Glen Park at Long Beach.

On August 13, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit. LPA Dabuet met with Executive Director ACE HUYNH to discuss an incident involving Resident #1 (R1) that occurred on August 7, 2026. The Department received an Unusual Incident Report (LIC 624) on August 7, 2026, regarding an incident that took place at 10:30 AM. It was reported that R1 eloped unsupervised from the community. R1 had been admitted to the community on July 24, 2026, and was diagnosed with a Major Neurocognitive Disorder (NCD). R1 resided on the second floor, which is designated as the "memory care" area. According to Staff #1 (S1) and Staff #2 (S2), while conducting routine checks on residents, they discovered that R1 was not in their room or anywhere on the floor. They immediately contacted the front desk to initiate an elopement alert. Surveillance camera footage confirmed that R1 exited the facility through the front exterior gate without supervision. A door on the second floor, which required a key fob to open, had malfunctioned, allowing R1 to leave the premises via the exterior stairs. R1 was located by law enforcement, who contacted the family, and R1 was returned to the facility on August 8, 2026. Upon return, R1 was reassessed by a Licensed Vocational Nurse (LVN), who found no signs of injury or discomfort. S1 informed the family representative and the physician about the incident. The Department reviewed (R1)'s Medical Assessment LIC 602A (dated 06/16/26) revealed that R1 has a history of "unsafe wandering" and "elopement" which is associated with behaviors in residents diagnosed with (NCD). Further review of camera surveillance footage (dated 08/07/26) verified R1's elopement from the premises. (Evaluation Report continues 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 The licensee violates Title 22, Section 87411, Personnel Requirements. California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 809-D). An exit interview was conducted, and a copy of the Evaluation Report and Appeal Rights was provided to Ace ACE HUYNH .

During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Brenna Randolph, Business Office Manager, and a copy of this report and the Appeals Rights were provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff do not ensure medication records are properly managed The allegation alleges that there was no incident report for a resident’s medication that was observed on their bed and not taken. During the facility visit, LPA conducted an audit of ten (10) residents Centrally Stored Medications using the electronic Medication Administration Record (eMAR). During the review, LPA observed the following medications not signed off as taken or refused for Resident R1, R13-R21: >Resient R1 -Divalproex Sod ER 500mg > not signed off on MAR 07/03/2026, no comments -Donepezil HCL 5 MG Tables > not signed off on MAR 07/03/2026, no comments -Mirtazapine 15mg > not signed off on MAR 07/03/2026, no comments -Mirtazapine 7.5mg > not signed off on MAR 07/03/2026, no comments -Atrovastain 20mg > not signed off on MAR 07/03/2026, no comments -Busprione HCL 10mg > PM not signed off on MAR 07/02/2026, 07/05/2026, and 07/11/2026, no comments -Quietapine Fumarate 25mg > PM not signed off on MAR on 07/03/2026, no comments. >Resident R13 -Eliquis 5mg > not signed off AM on MAR 07/08/2026 and 07/10/2026, no comments -Escitalopram 5mg > not signed off on MAR 07/08/2026 and 07/10/2026, no comments -Potassium CL ER 20 Meq > not signed off on MAR 07/08/2026 and 07/10/2026, no comments -Folic Acid 1mg> not signed off on MAR 07/08/2026 and 07/10/2026, no comments -Hydralazine 50mg > not signed off on AM MAR 07/08/2026 and 07/10/2026, no comments -Metoprolol Taritrate 25mg> not signed off on AM MAR 07/08/2026 and 07/10/2026, no comments -Vitamin B-1 100mg> not signed off on MAR 07/08/2026 and 07/10/2026, no comments -Vitamin B12 500mcg > not signed off on AM MAR 07/08/2026 and 07/10/2026, no comments >Resident R14 -Asprin EC 81 mg > not signed off on AM MAR 07/08/2026, no comments -Docusate Sodium 100mg > not signed off on AM MAR 07/08/2026, no comments -Fluticasone Prop 50 mcg > not signed off on AM MAR 07/08/2026, no comments. -Lactulose 10 gm/15ml > not signed off on AM MAR 07/08/2026, no comments. -Pantoprazole SOD DR 40mg > not signed off on AM MAR 07/11/2026 and 07/12/2026, no comments. -Potassium CL ER 20 MEQ > not signed off on AM MAR 07/08/2026, no comments. 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 -Vitamin D3 2000 IU 50 MG >Not signed off on AM 07/11/2026. > Resident R19 -Levothyroxine 50 MCG > Not signed off on AM 07/11/2026. No comments. > Resident R20 - Aspirin 81 MG > Not signed off on AM 07/10/2026. No comments. -Clopidogrel 75 MG > Not signed off on AM 07/10/2026. No comments. -Famotidine 20 MG > Not signed off on AM 07/10/2026. No comments. -Metoprolol Tartirate 50 MG > Not signed off on AM 07/10/2026. No comments. - Naltrexone 50 MG > Not signed off on AM 07/11/2026 and 07/12/2026. No comments. -Quetiapine Fumarate 100 MG > Not signed off on AM 07/10/2026. No comments. -Vitamin B-12 1,000 Unit> Not signed off on AM 07/10/2026. No comments. -Vitamin D3 5,000 Unit > Not signed off on AM 07/10/2026. No comments. > Resident R21 -Atorvastatin 40 MG > Not signed off on PM 07/01/2026, 07/02/2026, and 07/03/2026. No comments. -Divalproex SOD DR 125 mg > Not signed off on PM 07/02/2026, 07/05/2026, and 07/11/2026. No comments. -Donepepezil HCL 5 MG > Not signed off on PM 07/3/2026. No comments. -Memantine HCL 5 MG > Not signed off on PM 07/02/2026, 07/05/2026, and 07/11/2026. No comments. -Quetiapine Fumarate 100 MG > Not signed off on PM 07/03/2026. No comments. -Senna 8.6 MG > Not signed off on PM 07/02/2026, 07/05/2026, and 07/11/2026. No comments. During interviews with Staff S1-S7, were asked if staff keep accurate records of residents medications and doses taken, seven (7) out of seven (7) stated yes, staff keep accurate records of residents medications taken. During interview's with Residents R1-R12, were asked if they feel staff properly manage their medication records, twelve (12) out of twelve (12) stated yes, they believe staff properly manage their medication records. 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 -Quetiapine Fumarate 50mg > not signed off on PM MAR 07/08/2026, no comments. -Refresh Tears 0.5% drops 1 OP > not signed off on AM MAR 07/08/2026, no comments. -Resperidone 0.5 MG > Not signed off on AM MAR 07/08/2026, no comments >Resident R16 -Amlodipine Besylate 5 MG> not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Ammonium Lactate 12% Cream> not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Asprin EC 81 MG > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Clopidogrel 75 MG > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Escitalopram 10 MG > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Famotidine 20 MG > not signed off on AM and PM MAR for 07/07/2026 and not signed off on AM 07/10/2026, no comments. -Geri-Mucil Powder 1 PO > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Glucosamine Daily Complex T 1 PO > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Januvia 100 MG - not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Metformin 500MG > not signed off on AM and PM MAR 07/07/2026 and not signed off on AM 07/10/2026, no comments. -Sitagliptin Phos 100 MG > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Tamsulosin 0.4 MG > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. >Resident R17 -Aripiprazoles 5 MG > 07/11/2026 pill in packet, not signed on MAR, and no comment. 07/12/2026 pill in packet, not signed on MAR, and no comment. 07/13/2026 removed from packet, not signed off on MAR, and no comment. 07/14/2026 removed from packet, not signed off on MAR, and no comment. -Hydrocodone-Acet 5-325 > Not signed off on eMAR for 07/08/2026 and 07/11/2026 -Lidocaine 4% Patch > Not signed off on MAR for 07/11/2026. No Comment. -Pantoprazole SOD DR 40 MG > Not signed off on 07/11/2026 and 07/12/2026. -Vitamin C 1,000 MG > Not signed off on MAR on 07/11/2026, No comment. -Vitamin D3 50 MG > Not signed off on MAR on 07/11/2026, No comment. > Resident R18 -Oxybutynin 5 MG - Not signed off on 07/11/2026 12pm. No comments. -Pantoprazole SOD DR 40 MG > Not signed off on AM 07/11/2026 and 07/12/2026. No comments.

Allegation : Facility staff did not provide communication with authorized representative. It was alleged that the facility failed to communicate with the authorized representative regarding the resident’s care and condition. On 04/01/2026 between 9:27am - 9:50am, the Department interview A1 regarding the allegation. A1 denied the allegation and stated not being aware of any concerns. A1 stated multiple staff communicate with families as needed. On 04/01/2026, between 10:00am - 11:50am, the Department interviewed seven (7) staff in regards to the allegation.  7 out of 7 staff denied the allegation and stated they would refer the representative to the Administrator, med tech, or front desk. On 04/01/2026, between the hours of  2:24pm - 3:05pm, the Department interviewed ten (10) residents in regards to the allegation.  8 of out 10 residents denied the allegation and expressed no concerns with communication. Several residents independently manage their own communication or do not have family. 2 out of 10 residents did not confirm nor deny the allegation and mentioned having no family (R8) and or does not communicate with their family (R4). On 05/18/2026, between the hours of 3:00pm - 4:00pm, the Department conducted a records review and observed the following:  R1 has a POA, according to a document titled Power of Attorney for California (dated on 05/11/2024). This POA is also mentioned on  the LIC 601 has the person responsible for final affairs, payment for care and legal guardian if any and this is also indicated on LIC 603 that POA is the person who manages R1’s finances. On 07/07/2026 between 11:45am – 1:00pm, the Department conducted further review of four (4) internal resident incident reports dated (2) on 07/08/2025, 11/23/2025, and 01/21/2026. The incident report dated 07/08/2025 documented that R1 was sent to the hospital and the written narrative stated that the POA was notified; however, the “Responsible Party” section reflected “No” for contact made. The incident report dated 07/08/2025 documented R1’s return from the hospital and indicated that discharge paperwork was scanned to GPDocs, the pharmacy, and the former office desk manager, and that the POA was notified; however, the “Responsible Party” section again reflected “No” for contact made. The incident reports dated on 10/11/2025 of an unwitnessed fall, on 11/23/2025 R1 screaming and shaking and on 01/21/2026 documented a witnessed fall in which 911 was called; however, the “Responsible Party” section reflected “No” for contact made. Based on the 4 incident reports, the Department observed that “No” was consistently checked for contact made to the responsible party, indicating that the authorized representative was not contacted at the time of each incident. The Department did not observe supplemental documentation indicating that communication occurred outside of the incident reports. 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 information gathered through interviews and record reviews, there is not enough evidence to support the allegation. 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 : Facility staff did not respond to resident’s call button in a timely manner. It was alleged that staff failed to respond promptly when the resident activated the call button and left without prompt assistance when using the call bell, with delays reported up to 30 minutes. On 04/01/2026 between 9:27am - 9:50am, the Department interview A1 regarding the allegation. A1 denied the allegation and stated not being aware of any delays and ensure staff responds right away. A1 stated no response logs are maintained. On 04/01/2026, between 10:00am - 11:50am, the Department interviewed seven (7) staff in regards to the allegation. 6 out of 7 staff denied the allegation. 1 out of 7 staff did not confirm nor deny the allegation & reported that call light delays occur when caregivers are assisting other residents. On 04/01/2026, between the hours of 2:24pm - 3:05pm, the Department interviewed ten (10) residents in regards to the allegation. 5 out of 10 confirmed the allegation & reported delayed call light response with R2 mentioning waiting two hours at one time. 4 out of 10 residents denied and stated they do not use the call button. 1 out 10 residents did not confirm nor deny the allegation but mentioned a time period of 10 -15 minutes wait. On 04/01/2026 at 2:34pm, the Department conducted a call light inspection in room 245. At 2:41pm, facility staff entered room 245 to respond to the activated call light, resulting in a total response time of 7 minutes. On 07/07/2026 between 2:02pm – 2:23pm, the Department continued conducting call light inspections and observed the following: at 2:02pm, the call light was activated in room 137 and answered at 2:06pm, resulting in a four-minute response time. At 2:08pm, the call light was activated in room 115. At 2:09pm, two (2) staff walked by and did not acknowledge the call light. The call light was answered at 2:10pm by another staff, resulting in a two-minute response time. At 2:11pm, the call light was activated in room 130. At 2:13pm, two staff walked by and did not acknowledge the call light. At 2:14pm, a third staff walked by and did not address the call light. Between 2:15pm – 2:21pm, two additional staff walked by and did not address the call light. Between 2:11pm – 2:21pm, the call light in room 130 remained unanswered, resulting in a ten-minute period with no staff response. At 2:22pm, a staff informed a caregiver that the resident in room 102 needed a diaper change. The caregiver stated they were attending to two other residents and asked the staff to notify someone at the front desk. At 2:23pm, another caregiver entered room 102 with diapers to assist the resident with the diaper change, resulting in a one-minute response time. 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 is not providing adequate food service resulting in resident weight loss. It was alleged that a resident experienced weight loss due to inadequate food services. It was reported that meals were not consistently consumed and that staff did not ensure adequate food intake. On 04/01/2026 between 9:27am - 9:50am, the Department interview A1 regarding the allegation. A1 denied the allegation and stated there was no documented weight loss and no special diet per LIC 602. A1 stated no concerns were raised by the family and no physician or dietitian was consulted. On 04/01/2026, between 10:00am - 11:50am, the Department interviewed seven (7) staff in regards to the allegation. 6 out of 7 staff denied the allegation. 1 out of 7 staff did not confirm nor deny the allegation and reported the resident sometimes does not finish meals but stated concerns are reported to the nurse. On 04/01/2026, between the hours of 2:24pm - 3:05pm, the Department interviewed ten (10) residents in regards to the allegation. 2 out of 10 resident confirmed the allegation, of which one resident mention weight loss, while the other resident mentioned not receiving enough food and missing meals. 7 out 10 residents denied the allegation and had no concerns with food service. Of the 8 residents who denied the allegation ; 1 resident mentioned losing weight but did not attribute it to food service. 1 out of 10 resident did not confirm nor deny the allegation but mentioned sometimes not receiving enough food. On 05/18/2026, between the hours of 3:00pm - 4:00pm, the Department conducted a records review and observed the LIC 625 Appraisal/Needs & Service Plan documents R1 is on a NAS diet with thin liquids but according to the LIC 602A Physician's Report for RCFE documented that the resident was not on a special diet and required “No Added Salt” with thin liquids. The Department reviewed the March 2026 weight log, which documented three consecutive refusals (“Refused x3”) for scheduled weigh-ins by R1. No weight loss was documented. On 07/07/2026 between the hours of 12:30pm - 12:45pm, the Department reviewed the facility's four-week menu cycle utilized during Spring 2025. Although the menus are labeled "Spring 2022" and "Spring 2023," facility Administrator indicated these menus were the menus in use during Spring 2025. The menus reflected planned daily breakfast, lunch, dinner, and evening snacks, including a variety of proteins, fruits, vegetables, grains, dairy products, and beverages. Breakfast meals included items such as eggs, oatmeal, pancakes, waffles, French toast, breakfast meats, toast, cereal, fruit juice, coffee, tea, and milk. Lunch and dinner menus included a variety of entrees consisting of chicken, turkey, beef, pork, fish, tuna, and pasta dishes, accompanied by vegetables, rice, potatoes, beans, salads, soups, bread, fresh fruit, and desserts. Evening snacks included items such as yogurt, pudding, muffins, granola bars, fruit, crackers, cookies, ice cream, and nutritional beverages 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 information gathered through interviews and record reviews, there is not enough evidence to support the allegation. 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. Exit interview conducted with Catherine Dacara (Assistant Administrator) and copy of this report was provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The investigation revealed the following: Allegation: Facility staff did not meet resident’s care needs, resulting in resident obtaining m

On June 15, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit to the facility following an incident reported by the facility that occurred on June 6, 2026. During the visit, the LPA met with Anita Csukardi & Ace Huynh, Executive Directors to explain the purpose of the inspection. The El Segundo Regional Office Adult and Senior Care received an Unusual Incident Report (LIC 624) on June 8, 2026, stating that Resident #1 (R1) had been given the wrong medication. On June 6, 2026, at 4 PM, the medication technician mistakenly verified only (R1's) last name without confirming the correct resident. Consequently, (R1) was administered medications intended for another resident with the same last name. As a result, both Metformin and Senna were given to (R1) in error, leading to hospitalization in the emergency room. The Department found that the facility was not in compliance with Title 22 Regulations and issued citations as follows: 87465(c)(2) Incidental Medical and Dental Care Services. The investigation revealed that the facility failed to comply with Title 22 regulations. The LPA reviewed (R1’s) Physicians Report (LIC 602A) (dated 07/27/23) and Medication List (dated 06/15/26), which confirmed that (R1) was not prescribed Metformin by (R1's) physician. Based on interviews, observations, and record reviews, the licensee was found in violation of the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies have been issued, and an exit interview was conducted with Ace Huynh, Executive Director. A copy of this report is provided, along with the appeal rights.

Regarding the allegation, “Facility did not maintain a safe and healthful environment for the resident,” it was alleged that a resident was subjected to ongoing noise disturbances due to a roommate’s loud television at night, resulting in sleep disruption. Records review revealed internal incident reports dated 03/12/2026 and 03/13/2026 documenting concerns regarding loud television use and roommate conflict between R1 and R2. Documentation indicated that R1 reported concerns regarding television volume and difficulty sleeping. Records also indicated that staff provided reminders to R2 regarding house rules, including lowering television volume and use of headphones at night. However, the facility did not provide additional requested documentation, including behavior logs, complaint logs, or other records demonstrating ongoing monitoring, follow-up actions, or effective resolution of the roommate conflict. Resident interviews revealed that R1 reported concerns regarding loud television volume at night and disruption of sleep. Staff interviews revealed ongoing roommate conflict between R1 and R2 involving television volume, different sleep schedules, and sleep disruption. Staff further reported that incident reports were completed, the issue was brought to administration, and staff attempted verbal interventions including reminders, counseling, mediation, and review of house rules. S1 reported addressing the concern by counseling the resident, reviewing house rules, and offering a room change. However, both residents declined relocation and staff reported the concern remained ongoing at the time of the investigation. Observations revealed that residents were observed in their rooms and common areas, and the facility appeared calm during the visit. Based on interviews conducted, observations made, and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation that the facility did not maintain a safe and healthful environment for the resident due to ongoing noise disturbance and sleep disruption is Substantiated. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468.1(a)(2), Personal Rights of Residents in All Facilities. A citation is being issued on the attached (LIC9099-D). An exit interview was conducted with the Administrator. A copy of this report and appeal rights were provided to the Administrator. 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: Regarding the allegation that a resident attempted to run over another resident with a wheelchair, interviews conducted with residents and staff did not corroborate the allegation. Staff interviewed denied knowledge of physical aggression or wheelchair aggression between R1 and R2. S1 stated this concern had not been previously reported. Records reviewed did not contain incident reports, behavior logs, or other documentation supporting the allegation. During the visit, LPA did not observe physical aggression between residents. Regarding the allegation that a resident yelled at another resident, interviews conducted with residents and staff did not corroborate the allegation. Staff interviewed denied knowledge of yelling between R1 and R2. S1 stated this concern had not been previously reported. Records reviewed did not contain incident reports, behavior logs, or other documentation supporting the allegation. During the visit, LPA did not observe yelling or active conflict between residents. Regarding the allegation that a resident used abusive language toward another resident, interviews conducted with residents and staff did not corroborate the allegation. Staff interviewed denied knowledge of abusive language between R1 and R2. S1 stated this concern had not been previously reported. Records reviewed did not contain incident reports, behavior logs, or other documentation supporting the allegation. During the visit, LPA did not observe abusive language or active conflict between residents. Based on interviews conducted, observations made, and records reviewed, although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violations occurred. Therefore, the allegations are Unsubstantiated. No deficiencies were cited regarding these allegations. An exit interview was conducted with the Administrator. A copy of this report was provided to the Administrator.

LIC 601: Identification & Emergency Information (R1 dated 03/09/2026 & R2 dated 02/26/2025), LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (R1 dated 08/21/2025 & R2 dated 02/07/2025), LIC 603: Preplacement Appraisal Information (R1 dated 08/27/2025 & R2 dated 02/07/2025), Admission Agreement (R1 dated 09/19/2025 & R2 dated 02/28/2025, R1's New Resident Account Set Up (dated 09/19/2025), R1's LIC 9172 Functional Capability Assessment (dated 08/27/2025), R1's Concise Care Group (dated 08/06/2025), R1's Patient Chart (not dated), Besht Wellness (dated 03/05/2026), R1's Appraisal/Need & Service Plan (dated 12/19/2025), R1's Invoice for Monthly Room Charge (September 2025 -April 2026) R2's Internal Resident Incident Report (dated 09/26/2025) and R1's & R2's ALl Order Administered/ Medication List (January 2026- June 2026) . The investigation revealed the following: Allegation: Facility staff mismanage residents’ medications. It was alleged that residents’ medications were not administered as prescribed and that documentation was incomplete. On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated medtechs assist with self-administered medications when LVNs are unavailable. A1 reported she was not aware of any missed doses or medication errors. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Four (4) out of five (5) staff denied the allegation. One (1) staff was unaware. Staff reported they were not aware of missed doses and stated they notify the med-tech or charge nurse if unable to administer medications. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed ten (10) residents regarding the allegation. One (1) out of ten (10) residents confirmed the allegation. One (1) out of ten (10) was unsure of the allegation. Eight (8) out of ten (10) denied the allegation. Of the one (1) resident who confirmed the allegation, the resident reported missed doses. Of the one (1) resident who was unsure mentioned being not sure of their medication management. 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 05/13/2026 between 10:00am – 11:00am, the Department conducted a records review of the April and May 2026 Medication Administration Records (MARs) and identified 42 undocumented medication administrations affecting eight (8) residents. The review showed missing initials for medications assigned to R1, including 6 missed doses of Carvedilol, 3 of Duloxetine, 14 of Furosemide, and 9 of Gabapentin on various dates in April 2026; R2 had 2 missed doses of Sacubitril/Valsartan, 2 of Magnesium Oxide, 2 of Vitamin C, and 1 multivitamin dose between April 10–18, 2026; R3 had 2 missed doses of AmoxClav, 1 of Olanzapine, and 1 Lidocaine patch between April 6–15, 2026; R4 had 2 missed doses of Polyethylene Glycol, 3 of Amlodipine, and 2 of Atorvastatin between April 12–20, 2026; R5 had 1 missed dose each of Benazepril, Eliquis, and Refresh Tears on April 9, 13, and 17, 2026; R6 had 2 missed doses of Divalproex, 2 of Vitamin D3, 3 of Docusate Sodium, 4 of Famotidine, 1 of Omega-3 Ethyl Esters, and 1 of Buspirone between April 5–22, 2026; R7 had 20 missed doses of Lantus Solostar, 3 of Metformin, and 2 of Xiidra throughout April 2026; and R8 had 2 missed doses of Levetiracetam and 1 missed dose each of Lisinopril, Sertraline, Acetazolamide, Bisacodyl, Ipratropium-Albuterol, Isosorbide Dinitrate, Jardiance, and Triamcinolone between April 7–25, 2026. The Department also observed nine (9) medications remaining inside bubble packs despite being initialed as administered, with no documentation explaining the discrepancies. Based on the Department'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 Catherine Dacara (Assistant Administrator) 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 LIC 601: Identification & Emergency Information (R1 dated 03/09/2026 & R2 dated 02/26/2025), LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (R1 dated 08/21/2025 & R2 dated 02/07/2025), LIC 603: Preplacement Appraisal Information (R1 dated 08/27/2025 & R2 dated 02/07/2025), Admission Agreement (R1 dated 09/19/2025 & R2 dated 02/28/2025, R1's New Resident Account Set Up (dated 09/19/2025), R1's LIC 9172 Functional Capability Assessment (dated 08/27/2025), R1's Concise Care Group (dated 08/06/2025), R1's Patient Chart (not dated), Besht Wellness (dated 03/05/2026), R1's Appraisal/Need & Service Plan (dated 12/19/2025), R1's Invoice for Monthly Room Charge (September 2025 -April 2026) R2's Internal Resident Incident Report (dated 09/26/2025) and R1's & R2's ALl Order Administered/ Medication List (January 2026- June 2026) . The Investigation revealed the following: Allegation: Facility staff do not ensure that residents’ toileting needs are met. It was alleged that residents were not receiving timely assistance with toileting and incontinence care due to chronic understaffing, resulting in delays in responding to care needs and insufficient break coverage. On 04/07/2026 between the hours of 8:40am - 8:52am, the Department interviewed A1 in regards to the allegation. A1 denied the allegation, stated not being informed of any resident left soiled or any staff refusing assistance due to being on break. A1 explained that the facility uses a break schedule to ensure coverage and stated not being present during the reported incident and did not receive follow-up information. On 04/07/2026 between the hours of 11:55am - 1:33pm, the Department interviewed 5 staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they had not observed a resident being left soiled, had not refused assistance due to being on break, and stated that another caregiver is assigned to provide coverage when a staff member is on break. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents was aware of the allegation. Nine (9) out of ten (10) residents denied the allegation. Residents reported they independently manage toileting or receive timely assistance. One resident reported a single instance where staff stated they were on break in regards to the delay in responding to care needs. 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 05/13/2026 between the hours of 10:00am - 11:00am, the Department conducted a records review of resident assessments and facility documentation and did not observe any records indicating unmet toileting needs or delays in incontinence care. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. 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: Facility staff did not treat residents with dignity and respect. It was alleged that staff entered rooms without knocking, spoke rudely to residents, and refused to provide their names. On 04/07/2026 between 8:40am -8:52am, the Department interviewed the Administrator (A1) regarding the allegation. A1 denied the allegation and mentioned not being informed of staff entering rooms without knocking, speaking rudely to residents, or refusing to provide their names. A1 stated staff are expected to knock before entering and identify themselves when asked, and no complaints of disrespectful conduct had been reported. On 06/03/2026 between 9:24am - 9:42am, the Department re-interviewed A1 to obtain additional information in regards to the allegation. A1 denied receiving any reports of staff entering rooms without knocking, speaking rudely to residents or visitors, refusing to provide their names, or making inappropriate statements. A1 stated staff are trained to uphold resident Personal Rights, including respectful communication and proper room entry procedures. A1 reported that R1 approached her the day after 04/02/2026 to apologize for R1's visitor’s behavior such as being rude towards the staff. A1 stated she spoke with the involved staff (S4), reviewed expectations regarding respectful communication, and reinforced de-escalation procedures. A1 reported no residents had expressed concerns about staff conduct or indicated a desire to move out due to staff behavior. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they knock before entering resident rooms, do not speak to residents in a rude manner, and provide their names when requested. Staff stated they were not aware of any incidents involving rude tone or refusal to identify themselves. 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 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. Two (2) of ten (10) residents confirmed the allegation. Eight (8) of ten (10) residents denied the allegation. Two residents reported incidents involving rude tone or failure to knock; the remaining residents reported staff knock before entering and treat them respectfully. On 05/13/2

On 05/29/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit. The purpose of this visit is to deliver deficiencies observed on 05/22/2026 during a complaint investigation visit control number 11-AS-20260519135515. LPA met with the Executive Director, Ace Huynh and the purpose of the visit was explained. LPA was granted entry to the facility. Deficiencies observed on 05/22/2026 were as follows: · The facility did not submit Unusual Incident/Injury Reports (UIRs) for Resident 1(R1). o Internal Resident Incident Report dated 02/06/2025, indicated that R1 was hospitalized and not in the facility. o Friendly Reminder letter dated 02/20/2025, stated that R1 was not complying with the facilities House Rules and/or policies and stated that R1 had until 03/20/2025 to clear out the room; the letter went on to explain that “The room is extremely cluttered. This poses a fire risk and makes it difficult for our staff to assist R1 ”; furthermore, it indicated failure to resolve will lead to the beginning of eviction proceedings. o Internal Resident Incident Report dated 03/11/2025, described R1’s room as a fire hazard. o Internal Resident Incident Report dated 03/22/2025, indicated that R1’s room still needs to be de-cluttered. o Internal Resident Incident Report dated 02/17/2026, indicated that R1 went to the hospital and was diagnosed with shingles. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 · The facility did not have a yearly Appraisal and Needs Services Plan [ANS) also known as a reappraisal] for R1. o R1’s ANS dated 01/30/2025 was not signed by R1 nor facility staff. o The facility did not have an ANS for R1 for the year 2026. · The facility did not have a yearly updated Physicians Report (e.g. annual medical routine visit) for R1. o R1’s Physicians Report was dated 04/24/2023. o There was no documentation explaining as to why R1 did not receive an annual medical routine visit for 2024, 2025, nor 2026. Deficiencies are being cited based on record review in accordance with the California Code of Regulations, Title 22, see LIC809Ds. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Executive Director, Ace Huynh.

R1's LIC 9172 Functional Capability Assessment (dated 08/27/2025), R1's Concise Care Group (dated 08/06/2025), R1's Patient Chart (not dated), Besht Wellness (dated 03/05/2026), R1's Appraisal/Need & Service Plan (dated 12/19/2025), R1's Invoice for Monthly Room Charge (September 2025 -April 2026) R2's Internal Resident Incident Report (dated 09/26/2025) and R1's & R2's ALl Order Administered/ Medication List (January 2026- June 2026) . The investigation revealed the following: Allegation: Facility staff mismanage residents’ medications. It was alleged that residents’ medications were not administered as prescribed and that documentation was incomplete. On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated med-techs assist with self-administered medications when LVNs are unavailable. A1 reported not being aware of any missed doses or medication errors. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Four (4) out of five (5) staff denied the allegation. One (1) staff was unaware. Staff reported they were not aware of missed doses and stated they notify the med-tech or charge nurse if unable to administer medications. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegatio n. One (1) of ten (10) residents confirmed the allegation. One (1) out ten (1) resident was unsure of the allegation. Eight (8) out of ten (10) denied the allegation. One resident reported missed doses; another resident was unsure of their medication management. On 05/13/2026 between the hours of 10:10am – 11:00am, the Department conducted a records review of the April and May 2026 Medication Administration Records (MARs) and observed multiple missing staff initials indicating undocumented medication administration for several residents. The Department also observed medications remaining inside bubble packs despite being initialed as administered. Missing initials were noted for daily medications which include, diabetic medications, antihypertensives, anticoagulants, and ophthalmic treatments. These discrepancies were observed for multiple residents on multiple dates, and no documentation was found to explain the missing initials or unadministered medications. Based on the Department'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 R1's LIC 9172 Functional Capability Assessment (dated 08/27/2025), R1's Concise Care Group (dated 08/06/2025), R1's Patient Chart (not dated), Besht Wellness (dated 03/05/2026), R1's Appraisal/Need & Service Plan (dated 12/19/2025), R1's Invoice for Monthly Room Charge (September 2025 -April 2026) R2's Internal Resident Incident Report (dated 09/26/2025) and R1's & R2's ALl Order Administered/ Medication List (January 2026- June 2026) . The Investigation revealed the following Allegation: Facility staff do not ensure that residents’ toileting needs are met. It was alleged that residents were not receiving timely assistance with toileting and incontinence care due to chronic understaffing, resulting in delays in responding to care needs and insufficient break coverage. On 04/07/2026 between the hours of 8:40am - 8:52am, the Department interviewed A1 in regards to the allegation. A1 denied the allegation, stated not being informed of any resident left soiled or any staff refusing assistance due to being on break. A1 explained that the facility uses a break schedule to ensure coverage and stated not being present during the reported incident and did not receive follow-up information. On 04/07/2026 between the hours of 11:55am - 1:33pm, the Department interviewed 5 staff regarding the allegation. five (5) staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they had not observed a resident left soiled, had not refused assistance due to being on break, and stated that another caregiver is assigned to provide coverage when a staff member is on break. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents was aware of the allegation. Nine (9) out of ten (10) residents denied the allegation. Residents reported they independently manage toileting or receive timely assistance. One resident reported a single instance where staff stated they were on break in regards to the delay in responding to care needs. On 05/13/2026 between the hours of 10am - 11am, the Department conducted a records review of resident assessments and facility documentation and did not observe any records indicating unmet toileting needs or delays in incontinence care. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. 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. 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 treat residents with dignity and respect. It was alleged that staff entered rooms without knocking, spoke rudely to residents, and refused to provide their names. On 04/07/2026 between the hours of 8:40am – 8:52am the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated not being informed of any staff entering rooms without knocking, speaking rudely to residents, or refusing to provide their names. A1 stated staff are required to knock before entering rooms and provide their names when asked, and A1 did not receive any complaints regarding disrespectful conduct. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they knock before entering resident rooms, do not speak to residents in a rude manner, and provide their names when requested. Staff stated they were not aware of any incidents involving rude tone or refusal to identify themselves. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. Two (2) of ten (10) residents confirmed the allegation. Eight (8) of ten (10) residents denied the allegation. Two residents reported incidents involving rude tone or failure to knock; the remaining residents reported staff knock before entering and treat them respectfully. On 05/13/2026 between the hours of 10:00 AM – 11:00 AM, the Department conducted a records review of facility policies, resident rights documentation, and internal records and did not observe any documentation indicating staff failed to treat residents with dignity or respect. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. 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. 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 do not ensure residents’ medical needs are being met. It was alleged that residents were not receiving ordered physical therapy or medical services. On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated not being aware of any resident failing to receive ordered physical therapy or medical services. A1 stated the facility follows up with therapy providers when services are missed and had not received reports of unmet medical needs. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Four (4) out of five (5) staff denied the allegation. One (1) out of five (5) staff was unaware of the allegation. Staff reported they had not observed residents missing medical services and stated they notify the LVN or med-tech when residents report concerns. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents confirmed the allegation. Nine (9) of ten (10) residents denied the allegation. One resident reported not receiving physical therapy; other residents reported receiving medical services as ordered or stated delays were due to insurance authorization rather than facility action. On 05/13/2026 between the hours of 10:00am – 11:00am, the Department conducted a records review of LIC 602s, LIC 603s, and medical documentation and did not observe any records indicating missed medical services or lack of follow up by the facility. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. 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. 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 do not ensure food served is of good quality. It was alleged that the food served to residents was of poor quality

On 05/13/2025 at 8;15am, the Department conducted an unannounced Case Management Deficiencies visit. During at 8:30 AM, the Department met with Catherine Dacara (Assistant Administrator) and explain the purpose of the visit. On 04/03/2026, upon the Department issuing a Technical Violation for 87465(a)(4) with a due date of 04/17/2026, the Department also requested that the facility submit employee training records from hire date to present by the end of the week of 04/03/2026 in relation to Complaint Control #11-AS-20251104162513. On 04/17/2026 at 5:55 PM, the Department received an email from the facility’s Assistant Administrator containing a PDF attachment titled Allegiance Valley Pharmacy Audited and Reviewed Medication Management Program Training dated 04/15/2026. On 05/11/2026 at 8:00am via email and on 05/13/2026 at 8:30am in person, the Department requested for staff training records from hire date to present related to Complaint Control #11-AS-20251104162513. The facility did not provide the requested documentation until 12:00 PM. Upon review, the training records submitted reflected training years 2021–2026, but did not include training records from previous employers for staff listed on the LIC 811, as requested As a result, according to the California Code of Regulations (Title 22, Division 6, Chapter 8) the facility did not comply with Title 22, Section 87412(f)(1) , which states: All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. The facility failed to make provide personnel training records upon request in a timely manner An exit interview was conducted with Assistant Administrator Catherine Dacara. A copy of this report with appeal right were provided.

No active conflict was observed at the time of the visit. Records review revealed the following: Records for R1 indicate a diagnosis of end-stage renal failure requiring ongoing dialysis treatment and that R1 requires assistance with activities of daily living and supervision, including night supervision. Records for R2 indicate physical impairment requiring assistance with activities of daily living. LPA reviewed internal incident reports dated 03/12/2026 and 03/13/2026 documenting complaints regarding loud television use and roommate conflict between R1 and R2. Documentation indicates that R1 reported an inability to sleep due to the volume of the television, and staff provided reminders to R2 regarding house rules, including lowering the volume and using headphones at night. However, the facility did not provide additional requested documentation, including behavior logs, complaint logs, or records demonstrating ongoing monitoring, follow-up actions, or resolution of the roommate conflict. Records reviewed support the allegation, as the documentation confirms the reported concern and demonstrates that interventions were limited to reminders, without evidence of effective resolution, despite the resident’s medical condition requiring adequate rest and supervision. Regarding the allegation, “Facility did not maintain a safe and healthful environment for the resident,” it is being alleged that a resident was subjected to ongoing roommate conflict, including noise disturbances, lack of shared space access, and disruption of sleep, and that staff failed to ensure effective resolution of the situation. Interviews conducted revealed the following: Four residents (R1–R4) reported concerns supporting the allegation, while 10 out of 14 residents reported no concerns. Residents who reported concerns described ongoing roommate conflict involving loud television use at night, lack of respect, and misuse of shared space, as well as feeling unsafe due to roommate conflict and experiencing ongoing issues involving noise, hygiene concerns, and unresolved conflict lasting approximately six months. Interviews with 5 staff (S1–S5) supported the allegation, as staff confirmed that the roommate conflict between R1 and R2 has been ongoing for several months. Staff reported that R1 requires rest due to dialysis treatment, while R2 maintains a conflicting sleep schedule and uses the television at a high volume. Staff further reported that incident reports were completed and the issue was brought to administration, and that staff attempted verbal interventions such as reminders and mediation. S1 reported addressing the concern by counseling the resident, reviewing house rules, and offering a room change; however, both residents declined relocation, and the issue remained ongoing at the time of the investigation. Additional statements indicated that R1 may have difficulty reporting concerns due to language barriers. Please see (LIC9099-C) for report continuation. 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 evidence gathered, interviews conducted, observations, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation “Facility did not maintain a safe and healthful environment for the resident” is found to be substantiated. The facility identified the roommate conflict and implemented initial interventions; however, those actions were not effective, and the issue continued to impact the resident’s health and well-being. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87307(d)(2). A citation is being issued on the attached (LIC 9099D). An exit interview was conducted, and a copy of this report, along with appeal rights, was provided to the Administrator.

Interviews Conducted revealed: Staff (1-6) confirmed the facility’s medication scanner was functioning properly from January 2026 to present date. R1 stated that routine medications are often not administered on time. Staff (S1–S6) confirmed that MAR entries include the medication name, dosage, administration time, and staff initials, stamped at the time of administration. Observations: LPA observed a demonstration by five staff members (S1–S5) of the medication scanner scanning a sample resident medication. The printed timestamp accurately reflected the time, date, and medication description at the time the sample was conducted. Records Review: MARs for R1 from December 2025 and January 2026 indicate multiple routine medications were administered 1–2 hours after the prescribed time. The scanner demonstration confirmed equipment is operational, eliminating equipment malfunction as a justification for late administration as previously stated. Based on the evidence gathered, interviews conducted, observations, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation is SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, §87465, Incidental Medical and Dental Care. A citation is being issued on the attached LIC-9099D. An exit interview, a copy of this report, and appeal rights were provided to the Administrator.

The investigation revealed the following: Allegation: Staff do not ensure resident's personal hygiene needs are being met. It was alleged that facility staff do not ensure the resident's personal hygiene needs are being met. The resident stated the last time they received a bed bath from facility staff was around 2 or 3 months ago. The resident mentioned that it has been around 1 year since receiving an actual shower. It was also reported that facility staff do not assist with personal hygiene which the resident needs assistance with. On 02/19/2026 between the hours of 8:42am - 8:49am, LPA interviewed A1 regarding the allegation. A1 denied the allegation. A1 stated the resident is scheduled to receive showers at least twice per week per the Admission Agreement , but indicated the resident often receives bed baths instead , reportedly twice a week , and that hygiene care is provided daily by direct care staff . A1 stated she does not personally assist with hygiene care , but that staff assist the resident with changing clothes, incontinence care, and brushing teeth on a daily basis . A1 acknowledged that deviations from showering may occur due to resident refusal or health-related issues (e.g., pain preventing movement) . A1 reported that the facility maintains records of bathing and hygiene care , and that staff are responsible for documenting care and reporting when hygiene supplies are low , at which point the family is notified or the facility provides items if needed . On 02/19/2026 between the hours of 9:21am -11:38am, LPA interviewed 5 staff in regards to the allegation. 2 of 5 staff confirmed the allegation and stated Resident 1 (R1) has been refusing showers since last year and cannot remember the last time R1 received a shower. Staff stated R1 gets bed baths usually twice a week but has been refusing. 1 of 5 staff did not confirm nor deny the allegation and stated the resident gets showers 3 days a week or upon request from the resident, and last month upon being assigned to the unit where R1 resides, personal hygiene assistance would be about 3 times a week. 2 of 5 staff were unaware of the allegation and stated they work in the memory care unit and do not assist R1 with showering or personal hygiene needs. Staff mentioned the facility keeps records using communication logs and shower sheets when residents are bathed or showered, and caregivers have to sign a shower sheet and document in the Activities of Daily Living (ADL) book. 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 02/19/2026 between the hours of 12:01pm - 2:11pm, LPA interviewed 10 residents in regards to the allegation. 2 of 10 residents confirmed the allegation. 1 of the 2 residents stated the last time they received assistance with a shower from staff is like months to a year. The resident stated it is not really often and once caregivers see the residents can independently take care of themselves, then no care is provided by staff even though the facility is supposed to provide care which is mentioned in their contract (Admission Agreement). Of the 2 resident who confirmed the the allegation mentioned staff are too slow with assisting and or never come, so they have to take their own shower because they cannot trust nor put their care in the hands of the caregivers. 1 of 10 residents did not confirm nor deny the allegation and stated staff help with changing and assist with their catheter, and about two weeks ago they had a bed bath. The resident stated they never refused bed baths/showers but would like a bed bath at least twice a week. 7 of 10 residents denied the allegation and stated they take their own showers independently, never ask for help since they do this themselves, take care of their own personal hygiene, and do not ask staff for help because they are independent. On 02/23/2026 between the hours of 8:30am - 11:00am, LPA conducted a records review and observed the following: According to the LIC 602A Physician's Report (dated 06/18/2024), page 5 of 9, Section 2 (Capacity for Self-Care), the resident is marked No for being able to bathe, dress, or groom self. Similarly, the LIC 603 Pre-Placement Appraisal Information (dated 07/04/2024) indicates Yes for needing help with bathing, hair care, and personal hygiene. Furthermore, the Admission Agreement under Section 3 (Basic Services), Item 8, specifies assistance with the following activities: a. dressing, c. toileting, d. bathing (twice weekly), and e. grooming. The shower logs for the month of February revealed R1's showers days are marked for Tuesdays and Thursday in the Spa Room. On the Resident Tracking Sheet (February 2026) for R1's during the AM, PM and NOC Shift it revealed: During the hours of 7am, 9am, 11am, 1pm, 3pm, 5pm, 7pm, 9pm, 10:30pm, 12am, 2am, 4am, 6am that S on the key which means for Supervised Safety was provided to the R1 on 02/01 - 02/05, 02/09 - 02/14, 02/17 - 02/18, 02/28 - 02/29. The following dates had no initials 02/06 - 02/08, 02/15 - 02/19 - 02/22. The facility did not provide written documentation of R1 refusing a shower and or bed bath. 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 The facility’s direct care staffing schedules from 02/08/2026 - 02/21/2026, stated the following: During the week of (02/08–02/14), the AM shift utilized 5 to 7 caregivers, the PM shift maintained 5 to 6 caregivers, and the NOC shift utilized 3 to 4 caregivers. Memory care coverage during this period consisted of 1 to 2 caregivers per shift. During the week of (02/15/2026 – 02/21/2026), staffing levels fluctuated, with the AM shift utilizing 4 to 7 caregivers and the PM shift utilizing 5 to 7 caregivers. The NOC shift had 2 caregivers on 02/16, 02/17, and 02/21. While memory care usually maintained 2 caregivers during the day, it dropped to 1 caregiver during the PM shift on 02/21 and remained at 1 caregiver for the majority of the NOC shifts throughout both weeks. 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 Catherine Dacara (Administrator) and a copy of this report was provided with appeal rights

Investigation revealed the following: Allegation: “Licensee did not follow proper eviction procedures for resident”, it is being alleged that the facility did not follow proper eviction procedures for R1. Interviews conducted revealed the following: According to S1 the facility did follow proper eviction procedures. According to R1 the facility did not follow proper eviction procedures, furthermore, R1 indicated that they do not read or understand the English language, additionally, R1 indicated that they received their Eviction Notice in English and not in their native language. R1’s records reviewed revealed the following: the New Resident Alert states R1 “only speaks Spanish.” The Thirty Day Notice to Quit dated 05/07/2025 indicates that R1 did not follow general policies of the facility [referring to CCR87224(a)(3)] but did not describe how R1 did not follow said general policies of the facility, furthermore, the document indicates that R1 is not an appropriate fit for the facility [referring to CCR87224(a)(4)] but did not conduct/provide a reappraisal of R1 as stated in regulation CCR87224(a)(4) and explain how R1 is not an appropriate fit for the facility. Substantiated: Based on interviews and record reviews, 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. An exit interview was conducted, plans of corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Interim Executive Director, Catherine Dacara .

The investigation revealed the following: Allegation: Facility staff sexual abused resident in care. The department interviewed A1 regarding the allegation. A1 stated S1 was terminated from the facility for job performance issues, inappropriate interactions with residents, and inappropriate communications with fellow staff members. A1 stated R1 reported to staff members that S1 kissed R1 on the neck and chest and touched himself through his pants while in front of R1. The department interviewed S1–S3 regarding the allegation. One out of three staff interviewed denied the allegation, stating he was always professional and never displayed any inappropriate behaviors, such as kissing residents or touching himself while employed at the facility. Two out of the three staff interviewed confirmed being aware of S1’s inappropriate interactions with residents, which consisted of kissing residents on the cheek or chest and touching himself in front of residents. The department interviewed Witness #1, and W1 stated S1 was employed by the facility but was quickly terminated for inappropriate interactions with a resident, as well as job performance issues. W1 stated the inappropriate interaction with a resident occurred when S1 was found lying in a resident’s bed next to the resident while on his phone. The department interviewed R1 regarding the allegation, and R1 confirmed the allegation and disclosed S1 kissed R1 on the cheek and chest and touched himself through his pants. R1 further stated S1 hugged R1 every time S1 saw R1, and all of S1’s inappropriate behaviors made the resident uncomfortable. The department obtained a copy of the Long Beach Police Department report, which contains statements from facility staff regarding S1’s inappropriate behaviors. The department reviewed S1’s termination documents from Glen Park at Long Beach and another facility, both of which list similar reasons for S1’s termination, including inappropriate interactions with residents. Based on interviews conducted and records reviewed the department finds enough evidence to support that S1 sexually abused R1. 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. Exit interview conducted with Catherine Dacara (Assistant Administrator) and copy of this report was provided with appeal rights.

Medication Management Program verification, med tech Certification of Completion in Basic Medication Training, and med tech Basic Medication Shadow Training Logs. The following additional documents were requested and are to be emailed to LPA Unusual Incident Reports (URI), Physician’s Orders, Needs and Service Plan, and Medication Administration Records (MAR). The investigation revealed the following: Allegation: Staff are not following resident’s diabetic needs The allegation alleges that med techs are giving residents their insulin. During the facility visit, LPA observed residents going to the Medication Room to see the trained LVN, to have their blood sugar level checked, and to receive their insulin injections. During the visit, LPA observed insulin secured in a locked refrigerator, in the medication room. During record review, LPA reviewed the training and in-service logs for the LVN and medication technicians and observed they have received training regarding medication administration. LPA reviewed the Plan of Operation that indicates a licensed skilled professional can assist with self-administration of injections. LPA received and reviewed Resident R2-R 11’s Medication Administration Record (MAR) and observed glucose testing and insulin injections signed off by the LVN. During interviews with Staff S1-S8, were asked who checks residents’ sugar and provides insulin injections, eight (8) out of eight (8) stated the LVN is who tests residents’ sugar and gives insulin injections. During interviews with Residents R1-R11, were asked who provides them with their insulin shots and tests their sugar, eight (8) out of eleven (11) stated the nurse gives them their shots and tests their sugar. One resident stated they do their own sugar testing, and the nurse is there to document the numbers, and they do their own injections with the nurse watching. Two residents stated they do not require glucose testing or insulin injections. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . 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 are not providing adequate food service The allegation alleges that residents are unable to get a second serving of food during mealtimes due to the kitchen running out of food. During the facility inspection, LPA observed lunch being prepared and served. LPA observed staff preparing residents plates using scoopers measuring half (1/2) a cup for mixed vegetables, fruit, and stuffing. Soup was measured using an 8 fluid ounce ladle. Residents were provided with one to two pieces of chicken with gravy. LPA observed a resident who wanted an alternative meal, and they were provided with either a turkey or ham sandwich, fruit, vegetables, soup, and stuffing. LPA observed multiple residents served a second serving of lunch. After all residents were provided with their meals, LPA observed an ample supply of prepared food still in the kitchen. Additionally, LPA inspected the food supply in the kitchen and observed a two (2) day supply of perishable foods and a seven (7) day supply of nonperishable foods. During record review, LPA received and reviewed invoices from Sysco listing food deliveries on the following dates 12/03/2025, 11/28/2025, 11/25/2025, 11/21/2025, 11/18/2025, 11/14/2025, 11/11/2025, 11/07/2025, 11/05/2025, and 11/04/2025. The food delivered consisted of dairy, meats, poultry, canned goods, frozen goods, dry goods, and condiments. Additionally, LPA received and reviewed the Sanitation and Food Safety Checklist for Assisted Living dated 09/25/2025 and 11/07/2025. On both forms, indicates the facility has a “one week of nonperishable food and 2 days perishable are available.” During interviews with Staff S1-S8, were asked if residents are able to have a second serving during mealtimes, eight (8) out of eight (8) stated residents are able to have a second serving of food during mealtimes. During interviews with Residents R1-R11, were asked if they are provided with enough food throughout the day, eleven (11) out of eleven (11) stated yes, they are provided with enough food throughout the day. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . Allegation: Staff are eating the food for the residents The allegation alleges that staff are eating all the food resulting in there not being enough food for residents. During the facility inspection, LPA observed lunch being prepared and served. LPA observed staff preparing residents plates using scoopers measuring half (1/2) a cup for mixed vegetables, fruit, and stuffing. Soup 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 was measured using an 8 fluid ounce ladle. Residents were provided with one to two pieces of chicken with gravy. LPA observed a resident who wanted an alternative meal, and they were provided with either a turkey or ham sandwich, fruit, vegetables, soup, and stuffing. LPA observed multiple residents served a second serving of lunch. After all residents were provided with their meals, LPA observed an ample supply of food prepared in the kitchen. LPA did not observe any staff eating the food that was served from the kitchen. During review of an Admission Agreement, LPA observed a resident’s guest may purchase a meal and eat with the resident they are visiting. During interviews with Staff S1-S8, were asked if staff eat the food served to the residents, six (6) out of eight (8) stated they have eaten or seen staff eating the food served to the residents. Additionally, four (4) out of eight (8) stated meals are available for purchase and some staff eat the food for quality testing. During interviews with Residents R1-R11, were asked if there has been a time they wanted a second serving and it was not available due to the kitchen running out of food, eleven (11) out of eleven (11) stated no, the kitchen has not run out of food. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . An exit interview was conducted with Catherine Dacara, and a copy of this report was provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Medication Management Program verification, med tech Certification of Completion in Basic Medication Training, and med tech Basic Medication Shadow Training Logs. The following additional documents were requested and are to be emailed to LPA Unusual Incident Reports (URI), Physician’s Orders, Needs and Service Plan, and Medication Administration Records (MAR). The investigation revealed the following: Staff are mishandling the residents medications The allegation alleges residents are not getting their medication because the medication is missing. During the facility inspection, LPA conducted a medication review for eight (8) residents. LPA observed three (3) out of eight (8) residents had medications that were unable to be located in the medication cart and medication room. Additionally, LPA observed two (2) out of eight (8) resident’s medications were not consistent with documented records. During interviews with Staff S1-S8, were asked if there have been any medication errors or missing medications in the past, five (5) out of eight (8) staff stated yes, there was recently a medication error that was documented and reported. During interviews with Residents R1-R11, were asked if there have been any medication errors or missing medications in the past, four (4) out of eleven (11) stated yes, they have had missing medications that the staff did not know what happened to them. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Assistant Administrator, Catherine Dacara, and a copy of this report and Appeal Rights were provided.

On 01/07/2025, The Department conducted an unannounced visit to deliver findings for the alleged allegations for complaint Control Number 11-AS-20251223093452 . LPA met with Catherine Dacara (Assistant Administrator) as the purpose of the visit was explained. On 01/07/2025 between the hours of 8:30am - 8:45am, 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 10 (R10) having an unwitnessed fall and being sent out to the hospital on 12/09/2025. 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 Catherine Dacara (Assistant Administrator) , appeal rights explained, and a copy of this report was provided.

On 12/19/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced complaint investigation visit regarding Complaint Control Number 11-AS-20250722112818. The department observed deficiencies during the course of the investigation and delivered deficiencies to the Executive Director, Jennifer Rivas . The following deficiencies were observed: · Pictures taken in the medication room show that injection needles were improperly discarded. Injection needles were in white trash bags. On 8/22/2025, LPA Leandro toured the medication room and confirmed that said pictures were taken in the facility's medication room. Interviews with staff and witnesses confirmed that the facility has improperly discarded injection needles. · On 08/22/2025 and 12/12/2025 one glucometer was observed in the medication room; according to staff and witnesses (on both days) one glucometer is used for all residents who require glucose testing. On 12/12/2025, LPA requested to view extra glucometers but medication room staff was unable to show LPA extra glucometers; staff did not know if the facility had extra glucometers. · Interviews with staff and witnesses on 08/22/2025 and 12/12/2025 in the medication room confirmed that the facility uses one glucometer for all the residents who require glucose testing. 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 12/12/2025, the medication room’s refrigerator was at 55 degrees Fahrenheit. The refrigerator had insulin medication and other medications that had to be refrigerated at 36 to 46 degrees Fahrenheit. The facilities freezer had a large block of ice on the bottom and a soda inside it next to ice packs. The refrigerator/freezer has a sign that states “Please Do Not Store Food.” · Interviews conducted with staff, residents, and witnesses indicated that a Medical Technician (MedTech) has provided injections and blood sugar checks (glucose testing) to residents. · Interviews and records reviewed confirmed that residents have not been receiving their medical injections nor glucose testing as prescribed. · Records reviewed and interviews with residents, staff, and witnesses confirmed that residents who require assistance with glucose testing and injections did receive assistance with hand-over-hand and did not receive their medication/medical care as prescribed. Deficiencies are being cited based on observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Executive Director, Jennifer Rivas .

The investigation consisted of the following: On 07/24/2025, facility records were gathered. On 08/22/2025, a tour of the facility was conducted, interviews were conducted, and facility records were gathered. A tour of the facility consisted of the medication room and kitchen. Interviews consisted of Witness 1 (W1), Resident 1 (R1) to Resident (6), and Staff 1 (S1) to Staff (7). On 08/25/2025, Staff 8 (S8) was interviewed. On 12/11/2025, interviews were conducted, records were gathered and reviewed. Interviews consisted of Witness 2 (W2), Resident 7 (R7) to Resident 11 (R11), and Staff 9 (S9). On 12/12/2025, a tour of the Medication Room was conducted, interviews were conducted, records were gathered and reviewed. Interviews consisted of R5, R7, R10, Resident 12 (R12) to Resident 14 (R14), Staff 10 (S10), and Witness 3 (W3). R1’s to R15’s records were reviewed which consisted of Medication Administration Records (MARs), Physicians Reports, and Residents that Receives Daily Insulin/Boold Sugar Checks. Facility records reviewed consisted of Personnel Reports, Resident Rosters, Schedule Reports, Staff Training's. Other pertinent records were also reviewed during this investigation. Investigation revealed the following: Allegation: “Staff do not ensure an appropriate skilled professional is administering insulin to residents.” Interviews conducted revealed the following: On 08/22/2025, W1 indicated that there was no Licensed Vocational Nurse (LVN) in the morning shifts, and a Medical Technician (MedTech) was providing insulin and providing blood sugar checks to residents. On 08/22/2025, S1 indicated that they are the only LVN in the facility and they work Monday to Friday from 7 AM to 4 PM. Moreover, S1 indicated that recently they started to work weekend shifts. Furthermore, S1 indicated that they “usually make it” to provide residents with their injections and blood sugar checks. S1 was asked what happens when they do not make it and S1 did not answer the question. On 08/22/2025, S2 indicated that S1 does not come in during the weekends and residents do not receive their injections nor blood sugar checks on the weekends. 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 08/22/2025, S3 indicated that S1 sometimes comes in during the weekends and sometimes agency LVNs (the facility contracts agency staff when they are short staffed) come in during the weekends but sometimes no LVNs come during the weekends; S3 is not sure what happens when no LVNs come in. On 08/22/2025, S7 indicated that before there were no LVNs in the facility during the weekends and a MedTech had to come in the facility and provide injections and blood sugar checks to residents. On 08/25/2025, S8 indicated that they have witnessed MedTech’s provide injections and blood sugar checks to residents. Furthermore, S8 explains that the facility has requested for them to provide injections and blood sugar checks to residents because the LVN was not in the facility, S8 declined and indicated, that day, residents did not receive their injections nor blood sugar checks. On 12/11/2025, S9 indicated that they have heard of a MedTech providing injections and blood sugar checks to residents. On 12/12/2025, S10 indicated that on 12/10/2025 an agency LVN did not provide injections nor blood sugar checks to residents. On 12/12/2025, W3 confirmed that an agency LVN did not provide injections nor blood sugar check to residents. W3 explained that on 12/11/2025 residents informed them that they were upset that they did not receive their insulin injections nor blood sugar checks. Interviews conducted with R1 to R14 revealed the following: 6 out of 14 residents agreed with the allegation; indicating that there have been days when a MedTech provided them with blood sugar checks and when they did not receive their insulin injection, injection, nor blood sugar check. 6 out of 14 residents are not sure if there have been days when they have missed an injection or blood sugar check. 2 out of 14 residents are certain that a nurse provides them with their medication as required by their physician. Records reviewed revealed the following: Personnel Report dated 7/7/2025, indicated that S1’s job title is “LVN”, and their schedule is Monday to Friday from 7:00 AM to 4:00 PM, as well as S1 is the only LVN in the facility. S1 holds a State of California Board of Vocational Nursing and Psychiatric Technicians License for Vocational Nurse. 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 Personnel Report dated 12/09/2025, showed that there is no LVN in the report. Residents Physician’s Reports revealed the following: Physician’s Reports for R1, R4, R9, R7, R10, R13, R14, and R15 indicated that residents cannot manage their own medication including providing themselves with injections and performing their own glucose testing (blood sugar checks). Physician’s Report for R5 indicated that resident can provide their own injections with assistance, but they are not able to perform their own glucose testing. Physician’s Report for R11 indicated that resident can provide their own injections but requires their insulin dosage to be drawn before self-injections, and they are not able to perform their own glucose testing. Residents MARs revealed the following: According to R1’s MAR they did not receive their “AM” blood sugar check and insulin injection on 06/02/2025 and 06/19/2025; R1 did not receive their “PM” blood sugar checks and “PM” insulin injections on 05/10/2025, 05/11/2025, 05/17/2025, 05/18/2025, 05/25/2025, 06/07/2025, 06/15/2025, and 07/20/2025. According to R4’s MAR they did not receive their “AM” blood sugar check from 05/03/2025 to 05/31/2025; R4 did not receive their “PM” blood sugar check and insulin injection on 05/10/2025, 05/11/2025, 05/25/2025, 6/7/2025, 06/15/2025, 06/31/2025, and 7/20/2025; R4 did not receive their Ozempic injection on 07/10/2025 and 07/17/2025. According to R5’s MAR they did not receive their “PM” blood sugar checks and “PM” insulin injections on 05/10/2025, 05/11/2025, 05/18/2025, 05/25/2025, 06/07/2025, 06/09/2025, 06/15/2025, and 12/10/2025; R5 did not receive their “PM” insulin injection on 07/20/2025. According to R7’s MAR they did not receive their “AM” blood sugar check and insulin injection on 06/19/2025 and 12/10/2025; R7 did not receive their “PM” blood sugar checks and “PM” insulin injections on 05/10/2025, 05/11/2025, 05/18/2025, 06/07/2025, 06/15/2025, 07/20/2025, and 12/10/2025. According to R8’s MAR they did not receive their “AM” blood sugar check and insulin injection on 06/19/2025. According to R10’s MAR they did not receive their “AM” blood sugar check and insulin injection on 05/27/2025, 06/19/2025, 07/11/2025, and 12/10/2025. According to R12’s MAR they did not receive their 4:00 PM blood sugar check on 12/04/2025 and 12/06/2025; R12 did not receive their 8:00 AM blood sugar check on 12/10/2025. According to R14’s MAR they did not receive their 8:00 AM insulin injection on 12/10/2025. Schedule Reports revealed the following: From 06/29/2025 to 7/26/2025 and 08/10/2025 to 08/30/2025, S1 is scheduled from 7:00 AM to 4:00 PM and “Open As Needed” on Saturdays and Sundays. From 08/03/2025 to 08/09/2025, S1 was scheduled off. 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 S1’s Time Card Reports from 05/01/2025 to 07/31/2025 revealed the following: S1 did not work on 05/10/2025, 06/07/2025, 06/09/2025, and 07/11/2025. S1 did not work in the afternoon and evening of 05/11/2025, 05/18/2025, 06/10/2015, and 07/25/2025. S1 did not work early in the early morning, afternoon and evening time on 05/25/2025. S1 did not work early in the morning and evening of 06/15/2025. S1 did not work from 8:00 AM to 11:59 PM on 06/05/2025. S1 did not work in the morning and afternoon of 07/05/2025. Observations revealed the following: Pictures taken in the medication room show that injection needles were improperly discarded. Injection needles were in white trash bags. On 8/22/2025, LPA Leandro toured the medication room and confirmed that said pictures were taken in the facility's medication room. On 12/12/2025, the medication room’s refrigerator was at 55 degrees Fahrenheit. The refrigerator had insulin medication and other medications that had to be refrigerated at 36 to 46 degrees Fahrenheit. The facilities freezer had a large block of ice on the bottom and a soda inside it next to ice packs. The refrigerator/freezer have a sign that states “Please Do Not Store Food.” Substantiated: Based on interviews, observations, and records reviewed 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 is being cited on the attached LIC 9099D. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Executive Director, Jennifer Rivas.

Investigation revealed the following: Allegation: “Staff do not insure an appropriate skilled professional is administering insulin to residents.” Interviews conducted revealed the following: On 08/22/2025, W1 indicated that there was no Licensed Vocational Nurse (LVN) in the morning shifts, and a Medical Technician (MedTech) was providing insulin and providing blood sugar checks to residents. On 08/22/2025, S1 indicated that they are the only LVN in the facility and they work Monday to Friday from 7 AM to 4 PM. Moreover, S1 indicated that recently they started to work weekend shifts. Furthermore, S1 indicated that they “usually make it” to provide residents with their injections and blood sugar checks. S1 was asked what happens when they do not make it and S1 did not answer the question. On 08/22/2025, S2 indicated that S1 does not come in during the weekends and residents do not receive their injections nor blood sugar checks on the weekends. On 08/22/2025, S3 indicated that S1 sometimes comes in during the weekends and sometimes agency LVNs (the facility contracts agency staff when they are short staffed) come in during the weekends but sometimes no LVNs come during the weekends; S3 is not sure what happens when no LVNs come in. On 08/22/2025, S7 indicated that before there were no LVNs in the facility during the weekends and a MedTech had to come in the facility and provide injections and blood sugar checks to residents. On 08/25/2025, S8 indicated that they have witnessed MedTech’s provide injections and blood sugar checks to residents. Furthermore, S8 explains that the facility has requested for them to provide injections and blood sugar checks to residents because the LVN was not in the facility, S8 declined and indicated, that day, residents did not receive their injections nor blood sugar checks. On 12/11/2025, S9 indicated that they have heard of a MedTech providing injections and blood sugar checks to residents. On 12/12/2025, S10 indicated that on 12/10/2025 an agency LVN did not provide injections nor blood sugar checks to residents. On 12/12/2025, W3 confirmed that an agency LVN did not provide injections nor blood sugar check to residents. W3 explained that on 12/11/2025 residents informed them that they were upset that they did not receive their insulin injections nor blood sugar checks. 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 conducted with R1 to R14 revealed the following: 6 out of 14 residents agreed with the allegation; indicating that there have been days when a MedTech provided them with blood sugar checks and when they did not receive their insulin injection, injection, nor blood sugar check. 6 out of 8 residents are not sure if there have been days when they have missed an injection or blood sugar check. 2 out of 14 residents are certain that a nurse provides them with their medication as required by their physician. Records reviewed revealed the following: Personnel Report dated 7/7/2025, indicated that S1’s job title is “LVN” and their schedule is Monday to Friday from 7:00 AM to 4:00 PM, as well as S1 is the only LVN in the facility. S1 holds a State of California Board of Vocational Nursing and Psychiatric Technicians License for Vocational Nurse. Personnel Report dated 12/09/2025, showed that there is no LVN on the report. Residents Physician’s Reports revealed the following: Physician’s Reports for R1, R4, R9, R7, R10, R13, R14, and R15 indicated that residents cannot manage their own medication including providing themselves with injections and performing their own glucose testing (blood sugar checks). Physician’s Report for R5 indicated that resident can provide their own injections with assistance, but they are not able to perform their own glucose testing. Physician’s Report for R11 indicated that resident can provide their own injections but requires their insulin dosage to be drawn before self-injections, and they are not able to perform their own glucose testing. 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 Residents MARs revealed the following: According to R1’s MAR they did not receive their “AM” blood sugar check and insulin injection on 06/02/2025 and 06/19/2025; R1 did not receive their “PM” blood sugar checks and “PM” insulin injections on 05/10/2025, 05/11/2025, 05/17/2025, 05/18/2025, 05/25/2025, 06/07/2025, 06/15/2025, and 07/20/2025. According to R4’s MAR they did not receive their “AM” blood sugar check from 05/03/2025 to 05/31/2025; R4 did not receive their “PM” blood sugar check and insulin injection on 05/10/2025, 05/11/2025, 05/25/2025, 6/7/2025, 06/15/2025, 06/31/2025, and 7/20/2025; R4 did not receive their Ozempic injection on 07/10/2025 and 07/17/2025. According to R5’s MAR they did not receive their “PM” blood sugar checks and “PM” insulin injections on 05/10/2025, 05/11/2025, 05/18/2025, 05/25/2025, 06/07/2025, 06/09/2025, 06/15/2025, and 12/10/2025; R5 did not receive their “PM” insulin injection on 07/20/2025. According to R7’s MAR they did not receive their “AM” blood sugar check and insulin injection on 06/19/2025 and 12/10/2025; R7 did not receive their “PM” blood sugar checks and “PM” insulin injections on 05/10/2025, 05/11/2025, 05/18/2025, 06/07/2025, 06/15/2025, 07/20/2025, and 12/10/2025. According to R8’s MAR they did not receive their “AM” blood sugar check and insulin injection on 06/19/2025. According to R10’s MAR they did not receive their “AM” blood sugar check and insulin injection on 05/27/2025, 06/19/2025, 07/11/2025, and 12/10/2025. According to R12’s MAR they did not receive their 4:00 PM blood sugar check on 12/04/2025 and 12/06/2025; R12 did not receive their 8:00 AM blood sugar check on 12/10/2025. According to R14’s MAR they did not receive their 8:00 AM insulin injection on 12/10/2025. Schedule Reports revealed the following: From 06/29/2025 to 7/26/2025 and 08/10/2025 to 08/30/2025, S1 is scheduled from 7:00 AM to 4:00 PM and “Open As Needed” on Saturdays and Sundays. From 08/03/2025 to 08/09/2025, S1 was scheduled off. S1’s Time Card Reports from 05/01/2025 to 07/31/2025 revealed the following: S1 did not work on 05/10/2025, 06/07/2025, 06/09/2025, and 07/11/2025. S1 did not work in the afternoon and evening of 05/11/2025, 05/18/2025, 06/10/2015, and 07/25/2025. S1 did not work early in the early morning, afternoon and evening time on 05/25/2025. S1 did not work early in the morning and evening of 06/15/2025. S1 did not work from 8:00 AM to 11:59 PM on 06/05/2025. S1 did not work in the morning and afternoon of 07/05/2025. 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 Observations revealed the following: Pictures taken in the medication room show that injection needles were improperly discarded. Injection needles were in white trash bags. On 8/22/2025, LPA Leandro toured the medication room and confirmed that said pictures were taken in the facility's medication room. On 12/12/2025, the medication room’s refrigerator was at 55 degrees Fahrenheit. The refrigerator had insulin medication and certain medicines had to be refrigerated at 36 to 46 degrees Fahrenheit. The facilities freezer had a large block of ice on the bottom and a soda inside it next to ice packs. The refrigerator/freezer have a sign that states “Please Do Not Store Food.” Substantiated: Based on interviews, observations, and records reviewed 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 is being cited on the attached LIC 9099D. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Executive Director, Jennifer Rivas.

Investigation revealed the following: Allegation: “Staff do not ensure food is stored properly”, it is being alleged that the facility food is not of good quality and not stored properly. On 08/22/2025, a kitchen tour was conducted, and the following was observed: at 12:04 PM LPA Leandro took a picture of mashed potatoes on a paper plate without a cover (e.g. plastic wrap) inside the refrigerator; at 12:04 PM LPA Leandro took a picture of a cotton cleaning towel inside the refrigerator; at 12:05 PM LPA Leandro took a picture of strawberries with mold on them inside the refrigerator, the mold was fuzzy with green and white; at 12:06 PM LPA Leandro took a pictures of sweet potatoes with mold on them inside the refrigerator, the mold was fuzzy with green and white; at 12:06 PM LPA took a pictures of tomatoes with mold on them inside the refrigerator, the mold was black and fuzzy; (facility staff discarded said produce). Substantiated: Based on observations 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 is being cited on the attached LIC 9099D. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Executive Director, Jennifer Rivas. 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 Investigation revealed the following: Allegation: “Staff do not ensure residents are cleaned properly”, it is being alleged that staff refuse to provide residents with showers. Interviews conducted with R1 to R11 revealed the following: 10 out of 11 residents denied the allegation and 1 out of 11 residents agreed with the allegation. Interviews conducted with S1 to S9 revealed the following: 9 out of 9 staff denied the allegation. Interviews conducted with W1 to W2 revealed the following: 1 out of 2 witnesses denied the allegation and 1 out of 2 witnesses did not know if said allegation did or did not occur. Records reviewed of Shower Schedules from 05/01/2025 to 07/25/2025 indicates that staff: “assist” residents with showers, “stand by” when residents showers, and “remind” residents to shower. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was left with the Executive Director, Jennifer Rivas.

On 10/08/2025, Licensing Program Analyst (LPA), Socorro Leandro conducted a case management to deliver a deficiency relating to complaint control number: 11-AS-20250919141527. LPA met Assistant Administrator, Jennifer Rivas and explained the purpose of the visit. LPA was allowed entrance to the facility. On 10/06/2025, Staff 1 (S1) indicated that the Sherrif’s had be in the facility 3 times all ready and that Resident 1 (R1) had received a court order for them to leave the facility. Records reviewed revealed the following: R1 received a L.A. Superior Court, Long Beach, Eviction Restoration Notice dated 10/06/2025 and the department was not notified. A deficiency is being cited based on interviews conducted and records reviewed in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding Reporting Requirements. An exit interview was conducted, plans of corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Assistant Administrator, Jennifer Rivas.

The investigation revealed the following: Allegation 1: Facility staff not providing adequate food service It was alleged that for the past months facility staff were not providing vegan meals. The resident often received only a slice of bread and some canned vegetable. On 05/12/2025 at 10:30 AM, LPA interviewed Assistant Administrator (A1), who denied the allegation, stating that "If a resident has a special diet, we follow the doctor's orders. It is posted in the kitchen and on the table. If they’re still hungry, snacks and an alternative menu are available.” On 05/12/2025, between 10:30 AM – 1:55 PM, and on 07/10/2025 between the hours, 9:55am - 9:57am, LPA interviewed 9 staff regarding the allegation: 9 of 9 staff denied the allegation. 1 out of 9 staff stated Resident 1 (R1) is the only is the only vegan resident and upon all resident admission, they request for dietary restrictions.  Also Staff 9 stated that the vegan resident is offered salad, tuna, sugar-free jello, sugar-free pudding, cottage yogurt. And further stated if the resident would like more food or alternative option available are chicken, vegetables, and green salad. Between 9:48 AM – 2:37 PM, LPA interviewed 11 residents: 1 of 11 residents confirmed the allegation, 4 of 11 residents denied the allegation and 7 of 11 residents were aware of the allegation. On 06/24/2025, LPA conducted a records review and observed the following: For Resident's 1 (R1) LIC 603 Replacement Appraisal Information, under the Social Factor section it states vegetarian and under the service needed, its check yes for special diet/observation of food intake is vegetarian, rice upsets stomach. For Resident's 1 (R1) LIC 625 Appraisal/Needs & Service Plan on page 1 of 4 it states under the background information section "Now she's on vegan diet, no rice. Rice upsets her stomach. On 07/10/2025, LPA conducted a tour of the kitchen and dining room and observed the following: Resident 1's dietary instructions and name tags are not post on the table of the dining room nor in the kitchen. 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 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 2: Facility staff are unable to communicate effectively with the residents It was alleged that the resident attempted to communicate with the kitchen staff, but they do not understand her because they only speak Spanish. On 05/12/2025 at 10:30 AM, LPA interviewed Assistant Administrator (A1), who denied the allegation, stating “Most residents here speak two to three languages. We have bilingual staff, and I also use Google Translate if needed. If there’s a barrier, we call the family or public guardian to assist.” Between 10:30 AM – 1:40 PM, LPA interviewed 9 staff regarding the allegation: 9 of 9 staff denied the allegation and stated that staff will collaboration with bilingual coworkers to overcome language barriers and or use of translation tools such google translator to communicate with the residents as needed. Between 9:48 AM – 2:37 PM, LPA interviewed 11 residents: 2 of 11 residents confirmed the allegation of which one of the residents expressed that staff ignored them, didn’t understand them, or failed to assist them when communication challenges arose. 8 of 11 residents denied the allegation stated that staff were helpful and compassionate, and communication was not an issue and 2 of 11 residents did not confirm or deny. Based on information gathered, interviews, and record reviews, there is not enough 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. No deficiencies were cited for the allegations above. An exit interview was conducted, and a copy of this report was provided to Christopher Redmond (In-Training Executive Director).

On 07/24/2025 at 8:40am Licensing Program Analyst (LPA) Zina Brown and Lizeth Villegas and conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Catherine Dacara (Assistant Administrator) and explained the purpose of today’s visit. The facility is licensed to serve four (4) ambulatory, 174 non-ambulatory, and 30 bedridden resident age 60 and above. The facility is approved to accept or retain 30 residents on hospice and may accept or retain reside who have dementia. Currently, the facility has 92 residents. The facility has a current administrator certificate (#7019164740 Exp. 8/12/25) for Melissa Flores. The facility has liability insurance with Bridgeway Insurance Company with each occurrence at $1,000,000 and general aggregate at $3,000,000 (policy #8H-A7-MM-0002272 valid 12/05/2024 - 12/05/2025) The facilities annual fees are current. The two-story commercial building consists of one hundred (100) resident bedrooms, multiple resident bathrooms,(3) common bathrooms, (4) shaded patios, (1) smoking area, dining room, commercial kitchen, staff room, office area, media room, garden area, a laundry, and multiple storage rooms. The facility has a memory care unit with delay egress doors. LPA's Brown and Villegas conducted a records review of (10) resident records, (10) staff records, and the facility disaster plan. Facility disaster plan is observed to be current and in compliance with Title 22 regulations at the time of visit. LPA Brown conducted a review of (9) Resident Medication Administration Records did observe discrepancies at the time of visit. 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 Between the hours of 9:25am - 10:05am, LPA Villegas and staff toured the physical plant. Ten (10) bedrooms were inspected, (3) of the (7) bedrooms inspected were in the memory care unit. All bedrooms were observed to have pull cords located next to the residents bed and in the bathroom. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for residents’ personal belongings is available. In the memory care unit, the resident have auditory alarms located on outside patio doors. The water temperature was tested in (10) resident bathrooms. All rooms had the required furniture. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. LPA observed the facility to have a first aid kits, manual, and emergency supplies. A comfortable temperature was maintained in the facility. LPA observed the facility to be sanitary, well maintained, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed and are accessible to residents. The commercial kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. LPA observed the kitchen area to be clean and free from pests. The facilities fire extinguishers were checked and found to be fully charged and accessible; and last serviced on 09/20/2023 . All exit doors in the facility have alarm systems. The facility has hardwired and battery-operated smoke and carbon monoxide detectors and are in working condition. A working landline telephone remains available. The last fire drill was conducted 07/13/2025. There were no bodies of water or obstructions on the premises. LPA observed the following not in compliance: On 07/24/2025, LPA observed no personnel record on file for Staff #9 and medication discrepancies. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did observe deficiencies, and citations were issued at this time. Exit interview was held and a copy of the Facility Evaluation Report with Appeal Rights were provided to Catherine Dacara (Assistant Administrator)

On 05/22/25, the department requested the following documents: staff roster, resident roster, and the shower schedule. The department conducted interviews with staff #1 - #7 (S1 – S7), residents #3 - #4 (R3 – R4), and attempted to interview residents #1 - #2 (R1 – R2). On 07/16/25, the department conducted interviews with staff #8 (S8), (R2), residents #5 - #10 (R5-R10), and attempted to interview R1. On 07/23/25, the department received the following documents: Medication Administration Records (MAR) for R1, R3, and R4, for the months of March, April, and May 2025, and the facility’s activities calendar for the month of June. Additionally, the department conducted a tour of the kitchen and dining room. The investigation revealed the following: Allegation: Staff are not providing residents with daily meals. It is being alleged that the facility is not providing a resident with their daily meals. It is also being alleged that the facility is not providing the resident with their dietary needs. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those interviewed, 8 out of 8 staff denied the allegation. 8 out of 8 staff stated that residents receive three meals a day, including snacks in between. 8 out of 8 staff said that the facility does accommodate residents with special dietary needs. S1 stated that all residents receive three meals daily, including snacks, and that meals are determined based on their dietary needs. S1 said that if a resident has a special diet, the facility follows the doctor's orders, and it’s posted in the kitchen. If the residents are still hungry, snacks and alternative menu options are always available. On 05/22/25, between 1:30 PM and 3:00 PM, the department interviewed R3-R4. On 07/16/25, the department interviewed R2, and R5-R10. The department was unable to interview R1 on both dates. Of those interviewed, 7 out of 9 residents said that staff are providing them with their daily meals. 7 out of 9 residents stated that they had no complaints about the food being served at this facility. 7 out of 9 residents said this facility is meeting their dietary needs. The Department reviewed the Menu for the months of March, April and May 2025, and observed that the residents are getting a variety of nutritious foods for breakfast, lunch, and dinner. The menu was a healthy diet that emphasizes a wide variety of foods from all food groups, including fruits, vegetables, grains, lean protein sources (like fish, beans, eggs, lean meats) and dairy and dairy alternatives. 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 07/23/25, the department conducted a tour of the kitchen and dining room and observed residents’ special dietary instructions posted on a board in the kitchen. Additionally, the department observed that residents were served lunch soup, vegetables, a turkey club sandwich, salad and chips. The department observed some residents immediately ate the food while others spent leisure time socializing along with their meals. 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 are not addressing resident bathing needs. It is being alleged that staff are not assisting a resident with bathing. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those interviewed 8 out of 8 staff denied the allegation. 8 out of 8 staff stated that staff assist residents with bathing 2-3 times a week. S1 said the caregivers are well organized, and they directly help the residents with their bathing needs. S1 said the facility has what they call “zones”, and each caregiver has their own zone. That caregiver gets to know the residents within that zone and offers to assist the residents with showers every morning. On 05/22/25, between 1:30 PM and 3:00 PM, the department interviewed R3-R4. On 07/16/25, the department interviewed R2, and R5-R10. The department was unable to interview R1 on both dates. Of those interviewed, 3 out of 9 residents said staff assist them with their bathing needs, while 6 out of 9 residents said they do not require any assistance with bathing. 7 out of 9 residents said they are satisfied with the services provided to them. The department reviewed the facility’s shower schedules for the months of March 2025 and May 2025. The department observed that residents are divided by zones 1-3, and each resident is scheduled to shower 2-3 times a week. 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. 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: Staff are restricting residents from participating in activities. It is being alleged that a resident is being restricted from engaging in activities. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those interviewed 8 out of 8 staff denied the allegation. 8 out of 8 staff said that residents are encouraged daily to participate in activities. On 05/22/25, between 1:30 PM and 3:00 PM, the department interviewed R3-R4. On 07/16/25, the department interviewed R2, and R5-R10. The department was unable to interview R1 on both dates. Of those interviewed, 9 out of 9 residents said staff do not restrict them from participating in any activities. 7 out of 9 residents said they are satisfied with the services provided to them. The Department reviewed the facility's activities calendar, which featured daily events, social activities, arts and crafts, yoga, table games, bingo, karaoke and spa days planned for residents in care. 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 are financially abusing residents. It is being alleged that staff are withdrawing money from a resident’s account without their consent. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those interviewed 8 out of 8 staff denied the allegation. On 05/22/25, between 1:30 PM and 3:00 PM, the department interviewed R3-R4. On 07/16/25, the department interviewed R2, and R5-R10. The department was unable to interview R1 on both dates. Of those interviewed, 9 out of 9 residents said staff have not financially abused them. 9 out of 9 residents said they do not know if staff are financially abusing a resident. 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. 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: Staff do not respond to residents’ call button in a timely manner. It is being alleged that staff are not responding to a residents call button. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those interviewed, 8 out of 8 staff denied the allegation. 8 out of 8 staff said that staff usually take 5 minutes to respond when a resident activates their call light. S1 stated that when a resident activates their call light or button, that call will go directly to the reception desk. The staff at the reception desk have radios, and they will radio a caregiver for assistance. S1 said they also have a paging system if needed. On 05/22/25, between 1:30 PM and 3:00 PM, the department interviewed R3-R4. On 07/16/25, the department interviewed R2, and R5-R10. The department was unable to interview R1 on both dates. Of those interviewed, 9 out of 9 residents denied the allegation. 5 out of 9 residents said staff take about 5 minutes to respond when a resident activates their call light. 7 out of 9 residents said they are satisfied with the services provided to them. 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. An exit interview was conducted, and a copy of the report was provided to Christopher Redmond, Executive Director Intern. 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 conducted interviews with staff #1 - #7 (S1 – S7), residents #3 - #4 (R3 – R4), and attempted to interview residents #1 - #2 (R1 – R2). On 07/16/25, the department conducted interviews with staff #8 (S8), (R2), residents #5 - #10 (R5-R10), and attempted to interview R1. On 07/23/25, the department received the following documents: Medication Administration Records (MAR) for R1, R3, and R4, for the months of March, April, and May 2025, and the facility’s activities calendar for the month of June. Additionally, the department conducted a tour of the kitchen and dining room. The investigation revealed the following: Allegation: Staff are not dispensing medication as prescribed. It is being alleged that the facility is not administering a resident’s medication as prescribed. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those inte