Brittany House.

On 04/24/26, the Department obtained the Aging Report dated 12/2025, Face Sheet, and Emergency Information dated 07/17/24 for R1. On 10/09/2025, LPA Watson conducted interviews with Resident #1 – Resident #12 (R1–R12) and Staff #1 – Staff #7 (S1–S7). The investigation revealed the following: Allegation: Staff did not provide residents with proper notification prior to rate increase. It is alleged that R1 was not provided with the required advance notification of rate increases, leaving R1 uninformed of changes to the terms of their rental agreement. On 10/09/2025 between 08:20 AM – 04:59 PM, the Department interviewed Administrator Joel Niblett (S1). During the interview, S1 was asked when the most recent rate increase went into effect for the residents at Brittany House. S1 stated that the most recent rental rate increase, for Brittany House went into effect after residents were given advance notice by email communication. The Department requested documented proof of the rate increase notification from the facility, residents, and R1’s conservatorship; however, the Department was unable to obtain any email or written notification showing that the facility provided residents with advance notice of the rate increase that affected their monthly rental rates. On 10/09/2025 between 08:20 AM – 04:59 PM, the Department conducted interviews with Staff #1–#7 (S1–S7). Out of those interviewed, 7 out of 7 staff denied the above allegation. On 10/09/2025 between 08:20 AM – 04:59 PM, the Department conducted interviews with residents (R1–R12). Out of those interviewed, 12 out of 12 residents denied the above allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be Substantiated. Per California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and a citation was issued (ref. LIC 9099D). Exit interview was conducted, appeal rights explained, and a copy of this report was provided to Administrator Esperanza Naaktegboren.

The investigation revealed the following: Regarding the allegation "Staff do not provide adequate supervision resulting in residents eloping", it is being alleged that the facility is very understaffed which resulted in resident(s) eloping from the facility. Record reviews revealed that on 09/10/25 a resident was found by first responders, unassisted, out in the community. CDSS Interviews revealed that one (1) staff denied CDSS interviews, three (3) out of eight (8) staff disagreed with the allegation, while four (4) out of eight (8) staff agreed with the allegation. One (1) out of four (4) residents denied CDSS interviews, one (1) out of four (4) residents disagreed with the allegation, while two (2) out of four (4) residents agreed with the allegation. Interviews with witnesses have revealed that one (1) out of three (3) witnesses have disagreed with the allegation, while two (2) out of three (3) witnesses have agreed with the allegation. S1 has stated, “A lot of staff called out in unison”. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated . California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D. Based on record reviews and interviews conducted, the licensee failed to provide adequate resident supervision by staff. There has been one (1) deficiency cited during today’s inspection. An exit interview was conducted with Esperanza Naaktgeboren - Executive Director (S9), and a copy of this report has been provided.

On 04/24/26, the Department obtained the Aging Report dated 12/2025, Face Sheet, and Emergency Information dated 07/17/24 for R1. On 10/09/2025, LPA Watson conducted interviews with Resident #1 – Resident #12 (R1–R12) and Staff #1 – Staff #7 (S1–S7). The investigation revealed the following: Allegation: Staff did not provide residents with proper notification prior to rate increase. It is alleged that R1 was not provided with the required advance notification of rate increases, leaving R1 uninformed of changes to the terms of their rental agreement. On 10/09/2025 between 08:20 AM – 04:59 PM, the Department interviewed Administrator Joel Niblett (S1). During the interview, S1 was asked when the most recent rate increase went into effect for the residents at Brittany House. S1 stated that the most recent rental rate increase, for Brittany House went into effect after residents were given advance notice by email communication. The Department requested documented proof of the rate increase notification from the facility, residents, and R1’s conservatorship; however, the Department was unable to obtain any email or written notification showing that the facility provided residents with advance notice of the rate increase that affected their monthly rental rates. On 10/09/2025 between 08:20 AM – 04:59 PM, the Department conducted interviews with Staff #1–#7 (S1–S7). Out of those interviewed, 7 out of 7 staff denied the above allegation. On 10/09/2025 between 08:20 AM – 04:59 PM, the Department conducted interviews with residents (R1–R12). Out of those interviewed, 12 out of 12 residents denied the above allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above mentioned allegation is found to be Substantiated. Per California Code of Regulations (Title 22, Division 6, Chapter 8), the above mentioned deficiency was observed, and a citation was issued (ref. LIC 9099D). Exit interview was conducted, appeal rights explained, and a copy of this report was provided to Administrator Esperanza Naaktegboren.

The investigation revealed the following: Allegation: Staff did not dispense residents' medication as prescribed. It was alleged that facility staff failed to dispense residents' medications as prescribed, as multiple prescribed medications appeared unused for extended periods, and residents experienced untreated medical conditions and panic attacks despite active medication orders. On 01/14/2026 at 3:05pm, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated medtechs provide medications to residents. A1 stated the facility contacts the pharmacy for refills when a resident's medication runs out or needs to be refilled. A1 stated medtechs follow the prescription order when a resident requests a PRN medication like Ativan. A1 stated medications are documented both electronically and manually when administered to residents. On 01/14/2026 between the hours of 11:05am - 1:33pm, the Department conducted 7 interviews with staff in regards to the allegation. 1 of 7 staff confirmed the allegation and stated sometimes the residents are not getting their medication as prescribed. 3 of 7 staff denied the allegation and stated medtechs provide medications to residents and document using QuickMar or a laptop, and medtechs follow the prescription order for PRN medications like Ativan. 3 of 7 staff were unaware of the allegation and stated they are not medtechs so they do not administer medications, but they notify the medtech when a resident requests PRN medication. On 01/14/2026 between the hours of 11:05am -1:33pm and on 02/23/2026 between the hours of 1:29pm -1:37pm, the Department conducted 10 resident interviews in regards to the allegation. 3 of 10 residents confirmed the allegation and stated they do not get their medicine every day when they are supposed to, sometimes staff do not give them medicine, and they have asked for medicine and not gotten it. 1 of 10 resident did not confirm nor deny the allegation and stated they try to get medicine but sometimes forget. 6 of 10 residents denied the allegation and stated they get their medicine every day when they are supposed to, staff give them medicine when needed, and staff put cream or ointment on their skin when it itches. Investigation findings continue 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 On 02/20/2026 between the hours of 3:38pm - 3:50pm, the Department conducted a record review and observed the following: From October 2025 through January 14, 2026, the Department observed a failure to dispense medications as prescribed. The "Exceptions" and "Pass Notes" logs documented hundreds of missed doses, primarily attributed to a persistent pattern of "Resident Refusal." Many of these refusals occurred because staff failed to administer medication when the resident was asleep, with staff documenting that they "didn't wanna wake up" the resident or that the resident believed "sleep is more important." The Medication Administrator Record showed the failed to maintain an adequate supply of medication, with numerous entries citing medications as "pending delivery," "awaiting RX refill," or "not in cart" for consecutive days. Per the resident's primary diagnoses of Heart Failure and Chest Pain, medications like Furosemide, Bisoprolol, and Losartan—as well as psychiatric medications like Sertraline for anxiety—were routinely omitted for weeks at a time. Substantiated: Based on the Department observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted with Esperanza Naaktgeboren (Adminstrator) and a copy of this report was provided 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 The investigation revealed the following: Allegation: Staff did not assist resident with care needs in a timely manner. It was alleged that facility staff failed to assist a resident with care needs in a timely manner, as the resident reportedly experienced severe pain and panic without staff assistance, resulting in emergency medical services being contacted by a family member. On 01/14/2026 at 3:05pm, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated residents ask caregivers for help and use the call system when they need assistance. A1 stated the response time when a resident requests assistance is promptly and as needed. A1 stated to see the schedule for the number of staff on duty during different shifts to respond to residents. A1 stated the facility calls 911 as needed for both medical and emotional emergencies when a resident experiences such situations. On 01/14/2026 between the hours of 11:05am -1:33pm, the Department conducted 7 interviews with staff in regards to the allegation. 1 of 7 staff confirmed the allegation and stated sometimes residents have to wait for assistance for hours. 1 of 7 staff did not confirm nor deny the allegation and stated residents may have to wait for assistance if there is an emergency in two different units, but staff would communicate to check on the other resident. 5 of 7 staff denied the allegation and stated residents call for assistance by using the call light or yelling out loud, response time is usually right away or within 5-10 minutes, and staff call 911 or notify the medtech/LVN for medical or emotional emergencies. On 01/14/2026 between the hours of 11:05am -1:33pm and on 02/23/2026 between the hours of 1:29pm -1:37pm, the Department conducted 10 resident interviews in regards to the allegation. 2 of 10 residents confirmed the allegation and stated staff do not come quickly when they need help. 1 of 10 resident did not confirm nor deny the allegation and stated they have had to called for help. 7 of 10 residents denied the allegation and stated staff come quickly when they need help and or they find someone to help them if they feel pain or scared. On 02/23/2026 between the hours of 2:37pm - 3:02pm, the Department conducted a call light test and observed the following: In Room 310, the Department pulled the call light which is the old system at 2:37pm and waited for ten minutes and noticed that at 2:47pm staff did not come to answer the call light. In Room 104, the Department pulled the call light at 3:01pm & staff responded at 3:02pm. In Room 105, the Department pulled the call light at 3:06pm & responded at 3:06pm. Overall during the call light test, in one of the rooms such as Room 310 demonstrated a response time (from 2:37pm - 2:47pm) that was not immediate, while the remaining rooms showed prompt response times within one minute (from 3:01pm - 3:02pm). 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 records review, interviews, and observations, the Department did not find sufficient 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. Allegation: Staff did not safeguard resident's personal belongings. It was alleged that facility staff failed to safeguard a resident's personal belongings, as valuable jewelry and personal items were reported missing and possibly replaced without authorization. On 01/14/2026 at 3:05pm, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated the facility has an inventory list and monitors resident belongings as procedures in place to protect residents' personal belongings. A1 stated valuable items are documented on an inventory list and an in-house safe is provided as needed. A1 stated the facility attempts to help find missing items if a resident reports missing property. A1 stated staff have access to residents' rooms. On 01/14/2026 between the hours of 11:05am -1:33pm, the Department conducted 8 interviews with staff in regards to the allegation. 2 of 8 staff confirmed the allegation and stated half of the residents' items are missing, due to some of the residents wander at night and take other residents' personal belongings, and it is hard to protect residents' personal belongings. 1 of 8 staff did not confirm nor deny the allegation and stated valuable items are documented in communication documentation to inform the nighttime care staff, and the facility purchased drawers that have locks. 5 of 8 staff denied the allegation and stated caregivers have to label residents' belongings with the resident's full name, valuables are locked and documented in a log book, and staff notify supervisors when a resident reports missing property. Staff also stated caregivers, medtech, LVN, supervisors, housekeeping, maintenance, directors, and family have access to residents' rooms. On 01/14/2026 between the hours of 11:05am -1:33pm and on 02/23/2026 between the hours of 1:29pm - 1:37pm, the Department conducted 10 resident interviews in regards to the allegation. 3 of 10 residents confirmed the allegation and stated they have had jewelry or special items in their room, that have gone missing from their room. 7 of 10 residents denied the allegation and stated they do not have jewelry or special items in their room, nor has anything gone missing from their room, and they themselves or their family help them keep track of their things. The investigation findings continue 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 On 02/20/2026 between the hours of 3:38pm - 3:50pm, the Department conducted a record review and observed the following: The department did

The investigation revealed the following: Regarding the allegation " Staff do not provide adequate supervision resulting in residents eloping", it is being alleged that the facility is very understaffed. Record reviews revealed that there are about 90 staff associated at the facility. S1 has stated "There's been a spike in people calling out.". LPA's Interviews revealed that eight (8) out of thirteen (13) interviews have agreed with the allegation (W1/2/3, R3 & S5 through S8). Therefore, the above allegation is found to be Substantiated . California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D. An exit interview was conducted with Esperanza Naaktgeboren - Executive Director (S9), and a copy of facilities’ appeal rights and this report has been provided.

The investigation revealed the following: Allegation: Staff did not dispense residents' medication as prescribed. It was alleged that facility staff failed to dispense residents' medications as prescribed, as multiple prescribed medications appeared unused for extended periods, and residents experienced untreated medical conditions and panic attacks despite active medication orders. On 01/14/2026 at 3:05pm, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated medtechs provide medications to residents. A1 stated the facility contacts the pharmacy for refills when a resident's medication runs out or needs to be refilled. A1 stated medtechs follow the prescription order when a resident requests a PRN medication like Ativan. A1 stated medications are documented both electronically and manually when administered to residents. On 01/14/2026 between the hours of 11:05am -1:33pm, LPA conducted 7 interviews with staff in regards to the allegation. 1 of 7 staff confirmed the allegation and stated sometimes the residents are not getting their medication as prescribed. 3 of 7 staff denied the allegation and stated medtechs provide medications to residents and document using QuickMar or a laptop, and medtechs follow the prescription order for PRN medications like Ativan. 3 of 7 staff were unaware of the allegation and stated they are not medtechs so they do not administer medications, but they notify the medtech when a resident requests PRN medication. On 01/14/2026 between the hours of 11:05am -1:33pm and on 02/23/2026 between the hours of 1:29pm -1:37pm, LPA conducted 10 resident interviews in regards to the allegation. 3 of 10 residents confirmed the allegation and stated they do not get their medicine every day when they are supposed to, sometimes staff do not give them medicine, and they have asked for medicine and not gotten it. 1 of 10 resident did not confirm nor deny the allegation and stated they try to get medicine but sometimes forget. 6 of 10 residents denied the allegation and stated they get their medicine every day when they are supposed to, staff give them medicine when needed, and staff put cream or ointment on their skin when it itches. On 02/20/2026 between the hours of 3:38pm - 3:50pm, LPA conducted a record review and observed the following: From October 2025 through January 14, 2026, LPA observed a failure to dispense medications as prescribed. The "Exceptions" and "Pass Notes" logs documented hundreds of missed doses, primarily attributed to a persistent pattern of "Resident Refusal." Many of these refusals occurred because staff failed to administer medication when the resident was asleep, with staff documenting that they "didn't wanna wake up" the resident or that the resident believed "sleep is more important." The Medication Administrator Record showed the failed to maintain an adequate supply of medication, with numerous entries citing medications as "pending delivery," "awaiting RX refill," or "not in cart" for consecutive days. Per the resident's primary diagnoses of Heart Failure and Chest Pain, medications like Furosemide, Bisoprolol, and Losartan—as well as psychiatric medications like Sertraline for anxiety—were routinely omitted for weeks at a time. Substantiated: Based on LPA's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was provided 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 Allegation: Staff did not assist resident with care needs in a timely manner. It was alleged that facility staff failed to assist a resident with care needs in a timely manner, as the resident reportedly experienced severe pain and panic without staff assistance, resulting in emergency medical services being contacted by a family member. On 01/14/2026 at 3:05pm, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated residents ask caregivers for help and use the call system when they need assistance. A1 stated the response time when a resident requests assistance is promptly and as needed. A1 stated to see the schedule for the number of staff on duty during different shifts to respond to residents. A1 stated the facility calls 911 as needed for both medical and emotional emergencies when a resident experiences such situations. On 01/14/2026 between the hours of 11:05am -1:33pm, LPA conducted 7 interviews with staff in regards to the allegation. 1 of 7 staff confirmed the allegation and stated sometimes residents have to wait for assistance for hours. 1 of 7 staff did not confirm nor deny the allegation and stated residents may have to wait for assistance if there is an emergency in two different units, but staff would communicate to check on the other resident. 5 of 7 staff denied the allegation and stated residents call for assistance by using the call light or yelling out loud, response time is usually right away or within 5-10 minutes, and staff call 911 or notify the medtech/LVN for medical or emotional emergencies. On 01/14/2026 between the hours of 11:05am -1:33pm and on 02/23/2026 between the hours of 1:29pm -1:37pm, LPA conducted 10 resident interviews in regards to the allegation. 2 of 10 residents confirmed the allegation and stated staff do not come quickly when they need help. 1 of 10 resident did not confirm nor deny the allegation and stated they have had to called for help. 7 of 10 residents denied the allegation and stated staff come quickly when they need help and or they find someone to help them if they feel pain or scared. On 02/23/2026 between the hours of, LPA conducted a call light test and observed the following: In Room 310, LPA pulled the call light which is the old system at 2:37pm and waited for ten minutes and noticed that at 2:47pm staff did not come to answer the call light. In Room 104, LPA pulled the call light at 3:01pm & staff responded at 3:02pm. In Room 105, LPA pulled the call light at 3:06pm and staff responded at 3:06pm. Substantiated: Based on LPA's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted with Amy Kaplli (Wellness Director and a copy of this report was provided 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 The investigation revealed the following: Allegation: Staff did not safeguard resident's personal belongings. It was alleged that facility staff failed to safeguard a resident's personal belongings, as valuable jewelry and personal items were reported missing and possibly replaced without authorization. On 01/14/2026 at 3:05pm, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated the facility has an inventory list and monitors resident belongings as procedures in place to protect residents' personal belongings. A1 stated valuable items are documented on an inventory list and an in-house safe is provided as needed. A1 stated the facility attempts to help find missing items if a resident reports missing property. A1 stated staff have access to residents' rooms. On 01/14/2026 between the hours of 11:05am -1:33pm, LPA conducted 8 interviews with staff in regards to the allegation. 2 of 8 staff confirmed the allegation and stated half of the residents' items are missing, due to some of the residents wander at night and take other residents' personal belongings, and it is hard to protect residents' personal belongings. 1 of 8 staff did not confirm nor deny the allegation and stated valuable items are documented in communication documentation to inform the nighttime care staff, and the facility purchased drawers that have locks. 5 of 8 staff denied the allegation and stated caregivers have to label residents' belongings with the resident's full name, valuables are locked and documented in a log book, and staff notify supervisors when a resident reports missing property. Staff also stated caregivers, medtech, LVN, supervisors, housekeeping, maintenance, directors, and family have access to residents' rooms. On 01/14/2026 between the hours of 11:05am -1:33pm and on 02/23/2026 between the hours of 1:29pm - 1:37pm, LPA conducted 10 resident interviews in regards to the allegation. 3 of 10 residents confirmed the allegation and stated they have jewelry or special items in their room, that have gone missing from their room. 7 of 10 residents denied the allegation and stated they do not have jewelry or special items in their room, nor has anything gone missing from their room, and they themselves or their family help them keep track of their things. The investigation findings continue 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 On 02/20/2026 between the hours of 3:38pm - 3:50pm, LPA conducted a record review and observed the following: The department did not receive a LIC 624 Unusual Incident/Injury Report from the facility in regards to Resident 1 (R1)'s personal belongings such as valuable jewelry and personal items reported missing. According to Brittany House's Personal Property Theft & Loss Property policy, it states: "We do not have a safe or other means of safely securing valuables. They are encouraged to use their own private banking institution to provide this service. We shall provide a lock for the resident's bedside drawer or cabinet upon request o

On 1/22/2026, at 9:30am, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced Case Management visit to the facility in connection with complaint #11-AS-20251118115055 that was conducted on 11/24/2025. The LPA met with Joel Niblett, Executive Director, and explained the purpose of the visit. The department determined that the facility was not in compliance with Title 22 Regulations in connection with the complaint and issued additional citations for 87405(b)(2) Administrator Qualifications and 87211(a)(B)(D) Reporting Requirements. Citation: 87211(a)(B)(D) Reporting Requirement was cleared during today’s visit. Citation: 87405(b)(2) Administrator Qualifications has a plan of correction due date of 2/6/2026. An exit interview was conducted with Joel Niblett, Executive Director, and a hard copy of this report was provided.

Plan (Printed On: 11/24/2025), Lakewood Regional Medical Center Visit Summary (Dated: 08/16/2025, 11/01/2025), Preplacement Appraisal Information (Dated: 08/11/2025), Rose Villa Care Center Discharge Report (Dated: 12/16/2025), Rose Villa order Summary report (Dated: 12/15/2025) and Med Tech to Med Tech Communication Log (Dated: 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025) from the facility. The investigation revealed the following : Allegation #1-Staff did not address residents’ change of condition. The details of the complaint alleged that the facility did not address the residents’ change of condition. It was reported that the resident had bandages wrapped around their toe, when it was inquired why, staff stated that perhaps the residents’ shoes were too tight and probably caused the blistering on their foot. Subsequently, without medical attention, the residents’ foot became swollen, and their toe became infected. The resident as sent to the hospital on 11/01/2025 and it was determined R1’s toe needed to be amputated. On 11/24/2025, from 9:20am-2:00pm, the department interviewed staff (S1-S6), witness (W1), and residents (R1-R10) regarding the allegation. 4 of 6 staff stated that they notified the nurse (LVN) about the residents’ swollen foot and contacted the family member. They stated that the nurse is responsible for getting medical assistance for the residents. One staff member stated that the resident (R1) told them that their foot was swollen and needed assistance; staff stated that they advised the LVN of the problem. S6 stated that they were notified of the resident’s swollen foot on the day they were sent to the hospital for evaluation. S6 also stated that the toe looked red and had some discharge. Staff also stated that residents are checked on every one to two hours a day to assess their condition. The department interviewed residents (R1-R10) about the allegation and 6 of 10 residents that were interviewed stated that they believed the staff would not know if they had a change in their condition. When asked why, they stated that they believe they need more training. The department also interviewed witness (W1) about the incident, and they stated that the nursing team never called or had communication with them regarding R1, even when (W1) discovered that R1s foot was swollen and bandaged. Report Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The department reviewed the Appraisal & Needs Service Plan (Printed On: 11/24/2025), Physician’s Report (Dated: 08/12/2025), Med Tech to Med Tech Communication Log (Dated: 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025), Rose Villa Care Center Discharge Report (Dated: 12/16/2025), Rose Villa Order Summary report (Dated: 12/15/2025) and observed that the Med Tech Communication Log noted that first aid was applied because R1s foot was swollen on 10/25/2025, 10/29/2025, 10/30/2025, and 11/1/2025. The log noted that the LVN and family member were notified. However, medical services were not notified to address R1s change in condition; resulting in R1s toe becoming infected and amputated. The department also reviewed the discharge report from Rose Villa Care Center that advised R1 had a complete traumatic amputation of one right toe. Additionally, the department reviewed Lakewood Regional Medical Center Visit Summary (Dated: 08/16/2025) showing the resident had a prior history of a fall causing a right elbow fracture. Community Care Licensing Division did not receive an incident report detailing the hospital visit, amputation, nor the swollen foot. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not address residents’ change of condition, is found to be Substantiated . Title 22, Division 6, Chapter (8) is cited on the attached LIC 9099D. Citation: 87466 Observation of Resident Deficiencies were issued and plans of corrections were discussed. Note: *Citations that are not cleared by the POC due date of 1/22/26 will have a $100 fine assessed for each day that the citation is not cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. Citation cleared on todays visit. ECP: At this time, an Enhanced Civil Penalty determination is pending in reference to Health & Safety Code 1569.49(f)“Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” Civil Penalty: An immediate $500 Civil Penalty was assessed for resident’s toe amputation. Report Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation #2- Staff did not seek medical attention for resident in a timely manner. The details of the complaint alleged that the facility did not seek timely medical attention for the resident. It was reported that the residents’ foot became swollen and their toe became infected and needed to be amputated, as a result of inaction by the facility. On 11/24/2025, from 9:20am-2:00pm, the department interviewed staff (S1-S6), witness (W1), and residents (R1-R10) regarding the allegation. 4 of 6 staff stated that they told the nurse about the resident and they were responsible for getting medical services involved, if appropriate. They also stated that they believed the resident was going to get medical services for their swollen foot. While S6 stated that they were notified of the resident’s swollen foot on the day they were sent to the hospital for evaluation. S6 also stated that the toe looked red and had some discharge on the day they were sent to the hospital for evaluation. The department interviewed residents (R1-R10) about the allegation and 4 of 10 residents that were interviewed stated that staff have sought medical attention for them in a timely manner in the past. The department interviewed witness (W1) about the allegation, and they stated that they believed the facility did not seek medical attention for the resident in a timely manner. Additionally, they stated that they were not made aware of the condition before it got to the point where R1s toe needed to be amputated. The department could not review the LIC624 Unusual Incident Report about the swollen foot or subsequent hospitalization because the facility failed to submit it to Community Care Licensing Division within seven days of the occurrence. The department did review the Med Tech to Med Tech Communication Log (Dated: 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025) that noted R1 was receiving first aid for the swollen foot, but it did not specify that medical services were notified, or any action taken on behalf of the resident. The department also reviewed the discharge report from the Skilled Nursing Facility, Rose Villa Care Center, that advised R1 had a complete traumatic amputation of one right toe. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not seek medical attention for resident in a timely manner, is found to be Substantiated . Title 22, Division 6, Chapter (8) is being cited on the attached LIC 9099D. Citation 87411 Personnel Requirements – General Deficiencies were issued and plans of corrections were discussed. Report Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Note: *Citations that are not cleared by the POC due date of 2/6/26 will have a $100 fine assessed for each day that the citation is not cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. An exit interview was conducted with Joel Niblett, Executive Director, and a hard copy of this Complaint Investigation Report was provided.

On 01/26/2026 at 8:25 am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced case management visit and met with Joel Niblett (Administrator) to explain the purpose of the visit. On 01/15/2026, the Department conducted its annual inspection and issued a deficiency for Title 22 Regulation for Criminal Background Clearance 87355(e)(3). As a result of the deficiency cited on 01/15/2026, and as of today, 01/21/2026, the deficiency is being re-issued with civil penalties being assessed under the California Code of Regulations, Title 22, Division 6, Chapter 8. Please refer to the attached document LIC 809-D for more information. An exit interview was conducted with Joel Niblett (Administrator), and a copy of this report was provided, including information about appeal rights.

The investigation revealed the following: Allegation: Unqualified facility staff administered medication to resident It was alleged that an unqualified facility staff administered liquid narcotic medication to the resident at least two times in the middle of the night (late night 10/30/2025 or early morning 10/31/2025), following the first dose given to Resident 9 (R9) by their hospice nurse on the evening of 10/30/2025. On 11/17/2025 at 9:54am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated medtechs and LVNs are authorized and trained to administer medication at the facility. A1 also stated the procedure for giving medication to hospice residents, especially after hours, is per the doctor's orders. A1 mentioned there have not been any situations where a staff member who is not medication certified gave medication to a resident, and all new staff are medtech certified. On 11/17/2025 between the hours of 10:02am -12:52pm and on 12/02/2025 between the hours of 12:26pm - 3:02pm, LPA conducted 10 interviews with staff regarding the allegation. 2 of 10 staff were aware of the allegation, of which 1 staff member stated Resident 9 (R9)'s relative mentioned Staff 11 (S11) who administered narcotic medication mixed together with another medication. 1 of 10 staff was unaware of the allegation and stated not having knowledge of a staff who is not medication certified administering medication to a resident. 7 of 10 staff denied the allegation, of which 2 staff have never witnessed a staff who is not medication certified administering medication to a resident, while 1 staff is a medtech who ensures to read medication labels and dosages while administering medication but does not have any knowledge of what occurs after hours due to not being scheduled during that time period. On 11/17/2025 between the hours of 2:05pm - 3:00pm, then on 12/02/2025 between the hours of 1:21pm - 3:40pm and on 01/26/2026 between the hours of 9:30am -10:22am, LPA conducted 9 interviews with residents regarding the allegation. 1 of 9 residents did not confirm nor deny the allegation and stated staff does not identify nor verify what medications are being given. The medtech just watches to ensure medication is taken. 1 of 9 residents confirmed the allegation, stating that in the past couple of days medication was administered at 10pm by the medtech. 7 of 9 residents denied the allegation and stated not witnessing staff giving medication late at night or at times when the nurse, medtech, or hospice workers are not present. However, 1 of the 7 residents expressed wanting more communication and explanation regarding what the medication is for and why the medication needs to be taken. On 01/20/2026 between the hours of 2:58pm -3:20pm, LPA conducted a records review and observed the following for Resident 9 (R9) Medication Administration Record (MAR) for the month of October 2025. On 10/30/2025 and 10/31/2025 it was not marked off on the MAR that narcotic medication (morphine) SULF 100 mg/5 ML CONC was administered to the resident. Also, LPA observed that the department did not receive a LIC 624: Unusual Incident/Injury Report via fax in regards to R9 receiving a double dosage of narcotic medication which caused R9 to overdose and the facility administering the Narcan to sedate the resident. Investigation findings continue 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 On 01/21/2026 between the hours of 12:10pm -12:15pm, LPA conducted a records review and observed the following: According to the Physician Order from Committed Hospice Care Inc for List of New/Refill Order, Start date 10/28/2025 for Morphine Sulfate 15 mg tablet with a dosage of 0.5 tablet oral every 4 hours as needed for pain and discontinue on 10/31/2025. Start date 05/25/2025 for Morphine Sulfate 20mg/1mL Solution with quantity 30 ml and a dosage of 0.25ml (5mg) oral every 4 hours as needed for severe pain and discontinue on 10/31/2025. Start date 10/30/2025 for Lorazepam 1 mg with the start date 10/30/2025 with 1 tablet dosage oral to be given 2x daily at 9am and 5pm for anxiety and restlessness and discontinue on 10/31/2025. On 01/21/2026 between the hours of 9:10am -10:31am, LPA at the time requested a copy of Staff 11 (S11) medication administration training and, the facility was unable to provide proof of medication certification for Staff 11 (S11). Based on LPA's interviews and record review, Staff 11 administered medication to Resident 9 which resulted in R9 overdosing on medication and facility staff administering Narcan. Staff 11 does not have any documented training for medication administration. Substantiated: Based on LPA's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Allegation: Facility staff did not seek timely medical attention for resident It was alleged that facility staff did not seek timely medical attention for a resident following an overdose of medication and the administration of Narcan. On 11/17/2025 at 9:54am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated the process upon finding a resident unresponsive or in distress is to promptly contact emergency first responders for residents who experience a medical problem or need urgent help. Regarding the actions taken on the morning of 10/31/2025, A1 stated calling hospice and declared the decision made about calling emergency responders. Investigation Findings continues 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 On 11/17/2025 between the hours of 10:02am -12:52pm and on 12/02/2025 between the hours of 12:26pm -3:02pm, LPA conducted 10 interviews with staff regarding the allegation. 4 of 10 staff were aware of the allegation and stated being informed about what had occurred with Resident 9 (R9). 2 of 10 staff did not confirm nor deny the allegation, with 1 of the staff stating being scheduled to work on the evening of 10/31/2025 and explaining the process of what decision should be made about calling 911 or administering Narcan. The other staff said upon observing Resident 9 (R9), who appeared to be heavily sedated and drooling, a medtech made the decision to administer Narcan. 4 of 10 staff were unaware of the allegation, with 1 staff stating this is a question for the medtech, while the other 3 staff stated not being scheduled to work on the day of the incident. On 11/17/2025 between the hours of 2:05pm - 3:00pm, then on 12/02/2025 between the hours of 1:21pm -3:40pm and on 01/26/2026 between the hours of 9:30am - 10:22am, LPA conducted 9 interviews with residents regarding the allegation. 3 of 9 residents confirmed the allegation, with 1 of the 3 residents stating they have witnessed a delay with resident health concerns regarding their neighbor. 6 of 9 residents denied the allegation. Out of the 6 residents who denied the allegation, 4 of those residents expressed the facility staff calls for outside assistance from emergency first responders right away. On 01/21/2026, LPA conducted a record review between the hours of 12:00pm -12:05pm, and observed the following: Resident 9 (R9)'s communication log (dated 10/30/2025) by Staff 11 states resident declined medical attention, confirmed and spoke with R9 family member by phone and in person. On 01/20/2026, between the hours of 4:25pm - 4:30pm, LPA conducted a records review and observed the following: the department did not receive a LIC 624: Unusual Incident/Injury Report via fax in regards to R9 being transported by emergency first responder nor R9's refusal of wanting to go to the hospital in regard to overdose and the administration of Narcan. Based on the LPA conducting interviews and records review, the facility failed to seek timely medical attention when the resident appeared to be in distress and waited until an hour later to administer Narcan. Substantiated: Based on LPA's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Investigation Findings continues 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 Allegation: Facility staff did not properly report incident On 11/17/2025 at 9:54am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated the steps staff are required to take when a resident has a serious incident that occurs such as an overdose is to call 911. Also, A1 stated medtech and LVN are responsible for notifying the representative, hospice, and licensing after an incident occurs. In the event something unusual or unsafe happens, staff communicate by phone notification and folders for shift to shift communication. A1 mentioned not witnessing staff failing to document and or follow up on an incident. On 11/17/2025 between the hours of 10:02am -12:52pm and on 12/02/2025 between the hours of 12:26pm -3:02pm, LPA conducted 10 interviews with staff regarding the allegation. 7 of 10 staff denied the allegation. 2 of 10 staff confirmed the allegation with 1 staff stating witnessing the LVN all the time failing to document and or follow up on incidents that occur. 1 of 10 staff was unaware of the allegation, not knowing if the medtech and LVN conduct follow up in regards to incidents that occur. On 11/17/2025 between the hours of 2:05pm - 3:00pm, then on 12/02/2025 between the hours of 1:21pm

On 01/15/2026 at 8:15am, Licensing Program Analysts (LPAs) Zina Brown, Lizeth Villegas & Ernand Dabuet conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one- year inspection (due February 2026). LPA met with Joel Niblett and the purpose of the visit was discussed. Facility is licensed to serve age range 60 and over which is approved for 170 non-ambulatory of which 24 may be bedridden (bedroom 301 - 303, 307 - 308, 311-314 may have 2 bedridden) and bedroom #304-306 and 309 may have 1 bedridden only with a waiver granted for hospice care for ten (10). There are (71) ambulatory residents, (48) non-ambulatory residents, (60) residents are diagnosed with dementia, (25) residents receiving home health, (18) residents receiving hospice care services and (2) resident receiving palliative care. The last fire inspection was completed on 05/08/2024. The facility does not handle any of the residents’ money. The facility has a current administrator certificate (7002290740) for is Joel Niblett valid 08/16/2025 - 08/15/2027. The facility has liability insurance with Mercer Insurance Company (NAIC# 14478) with each occurrence at $1,000,000 and general aggregate 3,000,000 as effective as of 07/31/2025 - 07/31/2026. The facility annual fee is $2,311. which is due on February 9, 2026. LPA provided pin #312963 if facility choose to make facility annual payment online. The facility a single story building consisting of: (142) resident bedrooms, (43) Full bathrooms, kitchen, (4) dining area, laundry room, medication room and (10) outdoor shaded patio areas. LPA Villegas toured the 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, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 72.8F - 101.1F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Report continues on LIC 809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 A review of (10) residents files, (12) staff personnel files and (10) Medication Administration Records (MAR) and did observe discrepancies at the time of visit. Fire and Disaster Drills were conducted on 12/01/25 at 1:00 PM. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises. Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8); LPAs observed the following deficiencies: On 01/15/2026, between the hours 9:55am - 1:30pm, LPAs conducted a physical plant tour & records review and observed the following: For 87355(e)(3) Criminal Record Clearance: 3 of 12 staff are not associated with the facility. For 87465(d)(3) Incidental Medical & Dental Care Services; 6 of 10 resident had incompletion registration on the Medication Administrator Record (MAR) For 87411(c) Personnel Requirements: 1 of 12 staff ; no personnel record on file, 2 of 12 staff ; no TB Test on file 3 of 12 staff : no health screening on file and 6 of 12 staff ; no CPR on file For 87303(e)(2) Maintenance & Operation: The water test in Unit 2 shower Room 101.1F, bathroom in room 223 tested at 72.8F, and room 231 water tested at 80.4F, For 87307(2)(B) Personal Accommodations & Service: rooms 402 , 412, 214,236, 223, 231, 305 are missing a lamp and in rooms 236, 223, 231, 305 missing chairs. For 1569.625(a)(b) Training Requirement for Direct Care Staff: all staff did not have the required training needed to be in compliance with Title 22 regulations Health & Safety Code. An exit interview was conducted Joel Niblett, and a copy of Report and Appeal Rights provide d.

Investigation Revealed the Following: Allegation: Staff did not notify resident's responsible party of a scabies outbreak. The details of the complaint alleged that facility did not notify (R#1)’s responsible party regarding scabies outbreak. On January 14, 2026, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a comprehensive records review, including (R#2)’s staff notes. The review found that on December 7, 2025, an email was sent to (R#2)’s home health provider regarding a possible health condition. The facility isolated (R#2) on December 8, 2025. On December 15, 2025, a health condition was diagnosed, and the following medications were prescribed: ivermectin 3mg oral tablets and permethrin 5% cream. LPA Iniguez also reviewed (R#1)’s staff notes dated 12/8/25, 12/9/25, 12/14/25, and 12/26/25, and observed no documentation indicating that facility staff informed (R#1)’s representative of (R#2)’s “health condition.” On 1/14/26 at approximately 10:30 AM, Licensing Program Analyst Alfonso Iniguez spoke with (A#1). LPA inquired if the facility had reported (R#2)’s health condition to (R#1)’s responsible party, since (R#1) and (R#2) shared a room. (A#1) responded that this responsibility belonged to the facility nurse (S#2) and wellness director (S#1), and stated, “otherwise I don’t know if it was reported.” On 1/14/2026 at approximately 10:30 AM, Licensing Program Analyst Alfonso Iniguez asked (S#1) if documentation existed showing staff reported (R#2)’s health condition to (R#1)’s responsible party. (S#1) confirmed there was no written record in the residents’ notes and indicated the facility nurse (S#2) could provide further information. Evaluation Report continues 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 On 1/14/2026 at approximately 11:00 AM, Licensing Program Analyst Alfonso Iniguez requested documentation from (S#2) confirming that staff reported (R#2)’s communicable disease outbreak to (R#1)’s responsible party. (S#2) reviewed the resident’s electronic notes and found no record of staff notifying (R#1)’s responsible party about (R#2)’s health condition. LPA Iniguez then asked (S#2) to print the notes. During this investigation, LPA found sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). An exit interview was conducted, and a copy of the Complaint Report was given to Joel Niblett/Administrator.

On 12/17/2025, at 00:00, Licensing Program Analyst, LPA Zina Brown conducted a Case Management for complaint Control Number 11-AS-20251201153121 . LPA met with Joel Niblett (Administrator) as the purpose of the visit was explained. On 12/02/2025 between the hours of 8:55am – 4:15pm LPA conducted an initial unannounced complaint investigation in regards to a resident sustained an unstageable pressure injury due to staff neglect/lack of supervision. Based on records review the facility retained Resident 1 (R1), who had a unstageable pressure injury which is prohibited by title 22 regulations. The facility failed to submit an exception request from the department to retain R1. Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D. Exit interview conducted with Joel Niblett (administrator), and copy of this report was provided with appeal rights.

The investigation revealed the following: Allegation: Staff did not provide resident's authorized representative with an itemized list of charges It is alleged that the facility did not provide Resident 1's representative with an itemized list of additional care services at the time of admission. On 10/13/2025, between the hours of 11:15am - 12:09pm, LPA interviewed Administrator (A1) regarding the allegation. A1 neither confirmed nor denied the allegation. A1 stated based on the physician report determines how charges and extra care fees are explained and to the residents and their representative. A1 responded not applicable and did not provide the process. On 10/13/2025, between the hours of 9:04am - 1:00pm LPAs conducted interviews with Staff (S1-S9). 8 of 9 staff were unaware of the allegation as the caregivers have no knowledge of families being given itemized list of charges or a breakdown of extra care services. 1 of 9 staff did not confirm nor deny the allegation and S9 stated not generating the statement for invoices as that was the role of someone else who no longer works for the facility. However, Grandview does the billing for the residents. However, S9 stated its two care levels which is 17 (is when resident can still feed themselves, some in a wheelchair and ambulate) and level 22 (handfeeding, full care assist). S9 also stated R1 was level 22 because R1 couldn’t sit up without assistance and needed repositioning and transfers. On 10/13/2025 between the hours of 12:30pm - 12:45pm & on 12/03/2025 between the hours of 4:00pm -5:00pm, LPA conducted a records review and observed the following: receipts for care $7,200 - dated 07/28/2025 , for deposit (#4255) $500 - dated 07/25/2025, for deposit (#4258) $500 - dated 08/01/2025, for other half of pay (#4261) - $500 dated 08/09/2025, for September 2025 rent (#4267) $8,825. - dated 09/02/2025. Also based on Resident 1's Admission Agreement (signed on 07/29/2025) R1's room rate for a semi-private studio cost $5,000 with an additional miscellaneous care fee of $2,200 which comes to a total of $7,200. The review of the Admission Agreement does not itemize nor specify what the miscellaneous care service consist of nor rates of care services. LPA also review the invoices (statement dates 09/01/2025 and 10/01/2025). The review of both invoices show multiple dates and charges for room and board for $7200 and does not itemize the current months charges. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Report continues 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 The investigation revealed the following: Allegation: Resident's medical tube was pulled out due to staff neglect resulting in resident needing to go to the hospital. It is alleged that the facility failed to provide adequate supervision and medical care, resulting in the resident’s gallbladder (cholecystostomy) tube being pulled out on two separate occasions, which led to hospitalizations and infection. On 10/13/2025, between the hours of 11:15am - 12:09pm, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated Resident 1 (R1) did not have a g-tube and stated the resident was not on hospice nor receiving home health but was on Kaiser. On 10/13/2025, between the hours of 9:04am - 1:00pm, LPAs conducted interviews with Staff (S1-S8). 3 of 9 staff confirmed the allegation and stated by S2 observing R1 with a g-tube upon the partner of R1 informing staff that the g-tube was pulled out. S4 stated upon R1 first being at the facility he didn't have a g-tube but after the third time of R1 going to the hospital he returned to the facility with a g-tube. S8 stated R1 had a g-tube for 2-3 weeks which the caregiver did not know that R1 pulled out the g-tube himself. 1 of 9 staff denied the allegation and stated by S5 that R1 did not have a g-tube while residing at the facility. 3 of 9 staff were unaware of the allegation and stated having no knowledge of R1 having a g-tube. 2 of 9 staff didn't not confirm nor deny the allegation and stated upon admission resident never had a tube. However it was discovered R1 had some type gallbladder infestation which required him to have some kind of tube which he pulled out himself which isn't a g-tube. On 12/10/2025, the LPA conducted a records review and observed the following: In R1’s file, there was no documented care plan or approved exception request on file from the Department. The LPA observed a Kaiser Permanente discharge note dated 09/13/2025 indicating that R1 had a cholecystostomy tube. However, there was no documentation of a restricted health care plan or reappraisal related to the cholecystostomy tube. Additionally, the post-discharge plan of care did not document the presence of the cholecystostomy tube or the required care. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted with Administrator Joel Niblett and a copy of this report was provided with appeal rights.

The investigation revealed the following: Allegation #1-Staff did not address residents’ change of condition. The details of the complaint alleged that the facility did not address the residents’ change of condition. It was reported that the resident had bandages wrapped around their toe, when it was inquired why, staff stated that perhaps the residents’ shoes were too tight and probably caused the blistering on their foot. Subsequently, without medical attention, the residents’ foot became swollen, and their toe became infected and needed to be amputated. On 11/24/2025, from 9:20am-2:00pm, the department interviewed staff (S1-S5), witness (W1), and residents (R1-R10) regarding the allegation. 4 of 5 staff stated that they notified the nurse (LVN) about the residents’ swollen foot and contacted the family member. They stated that the nurse is responsible for getting medical assistance for the residents. One staff member stated that the resident (R1) told them that their foot was swollen and needed assistance; staff stated that they advised the LVN of the problem. Staff also stated that residents are checked on every one to two hours a day to assess their condition. The department interviewed residents (R1-R10) about the allegation and 6 of 10 residents that were interviewed stated that they believed the staff would not know if they had a change in their condition. When asked why, they stated that they believe they need more training. The department also interviewed witness (W1) about the incident, and they stated that the nursing team never called or had communication with them regarding R1, even when (W1) discovered that R1s foot was swollen and bandaged. The department reviewed the Appraisal & Needs Service Plan (Printed On: 11/24/2025), Physician’s Report (Dated: 08/12/2025), and the Med Tech to Med Tech Communication Log (Dated: 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025) and observed that the Med Tech Communication Log noted that first aid was applied because R1s foot was swollen on 10/25/2025, 10/29/2025, 10/30/2025, and 11/1/2025. The log noted that the LVN and family member were notified. However, medical services were not notified to address R1s change in condition; resulting in R1s toe becoming infected and amputated. Additionally, the department did not receive an incident report detailing the hospital visit, amputation, nor the swollen foot. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not address residents’ change of condition, is found to be Substantiated . Title 22, Division 6, Chapter (8) is being cited on the attached LIC 9099D. Report Continued On LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation #2- Staff did not seek medical attention for resident in a timely manner. The details of the complaint alleged that the facility did not seek timely medical attention for the resident. It was reported that the residents’ foot became swollen and their toe became infected and needed to be amputated, as a result of inaction by the facility. On 11/24/2025, from 9:20am-2:00pm, the department interviewed staff (S1-S5), witness (W1), and residents (R1-R10) regarding the allegation. 4 of 5 staff stated that they told the nurse about the resident and they were responsible for getting medical services involved, if appropriate. Staff stated that they believed the resident was going to get medical services for their swollen foot. The department interviewed residents (R1-R10) about the allegation and 4 of 10 residents that were interviewed stated that staff have sought medical attention for them in a timely manner in the past. The department interviewed witness (W1) about the allegation, and they stated that they believed the facility did not seek medical attention for the resident in a timely manner. Additionally, they stated that they were not made aware of the condition before it got to the point where R1s toe needed to be amputated. The department could not review the LIC624 Unusual Incident Report about the swollen foot or subsequent hospitalization because the facility failed to submit it to Community Care Licensing Division within seven days of the occurrence. The department did review the Med Tech to Med Tech Communication Log (Dated: 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025) but it did not specify that medical services were notified, or any action taken on behalf of the resident. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not seek medical attention for resident in a timely manner, is found to be Substantiated . Title 22, Division 6, Chapter (8) is being cited on the attached LIC 9099D. Deficiencies were issued and plans of corrections were discussed. Note: *Citations that are not cleared by the POC due date of 12/05/25 will have a $100 fine assessed for each day that the citation is not cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. An exit interview was conducted with Joel Niblett, Executive Director, and a hard copy of this Complaint Investigation Report was provided.

On 11/21/2025 The Department conducted an unannounced visit to deliver findings for the alleged allegations for complaint Control Number 11-AS-20250909103914. LPA met with Joel Niblett (Administrator) as the purpose of the visit was explained. On 10/17/2025 between the hours of 4:11pm - 4:20pm LPA conducted a records review and observed the following: the department did not receive a LIC 625: Serious/Unusual Incident Report in regard to Resident 13 (R13) shaking from fever and having chills. The facility failed to report the incident as required to the department. Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D. Exit interview conducted, appeal rights explained, and a copy of this report was provided.

It is being alleged that changes in conditions are going unnoticed which lead to hospitalizations. On 10/20/25 from 9:00 am- 11am LPA conducted Interviews with R1-R10 regarding the allegation above. 8 of 10 residents denied the allegation above and reported seeing a Dr. when needed. 2 of 10 residents confirmed the allegation and reported they have not been seen by a Dr. when they do not feel good. On 10/20/25 from 1pm-2:30pm LPA conduct interviews with S1-S7. 7 of 7 staff interviewed denied the allegation above and reported that med techs or LVN will assess a resident for change in condition, and resident will be sent out as needed. Additionally, during interview S1 reported that when a change in condition is observed the standard would be to call 911. On 10/20/25 LPA conducted a file review of R11-13 files. During file review LPA did not observe a re-assessment available for review when R11 returned from the hospital. LP A also observed that there was no care plan for the catheter R11 returned to the facility with, nor was there any documentation indicating that staff have been trained in catheter care. Based on LPAs observations and interviews conducted, record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided.

Allegation: “Staff do not ensure resident has access to call button/pendent.” Observations revealed the following: On 11/07/2025, residents’ bedrooms and bathrooms in unit 1 had call buttons with a long string on the wall. On 11/13/2025 around 10:30 AM, room 404 did not have a call button with a long string on the wall, furthermore, S1 and Staff 8 (S8) searched R1’s room for the said call button and S8 found said call button in drawer. On 11/13/2025, S8 screwed the call button on the wall next to R1’s bed. Interviews conducted on 11/13/2025 revealed the following: R1 indicated that they did not know where call button was located; Staff 6 (S6) indicated that R1’s call button fell and they had their call button on their bed next to them; S1, Caregiver Supervisor morning shift and S7, Caregiver Supervisor evening shift both indicated that they were not informed that R1’s call button fell from the wall. Substantiated: Based on observations and interviews, 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 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided.

On 11/05/2025 at 8:25am, Licensing Program Analysts (LPA) Zina Brown conducted an unannounced visit to deliver findings for the alleged allegations for complaint Control Number 11-AS-20251006160920 . LPA met with Joel Niblett (Administrator) who was informed of the purpose of the visit. On 11/05/2025 between the hours of 8:25am -8:45am, LPA conducted a records review and observed the following: The facility did not submit a LIC 624 Unusual Incident/Injury Report in regards to Resident 1 being transported to Long Beach Memorial Hospital on 09/27/2025 nor a LIC 624A Death Report in regards to Resident 1 passing away at the hospital on 09/30/2025. The facility failed to report the incident as required to the department. Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D. Exit interview conducted with Joel Niblett (Administrator) and copy of this report was provided with appeal rights.

On 10/20/25, Licensing Program Analyst (LPA) Villegas conducted an unannounced case management deficiencies. The purpose of the visit is to issue a citation observed during the complaint investigation - Control 11-AS-20251015105817. During the complaint investigation, LPA learned that there was no documented care plan for the use of a catheter. Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D. Exit interview conducted with Executive Director Joe Niblett and copy of this report was provided with appeal rights.

The investigation revealed the following: Allegation: Staff did not seek timely medical attention It is being alleged that facility staff failed to contact emergency services for a resident in care. On 09/19/2025, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated that documentation reflected staff recognized the change in the resident’s condition and called 911 for medical attention. A1's expectation of the staff is to respond appropriately and take immediate action when a resident exhibits serious symptoms. A1 indicated that staff are expected to notify a Certified MedTech and/or a Licensed Nurse immediately, and 911 should be called as needed. On 09/10/2025 and 10/13/2025, LPA conducted interviews with Staff (S1- S4) regarding the allegation above. 1 out of 4 staff interviewed confirmed the allegation above and reported witnessing the incident in question with Resident 13 (R13), per 1 of 4 staff protocol was followed and 911 was called. 1 out of 4 staff interviewed reported being aware of the incident but did not witness it. 2 out of 4 staff interviewed denied the allegation and stated not having knowledge nor witness any emergency regarding the Resident 13 (R13). On 09/10/2025, between the hours of 10:17am - 11:42am LPA Brown conducted interviews with Residents 1-12 (R1-R12), regarding the allegation above. 1 of 12 residents confirmed the allegation and stated that on the day of 09/10/2025 and a week from 09/10/2025 their neighboring resident had to wait a long time before getting help from the facility staff. 11 of the 12 residents reported having no knowledge of the allegation above. On 10/17/2025 between the hours of 4:11pm - 4:20pm LPA conducted a records review and observed the following: the department did not receive a LIC 625: Serious/Unusual Incident Report in regard to Resident 13 (R13) shaking from fever and having chills. On 10/17/25 LPA reviewed the staff schedule (dated on 09/05/2025), and observed the following: during the AM shift two (2) caregivers in Units 1 and Unit 4, three (3) caregivers in Unit 2, one (1) caregiver in Units 3 and Unit 5. During the PM shift in Unit 1, Unit 3 , and Unit 5 - two (2) caregiver each were scheduled to work. In Unit 4 - one (1) caregiver is scheduled to work. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). 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 Allegation: Licensee did not ensure resident records were maintained and readily available for emergency medical staff It is being alleged that facility staff are not properly trained to communicate with emergency medical staff. On 08/11/2025, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated when emergency responders requested information for the resident, it is unknown what records were readily available for the first responders. A1 stated the Licensed Nurses and MedTech staff are trained and aware of where the medical chart is located, which includes the physician’s report, emergency contacts, insurance, and medication lists. A1 added that staff are instructed to provide this information upon request from emergency medical personnel. On 09/10/2025 and on 10/13/2025, LPA Brown conducted interviews with Staff (S1- S4) regarding the allegation. 3 out 4 staff interviewed confirmed of the allegation and stated caregivers are not trained on how to obtain resident records, and it's only Medtechs and/or LVNs who manage records in the event of an medical emergency. 1 out 4 staff denied the allegation and stated staff are trained to locate and provide LIC 602, medication list and facesheet of the resident. On 09/10/2025, between the hours of 10:17am - 11:42am LPA Brown conducted interviews with Residents 1-12 (R1-R12) regarding the allegation above. 9 of 12 residents interviewed reported being unaware of the allegation and stated not knowing if the facility has in their file their doctors name, list of medication and family contact information. 3 of 12 residents interviewed denied the allegation and stated they know the facility has their personal record on file. On 10/17/2025 between the hours of 4:20pm, LPA conducted a records review and observed that there is no training on file for staff to ensure resident record are maintained and readily available for emergency first responders. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D).

Investigation Revealed the Following: Allegation: Staff are not following proper eviction procedures The details of the complaint alleged that facility does not want to take (R#1) back from hospital. On October 14, 2025, at approximately 2:00 PM, during an interview with (S#1), it was mentioned that (R#1) is currently hospitalized and has a Foley catheter in place. (S#1) expressed concern about who would assist (R#1) with catheter care outside the hours when the Licensed Vocational Nurse (LVN), identified as (S#2), is on duty from 8:00 AM to 4:00 PM. Additionally, (S#1) noted that (R#1)’s insurance does not cover home health services for assistance with the Foley catheter. (S#1) also stated that they spoke with the hospital social worker to inform them that (R#1) requires more support than the facility can provide. Furthermore, (S#1) acknowledged that they did not assess (R#1) before discharge while the resident was still at the hospital, which prevented (R#1) from returning to the facility. During this investigation, the Department found sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). An exit interview was conducted, and a copy of the Complaint Report was given to Joel Niblett/Administrator.

On 08/07/2025 CCLD staff requested copies of Staff and Resident roster, LIC500, Physician Report, Incontinence care records, caregiver notes, Medication Administration Record for R1 and interviewed 4 staff and 6 residents. The investigation revealed the following: Regarding the allegation: “Staff did not provide adequate supervision, resulting in the resident falling and sustaining a fracture.” Records reviewed indicate the following: The Physician Report (dated 10/31/2024) indicates that R1 was non-ambulatory and had secondary diagnoses of Dementia. The Facility Service Plan (dated 09/06/2024) notes that R1 wanders throughout the building and into other residents’ rooms. R1 requires assistance with orientation, redirection, and wayfinding due to forgetfulness and difficulty concentrating. On 11/05/2024, the Specialty Hospice Care nurse instructed facility staff to assist R1 and not leave R1 unattended due to declining health and generalized body weakness. The Incident Report states that on 01/02/2025, R1 experienced a witnessed fall and was taken to the hospital. On 01/14/2025, R1 had an unwitnessed fall and was found on the floor near R1’s room, complaining of hip pain. On 01/15/2025, R1 again complained of right hip pain and was transported to the hospital. St. Mary’s Hospital medical records (dated 01/15/2025) confirm that R1 was diagnosed with a right femoral fracture. Interviews 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 indicate the following: Witness W1 stated that R1 was a fall risk and required supervision while ambulating with a walker. Staff members S1 through S13 consistently indicated that R1 was a fall risk and required supervision. S1 reported that on 01/14/2025, S1 and S2 were supervising R1 and other residents in the dining room. However, both staff members left the dining room to respond to an unexpected death in another resident’s room, leaving R1 unsupervised for approximately 20 minutes. During this time, R1 wandered away and had an unwitnessed fall in another resident’s room. Based on the records review and interviews, the preponderance of evidence standard has been met. Therefore, the allegation that “staff did not provide adequate supervision, resulting in the resident falling and sustaining a fracture” is found to be SUBSTANTIATED. 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 Seek Medical Attention for Resident.” This complaint alleged that staff failed to seek timely medical attention for a resident who was in pain after an unwitnessed fall. Records reviewed indicate the following: Physician Report (dated 10/31/2024) indicates that R1 was non-ambulatory and had secondary diagnoses of Dementia. R1 requires assistance with orientation, redirection, and wayfinding due to forgetfulness and difficulty concentrating. The Incident Report states that on 01/02/2025, R1 experienced a witnessed fall and was taken to the hospital. The incident reports dated 01/14/2025 and 01/15/2025 show that on 01/14/2025, R1 was found on the floor following an unwitnessed fall. On 01/15/2025, R1 complained of pain in the right hip. The medical report from St. Mary Medical Center indicates that R1 had fallen on 01/14/2025 and complained of right hip pain. On 01/15/2025, R1 was transported to the hospital and diagnosed with a right femoral fracture. Interviews revealed the following: Staff members S1 through S13 confirmed that R1 experienced an unwitnessed fall on 01/14/2025 and complained of right hip pain. Medtech Jordan Morales and caregiver Marie Reyes recognized that R1 was experiencing pain in the right hip/leg but did not notify the hospice agency or R1’s daughter/POA at the time. Based on observations and interviews conducted by CCLD staff, as well as the records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation that “Staff did not seek medical attention for the resident” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are cited on the attached LIC 9099D. An immediate civil penalty of $500.00 is being assessed, please see LIC421IM. 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 At this time, an additional civil penalty determination is pending in reference to The Welfare and Institutions Code Section 15610.67 which defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” An exit interview was conducted, and plans of corrections were developed and a copy of this report and appeals rights were provided to Administrator JOEL NIBLETT.

The investigation revealed the following: Regarding the allegation: “Staff did not provide adequate supervision, resulting in the resident falling and sustaining a fracture.” Records reviewed indicate the following: The Physician Report (dated 10/31/2024) indicates that R1 was non-ambulatory and had secondary diagnoses of Dementia. The Facility Service Plan (dated 09/06/2024) notes that R1 wanders throughout the building and into other residents’ rooms. R1 requires assistance with orientation, redirection, and wayfinding due to forgetfulness and difficulty concentrating. On 11/05/2024, the Specialty Hospice Care nurse instructed facility staff to assist R1 and not leave R1 unattended due to declining health and generalized body weakness. The Incident Report states that on 01/02/2025, R1 experienced a witnessed fall and was taken to the hospital. On 01/14/2025, R1 had an unwitnessed fall and was found on the floor near R1’s room, complaining of hip pain. On 01/15/2025, R1 again complained of right hip pain and was transported to the hospital. St. Mary’s Hospital medical records (dated 01/15/2025) confirm that R1 was diagnosed with a right femoral fracture. Interviews indicate the following: Witness W1 stated that R1 was a fall risk and required supervision while ambulating with a walker. Staff members S1 through S13 consistently indicated that R1 was a fall risk and required supervision. S1 reported that on 01/14/2025, S1 and S2 were supervising R1 and other residents in the dining room. However, both staff members left the dining room to respond to an unexpected death in another resident’s room, leaving R1 unsupervised for approximately 20 minutes. During this time, R1 wandered away and had an unwitnessed fall in another resident’s room. 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 records review and interviews, the preponderance of evidence standard has been met. Therefore, the allegation that “staff did not provide adequate supervision, Regarding the Allegation: “ Staff Did Not Seek Medical Attention for Resident.” This complaint alleged that staff failed to seek timely medical attention for a resident who was in pain after an unwitnessed fall. Records reviewed indicate the following: Physician Report (dated 10/31/2024) indicates that R1 was non-ambulatory and had secondary diagnoses of Dementia. R1 requires assistance with orientation, redirection, and wayfinding due to forgetfulness and difficulty concentrating. The Incident Report states that on 01/02/2025, R1 experienced a witnessed fall and was taken to the hospital. The incident reports dated 01/14/2025 and 01/15/2025 show that on 01/14/2025, R1 was found on the floor following an unwitnessed fall. On 01/15/2025, R1 complained of pain in the right hip. The medical report from St. Mary Medical Center indicates that R1 had fallen on 01/14/2025 and complained of right hip pain. On 01/15/2025, R1 was transported to the hospital and diagnosed with a right femoral fracture. Interviews revealed the following: Staff members S1 through S13 confirmed that R1 experienced an unwitnessed fall on 01/14/2025 and complained of right hip pain. Medtech Jordan Morales and caregiver Marie Reyes recognized that R1 was experiencing pain in the right hip/leg but did not notify the hospice agency or R1’s daughter/POA at the time. Based on observations and interviews conducted by CCLD staff, as well as the records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation that “Staff did not seek medical attention for the resident” is found to be SUBSTANTIATED. 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 California Code of Regulations, Title 22, Division 6, Chapter 8 are cited on the attached LIC 9099D. An immediate civil penalty of $500.00 is being assessed, please see LIC421IM. At this time, an additional civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” An exit interview was conducted, and plans of corrections were developed and a copy of this report and appeals rights were provided to Administrator Manager Joel Niblett (S1). 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 consisted of the following: Regarding the Allegation: “Staff did not prevent residents from developing a UTI while in care.” This complaint alleged that staff failed to provide residents with adequate assistance for their incontinent needs, resulting in Resident 1 (R1) developing two urinary tract infections (UTIs) while in care. Records reviewed indicate the following: At Specialty Hospice Care, R1 has a history of falls and a recent right hip fracture. The Physician Report (dated 10/31/2024) lists the primary diagnosis as non-ambulatory and the secondary diagnosis as urinary tract infection (UTI). It also notes bladder and bowel impairments and states that R1 requires assistance with bathing and toileting. St. Mary’s Hospital records (dated 01/15/2025) indicate that, multiple UTIs in the past, which were resolved with antibiotics. Interviews indicate the following : 9 out of 9 staff members denied the allegation. R1 could not be interviewed, as R1 no longer resides at the facility. 9 out of 12 residents denied the allegation. Based on the records reviewed and interviews conducted, the preponderance of evidence standard has not been met. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that "Staff did not prevent resident from developing a UTI while in care" is found to be UNSUBSTANTIATED . An exit interview was conducted, and a copy of this report was provided to Administrator Manager Joel Niblett (S1).

The investigation revealed the following: Allegation #1- Staff left resident in soiled clothing for a period of time. The details of the complaint alleged that emergency services came to the facility on 08/20/25 because the resident (R1) was having difficulties that needed to be addressed. While at the facility it was reported that (R1) was observed to not have been cared for properly and smelled as though (R1) had not showered in weeks and was in soiled clothing. On 08/27/25, from 9:30am-2:00pm, the department interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. 4 of 5 staff stated that the resident has a history of refusing to shower and urinating on themselves as well as in their room. They state that they make every effort to change the resident when they discover that the resident has urinated or defecated on themselves but adds that the resident is very aggressive and combative when they try to change the resident. They further state that it takes several caregivers to achieve this, and it happens multiple times per day, but they do their best to keep the resident dry. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed stated that they were never left in soiled clothing for an extended period of time. They state that the staff is attentive to their needs, when assistance is needed. The department reviewed the Caregiver Daily Flow Sheet and Shower Schedule (Dated: 08/01/2025-08/31/2025) and Service Plan (Dated: 07/09/2025) and observed the resident has refused to take a shower on the following dates: 08/01/25, 08/03/25, 08/05/25, 08/06/25, 08/10/25, and 08/18/25 which were the resident’s scheduled shower days. The department did not find any evidence that the issue was being properly addressed by the facility knowing that the resident has these particular ongoing issues. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff left resident in soiled clothing for a period of time, is found to be Substantiated . California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D. Allegation #2- Staff not keeping resident’s room free from odor. The details of the complaint alleged that the staff does not ensure that the resident’s room is free from odor. It was reported that staff is not ensuring that the resident is not urinating in the resident’s room and therefore the resident’s room smells of urine. On 08/27/25, from 9:30am-2:00pm, the department interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. 4 of 5 staff corroborated the allegation that Staff not keeping resident’s room free from odor. The majority of staff stated that the resident does urinate in their room and in their bed. They state that the resident’s room must be cleaned daily because the resident urinates in their urinal container and then pours it out onto the bed as well as on the floor. They further state that they make every effort to keep the room sanitized and clean and to change the resident often. However, this is an ongoing occurrence with the resident, stated staff. Report Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed stated that their room does not have any odors, and staff cleans their room daily. The department toured the resident’s room and observed that there is a strong urine smell as you enter the room, as well as stains on the carpet, which smells of urine. Based on observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation Staff not keeping resident’s room free from odor, is found to be Substantiated . California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D. Note: *Citations that are not cleared by the due date of 09/12/25 will have a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. Deficiency was cleared at the time of the visit. Deficiencies were issued and plans of corrections were discussed. An exit interview was conducted with Joel Niblett, Executive Director, and a hard copy of this Complaint Investigation Report was provided.

On 08/20/2025, Licensing Program Analyst (LPA), Antonine Richard, conducted a case management visit to document deficiencies observed during an investigation related to Complaint Control Number:11-AS-20250812125512. LPA explained the purpose of the visit to staff member Girma Yodit. On 08/20/2025 at 10:00 am, LPA conducted a file review. LPA found that one of the facility staff members did not have background clearance and was not associated with the facility. Interviews conducted, observation, and records reviewed revealed that the facility was not in compliance with the California Code of Regulations Title 22. Deficiency cited based on interviews conducted, records reviewed, and observation in accordance with the California Code of Regulations, Title 22. A copy of the appeal rights and this report was left with the Staff Girma Yodit. On 08/21/2025, the license was cited with Title 22 Criminal Clearance Record Regulations 87355(e)(2). Based on interviews, observation, and record reviews, the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. 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 Deficiency was issued. An exit interview was conducted with staff member, Girma Yodit. A copy of this report, appeal rights, and civil penalty was provided.

On 08/13/2025 around 08:00am Licensing Program Analyst (LPA) Jose Calderon initiated an announced Case Management - Other to Brittany House provide Technical Assistance to the above said facility. The LPA Calderon requested copies of the facility's records which include but are not limited to staff and resident rosters, 5 resident records. LPA Calderon conducted an interview with Administrator Joel Niblett. The Administrator Joel Niblett will provide updated status of resident’s records are secured. An exit interview was conducted with Administrator Joel Niblett and a hard copy was provided via email for signature.

On 5/29/2025, at 8:15 AM, Licensing Program Analyst (LPA) Bernadette Alle n conducted an unannounced visit to deliver findings for the alleged allegations for complaint Contr ol N umber 11-AS-20241217143234. LPA identified herself and met Joel Niblett- Administrator who was informed of the purpose of the visit. O n May 12, 2025, the LPA conducted a random audit of the Medication Administration Record (MAR) for Residents 1 through 4 (R1–R4). During the audit, LPA observed that R1’s medications appeared to have been dispensed; however, staff were unable to provide the corresponding MAR for review. Additionally, LPA noted that R2’s medications were recorded as dispensed on May 2 and May 12, 2025, but were still in their original packaging. Marcus Falanai resident care coordinator, was unable to confirm whether R2’s medications had actually been dispensed. Meanwhile, LPA verified that R3 and R4’s medications had been dispensed and signed off by a medtech. This violation poses a potential health, safety, or personal rights risk to residents in care and a citation was issued. On May 29, 2025, LPA conducted interviews, observations and reviewed the LIC500, noting that some staff members are listed as caregivers and medtechs. Interviews with S1, S2, S3, and S8 confirmed that they hold certifications but were unable to provide current copies. They also stated that they have registered for re-certification through Elite Medical Academy. Additionally, staff members S4, S5, and S6 have not been observed dispensing medications. Joel was informed that the absence of current certification documentation for staff members presents a potential health, safety, and personal rights risk to residents in care. As a result, a citation will be issued for failure to maintain complete and up-to-date staff files for review at the time of the visit. Continued.... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Interviews with S4, S5, and S6 confirmed that they do not have certification to dispense medications and have not administered medications to residents in care. The interview with Joel Niblette, the Administrator, verified that all staff members (S1–S9) have been provided links to register for medtech training through Elite Medical Academy as of May 29, 2025. Joel was informed that medtechs who are not certified should not be listed as medtechs. LPA requested that the LIC500 be updated with accurate titles until certifications are obtained. LPA also suggested to Joel Niblett the following regulations be read 87413,87412,87411,87465 and health and safety code 1569.625 An exit interview was conducted where this report LIC809, LIC809 -C and LIC809-D was discussed and provided to Joel Niblett at the conclusion of the visit