Crestavilla.

out of 4 staff interviewed and the Executive Director reported they have never taken anything from any resident and have never witnessed any staff member steal anything. 4 out of 4 residents interviewed reported they have never had anything stolen since they moved into the facility. Staff and the Executive Director reported they do not enter resident rooms without resident permission. Room entry is via a key card which tracks when and who enters any residents' room. A review of records shows R1 was the only person to enter their room except for one entry by staff member allowing a visitor for R1 to enter the room, R1 verified this information. A review of incident reports for the facility for 2026 shows no thefts have been reported by the facility. There is no evidence to corroborate the allegation, therefore the allegation is deemed unfounded meaning, that the allegation was false, could not have happened and/or is without a reasonable basis. The investigation into the allegation, staff steal money from resident, revealed the following. It was reported that staff take money from R1's room when they are not there or when they are asleep. No specific details were provided. R1 could not provide dates and times when cash was taken or the amounts of money that have been taken. R1 reported that they contacted law enforcement who left after a few minutes and they didn't do anything. R1 reported that they did not know who took their cash or when. R1 did not respond when asked if it was possible they spent the money or possibly put in the bank or somewhere else they forgot about. 4 out of 4 staff reported they have never witnessed or taken any money from any resident. 4 out of 4 residents reported they have never had any money taken from them at the facility. None of the evidence gathered supports the allegation. The allegation is deemed unfounded meaning, that the allegation was false, could not have happened and/or is without a reasonable basis. The investigation into the allegation, staff mishandle residents medication, revealed the following. It was reported that staff take R1's medication and it was witnessed by Resident 2 (R2). R2 denied the report. 4 out of 4 staff reported that they have never taken R1's medication or any residents' medication. A review of records shows R1 handles their own medication. R1 reported that over the years all of their medicaiton has been taken but did not provide any other details. Staff 1 who is authorized to handle resident medication reported that until a resident's medication is handled by the faciltity they do not handle their medication in any way. None of the evidence gathered supports the allegation, therefore the allegation is deemed unfounded meaning, that the allegation was false, could not have happened and/or is without a reasonable basis. 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 investigation into the allegation, staff open resident’s mail, revealed the following. It was reported that R1 orders items that are mailed and staff open the mail and steal the contents. R1 reported that their mail has never been stolen or opened by anyone. R1 reported that the items they have ordered and that were mailed were stolen later after they were received but not before they received them in the mail. 4 out of 4 staff reported they don't have access to resident's mail and have never stolen or opened anyone's mail. 4 out of 4 residents interviewed reported they have never had an issued with mail being stolen or open. Based on the evidence gathered the allegation, staff open resident’s mail, is deemed 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 the report provided.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. The Agency received a report that the facility had an increase in calls for emergency services (calls to 911) as compared to last year. LPA met with Executive Director (ED) Myra Aragones and explained the reason for the visit. LPA consulted with the ED regarding PIN 25-06-ASC Calling 9-1-1 In Residential Care Facilities For The Elderly (RCFE) . LPA discussed the PIN with the ED who stated all care staff will be retrained on PIN 25-06-ASC. LPA consulted with ED regarding reporting requirements. The ED reported that the priority of the facility is the health and safety of the residents and reported that 911 is only called when it is required. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by receptionist. LPA met with Myra Aragones, Executive Director, and LPA explained the nature of the visit. The facility is licensed to operate for (250) non-ambulatory, of which (10) may be bedridden elderly adults ages 60 and above. The facility is approved for (20) hospice residents. Currently the facility has (164) assisted living residents, (30) residents in memory care, and (11) hospice residents. Delayed egress doors for memory care only. This facility consists of two main areas. The assisted living and the memory care unit which are protected by delayed egress exits. The facility is a three-story structure located in a commercial neighborhood. It consists of the following: (211) resident bedrooms, (211) resident bathrooms, med rooms, a conference room, dining rooms, a laundry room, a mailroom, business offices, a commercial kitchen, a movie theater, (3) multi-purpose rooms, (8) storage rooms, (13) public restrooms, courtyard patio area, a salon, an exterior pool (under maintenance at time of visit), an employee lounge, and rooftop with art & crafts room, sun room area and lounge. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted including Activities Calendar and Food Menu. LPA Martinez along with the Interim Executive Director toured the physical plant of both the assisted living and the memory care unit. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at Continued on LIC809-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 time of visit. Maintenance records were observed in the main kitchen. LPA observed a bistro adjacent to the main dining room where residents can obtain different snacks and beverages selections than in the main dining area. The bistro offers snacks all day so residents may dine when convenient. LPA observed menus and the food offered is varied and healthful. Kitchen was inspected. During the tour LPA observed residents involved in an activity as well as a posted activity schedule including games, exercise, and outings at the facility. LPA inspected that medication is centrally stored in a safe locked location; facility has a medication room on the first floor where med carts are stored when not used. Med carts are used through the floors to pass out medication to residents. LPA observed and inspected medication carts that are used to dispense meds to residents and observed medication was labeled and stored inaccessible to residents in care. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. LPA inspected bedrooms for residents in the memory care unit and in floors 1-3. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Several resident bathrooms on each floor were tested for water temperature and water temperature measured between 105.6 to 109.4 Fahrenheit degrees in tested bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. LPA pushed the restroom call button in various resident rooms and response times were within 10 minutes. LPA observed several residents who appeared clean, and happy. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked in a locked in storage closets throughout the facility. LPA toured the memory care unit and observed a kitchen/ dining room as well as posted activity schedule for memory care residents. LPA observed residents in the memory care unit with care staff present. LPA observed the delayed egress exits to be functioning. Carbon monoxide detectors tested and noted to be operational. Fire extinguishers are fully charged and had a service date of September 18. 2025. Smoke detectors and sprinkler system are tested yearly by an outside agency, and LPA was provided with testing documentation, last testing was done February 24-28, 2025. Emergency drills are being conducted monthly on every shift with the last drill conducted on November 19, 2025. LPA observed stairwells have an emergency evacuation chair. Outside grounds have ample shaded seating for residents. LPA observed several courtyards with shaded seating areas for residents’ enjoyment. LPA observed a swimming pool in the outside perimeters of the assisted living side with a fence around it which is under maintenance and it not being used by residents Continued on LIC809-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 until repairs are completed. LPA observed the pool gate that has a self-latching and has a key card pad for access at the gate door for inaccessibility. LPA measured the pool fence was observed to enclose the entire pool area. LPA reviewed 15 resident files and 15 staff files. All resident files contained required documentation including updated physician reports and care plans. Staff files contained required documentation including health screens, first aid, and fingerprint clearance. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the Executive Director, and a copy of this report was provided to the facility.

LPA did not observe any insects, rodents or worms anywhere in the facility. Based on the evidence gathered the allegation is deemed unsubstantiated, Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.

The RCC contacted R1's responsible party and primary care physician (PCP). The PCP arranged for a Home Health visit which took place on August 12, 2025. The Home Health notes show both wounds are closed with no sign of infection. The Home Health notes describe the injuries as skin tears. The RCC reported that the injuries were cleaned daily and bandaged daily. LPA interviewed R1, R1 did not recall the incident and reported they did not fall recently. LPA interviewed R2 who reported there was no blood on R1's clothing and there minimal blood on the skin tears. The RCC reported that R1 only required first aid and because no pain was reported and no other injuries were noted it wasn't necessary to call 911. The RCC reported that R1 was not nervous or displaying any signs of distress. Based on the evidence gathered the allegation, staff did not get trimly medical care for resident is deemed 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 the report provided. 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 No evidence was gathered to support the allegation. Therefore the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 a written report to the responsible party concerning R1's injuries. California Code of Regulation (CCR) Title 22, Division 6, 87211(a)(1) states, " A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below." R1 received first aid for their injuries on their forearms so this incident qualifies under CCR Title 22, Division 6 87211(a)(1)(D) which states, " Any incident which threatens the welfare, safety or health of any resident". The incident involving R1 took place on August 3, 2025 and the facility did not report the incident in writing until August 12, 2025, 9 days later. A record review of incidents reports submitted to the Agency from the facility for the month of August 2025 show the facility did not report the incident to the Agency. Based on the evidence gathered, the preponderance of evidence standard has been met, therefore the allegation is substantiated. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations (CCR). An exit interview was conducted and a copy of the report provided along with appeal rights.

Licensing Program Analyst (LPA) Joseph Alejandre conducted an unannounced collateral visit in conjunction with complaint investigation 22-AS-20231004114033 at another licensed facility. LPA was greeted and granted entry into the facility. LPA met with General Manager Myra Aragones and explained the reason for the visit. During the visit, LPA met with Resident 1 (R1) to gather information pertaining to complaint #22-AS-20231004114033. Resident agreed to speak with LPA. Exit interview conducted with the General Manager and a copy of this report was provided.