Manzanita Village at Rancho Belago.

On January 28, 2026, the Department requested and obtain the following documents via email: Resident rights training (dated 3/27/25), Incontinent care training (dated 3/6/25), Service plan, physician’s report, and pre-placement appraisals for Residents (R1-R5), Incident/death report for R3 (dated 3/25/25). On January 29, 2026, The Department conducted interviews with Assistant Administrator (A2), and 4 staff (S1-S4) The investigation revealed the following: Allegation: Facility Staff neglected the needs of residents in care. The detail of the complaint alleges R1-R5 has been neglected by staff: Dinner was allegedly withheld from R2 and served 2 hours later, decline in R3’s health and sudden death allegedly was a result of neglect. R4 reportedly was left soiled for an extended period without being changed. R5 allegedly was denied cake repeatedly when R5 asked for it. On April 2, 2025, the Department interviewed 3 residents regarding the allegation, and on April 25, 2025, 5 additional residents were interviewed. 8 out of 8 residents denied the allegation, stating that staff provide appropriate care and they have not experienced neglect. Each resident confirmed that dinner is always served on time, snacks are never withheld, and 8 out of 8 residents indicated that they have never been left soiled for an extended period. On January 29, 2026, at 11:15am the Department interviewed Assistant Administrator (A2) who denied the allegation stating that no resident is ever denied food, residents are changed regularly and/or as needed. Additionally, A2 states that all staff have had Resident Rights training, and training on caring for incontinent residents. Lastly, A2 states that R3 was on hospice care at the time of her passing so A2 denies that there was neglect related to R3’s death. Page 2 of 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On January 29,2026, between 11:30 am and 1:00pm, the Department interviewed 4 staff (S1-S4) regarding the allegation. Of those interviewed, 4 out of 4 denied the allegation stating that meals are served at the designated time, and no residents are denied food. 4 out of 4 state that residents are changed regularly and as needed therefore, no resident is left soiled for extended periods of time. On January 29, 2026, the Department observed the facility during mealtimes and can confirm that the meal was served on time at time of visit. Additionally, the Department noted that there was sufficient staff present to provide adequate care and supervision to the residents. On January 29, 2026, the Department reviewed and evaluated the following documents: Staff in-service training on caring for incontinent residents (dated 3/6/25), Resident rights training (dated 3/27/25), R1-R5’s Service plans (dated 9/30/25, 4/30/25, 1/3/25, 1/20/26, physician’s reports (dated 4/22/25, 2/5/24, 1/8/25, 6/8/25, pre-placement appraisals (dated 2/24/24, 6/7/18), Incident/death report for R3 (dated 3/25/25), and meal schedule/menu (dated 1/25-1/31/25). During review of the documents, the Department found that the facility maintains that all staff are trained in incontinent care of the residents and have received resident rights training. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today’s visit. Exit interview conducted with Executive Director, Cristina Miller and a copy of report provided.

The investigation revealed the following: Allegation: Staff did not prevent resident from entering resident's room The detail of the complaint alleges staff did not prevent another resident from entering R1’s room. During the initial and subsequent visits, interviews with Executive Director and staff was conducted on 4/16/25, 4/25/25 and 11/21/25. It was revealed that incident did not occur, as there had been no such incident reported to them. 4 out of 4 staff interviewed denied the allegation stating if a resident entered another resident's room staff would notice and/or it would be captured by hallway cameras. It was also revealed that some residents wander but they are redirected by staff. Of the 5 residents interviewed, 4 out of 5 residents stated they had no issues with anyone coming into their room, nor had they witnessed another resident going into another resident’s room. 1 out of 5 residents was unavailable for interview. On January 30, 2026, the Department reviewed and the following documents: staff roster/schedule, resident roster, staff training: Understanding Wandering and Elopement and Abuse, Neglect, and Exploitation in the Elder Care setting . During review of the documents, the Department found that the facility maintains adequate staffing to meet residents’ needs, and the staff are trained in resident behaviors including wandering behaviors. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Page 2 of 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Lack of supervision resulted in resident pushing another resident The detail of the complaint alleges that a lack of supervision resulted in R1 being pushed out of bed. During the initial and subsequent interviews with Executive Director and staff on 4/16/25, 4/25/25 and 11/21/25, it was revealed that the incident did not occur, as there had been no reports of a resident being pushed out of bed. 4 out of 4 staff interviewed during that time stated that there was no indication that R1 was pushed out of bed. Of the 5 residents interviewed, 4 out of 5 residents stated they had no not heard of a resident being pushed out of bed. 1 out of 5 residents was unavailable for interview. On January 30, 2026, the Department reviewed and the following documents: staff roster/schedule, resident roster, staff training: Understanding Wandering and Elopement and Abuse, Neglect, and Exploitation in the Elder Care setting . During review of the documents, the Department found that the facility maintains adequate staffing to meet residents’ needs, and the staff are trained in resident behaviors including wandering and other behaviors. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today’s visit. Exit interview conducted with Cristina Miller, Executive Director and copy of report provided. Page 3 of 3

The investigation revealed the following: Allegation: Facility Staff neglected the needs of residents in care. The detail of the complaint alleges R1-R5 has been neglected by staff: Dinner was allegedly withheld from R2 and served 2 hours later, decline in R3’s health and sudden death allegedly was a result of neglect. R4 reportedly was left soiled for an extended period without being changed. R5 allegedly was denied cake repeatedly when R5 asked for it. On January 29, 2026, at 11:15am the Department interviewed Assistant Administrator (A2) who denied the allegation stating that no resident is ever denied food, residents are changed regularly and/or as needed. Additionally, A2 states that all staff have had Resident Rights training, and training on caring for incontinent residents. Lastly, A2 states that R3 was on hospice care at the time of her passing so A2 denies that there was neglect related to R3’s death. On January 29,2026, between 11:30 am and 1:00pm, the Department interviewed 4 staff (S1-S4) regarding the allegation. Of those interviewed, 4 out of 4 denied the allegation stating that meals are served at the designated time and no residents are denied food. 4 out of 4 state that residents are changed regularly and as needed therefore, no resident is left soiled for extended periods of time. On January 29, 2025, the Department observed the facility during mealtime and can confirm that the meal was served on time at time of visit. Additionally, the Department noted that there was sufficient staff present to provide adequate care and supervision to the residents. Page 2 of 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On January 29, 2025, the Department reviewed and evaluated the following documents: Staff in-service training on caring for incontinent residents (dated 3/6/25), Resident rights training (dated 3/27/25), R1-R5’s Service plans (dated 9/30/25, 4/30/25, 1/3/25, 1/20/26, physician’s reports (dated 4/22/25, 2/5/24, 1/8/25, 6/8/25, pre-placement appraisals (dated 2/24/24, 6/7/18), Incident/death report for R3 (dated 3/25/25), and meal schedule/menu (dated 1/25-1/31). During review of the documents, the Department found that the facility maintains that all staff are trained in incontinent care of the residents and have received resident rights training. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today’s visit. Exit interview conducted with Executive Director, Cristina Miller and a copy of report provided. Page 3 of 3

On January 05, 2026, Licensing Program Analyst (LPA) Venus Mixson arrived unannounced to look into a matter that was brought to the attention of Community Licensing. On December 22, 2025, the Regional office received information that a husband and wife had a physical altercation. LPA observed there were enough staff present to assist with the care and supervision of resident in care. There were working utilities, the facility was clean and free of clutter and debrief. LPA saw the required postings throughout the facility, and the maintenance and housekeeper teams were present and attending to their duties at the time of this visit. Facility was found to have the required amount of food and a variety of food types available. LPA Mixson saw caregivers assisting resident who required assistance with walkers, caregivers were observed walking by the residents side and offering assistance as needed. LPA's todays unannounced visit the LPA observed the facility was clean and free of debris and unpleasant odors. LPA was able to see and hear how the facility staff attended to the other residents in care due to the resident in question no longer residing at the facility. There were sufficient staff to attend to the care and supervision of the residents in care. The Med-techs were busy making their rounds, and assisting with the resident's medication management. An exit interview was conducted and a copy of this report discussed and provided to the Administrator, Brooke Huerta.

On December 30, 2025, LPAs Venus Mixson and Yolanda Delgado arrived unannounced to complete the previously started annual visit and met with the Administrator Anne Martinez. Additionally, LPAs conducted a case management visit to approve the facility capacity increase. LPAs conducted a tour of the facility and requested and received a copy of the most current LIC 9020. Client/ Resident roster. There were no observable health and safety concerns observed at the time of this visit. LPAs conducted a review of the six of the residents files and completed the annual visit. There were issues observed at the time of this visit. No further information was obtained at this time.

On December 22, 2025, LPAs Venus Mixson and Mia Lankford arrived at the facility unannounced in order to continue the Required Annual Inspection and met with the Licensee, Brooke Huerta. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for 125 Elderly Adults and is currently operating at a capacity of 123 for a RCFE facility type (740). The LPAs conducted a review of the facility staff files following is a summary of the file reviews. The LPAs requested and received 10 percent of the facility staff files and 10 percent of the facility resident files. The LPAs utilized the "Inspection Tool" Care-Tools to review the files and reviewed and documented the following items. 1st: FIRST AID CERTIFICATE FPCL/EXMP: FINGERPRINT CLEARANCES/EXEMPTIONS ED: EDUCATION VERIFICATION LIC198: CHILD ABUSE INDEX LIC501: PERSONNEL RECORD OR JOB APPLICATION LIC503: HEALTH SCREENING LIC508: CRIMINAL RECORD STATEMENT LIC9052: EMPLOYEE RIGHTS MTV: MEDICAL TRAINING VERIFICATION TB: TB TEST There were no visible deficiencies observed or cited during today's visit. An exit interview was conducted, and a copy of this report was discussed and provided to the Administrator, Brooke Huerta. 1st: FIRST AID CERTIFICATE FPCL/EXMP: FINGERPRINT CLEARANCES/EXEMPTIONS ED: EDUCATION VERIFICATION LIC198: CHILD ABUSE INDEX LIC501: PERSONNEL RECORD OR JOB APPLICATION LIC503: HEALTH SCREENING LIC508: CRIMINAL RECORD STATEMENT LIC9052: EMPLOYEE RIGHTS MTV: MEDICAL TRAINING VERIFICATION TB: TB TEST

Additionally, staff stated that they followed R1’s plan to reduce falls, but R1 did not call for assistance. Additional information received from interviews indicated that staff did remain with R1 until first responders arrived. Information obtained from an interview with R1 described that they attempted to get out of bed without notifying staff that they need assistance. R1 corroborated that they refused medical care as they were not experiencing pain. R1 stated they have not experienced staff delaying assistance for unreasonable amounts of time. R1 indicated there are no concerns with how the facility staff attend to their daily needs or supervision. Information obtained from interviews with additional residents indicated they feel safe while at the facility and have no concerns about how staff attend to their daily needs. Information obtained from interviews with Additional Witness indicated R1 had an unwitnessed fall and that R1 refused to be transported for further medical evaluation. On several unannounced visits, LPA observed R1 attempting to get up out of their wheelchair, prior to calling staff for assistance. A review of the records, including the facility’s policy and procedure regarding reporting, corroborated the information obtained. An additional review of the records, including R1’s needs and service plan, confirmed R1 is a fall risk and R1 is to call for assistance prior to transferring from their wheelchair. Based on information obtained from interviews, record reviews, and observations, the evidence received pertaining to the allegation that staff are not properly supervising a resident who is a fall risk has been deemed unsubstantiated. An unsubstantiated allegation means 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. An exit interview was conducted. A copy of this report was discussed and given to the Administrator, Brooke Huerta.

The investigation revealed the following: Allegation: Staff are not able to meet the needs of residents in care due to staff shortage. The detail of complaint alleges that on 5/5/24, only one staff member assisting all 20 residents. On December 16, 2025, at 1:30pm, the Department interviewed Brooke Abrego-Huerta (A1) who denied the allegation stating that the facility is not understaffed now and was not understaffed in May of 2024 as complaint indicated. A1 further stated that there is enough staff to meet the residents’ needs. On December 16, 2025, between 2:00pm and 3:30pm, the Department interviewed 5 staff (S1-S5) regarding the allegation. Of those interviewed, 5 out of 5 denied the allegation stating the facility has enough staff to meet the needs of the residents and has never been understaffed since they have been there. On December 16, 2025, at time of visit, the Department made observation during tour of the facility and observed adequate staff. On December 16, 2025, between 3:30pm and 4:30pm the Department interviewed 4 Residents (R1-R4). Of those interviewed, 4 out of 4 stated that they are treated well and stated that there is adequate staffing to meet their needs. Page 2 of 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On December 16, 2025, the Department reviewed and evaluated the following documents: Staff schedule (dated: December 2025, May 2024), client roster (dated 12/16/25) Riverside county food handler’s certificates for staff with the following expiration dates: 12/3/27, 11/18/27, 11/26/27, 11/6/27), Facility Menu (dated 12/14-12/20). During review of the documents the Department found that the facility maintains adequate staffing. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today’s visit. Exit interview conducted with Administrator and copy of report provided. Page 3 of 3

On December 11, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Licensee, Brooke Huerta. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for 125 Elderly Adults and is currently operating at a capacity of 123 for a RCFE facility type (740). LPA Mixson toured the facility along with the Licensee, Brooke Huerta and made observations pertaining to the annual visit. LPA inspected the facility inside and outside there were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. Additionally, there were no bodies of water on the premises. The facility is comprised of three buildings and is gated. Physical Plant: The facility phone number is (951) 379-0100 and it is operable. LPA Mixson observed a sampling of the residents’ living units, and each was furnished with required fixtures as per Title 22. Units observed included (8, 22, 27, and 109). LPA Mixson inspected a sample of the facility restrooms, and the hot water temperature tested within regulations on those restrooms sampled. The bathrooms were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something,” the "Personal Rights," and the LTCO poster. The cleaning supplies and sharp items were locked and inaccessible to the residents in care presently. There were designated storage spaces for the residents’ and staff’s files, and this office was locked and inaccessible to residents in care at the time of this annual visit. Medications : The medications were locked and inaccessible to residents in care. The nurses’ station was locked the medication records were maintained and there was a sufficient supply of medication for each resident. There were no documented errors observed on the centrally stored medication forms that were reviewed at the time of the annual visit. Additionally, the medications were stored in their original containers during this visit. The facility has several Med-techs and nurses available currently and a number of caregivers are present. Additionally, LPA observed the housekeeping team and the maintenance team arrived shortly after. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Food Service& furniture: The kitchen was clean and free or clutter and unsightly debris. The non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for the residents at this time. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. The overall facility is clean; the furniture is in good condition and arranged in a manner which provides space for the residents to move safely. The facility cooling system and other appliances were operable at present. The Licensee informed the LPA there were safety lights for night throughout the facility. Care & Supervision / Administration: There are adequate staff present for the care and supervision of the resident in care. The floor plans, telephone numbers and personal rights were found posted in the facility. The listed Administrator possesses a current administrator’s certificate. Records Reviewed and Resident/Staff Files: LPA reviewed staff files and reviewed the facility's staff schedule. The staff files reviewed have criminal clearance, updated training, along with current First Aid certification. Resident files reviewed possessed the required paperwork as per Regulations at the present. Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill met the Department standards and was conducted as required per standards. Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found required infection control measures met the Department requirements. An exit interview was conducted. A copy of this report was reviewed and given to the Licensee, Brooke Huerta.

On November 24, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a Health and Safety case management visit, and met with the Administrator, Brook Huerta. LPA Mixson toured the facility, along with the Administrator, Brook Huerta, and made observations. There were sufficient staff present to attend to the care and supervision of residents at the time of this case management visit. Residents were occupied with noon meal, medication management, and afternoon activities. There were no imminent health and/or safety concerns observed at present. LPA Mixson did not observe any obstructions or debris inside or outside of the facility. LPA observed the facility utilities to be operating without issue. LPA assessed the availability of food and observed there was a variety of food types available for the residents in care. Food supply meets the requirement of a two-day supply of perishable foods and a seven-day supply of non-perishable food items. Medications were found to be in sufficient supply, locked, and inaccessible to residents in care. Housekeeping team was present and making their rounds. Facility is clean, neatly organized, and has a supply of activities available for the residents in care. Activities Coordinator was present and facilitating scheduled activities. No unattended residents were observed currently. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and/or welfare of the residents in care. There were no visible deficiencies observed or cited during today's visit. An exit interview was conducted, and a copy of this report was provided to Administrator, Brook Huerta.

Allegation #2: The Resident's billing statement does not clearly state charges. The complaint alleged that the financial statements provided to the residents' responsible party were inaccurate. On October 27, 2025, from approximately 10:00 AM to 12:30 PM, LPA Richard interviewed the Assistant Executive Director (AED). The AED denied the allegations and explained that when the administration increased a resident's care level, the facility was required to conduct a new pre-appraisal to assess the resident's care needs. The AED also noted that the issue with the R1 billing statement was related to the previous administration and that the facility had corrected the problem. Additionally, the AED pointed out that the facility's admission agreement stated that rates would increase annually and that the responsible party would be notified in writing of any increase two months prior. During the same time period, LPA interviewed four staff members (S1-S4), all of whom denied the allegations. Later on, on October 27, 2025, from approximately 1:30 PM to 2:30 PM, LPA interviewed five residents (R2-R6). Three out of the five residents denied the allegations, stating that their representative would receive a letter regarding the matter. On October 23, 2025, LPA interviewed R1's responsible party, who confirmed that, following the new administration's takeover, they had refunded all charges. LPA's review of the R1 billing statement, dated January 31, 2023, indicated that the responsible party received a credit for the discrepancy. Unfortunately, LPA was unable to interview R1, as R1 passed away in December 2023. Report Continued on LIC9099C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated . Allegation #3: Staff are not providing services as agreed upon in the resident’s admission agreement. The complaint alleged that the resident relied on the services of a beauty shop on the premises, which was listed as a service in the admission agreement. The new administration terminated the beauty shop's services. On 10/27/2025, between approximately 10:00 AM and 12:30 PM, the LPA Richard interviewed the AED, who denied the allegations and stated that the facility has a beautician who comes every Wednesday to provide beauty services to residents. Furthermore, the LPA interviewed four staff members (S1-S4), who denied the allegation and said that the facility has a beautician who visits to assist residents with haircuts, nails, Shampoo, and other needs. On 10/27/2025, between approximately 1:30 PM and 2:30 PM, the LPA interviewed five residents. All five residents (R2-R6) denied the allegations and stated that a beautician visits them and helps them with their beauty needs. They also felt it was a good idea for the beauticians to come to their rooms to meet their needs. On 10/27/2025, the LPA reviewed the beautician's schedule, including services provided to residents upon request, and documented the dates and times of these services since 2024. Unfortunately, LPA was unable to interview R1, as R1 passed away in December 2023. Report Continued on LIC9099C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on the LPA observations, interviews, and record reviews, the Preponderance of evidence standard has not been met. 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 deficiency cited. An exit interview was conducted. A copy of the report was provided to the Assistant Executive Director Anna Martinez.

Allegation #1: Facility has insufficient staff to meet residents’ needs. The complaint alleged that residents are paying a significant amount of money, but their needs are not being met. On 10/27/2025, from approximately 10:00 AM to 12:30 PM, LPA Richard interviewed the AED, who denied the allegations and stated that we have enough staff to care for and meet the residents' needs. The AED also noted that the facility has staff on call in case of an emergency. LPA interviewed the (MT), who disagreed and said that the facility has more than enough staff to meet the residents' needs. At the same time, LPA interviewed (DSM), who denied the allegation and stated that we offer various dining services for breakfast, lunch, and dinner to serve residents. LPA also interviewed two staff members (S1 and S2), who denied the allegation and stated that the facility has on-call staff who can help if they are short-staffed. On 10/27/2025, from approximately 1:30 PM to 2:30 PM, LPA interviewed five residents (R1-R5). All five denied the allegation and said the facility served their food on time and met their needs. The caregivers are excellent at caring for them. During the same period, LPA's review of the facility personnel roster showed four on-call caregivers and two on-call Med Techs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated . Report Continued on LIC9099C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation #2: Staff failed to provide adequate food service. The complaint alleged that the facility doesn’t serve snacks to the residents in memory care. On 10/27/2025, between approximately 10:00 AM and 12:30 PM, LPA Richard interviewed the AED, who denied the allegations and stated that the facility serves three meals a day and provides snacks between breakfast, lunch, and dinner. At the same time, the LPA also interviewed the (MT), who denied the allegation. Additionally, the LPA interviewed with the (DSM), who denied the allegation and explained that they provide a great weekly menu and an options menu in case a resident does not like what is on the regular menu that day. They also offer snacks between meals for all residents. Furthermore, the LPA interviewed two staff members (S1-S2), who denied the allegation and stated that the residents have many food options. On 10/27/2025, between approximately 1:30 PM and 2:30 PM, the LPA interviewed five residents. All five residents denied the allegation and stated that the facility provides them with adequate food and snacks between meals. They also said that if they don’t like what food they are served, they can order something else. Report continued on LIC9099C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On 10/27/2025, LPA reviewed the facility's weekly menu, and the optional menu (dated Oct 26th - Nov 1st, 2025) showed a variety of food choices for the residents. LPA Richard observed the facility serving lunch at 12:00 pm; the residents had a large portion of food with side dishes, fruit, salad, dessert, and different types of beverages. Based on the LPA observations, interviews, and record reviews, the Preponderance of evidence standard has not been met. 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 deficiency cited. An exit interview was conducted. A copy of the report was provided to the Assistant Executive Director Anna Martinez.

LPA’s review of the records, including R1’s centrally stored medication record, medication record at the time of discharge, and discontinued medications list, verified the information provided through interviews. LPA’s review of the records confirmed there was no documentation recording that R1 missed their medication. LPA conducted a subsequent interview with additional witness and they advised that they were unaware that the medication was provided in single doses and is now confident that R1 did not miss any medication. Additional witness indicated there were no further concerns or issues. Although LPA was unable to speak with R1 to obtain additional information, there is sufficient evidence to provide that the allegation did not occur. Based on information obtained from interviews, record reviews, observations, the evidence received pertaining to the allegation, facility did not administer medication as prescribed, the allegation is unfounded. A finding of unfounded indicates that the allegation is false, could not have happened, or is without a reasonable basis. The agency has dismissed the complaint. An exit interview was conducted. A copy of this report was discussed and given to the Licensee, Brooke Huerta.

The change of face technique is a non-confrontational behavior intervention used when a resident becomes agitated during an interaction with a particular staff. The approach involves substituting the current staff with a different staff member, often leading to a reset in the residents emotional state. Through interviews, it was alleged that while showering R1, R1 took a step backwards, lost their balance, fell, and struck their head on the wall. The facility staff attempted to catch R1 prior to the fall but their attempt was unsuccessful. The facility’s protocol does not allow staff to move the residents after an injury as it may harm the residents. The ambulance was immediately called, however, a valid signed, Do Not Resuscitate (DNR) was located in R1’s file. Through observations, the facility’s bathrooms complied with Title 22, regulation 87303, as s howers were equipped with non-skid mats and grab bars. In addition, information obtained through interviews revealed that the facility’s protocol after any client falls, the service plan will be updated based on any specific need. This is to prevent any further falls and address safety measures. Residents will also participate in a re-evaluation provided by a medical professional after so many fall incidents. No reassessment was completed due to R1 passing. Furthermore, the facility complied with all protocols pertaining to R1’s needs and service plan, such as conducting checks on R1 and assisting R1 with their medications. Staffs training records were current, Staff implemented de-escalation techniques pertaining to R1’s agitated state at the time of the incident. According to the autopsy received by the Coroner’s Office, the reported cause of death was accidental and due to blunt force trauma. Based on observations, interviews and records reviewed, the allegation of staff was negligent in resident's death is unsubstantiated. A finding that is unsubstantiated means although the allegation may have happened and/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 at this time. An exit interview was conducted where a copy of this report was reviewed and provided to Assistant Director, Anna Martinez.

On May 20, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a Health and Safety case management visit, and met with the Administrator, Brook Huerta. LPA made introductions and stated the purpose of the visit. LPA Mixson toured the facility, along with the Administrator, Brook Huerta and made observations. There were sufficient staff present to attend to the care and supervision of residents at the time of this case management visit. Residents were occupied with noon meal, medication management, and afternoon activities. There were no imminent health and/or safety concerns observed presently. LPA Mixson did not observe any obstructions or debris inside or outside of the facility. LPA observed the facility utilities to be operating without issue. LPA assessed the availability of food and observed there was a variety of food types available for the residents in care. Food supply meets the requirement of a two-day supply of perishable foods and a seven-day supply of non-perishable food items. Medications were found to be in sufficient supply, locked, and inaccessible to residents in care. Housekeeping team was present and making their rounds. Facility is clean, neatly organized, and has a supply of activities available for the residents in care. Activities Coordinator was present and facilitating scheduled activities. No unattended residents were observed currently. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and/or welfare of the residents in care. There were no visible deficiencies observed or cited during today's visit. An exit interview was conducted, and a copy of this report was provided to Administrator, Brook Huerta.

Licensing Program Analyst (LPA), Stephanie Martinez, conducted a continuation of an unannounced required annual inspection at the facility. The LPA met with Executive Director (ED), Brooke Abrego-Huerta, and informed her of the purpose for the visit. Physical Plant / Environmental Safety: The LPA conducted a tour of the facility, accompanied by the facility maintenance director, Sammy Ortiz. The LPA observed the alarm system in all three (3) buildings to show, "system normal". Two (2) carbon monoxide devices were inspected in the two hundred and four hundred halls and observed to be operable. The LPA inspected three (3) bedrooms in both memory care buildings and four bedrooms in the assisted living building. The LPA observed a chair(s) to be missing in room 8 and 27, and 109; a night stand to be missing in room 27; and a drawer to be missing from the chest of drawers in room 22. These violations were addressed at the time of the LPA's visit. Therefore, an advisory notice will be issued. Bedrooms had sufficient lighting for resident needs. Resident bathrooms were observed to have grab bars available and slip resistant material present in the showers. The toilet, handwashing, and bathing facilities were all in working condition. The hot water temperature was tested and observed to be within regulatory requirements. The call system was tested and observed to be in working order. The LPA inspected and observed sufficient space for storage of supplies and equipment. Storage areas were observed to be appropriately secured for the safety of the residents in care. There are no pools or other bodies of water located at the facility. According to ED, Abrego-Huerta, there are no known firearms being stored at the facility. The facility does have a working telephone available for resident use. Staffing: Staff have current First Aid/CPR training on file. Separate staffing is available to perform independent tasks for the operation of the facility. According to ED, Abrego-Huerta, all personnel working in the facility are at least 18 years of age. Emergency training is provided to staff members who work the night shift. ED, Abrego-Huerta, is present at the facility during normal working hours and a manager has been observed to be responsible for the operation of the facility when the ED is temporarily absent. 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 Planned Activities: The facility does have activities for residents in care, which include socialization, group discussion, crafts, games, other recreation activities, and outings. The facility does have a staff member who has full responsibility to organize, conduct, and evaluate planned activities. There is sufficient space for activities at the facility. Food Service: The LPA inspected the facility's kitchen areas in all three (3) buildings and the food supply. The LPA observed all food to be of good quality. All readily perishable foods and beverages capable of supporting rapid and progressive growth of micro-organisms were stored in covered containers at appropriate temperatures. Soaps, detergents, cleaning compounds and similar substances were stored in areas separate from food supplies. All kitchen areas were kept clean and free of litter, rodents, vermin, and insects. Modified diets appear to be provided to residents in care as special diet needs were observed to be posted in the kitchen. There appeared to be at least 7 days worth of non-perishable food items and 2 days worth of perishable food items. Incidental Medical and Dental: The facility is arranging, or assisting in the arrangement of medical and dental care for residents. Staff are assisting residents with the administration of medication. Medication rooms were inspected in all three (3) buildings. Centrally stored medications were observed to be organized and inaccessible to unauthorized individuals. Medications were observed to be appropriately labeled. Centrally stored medication and destruction records were observed on file. Resident Records- Incidental Reports: The facility does maintain a continuing record of any illnesses, injury, or medical or dental care, when it impacts the resident's ability to function or the services needed. Resident records showed pre-admission appraisals, admission agreements, and medical assessments on file. Admission agreements appeared to meet regulatory requirements. Medical assessments appeared to have all the required medical information. The facility does conduct re-appraisals on residents, and updates are made to resident's written record of care. The facility currently has an approved hospice waiver for twenty (20) residents. There are currently ten (10) residents receiving hospice services. Residents with Special Health Needs : Resident hospice records were observed to have the required records. No smoking - Oxygen in use, signs were observed to be posted throughout the facility. Staff training in oxygen administration was observed to be completed. The facility does have secured perimeters available for residents diagnosed with dementia that wonder. No deficiencies were cited at the time of the visit. This report was reviewed with Executive Director, Brooke Abrego Huerta, and a copy was provided.

Licensing Program Analyst (LPA), Stephanie Martinez, conducted a required annual inspection at the facility. The LPA was allowed entrance into the facility and met with Executive Director (ED), Brooke Abrego-Huerta, and informed her of the purpose for the visit. The inspection included the following: Infection Control Plan: The facility has an Infection Control Plan in place. The plan does not appear to be reviewed annually, as documentation shows it was last reviewed on 05/04/2022. According to the ED, the facility is following the policies listed in the plan whenever there are infectious outbreaks within the facility. Operational Requirements: The facility does have a Plan of Operation available at the facility, which includes a Dementia Plan of Care and Bedridden Plan of Care. Proof of liability insurance was observed on file and expires on 06/01/2025. Personnel Records-Training: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Training on dementia care, postural supports, restricted health conditions, hospice and medication administration was observed on file; though incomplete. Postural support training, which is a required 4 hours, was not completed for four (4) care staff members. An advisory notice will be issued. Resident Rights-Information: The facility has internet accessible devices available for resident use. The LPA did not observe the complaint poster (PUB 475), non-discrimination notice, Personal Rights (87468.1) or Personal Rights of Residents in All Facilities (87468.2) to be posted. An advisory notice will be issued. Disaster Preparedness: The facility does have an emergency and disaster plan in place, which included contact information for appropriate agencies. Proof of staff training on emergency procedures was observed on file. Proof of emergency drills were observed on file; a Fire Drill was completed with staff and residents on 01/17/25. Due to insufficient time a follow up visit will have to be conducted to complete the inspection. This report was reviewed with ED Abrego-Huerta and a copy was provided.

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit at the facility to follow up on alleged thefts involving residents in care. The LPA met with Memory Care Director, Anna Martinez, and informed her of the purpose for the visit. Several reports were received by the Department, from the facility, regarding thefts of resident's property and valuables. One alleged theft involved Resident One (R1), who had a withdrawal of funds from their bank account in the amount of $1,000.00. According to a Report of Suspected Dependent Adult/Elder Abuse, R2's family member called the facility to report the resident loaned a staff member $100.00; however, after a review of bank records it was later found the check, dated 09/27/2024, was in the amount of $1,000.00. It was further alleged in the report that, R1 reported they deliberately placed $200 in a chest in their bedroom in front of the same staff member and later found the money was gone. According to the report, the staff member involved was Staff One (S1). A second report of alleged theft involved Resident Two (R2), whose bank card went missing and numerous unauthorized transactions totaling up to $8,000 being discovered. According to a Report of Suspected Dependent Adult/Elder Abuse, one purchase was made on 10/11/2024 at a beauty supply business. The business confirmed the identity of the individual who made the transaction, later identified as S1. According to a Notice to Employee as to Change in Relationship report, S1 was laid off/discharged on 10/14/2024. LPA made attempts at reaching S1 to obtain the staff member's statement; however, the attempts were unsuccessful. As of this date, R1 and R2 were not available for an interview. According to one staff interview, the incidences have been reported to law enforcement. Incident report numbers were obtained from the facility. The staff interview also revealed, as of two (2) weeks ago, that staff names have been assigned to their key fobs in order to show who last entered a resident's bedroom. It was further reported that staff, residents, and family members were notified in writing, that gifts and/or loans are not to be given to staff members of the facility. Additional time is required, prior to the closure of the investigation, in order to obtain further information. This report was reviewed with the Memory Care Director and a copy was provided. (NOTE: LPA was off the premises from 12:00 PM - 12:30 PM. Administrator, Brooke Abrego-Huerta, was unavailable for the LPA's visit.)

Licensing Program Analyst (LPA) Yolanda Delgado conducted an unannounced Case Management Death Report visit. LPA was greeted by Brooke Abrego-Huerta, Executive Director. LPA explained the purpose of the visit. The visit is in response to the death of Resident #1 (R1), that was reported on 09/09/2024 to have died of unknown cause on 09/07/2024. During LPA's visit, LPA reviewed R1's file and obtained copies of the following: ID/emergency Information, admission agreement, Physician's report, Appraisal/Needs and Services Plan, physician's orders, POLST, Medication list, three (3) statements and email notifications to CCLD. LPA also requested a copy of R1s death certificate when it is made available, and staff schedule for 9/6/2024 and 9/7/2024. During today's visit no deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to Brooke Abrego-Huerta along with a copy of the LIC811.

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to follow up on two incident reports received from the facility relating to alleged theft. The Department received two reports relating to the theft of personal items belonging to Resident One (R1). During the visit the LPA reviewed and collected relevant records. Additional time is required, prior to the conclusion of the investigation, in order to obtain further information. This report was reviewed with the Executive Director and a copy provided.

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to continue the required annual inspection which was started on 03/08/2024. The LPA was allowed entrance into the facility and met with Administrator, Brooke Abrego Huerta. Abrego Huerta was notified of the purpose for the visit. The facility currently has an approved Hospice Waiver for twenty (20) residents. The inspection included the following: Physical Plant: A tour of the facility's interior and exterior areas was completed; resident bedrooms were clean, had the required furniture and had sufficient lighting. There are no bodies of water located on the property. According to Administrator, Abrego Huerta, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet and shower used by residents. Bathroom faucets, showers, and toilets were observed to be in working order. Resident showers have non-skid material present. The LPA inspected the fire alarm panel and observed the system to show "normal". According to facility staff, the carbon monoxide and smoke detectors are combined on one device. The LPA observed a sprinkler system to be available in the bedrooms where bedridden residents were residing. The facility was observed to be clean and free of odors. Food Service: There is a minimum of 2 days of perishable foods and 1 week's supply of non-perishable foods available. The facility kitchen was toured and observed to be clean. Supplies were observed to be available. No presence of insects or rodents was observed in the kitchen areas. Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Dementia care training, Restricted Health Conditions training, and Hospice training was observed to be available and complete. Staff training records revealed the facility has also provided staff with additional training, such as personal rights training. The LPA was informed by Administrator Abrego Huerta that there are currently thirteen (13) residents in care who are receiving hospice 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 services. Hospice Care Plans were observed on file at the facility. There is a disaster and mass casualty plan in place. Proof of emergency drills were observed on file. All services requiring specialized skill are being performed by residents or personnel qualified as appropriately skilled professionals. The facility was observed to not be operating beyond the conditions specified on the license. Medication Review: The LPA reviewed resident medications. Medications were observed to have the required prescriptions on file. The facility's medication room was inspected and found to be clean and inaccessible to unauthorized individuals. An exit interview was conducted with Administrator Abrego Huerta; this report was reviewed, and a copy was provided. No citations were issued during this visit.

Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility to conduct a required annual inspection. The LPA met with Administrator, Brooke Abrego Huerta, and informed her of the purpose for the visit. Staff Interviews: Interviews were conducted with facility care staff. Staff displayed sufficient knowledge and awareness in providing appropriate care and supervision to residents. Emergency Disaster Plan: The Emergency Disaster Plan was reviewed. The plan was observed to require updates, as the plan indicates an emergency generator is available for use; however, according to one staff interview the facility has no generator on the premises. According to the Maintenance Director, contact information is available for a company who can provide an emergency generator. According to Administrator Huerta, the plan was last reviewed January 2024. Due to insufficient time a return visit will be conducted in order to complete the inspection. This report was reviewed with Administrator, Brooke Abrego Huerta, and a copy was provided.