(s) conducted and record review(s), the preponderance of evidence shows that the allegations 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. An exit interview was conducted, a copy of this report, appeal rights was provided to Nicole Anguiano, Business Office Manager.

Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived unannounced to the facility to conduct additional interviews with witnesses regarding complaint 18-AS-20240105081727. LPA was granted entry into the facility and met with Executive Director Teresa Mapilis. LPA explained the purpose of the visit. LPA was informed that the additional staff witness was scheduled to begin work at 2:00pm but called out due to a family emergency. LPA conducted an interview with Executive Director and documented the information on a LIC 812. No additional interviews were conducted. A copy of this document was provided to Executive Director Teresa Mapilis.