Park Regency Retirement Center.

This unannounced POC inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of verifying correction of deficiencies issued during the complaint inspection conducted on May 12, 2026, in connection with Complaint Control No. 22-AS-20220323083918 and the Case Management – Deficiencies inspection conducted on May 12, 2026. LPA met with Maintenance Director (MD) Jorge Garcia and Administrator (AD) Sabina Nayberg and explained the reason for today’s inspection. During the inspection, LPA and MD inspected the facility, conducted health and safety checks on residents present, and observed no health and safety issues. During the inspection, LPA and MD observed the following: Type B Violation cited under California Code of Regulations (CCR) Title 22, Section 87465(a)(4) pertaining to a resident’s medication not documented as administered has been CLEARED. On June 1, 2026, the former wellness director emailed LPA documentation of medication training. Type B Violation cited under California Code of Regulations (CCR) Title 22, Section 87303(i)(1)(A) pertaining to not checking on residents regularly when the signal system is malfunctioning has been CLEARED. On June 1, 2026, the former wellness director emailed LPA documentation of signal system training. Type B Violation cited under California Code of Regulations (CCR) Title 22, Section 87303(e)(4) pertaining to toilets not having grab bars has been CLEARED. On June 1, 2026, the former wellness director emailed LPA documentation and photographs of grab bars installed in 23 rooms where they were missing. During the inspection, LPA inspected 26 rooms and confirmed they all have grab bars for the toilets. 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 Type B Violation cited under California Code of Regulations (CCR) Title 22, Section 87463(a) pertaining to timely reappraising residents upon change of condition has not been cleared. The plan of correction was to create a protocol to ensure residents are reappraised timely and submit proof to LPA by June 9, 2026. Type B Violation cited under California Code of Regulations (CCR) Title 22, Section 87608(a)(3) pertaining to using postural supports without a doctor’s order has not been cleared. The plan of correction was to conduct training on postural supports and submit proof to LPA by June 9, 2026. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report, clear letters for all citations cleared during this inspection, and appeal rights was discussed with and provided to facility representative.

Regarding the allegation that staff did not provide proper medication assistance to resident in care: it was alleged that R1 did not take their medication because staff would leave R1’s room without confirming they took the medication. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed five residents and did not obtain information corroborating that medication technicians leave residents’ rooms without confirming residents have taken their medication. However, LPA reviewed R1’s care notes which indicate on May 12, 2021, a reminder was documented for the medication technicians emphasizing the importance of staying in the room and watching R1 drink a liquid medication, advising that R1 missing doses of this medication will alter R1’s potassium levels, and advising that on May 12, 2021 R1’s family reported that R1’s dialysis nurse found R1’s potassium levels to be dangerously high. In addition, LPA reviewed R1’s MAR which indicates R1’s Sevelamer Carbonate 800MG was not documented as being given for the noon dose on January 24, 2022. Regarding the allegation that a resident's call button was in disrepair: it was alleged that R1’s call button was not functioning for three weeks in January 2022. LPA reviewed the facility’s internal communications which document that the entire call system stopped functioning on February 16, 2022, and checks were conducted on all residents in lieu of the call system. However, per the facility’s’ internal communications, on February 17, 2022, a caregiver checked on R1, R1 complained that they had been calling for assistance, but the caregiver documented that the call light system was still not working and they had only checked on R1 because of their rounding. R1’s care notes and the facility’s internal communications do not document any issues with the call button system after February 17, 2022. Facility staff were supposed to conduct regular checks on residents while the call system was not working, but the information obtained shows that R1 was calling for assistance for an unknown length of time, the caregiver did not receive the signal or respond timely, and the caregiver only checked on R1 as part of their last check without realizing R1 had been calling for assistance. Regarding the allegation that facility did not maintain grab bars for each resident toilet: it was alleged that R1’s room did not have grab bars for the toilet and staff did not correct the issue. Per the facility’s resident roster and R1’s MAR, R1 resided in Room 165. LPA interviewed the facility’s maintenance director who stated there are two styles of bathrooms, where the old style has a sink that goes up to the toilet and the sink can be used as a grab bar, and the new style where the sink is far from the toilet and cannot be used as a grab bar. Per the facility’s maintenance director, grab bars are installed when requested by residents’ families. 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 inspected the facility and confirmed that the old style has a sink that goes up to the toilet and could possibly be used as a grab bar, but Room 165 does not have separate grab bar installed on the sink and the edge of the sink does not provide the same gripping surface as a true grab bar, meaning it does not meet the requirement that every toilet have a grab bar. In addition, LPA noted room 206 has the new style where the sink does not reach the toilet and there is no grab bar installed on the toilet. Regarding the allegation that staff did not complete a reappraisal on resident in care: it was alleged that in January 2022, R1 had a fall resulting in decreased arm mobility and the facility did not conduct a reappraisal or update R1’s care plan prior to R1 leaving the facility in February 2022. LPA reviewed R1’s care notes which document that on December 15, 2021, R1 had a fall, went to the hospital, and was picked up by their family to stay with their family. Per R1’s MAR, R1 returned to the facility on January 6, 2022. LPA reviewed R1’s care notes which document that on December 22, 2021, facility staff communicated with R1’s family regarding R1’s change of condition after their fall and documented R1’s new care needs and how they would be met. LPA reviewed a copy of R1’s service plan marked up on January 6, 2022 by the facility’s wellness director at the time that documents R1’s new care needs and documents that the facility would use a wheelchair for R1, but this document was never finalized. Per R1’s care notes, when R1 returned to the facility on January 6, 2022, facility staff requested an updated physician’s report from R1’ doctor and planned to update R1’s service plan. R1’s care notes document that on February 18, 2022, a care plan meeting was held with R1’s family, it was explained to R1’s family that R1’s service plan had not yet been updated because the facility was still waiting on an updated physician’s report from R1’s doctor, R1’s family was advised that staff are all aware of R1’s new care needs and the required care was being provided, and R1’s family advised the facility that R1 would be moving out. While the facility noted R1’s new care level and claimed to provide the newly required services, the facility did not need to wait for the new physician’s report in order to finalize the changes already discussed with R1’s family. In this case, R1 returned to the facility on January 6, 2022 and did not have a finalized updated service plan by the time they moved out on February 19, 2022. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. 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 when R1’s call button did function, R1 had to wait 30 minutes or longer for assistance from staff. LPA interviewed the administrator at the time who stated the average wait time is five to 10 minutes, with the old call button system wait times could not be tracked, but with the pendant system installed on March 1, 2022, they can now track wait times. LPA interviewed five residents and did not obtain information corroborating long wait times. LPA reviewed the facility’s internal communications which document that on February 9, 2022, R1 called for assistance at 5:08AM, requested a medication from the caregiver, and the medication was provided to R1 by the medication technician at 5:20AM. The facility’s internal communications also document that on January 21, 2022, at 5:40AM, R1 requested assistance, assistance was provided by a caregiver, and the encounter was completed and documented by the medication technician minutes later at 5:53AM. These incidents demonstrate rapid response times by staff. Per the facility’s internal communications, on February 11, 2022, R1 requested assistance at 3:08AM, stated they were hungry and wanted the medication technician to warm up the soup in their fridge and feed them, the medication technician advised R1 that they could not because they had to attend to other residents, and the medication technician went back and confirmed R1 was fine prior to 5:36AM when the encounter was documented. This incident demonstrates that R1’s call was answered, R1’s request could not be immediately fulfilled, and the staff checked back later to ensure R1 was doing well, although additional details, including whether R1 withdrew their request to eat so early in the morning or when the staff made their second check, were not documented and the staff no longer works at the facility. The information obtained is conflicting. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20220323083918. LPA met with Wellness Director (WD) Maria Vasquez and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, interviewed staff and residents, and obtained and reviewed copies of the resident roster, staff roster, a copy of Resident #1’s (R1) service plan marked up on January 6, 2022, and R1’s medical records. A witness observed R1 being placed in wheelchair at the facility. LPA reviewed a copy of R1’s service plan marked up on January 6, 2022 by the facility’s wellness director at the time that corroborates a wheelchair was used for R1. However, R1’s file and R1’s medical records do not contain a doctor’s order for a wheelchair. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20251230120343. LPA met with Administrator (AD) Miles Mouradian and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, interviewed AD, staff, and residents, and obtained and reviewed copies of the resident roster, staff roster, the facility’s care notes dated December 29, 2025, the facility’s call button logs, and Resident #1’s (R1) Needs and Services Plan dated November 9, 2024. Per R1’s Needs and Services Plan dated November 9, 2024, and the facility’s wellness director’s admission, R1 has not been reappraised yearly as required as their appraisal is over a year old. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

LPA inspected the facility in October 2021 and noted that there were not enough staff to readily assist LPA with the inspection, as all care staff were occupied providing care, the only office staff present had to cover reception until they were relieved, and the administrator at the time did not arrive until much later in the day. LPA also observed unpleasant odors from one memory care room, an unpleasant odor in the hallway possibly coming from one of the residents, and one memory care room had stains, crumbs, and debris on the floor as well as stains on the walls. When interviewed, the administrator at the time confirmed that the memory care recently had staffing issues, confirmed there was a lot of recent staff turnover, but otherwise denied the allegation, stating the facility was meeting its own staffing ratio with its staff and was also using a staffing agency to supplement staff. LPA reviewed the facility’s labor hour reports which indicate the number of caregiver hours were consistent from June through September 2021. LPA reviewed staffing agency invoices showing a small amount of staffing agency coverage during this time. LPA reviewed the facility’s termination report which shows that from June 2021 to the end of September 2021, 22 staff quit or were terminated. LPA interviewed five staff who corroborated that around September 2021, the facility had severe staffing issues due to staff turnover, there were fewer staff than there were supposed to be, especially in memory care, which negatively affected resident care, increased wait times for care, and increased the workload which caused more staff to leave. Staff interviewed also confirmed that there were instances where there was only one caregiver in memory care, that memory care would pull staff from the assisted living section leaving that section understaffed, and that the overnight shift was unable to meet the needs of the residents and left them all wet in the morning without changes. LPA interviewed six residents, five of whom corroborated that the facility had lost a lot of staff recently and three of whom confirmed residents were impacted by the staffing issues, including with longer wait times. Regardless of whether the facility was meeting its own staffing ratio, interviews with multiple residents and staff confirmed that the facility’s staffing level was insufficient to meet residents’ needs, including incontinence care. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

It was alleged that residents have to wait a long time to receive care when they activate their call buttons. LPA interviewed AD and WD who denied the allegation. Per WD, the expectation on staff is that calls for assistance are answered in 10 to 15 minutes, but during peak times such as meals many residents call at the same time to be taken to the dining room which increases response times. WD stated that if a new call comes in while a staff is already assisting a resident, the staff will go check on the new call to ensure it is not an emergency, go back to the resident they were assisting and complete the care they are providing, then address the new call. LPA interviewed 12 residents and obtained information that call button response times range from 15 to 40 minutes and received conflicting information about whether staff already assisting residents are pausing the care they are providing to check on new calls and determine if they are emergencies. LPA reviewed the facility’s call system logs and noted most calls for assistance are resolved within 15 minutes, but there were also multiple calls that took over 40 minutes, 50 minutes, and even an hour to resolve, which is too long for residents to wait for assistance with care needs or possible emergencies. AD stated that resident calls for assistance are first quickly answered by staff to determine the urgency and are only cleared once the care is completely provided. No information was obtained that the long wait times resulted in any injuries or illness to the residents. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. 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 the facility is understaffed resulting in inadequate care and supervision for residents. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed AD and WD who denied the allegation, stating the facility has enough staff and is currently hiring even more staff. Per WD, the average staffing ratio is about seven or eight care staff for the whole building during the day shift and three or four care staff during the overnight shift. LPA reviewed the facility’s staff schedule which shows four or five care staff for the day shifts in assisted living, four or five care staff for the day shifts in memory care, and three or four care staff for the overnight shift for the whole building. LPA interviewed 12 residents and obtained conflicting information, with some residents stating that the facility has enough staff and other residents stating that the facility needs more staff to meet residents’ needs, especially the overnight shift. However, per WD and the facility’s staff schedule, staffing for the overnight shift has already been increased. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

Regarding the allegation that staff did not ensure the facility grounds are properly maintained: it was alleged that the facility’s roof leaked and was damaged during recent rain. LPA inspected the facility and observed that the roof had recently leaked and that several ceiling tiles were damaged, missing, and/or stained in the first floor dining room and adjacent hallway. AD stated that no residents were present when some ceiling tiles had fallen down in the dining room, no leaks were present in any resident rooms, and the facility took measures to address the water damage and to limit the damage during future rain. LPA interviewed 10 residents, none of whom reported additional physical plant issues at the facility. LPA observed ceiling stains in one of these residents’ rooms and also that the bathroom of another resident had leaked during the recent rain. The facility has previously had multiple issues with its leaking roof, including substantial leaks in early 2025 in the same locations as the current leak, and AD admitted that the facility still has not begun a full roof repair and is instead taking temporary measures of placing a tarp over the damaged roof which has not worked to prevent the leaks. Based on the information obtained, the facility has not taken sufficient measures to repair its roof after multiple leaks resulting in continued leaks damaging the first floor and posing a potential slipping risk for residents during rainy days. Regarding the allegation that staff did not keep the facility free from mold: it was alleged that after a recent roof leak, stains on the ceiling and smells in the hallway indicate there may possibly be mold. LPA inspected the facility and observed that the roof had recently leaked and that several ceiling tiles were damaged, missing, and/or stained in the first floor dining room and adjacent hallway. LPA observed ceiling stains in one resident’s room and also that the bathroom of another resident had leaked during the recent rain. In addition to the stains on the ceiling tiles, much of the water damage is deep in the ceiling and could not be seen. During the inspection, a City of La Habra code enforcement official required mold testing based on their observations of the water damage. However, although the leak occurred weeks ago, facility staff stated they still had not tested for mold, meaning the facility did not take proper steps to ensure the facility was free from mold in light of conditions that present the risk for mold. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. 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 the facility is frequently short staffed, and in some instances in late October 2025 there were no caregivers or supervisors on duty. LPA interviewed AD who denied the allegation, stating that two caregivers resigned without notice recently but that the facility’s management team stepped in to cover. LPA interviewed WD who stated that the facility’s assisted living staffing schedule is for three or four caregivers plus one medication technician for the morning and afternoon shifts, with the memory care unit having its own separate set of three or four caregivers plus one medication technician for these shifts, and that during the overnight shift both the assisted living section and memory care unit share a set of three or four staff at least one of whom is a medication technician. Per WD, there were some recent call outs in assisted living and WD tried to get coverage for the call outs and covered some shifts themselves. LPA reviewed the facility’s timesheets for late October 2025 and confirmed that the facility’s staff levels were generally consistent with their staff schedule, although they did dip slightly low during certain afternoon shifts. However, per AD, even during these slight dips, the staffing level was above the facility’s minimum staffing requirement. LPA interviewed 10 residents and only one resident corroborated the allegation, stating that wait times for the call system could get very long, while the rest of the residents did not corroborate the allegation. Review of the facility’s recent call system logs, which includes dozens of calls, shows most calls are resolved within five or 10 minutes, although two calls took a little over 40 minutes. The information obtained is conflicting. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

It was alleged that due to lack of care and supervision, the facility not allowing R1’s family member to provide extra care, and the facility not assisting R1 with their walker, R1 sustained two falls in early September 2025, one of which resulted in a head injury and hospitalization. LPA inspected the facility, conducted health and safety checks on R1 and other residents, and observed no health and safety issues. LPA interviewed R1 who was unable to provide information regarding this allegation. LPA’s observations of staff ensuring R1 had access to and made use of their walker, as well as LPA’s interview with R1’s family member, did not corroborate that the facility did not assist R1 with their walker. Interviews with PA, facility staff, and R1’s family member revealed that while R1’s family member has a history of providing extra care for R1, during a COVID-19 outbreak in early September 2025, R1’s family member was either strongly encouraged or ordered not to visit with R1 due to COVID-19 precautions, R1’s family member stopped visiting R1 to provide extra care, and during R1’s family member’s absence, R1 suffered a fall resulting in hospitalization. However, regardless of whether R1’s family member was present to provide additional care, it was the facility’s responsibility to provide care and supervision to R1 in light of R1’s fall risk. LPA reviewed R1’s Care Plan which states that R1 is a fall risk and R1’s Care Notes which document previous falls on July 28, 2025, June 14, 2025, and May 19, 2025. Per R1’s Care Notes, R1 tested positive for COVID-19 on September 8, 2025 and interviews with staff revealed that R1’s COVID-19 infection caused R1 to grow increasingly weak. Per R1’s Care Notes, R1 suffered two falls on September 10, 2025, the second of which resulted in hospitalization. LPA reviewed R1’s Medical Records which show that R1 was hospitalized on September 10, 2025 through September 13, 2025 with a primary diagnosis of generalized weakness. Despite R1 being a fall risk with a history of falls and now having increased weakness due to COVID-19, the facility did not provide additional care and supervision to address R1’s increased fall risk resulting in two falls in one day. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. 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 the facility did not notify R1’s responsible party of R1’s falls in early September 2025. LPA interviewed facility staff who denied the allegation, stating that R1’s family member was always notified of incidents involving R1. LPA interviewed R1’s family member who indicated they were made aware of R1’s falls. LPA reviewed R1’s Care Notes which indicate R1’s family member was notified of R1’s recent falls. LPA interviewed one witness who stated that one of R1’s falls was reported after R1 was already at the hospital which did not allow R1’s family to accompany R1 to the hospital. However, based on R1’s Care Notes, R1 was bleeding and 911 was necessary, meaning the first priority for facility staff would be to ensure R1 was on the way to the hospital. While R1’s family member may have been notified after R1 was already at the hospital, the information is conflicting regarding whether the facility should have notified R1’s family earlier. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. 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 multiple residents are not having their briefs changed on a regular basis. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed PA and facility staff who denied the allegation. LPA interviewed R1’s family who did not corroborate any incontinence issues with R1 or other residents. LPA reviewed R1’s Care Schedule for September 2025 which shows staff documenting incontinence care for R1. LPA interviewed five residents who wear diapers and did not obtain information corroborating the allegation. The information obtained did not corroborate the allegation. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Maintenance Director (MD) Jorge Garcia and discussed the purpose of the inspection. Pending Administrator (PA) Miles Mouradian arrived during the inspection. LPA reviewed Infection Control requirements. At about 8:00AM, LPA and MD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication rooms and observed the following: Structure: this is a large commercial facility. Facility is composed of a single, two-story building with a delayed egress memory care unit on the second floor, a commercial kitchen and large dining room on the first floor, medication rooms on both floors, and resident rooms on all floors, along with multiple common areas, storage rooms, and a large central courtyard and a smaller courtyard dedicated to memory care with shaded seating for residents. There are a total of 86 resident rooms. Resident Bedrooms: the 10 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 10 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 117 and 120 degrees F in the 10 resident bathrooms tested. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the housekeeping closets. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. 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 The facility’s licensing fees are paid. At about 10:00AM, LPA reviewed 10 resident files and 5 staff files, interviewed 5 residents and 5 staff, and inspected medications for 5 residents. Facility does not handle resident money. During the inspection, LPA and AD observed the following: based on Guardian records, the licensee did not ensure Staff #1 (S1) was background cleared prior to working at the facility for the last two years; based on documents, the licensee did not ensure Staff #2 (S2), who is a medication technician, had documented medication training; and based on observation and documents, the licensee did not ensure Resident #1 (R1) received their Quetiapine 0.5MG on August 14, 2025 as the pill was still in the bubble pack and the MAR was blank and there is no indication of refusal. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421BG. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

It was alleged that R1 refused care from a staff, the staff brought another staff and forced care on R1, and R1 fought back and was injured with a skin tear as a result. LPA inspected the facility, conducted health and safety checks on residents, and observed that R1 has three small scabs on their left arm and a very large hand-shaped bruise on their right arm. Per R1’s Physician’s Report dated January 16, 2025, R1 has mild cognitive impairment but R1’s Medical Records indicate that R1 was diagnosed with dementia with behavioral disturbances on July 2, 2025. LPA interviewed R1 who was aware they were injured, but was unable to provide information regarding how the injuries were sustained due to R1’s dementia diagnosis and LPA noted R1 to be confused and easily agitated. LPA interviewed RCD who stated that on June 24, 2025, Staff #1 (S1) noted that R1, who lived in assisted living at the time, was very soiled and tried to provide care to R1, R1 refused, S1 brought Staff #2 (S2) to help, R1 resisted and attacked S1 and S2, and S1 and S2 completed care for R1 but R1 sustained a skin tear during the incident. LPA reviewed the facility’s investigation report dated July 8, 2025, which indicates that R1’s family had noted a recent cognitive decline in R1 prior to the incident and that shortly after the incident on June 24, 2025, R1 was medically reassessed with a diagnosis of dementia and admitted to the memory care unit. AD stated that after the incident, staff were retrained on resident refusals, providing care, and personal rights. LPA reviewed the staff files for S1 and S2 and confirmed they are both background cleared and have up to date training. LPA attempted to interview S1 and S2, but they were not available for interview. However, their statements are incorporated into the facility’s investigation report dated July 8, 2025 and LPA’s observations confirmed R1’s injuries. RCD stated that S1 and S2 did not follow facility protocol when they forced care on R1 and that they should have waited, given R1 time, called the family, called managers, and taken other measures to prevent the incident as it occurred. LPA reviewed R1’s Care Notes which indicate that R1 was observed to be very confused, not making any sense, and being rude and aggressive with staff and other residents since late February 2025, but R1 was allowed to stay in assisted living until the incident on June 24, 2025. Based on the information obtained, S1 and S2 forced care on R1, an assisted living resident who likely should have been in memory care, resulting in skin tears as well as a very large bruise on R1’s arm indicating that R1 was held very firmly during this incident. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. This is an amended report

It was alleged that facility staff are not dispensing medications as prescribed. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed PA and three staff and one staff admitted that Resident #1’s (R1) Fosfomycin, which is to be administered every three days to prevent urinary tract infections, was not given as prescribed, as there are still medications from the April 2025 shipment that remain, and the facility did not order a May 2025 supply. LPA inspected R1’s Fosfomycin and confirmed that five doses from the April 21, 2025, shipment, which should have been given to R1, are still present at the facility. LPA reviewed R1’s Medication Administration Records and noted that this medication is document as having been properly given to R1, which is incorrect. Facility staff were unable to provide an explanation as to why R1’s Fosfomycin was not given as prescribed or why it was documented as having been properly given, but stated the situation is being investigated. LPA inspected the Medication Administration Records for five additional residents and noted that Resident #2 (R2) did not receive any of their medications on May 1, 2025 due to lack of supply. Facility staff were unable to provide documentation of their attempts to follow up with R2’s doctor and pharmacy to ensure R2’s medications were delivered timely. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

It was alleged that large ceiling leaks developed resulting in wet floors and other unsafe conditions and the facility did not properly address the leaks or communicate the situation to residents’ responsible parties. LPA interviewed AD and facility staff who stated that in February 2025 there was a leak that affected the first-floor hallway and nearby rooms, the situation was communicated to affected residents, measures were taken to mitigate the effects of the leak and ensure the health and safety of residents, and the leak was repaired as quickly as possible. LPA inspected the facility, including 14 resident rooms and all common areas, and observed that the damage from the leak has been repaired. LPA interviewed 11 residents and did not obtain information corroborating the allegation. However, LPA observed large stains under the bathroom sink, as well as water damage on the wall behind the toilet, in one resident room which appeared old and had not been repaired. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. 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 that staff did not keep the facility free of mold: it was alleged that large ceiling leaks developed in the first-floor hallway near the dining room and in the second-floor memory care resulting in wet ceilings and mold and the facility did not properly address the mold. LPA interviewed AD and facility staff who stated that in February 2025 there was a leak that affected the first-floor hallway and nearby rooms, the leak was addressed as quickly as possible, the leak did not result in mold, facility staff tested affected rooms for mold and the results were negative, and the leak and ceiling were repaired and the carpets were changed to ensure no mold developed. LPA inspected the facility, including 14 resident rooms and all common areas, and did not observe evidence of mold. LPA interviewed 11 residents and did not obtain information corroborating the allegation. However, LPA observed large stains under the bathroom sink in one resident room as well as water damage on the wall behind the toilet which could possibly be mold. Per facility staff, this water damage has not yet been tested but is going to be repaired soon. The information obtained is conflicting. Regarding the allegation that staff did not take precautions to prevent the spread of illness: it was alleged that there was a large infectious disease outbreak, and the facility did not properly address the outbreak or report the situation to residents’ responsible parties. LPA reviewed facility incident reports dated December 19, 2024, and December 23, 2024, which indicate 11 residents developed gastrointestinal symptoms, the outbreak was reported to local public health, and the facility was following the infection control guidance provided by local public health. LPA reviewed the facility’s infection control plan and noted it to be complete and current. LPA interviewed AD and facility staff who stated the gastrointestinal outbreak affected a total of 15 residents, facility staff reported the outbreak to local public health and followed the infection control guidance they received, facility staff notified the families of all residents, the outbreak ended on January 1, 2025, and no residents were hospitalized because of the outbreak. LPA reviewed the facility’s communications with local public health which show the facility notified local public health of the outbreak and received guidance on infection control protocols. LPA inspected the facility and observed sufficient supplies of masks, gloves, sanitizer, and gowns and also observed staff wearing personal protective equipment (PPE) while providing care to residents. Out of the 11 residents interviewed, some recalled seeing staff take infection control precautions during this outbreak, while many were unable to say. The information obtained did not corroborate the allegation. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. 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, in late December 2024, there was a large infectious disease outbreak which was not handled properly because AD and facility staff are not properly trained. LPA interviewed AD and facility staff who stated the gastrointestinal outbreak affected a total of 15 residents, facility staff reported the outbreak to local public health and followed the infection control guidance they received, facility staff notified the families of all residents, the outbreak ended on January 1, 2025, and no residents were hospitalized because of the outbreak. LPA reviewed AD’s administrator certificate which is current and indicates that AD’s administrator training is current. LPA reviewed the training records for five staff and confirmed they have completed the required caregiver annual training. Per AD and facility staff, staff are trained on infection control as part of their training. LPA reviewed staff training records dated December 18, 2024, which show staff were trained on gastrointestinal infections as part of the facility’s response to this outbreak. LPA did not obtain any information corroborating this allegation. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Maintenance Director (MD) Jorge Garcia and discussed the purpose of the inspection. Administrator (AD) Ashley Willett arrived during the inspection. LPA reviewed Infection Control requirements. At about 8:00AM, LPA and MD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication rooms and observed the following: Structure: this is a large commercial facility. Facility is composed of a single, two-story building with a delayed egress memory care unit on the second floor, a commercial kitchen and large dining room on the first floor, medication rooms on both floors, and resident rooms on all floors, along with multiple common areas, storage rooms, and a large central courtyard and a smaller courtyard dedicated to memory care with shaded seating for residents. There are a total of 86 resident rooms. Resident Bedrooms: the 12 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 12 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 110 degrees F and 117 degrees in the 9 resident bathrooms inspected. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication rooms: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees have not been paid and are past due. At about 10:00AM, LPA reviewed 6 resident files and 6 staff files, interviewed 6 residents and 6 staff, and inspected medications for 6 residents. Facility does not handle resident money. 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 During the inspection, LPA and AD observed the following: based on documents, the administrator was changed in October 2023 but not all documents LPA requested were provided and the administrator still has not been updated; based on documents, the licensee has not paid their licensing fees for multiple years which are now past due; based on documents, the licensee did not ensure S1, S2, and S3 had current first aid training as their certificates were expired; and based on documents, the licensee did not ensure R1, who has dementia per their most recent Physician’s Report dated 01/30/23, received an annual medical assessment. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.