Atria Hacienda.

(Continued from page 1) Additional allegation stated staff did not properly assess Resident prior to admission; facility may have accepted R1 without fully assessing whether they had staffing, training and resources to manage common behavior systems. LPA reviewed R1’s face sheet, LIC602 dated 1/30/26, progress notes with intermittent dates from February 10, 2026 to March 2, 2026, admission packet, preplacement appraisal dated 1/27/26, slum exam dated 1/27/26. Prior facility order summary report dated 1/29/26 and resident roster. LPA was unable to interview R1 due to R1 moving out of the facility on March 2, 2026. A review of progress notes revealed that R1 was non-compliance with prescribed medications, facility contacted R1’s doctor regarding the behavioral changes in which R1’s doctor requested labs to be done and several attempts were made by the doctor and doctor’s staff coming to the facility to attempt to complete the lab request in which R1 refused to take a urine test to rule out signs and symptoms of an UTI and through interviews with staff it was revealed that R1 refused to take a urine test, a review of R1’s file did not corroborate that R1 received an eviction notice at anytime of R1’s stay at the facility and through interviews with Administrator and Witness it was revealed that R1 was not issued and did not received an eviction notice, R1’s Power of Attorney’s were updated on R1’s change of condition-aggressive behavior towards staff and clients. Interviews with staff did not corroborate that no proper assessment was done on R1 prior to admission and a review of R1’s preplacement appraisal dated 1/27/2026 revealed that an appraisal was completed with an exam for cognitive abilities and a functional capability completed on 1/27/2026 with R1. Based on LPAs observations, records review, and staff interview, this agency has investigated the complaint alleging resident sustained a UTI due to staff neglect, staff wrongfully evicted residents and staff did not properly assess resident prior to admissions and we have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Monique Moreira and a copy of this report along with LIC811 was provided. *LPA’s were away from the facility from 12:45-2:00 PM

On 09/25/25 Licensing Program Analyst (LPA) Javina George made an unannounced 1 year required visit. LPA met with Nathan Boese, Assistant Executive Director and informed of the purpose of the visit. The facility is licensed to serve. The facility has an approved hospice waiver for (16) residents with (9) currently receiving services. There are (61) residents receiving home health services and (3) residents that are self administering oxygen. A file review was conducted prior to making today's visit. The facility annual fees have been paid, and the governing body was observed to be in good standing. Below are the observations made during today's visit. The facility was observed to be clean and the passageways being free of any obstructions. The facility was observed to have the required postings. The fire extinguishers were fully charged and last serviced on 03/12/25. The emergency disaster drills are being conducted on a monthly basis, with the last drill being conducted on 09/19/25. The smoke and carbon monoxide detectors were observed to be operable and were being serviced during LPAs visit. The pull cords were randomly tested and found to be operable. The pool was observed to be secured. There are no known guns or ammunition on the premises. The hot water tested and found to be within regulatory limits. The medications and medication carts were locked inside the medication room. The facility is using and electronic MAR system. The sharps and chemicals were observed to be locked and inaccessible to residents in care. A file review of both staff and resident files were conducted. All staff interviewed and files reviewed were observed to have obtained criminal record clearance and to be associated to the facility. The Resident Medical Assistant staff were observed to possess valid CPR certification. The administrator Monique Moreira was observed to have valid certification that expires on 02/19/26. 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 resident files reviewed and are indicated on the LIC-811, confidential names list revealed that one (1) of the residents residing in memory care had not received an annual medical assessment. However the request was submitted on more than one occasion with the last time being on 07/19/25. All other documentation such as admissions agreements and appraisals were present. Additionally LPA verified contact information on file, and will update accordingly. A copy of the facility's liability insurance was obtained for the facility file at the regional office. Based on today's inspection the facility was inspected in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). No citations were issued An exit interview was conducted where a copy of this report, 809C, appeal rights were reviewed and provided to Nathan Boese, Assistant Executive Director.

Investigation Revealed the Following: Allegation: Resident was sexually assaulted while in care. The details of the complaint alleged that (R#1) was sexually assaulted by (R#2) while living at the facility. On August 3, 2025, at approximately 8:30 am, during the records review, the department observed the Riverside County Sheriff’s Department Report # T232650034 dated:9/22/23. The department noticed that the deputy assigned to investigate (R#1)’s alleged sexual assault by (R#2). After interviewing (R#1), the deputy stated that there were no signs of forceful interaction and that it was more likely consensual between (R#1) and (R#2). In addition, the department reviewed the copy of (R#1)’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A dated:12/14/22, the department observed that it was written on (R#1)’s assessment that they have a mild cognitive impairment, they are not confused or disoriented, are able to follow instructions, and able to communicate their needs. Moreover, the department reviewed the copy of (R#1)’s Preplacement Appraisal Information or LIC 603 dated:2/23/23, and the department observed that it was written that (R#1) ’s mental condition was alert, oriented, and did not need special supervision due to confusion or forgetfulness. Additionally, the department reviewed the copy of Staff Roster or LIC 500 dated: September 2023, the department observed that the day of (R#1)’s incident 9/22/23 at approximately 9:00 am, there were (5) caregivers in the memory care unit, the department noticed there were enough facility staff to provided care and supervision to (R#1 and R#2) and the rest of the residents. On October 6, 2023, the department interviewed the Assistant Executive Director (A#1). She stated that the incident between (R#1) and (R#2) was reported to her by (S#1). Additionally, (A#1) stated that she was told by (S#1) that (R#1) was not in distress after the incident happened. The day before the incident, (S#1) observed (R#1) and (R#2) “happy” and holding hands. Moreover, (A#1) stated that it was observed through the facility’s video surveillance cameras in the hallway (R#1) and (R#2) showing signs of affection to each other. In addition, (A#1) mentioned that the police department was called, but they found no issues after their investigation. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On October 6, 2023, the department interviewed facility staff 1 (S#1); they stated that the day of the incident between (R#1) and (R#2), increased supervision was in place for (R#1) and (R#2). Also, (S#1) stated that when the police came to investigate the incident, they determined that the incident between (R#1) and (R#2) was consensual. On October 6, 2023, the department interviewed facility staff member 2 (S#2). They reported that they consistently observed residents 1 (R#1) and 2 (R#2) sitting together at mealtimes and holding hands. (S#2) also stated that they have never witnessed (R#2) forcibly grab (R#1) to kiss them. Additionally, (S#2) mentioned that when (R#2) approaches (R#1) to kiss their cheek, (R#1) leans forward, and there is no indication of any force involved. On October 6, 2023, the department interviewed Witness 1 (W#1), who stated that they were present on the day of the incident involving (R#1) and (R#2). Additionally, (W#1) also mentioned that the day before the incident, they observed (R#1) and (R#2) sitting on a couch having a conversation. On October 6, 2023, the department interviewed resident 1 (R#1); they stated that they don’t know who R#2 is, nor can they remember their name. Also, (R#1) stated that they have not been out with any male, and they don’t have any male friends. On October 6, 2023, the department interviewed resident 2 (R#2); they stated that when they see R#1, they always greet them. (R#2) said that they don’t know (R#1)’s name or room number. Additionally, (R#2) stated that both themselves and (R#1) were only kissing and hugging, and no intimate interaction happened. Moreover, (R#2) indicated that they did not force anyone to be intimate with them. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 During this investigation, LPA did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Teresa Ramirez/Community Business Director.

Investigation Revealed the Following: Allegation: Staff are financially abusing resident. The details of the complaint alleged that facility staff is taking (R#1)’s money. On August 2, 2025, at approximately 9:00 a.m., during the records review, LPA Iniguez observed (R#1)’s Physicians Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602 dated: 9/1/24, it is mark that (R#1) has a cognitive impairment that may affect their decision making and judgment. In addition, LPA Iniguez reviewed (R#1)’s Durable Power of Attorney for Management of Property and Personal Affairs dated: 11/5/21. LPA Iniguez observed that (W#1) is the appointed agent for all (R#1)’s personal properties and financial decisions. Moreover, LPA Iniguez reviewed (R#1)’s (R#1)’s Residency Agreement dated: 9/1/2024, LPA Iniguez observed that the agreement has a Theft and Loss policy in place that follows the Health and Safety Code sec. 1569.13, this clause was reviewed and signed by (W#1) decision agent for (R#1). On August 2, 2025, at approximately 10:00 AM, during an Interview with the Administrative Assistant (A#1), she stated that the facility has a Theft and Loss policy in place and is also found on the residents’ agreements. In addition, (A#1) stated that she does not think the facility staff was financially abusing (R#1) or any other resident in care. On August 2, 2025, at approximately 8:30 AM, during a telephone conversation with (W#1), LPA Iniguez asked them if they have ever witnessed or known that facility staff are financially abusing (R#1) or taking their personal belongings, (W#1) responded, "No, I have never observed any staff doing that to (R#1). I visit them every other day unannounced, so I would notice right away if something like that was happening." Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On August 2, 2025, at approximately 8:30 AM, during a telephone conversation with (W#1), LPA Iniguez asked them if they have ever witnessed or known that facility staff are financially abusing (R#1) or taking their personal belongings, (W#1) responded, "No, I have never observed any staff doing that to (R#1). I visit them every other day unannounced, so I would notice right away if something like that was happening." On 8/2/25, at approximately 10:00 AM, Licensing Program Analyst-LPA Alfonso Iniguez was not able to spoke with (R#1) since they are no longer living at the facility. On August 2, 2025, at approximately 11:00 AM, during interviews with residents (R#2-R#9), (9) out of (10) stated that the facility staff had never taken any of their personal belongings. On August 2, 2025, at approximately 1:00 PM, during interviews with facility staff (S#1-S#5), (5) out of (5) stated that they had never taken (R#1) 's or any other resident in care's personal belongings. During this investigation, LPA did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Claudia Herrera/ Administrative Assistant. 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 8/2/25, at approximately 10:00 AM, Licensing Program Analyst-LPA Alfonso Iniguez was not able to spoke with (R#1) since they are no longer living at the facility. On August 2, 2025, at approximately 11:00 AM, during interviews with residents (R#2-R#9), (6) out of (10) stated that their family manages their finances, and (2) out of (10) stated that they manage their finances. Additionally, (9) out of (10) stated that the facility staff have never financially abused them. On August 2, 2025, at approximately 1:00 PM, during interviews with facility staff (S#1-S#5), (5) out of (5) stated that they treat all the residents with dignity and respect. Also, (5) out of (5) facility staff stated that they have not financially abused (R#1) or any other resident in care. Allegation: Staff do not safeguard resident's personal belongings. The details of the complaint alleged that facility staff is taking (R#1)’s personal property. On August 2, 2025, at approximately 9:00 a.m., during the records review, LPA Iniguez observed (R#1)’s Physicians Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602 dated: 9/1/24, it is mark that (R#1) has a cognitive impairment that may affect their decision making and judgment. In addition, LPA Iniguez reviewed (R#1)’s Durable Power of Attorney for Management of Property and Personal Affairs dated: 11/5/21. LPA Iniguez observed that (W#1) is the appointed agent for all (R#1)’s personal properties and financial decisions. Moreover, LPA Iniguez reviewed (R#1)’s (R#1)’s Residency Agreement dated: 9/1/2024, LPA Iniguez observed that the agreement has a Theft and Loss policy in place that follows the Health and Safety Code sec. 1569.13, this clause was reviewed and signed by (W#1) decision agent for (R#1). On August 2, 2025, at approximately 10:00 AM, during an Interview with the Administrative Assistant (A#1), she stated that the facility has a Theft and Loss policy in place and is also found on the residents' agreements. In addition, (A#1) stated that she does not think the facility staff was taking (R#1) or any other resident's personal belongings. Evaluation Report continues LIC 9099-C

Investigation Revealed the Following: Allegation: Resident sustained unexplained bruises while in care. The details of the complaint alleged that (PR#1) sustained unexplained bruises. On 7/13/25, at approximately 8:00 AM, during the records review, the department observed a copy of the Riverside County Sheriff's Department Incident Report dated:12/23/2023. In the report, it is written that a deputy was dispatched to an elder abuse call at the facility. The deputy spoke with (PR#1), who stated that they did not recall how they sustained their injury. Additionally, (PR#1) immediately stated that nobody did that to them, "it could have done it to myself while I was asleep, I do not recall how the injury occurred". On 1/19/24, during an interview with resident 1 (PR#1), they stated that they did not know how the injury might have happened; they assumed that while they were asleep, one of their hand rings might have been the cause. Additionally, (PR#1) stated that neither the facility staff nor the agency caregivers had assaulted them, (PR#1) said "I would have known if those things had happened to me". On 2/9/24, during an interview with witness 1 (PW#1), they stated that (PR#1) never called them to inform them that someone at the facility had assaulted them. Additionally, the department asked (PW#1) if they believed (PR#1) was in any danger residing at the facility, (PW#1) stated “no”. Also, the department asked (PW#1) if they felt anyone at the facility physically assaulted (PR#1), causing their injury; (PW#1) stated they did not. On 2/14/24, during an interview with witness 2 (PW#2), they stated that they saw (PR#1)’s injury and asked them what happened. (PR#1) stated that they did not know what happened. Also, (PR#1) stated that they did not fall, nor did anyone assault them. Additionally, (PW#2) stated that they believe (PR#1) was “very smart”; they feel that (PR#1) would remember if something happened to them. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On 3/6/24, during an interview with witness 3 (PW#3), they stated that (PR#1) explained to them that they just woke up that morning, and they had a mark under their eye. (PW#3) stated that they asked (PR#1) if anyone had struck them; they said no one had struck them. Also, (PW#3) asked (PR#1) if they felt, and they said no. Additionally, (PW#3) stated that they suspected (PR#1) quite possibly rolled over onto something in their sleep, or invertedly hit their face on something in the middle of the night. On 1/19/24, during an interview with Assistant Executive Director (PA#1), they stated that the facility staff informed them about (PR#1)’s injury, and they had observed their injury. Additionally, (PA#1) stated that they asked (PR#1) what happened, and they just replied that they had a little injury and did not know how they sustained it. On 1/19/24 and 3/13/24, during interviews with staff members 1 and 2 (PS#1 and PS#2), they reported noticing (PR#1)’s injury and inquired about the incident. (PR#1) stated that they could not recall what had happened. During this investigation, LPA did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Theresa Ramirez/Business Office Director.

The department conducted interviews with staff #1-#5 (S1-S5) and residents #3-#10 (R3-R10) and was unable to interview R1-R2. Furthermore, the department and Nathan Boese toured the facility and inspected rooms A202, A212, A124, A129, B101, B201 and common areas. The investigations revealed the following: Allegation: Staff are not ensuring residents’ showering needs are being met. It is being alleged that staff are not assisting residents with their bathing needs. On 07/12/25, between 11:00 AM and 12:00 PM the department interviewed S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. 5 out of 5 staff interviewed stated that residents are assisted with their showering needs based on their care plan. S1 stated that showers are in accordance with their care plan, and that on average most residents have shower/bathing assistance 1-2 times per week. On 07/12/25 between 01:30 PM and 02:35 PM, the department interviewed R3-R10. Of those interviewed, 7 out of 8 residents stated they do not require assistance with showering, and 1 out of 8 residents said their showering needs are being met. 8 out of 8 residents stated that they don’t know if any residents have gone weeks without showering. 8 out of 8 residents said they are satisfied with the services provided to them. Based on observation, interviews conducted, and records reviewed, there is not sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff are not providing adequate housekeeping services to residents. It is being alleged that resident’s room was observed to be filthy. On 07/12/25, between 11:00 AM and 12:00 PM, the department interviewed S1-S5. Of those interviewed, 5 out of 5 staff said staff is providing adequate housekeeping services to residents. 5 out of 5 staff said resident’s rooms are cleaned once a week, and as needed. 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 On 07/12/25 between 01:30 PM and 02:35 PM, the department interviewed R1-R10. Of those interviewed, 8 out of 8 residents stated that their room is cleaned once a week. 8 out of 8 residents stated that they are satisfied with the services provided to them. On 07/12/25, the department and Nathan Boese toured the facility and inspected rooms A202, A212, A124, A129, B101, B201 and other common areas. The department observed the rooms and the facility to be clean and in sanitary condition. Based on observation, interviews conducted, and records reviewed, there is not sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. The department did not observe any deficiencies during this visit, therefore no citations were issued. An exit interview was conducted with Nathan Boese, and a copy of this report is provided.

and between 1pm and 3:30pm LPA conducted interviews with staff #2-9 (S2-S9). On 06/29/25 LPA conducted a review of R1’s and S1’s file. The investigation revealed the following: Allegation: Facility staff member functional forged residents’ signature. It is being alleged that facility staff forged residents’ signature for the facility to bill for a higher level of care. On 06/28/25 from 8:45 am- 12pm LPA conducted Interviews with R#2-11 regarding the allegation above, 10 of 10 residents denied the allegation above and reported feeling safe and comfortable when assisted by facility staff. On 06/28/25 between 1pm and 3:30pm LPA conducted interviews with S#2-9 regarding the allegation above, 8 of 8 staff interviewed denied the allegation above. On 06/28/25 LPA unable to interview S1 as S1 is no longer employed at Atria Hacienda. On 06/28/25 LPA unable to interview R1 as R1 passed away while receiving care outside of Atria Hacienda. On 06/27/25 LPA conducted telephone interview with Witness #1 (W1) regarding the allegation above, Per W1 an assessment was conducted on R1 on 11/30/22, the assessment resulted in a change from level 1 care to level 6 care which is a difference of $4500 in care charges. W1 continued to report that the signature on the assessment agreeing to the additional care fees is not R1’s signature. On 06/29/25 LPA conducted a review of R1’s file, LPA observed 7 service plan assessment conducted on 5/25/23, 4/15/23, 2/25/23, 1/25/23, 11/29/22, 11/1/22,10/16/2022. Per assessment conducted on 11/29/22, R1 level of care was a 3, LPA did not observe any signatures on the assessment document. Per assessment dated 11/29/22 it is indicated facility staff would coordinate with resident and family to assure that services are in place to maintain safety for resident while in care. Additionally, during file review LPA did not observe any documentation indicating that R1 had a conservator nor power of attorney. Per R1’s file R1 was self responsible. On 06/29/25 LPA conducted a review of S1’s file, LPA did not observe any corrective action documentation linked to the allegation above. 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. Exit interview conducted, and a copy of this report was provided.

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff are not assisting resident with their care needs. It is alleged that staff are not assisting Resident #1 (R1) with care needs. (R1) is visually impaired and struggles with making appointments and follow-ups for outpatient treatments. (R1) needs assistance but cannot afford this service. No further information is available on this matter. A review of Resident #1's (R1) Residency Agreement (dated 01/18/23) shows that (R1) was admitted to Atria Hacienda on February 04, 2023. Additionally, an examination of the Identification and Emergency Information document (dated 05/02/23) reveals that a power of attorney is designated to manage financial matters, care payments, and legal affairs on behalf of (R1). On November 06, 2023, between 09:45 AM and 11:58 AM, the Department interviewed a resident member identified as Resident #1 (R1). (R1) expressed concerns about challenges in making outpatient treatment appointments. (R1) mentioned that long call waits, scheduling issues, and staff shortages necessitated leaving messages. (R1) noted that a part-time private care staff member provides additional assistance with this task. On June 21, 2025, between 11:45 AM and 12:15 PM, the Department conducted a supplemental interview with Resident #1 (R1). (R1) expressed that the staff is attentive and responsive and treats (R1) well. (R1) mentioned that (R1)'s Care Plan designates a Care Level 1, which includes escort services due to (R1)'s visual impairment. (R1) confirmed having a private care staff member who comes once a week for four hours to assist with tasks involving reading emails, shopping online, and scheduling appointments with health professionals. (R1) stated that (R1) prefers to remain independent and will make medical appointments with the primary care providers. (R1) can complete this duty using a Braille calendar. (R1) stated that although (R1) prefers to schedule appointments with health providers, the facility care staff will assist with this task if (R1) needs assistance. On June 21, 2025, between 10:20 AM and 01:29 PM, the Department interviewed resident members identified as Resident #2 through Resident #10 (R2-R10). (R2-R10) resident members claimed to have no concerns or issues with their care needs. (Evaluation Report continues LIC 9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Seven (7) out of the nine (9) residents member claimed to handle their own health appointments. (R2-R10) stated that facility care staff could assist if needed with this task. On November 06, 2023, and June 21, 2025, between 09:45 AM to 4:59 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members could not corroborate this claim. (S1-S5) reported that (R1) is independent and did not need help with medical appointments, only requiring minimal assistance like escort services. (S1) stated that the care staff was unaware of (R1)’s situation and would have gladly assisted if they had known as they understood (R1)’s limitations. On June 22, 2025, between 8:00 AM to 8:18 AM, the Department interviewed witness member identified as (R1)’s power of attorney as Witness #1 (W1). (W1) asserted that (R1) is independent, noting that (R1) is visually impaired, however can independently schedule health appointments. (W1) expressed confidence that the facility care staff provided adequate care and supervision with no concerns. As a result of record reviews of (R1)’s Physician’s Report LIC 624A (dated 01/23/23), Preplacement Appraisal LIC 603 (dated 01/29/23), Resident Functional Needs Service Plan (dated 02/04/23) verified that (R1) requires only escort services and is self-care independently. (R1) did not need special medical attention or incidental health and medical care assistance. A further review of facility Personnel Report LIC 500 (dated 11/06/23 and 06/13/25) revealed no shortage of care staff for AM, PM, and NOC shifts to assist with resident’s care needs. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated . An exit interview conducted with Resident Service Director Stephanie Roldan and copies of the report provided.

The witness informed LPA R1 resides at a skill nursing facility. This agency has investigated the complaint alleging the above allegations. Based on record review and interviews conducted all allegations are unfounded. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.

Investigation Revealed the Following: Allegation: Resident is being held at the facility against their will. The details of the complaint alleged that (R#1) was held against their will at the facility. On April 27, 2025, at approximately 8:30 AM, during a records review, LPA Iniguez observed a copy of (R#1)'s Durable Power of Attorney, which was dated and sealed on June 6, 2014. The document listed (W#1) as the decision-maker for (R#1). Additionally, LPA Iniguez reviewed (R#1)’s Identification and Emergency Information form or LIC 601, dated February 28, 2023. This form identified (W#1) as the person responsible for (R#1)'s financial affairs, payment for care, and as (R#1)'s legal guardian. Furthermore, LPA Iniguez noted that (R#1)’s facility face sheet, printed on April 22, 2025, indicated that (R#1) has a Durable Power of Attorney on file, with (W#1) listed as the responsible party. LPA Iniguez also reviewed (R#1)’s Admissions Agreement, which was dated February 28, 2023, and noted that (W#1) signed this document on behalf of (R#1). On April 26, 2025, at approximately 8:30 AM, during an interview with the Administrator (A#1), she stated that when (R#1) moved into the facility, they had a Durable Power of Attorney designating (W#1) as their decision-maker. Additionally, (A#1) mentioned that (R#1) was not admitted under false pretenses and was not held against their will while residing at the facility. On April 24, 2025, at approximately 3:00 PM, Licensing Program Analyst-LPA Alfonso Iniguez could not speak with (R#1) due to their cognitive impairment. On April 26, 2025, at approximately 10:00 AM, during interviews with residents (R#2-R#8), (7) out of (7) stated that they are not being held against their will and feel safe living here at the facility. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On April 26, 2025, at approximately 9:00 AM, during interviews with facility staff (S#1-S#4), (4) out of (4) stated that that when (R#1) moved into the facility, they had a Durable Power of Attorney designating (W#1) as their decision-maker. Additionally, (4) out of (4) facility staff mentioned that (R#1) was not admitted under false pretenses and was not held against their will while residing at the facility. On April 24, 2025, at approximately 8:30 AM, Licensing Program Analyst Alfonso Iniguez spoke via telephone with (W#1), who resides out of state. LPA Iniguez introduced himself and explained that he was calling to ask questions regarding the complaint allegation related to (R#1). He inquired whether (R#1) had been placed at the facility against their will. (W#1) responded, “No, they were not” confirming that (R#1) was not placed at the facility against their will or under false pretenses. (W#1) explained that the decision to place (R#1) in the facility was made because they were unable to meet (R#1)'s medical needs. Furthermore, (W#1) indicated that they held Durable Power of Attorney for both healthcare and financial decisions for (R#1). During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Stephanie Roldan/Resident Services Director.

Investigation Revealed the Following: Allegation: Staff are overcharging a resident for services not received. The details of the complaint alleged that facility staff is overhanging (R#1 and R#2) for services not received. On April 26, 2025, at approximately 2:00 PM, during a records review, LPA Iniguez observed that the admissions agreements for (R#1 and R#2), dated: September 21, 2022, included a clause under "Optional Services" stating, "We may also provide you with other Optional Services, if you request them, as described in Attachment F." This attachment outlines the optional services and associated fees. Additionally, LPA Iniguez noted that both (R#1 and R#2) had signed their admissions agreements on September 21, 2022. The LPA also reviewed the Physicians Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A, dated September 19, 2022. It indicated that the primary diagnosis for (R#1 and R#2) was not a factor influencing their decision-making. Furthermore, the report marked that they were neither confused nor disoriented, could follow instructions, and were able to communicate their needs. On April 26, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), she stated that (R#1 and R#2) signed their own admissions agreement upon entering the facility back on September 21, 2022. Also, (A#1) stated that the facility never overcharged (R#1 and R#2) for services not provided by the facility when they were living in here. On April 26, 2025, at approximately 10:00 AM, LPA Iniguez contacted former residents (R#1 and R#2) via telephone for the third time. They did not answer the call, so LPA Iniguez left a voice message. On April 26, 2025, at approximately 10:00 AM, during interviews with residents (R#3-R#9), (7) out of (7) stated that they had not been overcharged by the facility for services not provided to them. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On April 26, 2025, at approximately 9:30 AM, during interviews with facility staff (S#1-S#4), (4) out of (4) stated that (R#1 and R#2) were not overcharged by the facility for services they did not receive. Allegation: Staff did not prevent the residents from wandering. The details of the complaint alleged that (R#1 and R#2) wandered out of the facility alone in the middle of the night. On April 26, 2025, at approximately 2:00 PM, LPA Iniguez conducted a records review and examined the Physicians Report for Residential Care Facilities for the Elderly (RCFE), known as LIC 602A, dated September 19, 2022. The report indicated that Residents #1 (R#1) and #2 (R#2) were neither confused nor disoriented, could follow instructions, and could communicate their needs. Additionally, it was noted that both residents were able to leave the facility unassisted. During the review, LPA Iniguez also looked at (R#1)’s Unusual Incident Report, which was dated June 18, 2024. The report stated that (R#1) was observed by facility staff outside the community at approximately 6:00 AM searching for (R#2). Staff promptly redirected (R#1) back inside, and an incident report was created with the appropriate parties notified. Moreover, LPA Iniguez reviewed facility staff training materials regarding elopement of residents, lates staff training was conducted on 4/14/25. On April 26, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), she stated that neither (R#1 or R#2) wandered out by themselves in the middle of the night. Just the one incident when (R#1) was observed in front of the community looking for (R#2) at approximately 6:00 AM. Staff promptly re-directed them inside and documented this event on an LIC 624. On April 26, 2025, at approximately 10:00 AM, LPA Iniguez contacted former residents (R#1 and R#2) via telephone for the third time. They did not answer the call, so LPA Iniguez left a voice message. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On April 26, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#7), (7) out of (7) stated that they feel the facility staff will handle an elopement of a resident in care. On April 26, 2025, at approximately 9:30 AM, during interviews with facility staff (S#1-S#4), (4) out of (4) stated that (R#1) did not wander out of the facility in the middle of the night, both stated that (R#1) was observed one time in front of the community but was promptly re-directed by facility staff. Allegation: Staff did not keep the facility free from scabies. The details of the complaint alleged that (R#1 and R#2) contracted scabies while at the facility. On April 26, 2025, at approximately 02:00 PM, during the records review, LPA Iniguez reviewed (R#1) and (R#2) entire files, LPA Iniguez did not observe medical records regarding (R#1 and R#2) had contracted scabies during their stay at the facility. In addition, LPA Iniguez observed the facility's infection control plan dated September 2021; it is stated that the facility has a plan in case of an infectious disease or outbreak. On April 26, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), she stated that (R#1 and R#2) did not contract scabies while they resided at the facility. On April 26, 2025, at approximately 10:00 AM, LPA Iniguez contacted former residents (R#1 and R#2) via telephone for the third time. They did not answer the call, so LPA Iniguez left a voice message. On April 26, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#7), (7) out of (7) stated that they had never contracted scabies at the facility. On April 26, 2025, at approximately 9:30 AM, during interviews with facility staff (S#1-S#4), (4) out of (4) stated that (R#1 and R#2) never contracted scabies while they resided at the facility. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff unlawfully evicted the residents. The detail of the complaint alleges that facility staff gave an illegal eviction to (R#1 and R#2). On April 26, 2025, at approximately 2:00 PM, LPA Iniguez reviewed the records for (R#1 and R#2). During the review, LPA Iniguez found no eviction notices served to either (R#1 or R#2). Additionally, LPA Iniguez examined the Admissions Agreement contracts for both (R#1 and R#2), which were dated September 21, 2022. It was explained that a 30-day or 3-day notice may be issued if any written reasons outlined in the agreement apply to (R#1 or R#2). On April 26, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), she stated that the facility never gave an illegal eviction notice to (R#1 or R#2). On April 26, 2025, at approximately 10:00 AM, LPA Iniguez contacted former residents (R#1 and R#2) via telephone for the third time. They did not answer the call, so LPA Iniguez left a voice message. On April 26, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#7), (7) out of (7) stated that they had never received an illegal eviction notice from the facility. On April 26, 2025, at approximately 9:30 AM, during interviews with facility staff (S#1-S#4), (4) out of (4) stated that (R#1 and R#2) did not receive an illegal eviction notice from the facility. During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s). Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Nathan Boese/Assistant Executive Director.

(Continued from LIC9099-A Page) R1 revealed they had paid the remaining balance on their account. LPA conducted (2) staff interviews which revealed R1 was given an eviction notice and served an Unlawful Detainer, which was dismissed due to R1 paying their remaining balance. (2) staff interviews revealed the facility is not currently pursuing an eviction with R1. This agency has investigated the complaint alleging “Illegal eviction” of R1. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of 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 (Continued from LIC9099 page) LPA conducted (4) staff interviews. LPA conducted an interview with S1 who denied the allegations made, stating they did not threaten to lock R1 out of their unit or threaten R1 to sell their belongings and stating that they were accompanied by another staff member every time they spoke with R1. (2) of (4) staff interviewed had no knowledge of S1 threatening R1, while (1) of (4) staff revealed they accompanied S1 when they spoke to R1 and did not witness S1 threaten R1. Therefore, the allegation that R1 was threatened by staff is unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.

On 9/16/24 Licensing Program Analyst's (LPAs) Valerie Flores and Abdoulaye Zerbo conducted an unannounced one (1) year required visit. LPA's were greeted by the Executive Director, Monique Moreria, who was informed of the purpose of visit. All staff present were observed to have obtained proper fingerprint clearance and were associated to the facility. LPA's observed the following during today's visit: LPA's conducted a tour of the facility with Executive Director, Monique. The physical plant is a two-story structure that contains a total of 168 residents. While conducting the tour, LPA's observed all indoor and outdoor passageways were free of obstruction. The facility pool was gated and equipped with a self-latching door. The facility has more than a two (2) day supply of perishable foods and seven (7) day supply of non-perishable foods. Dishes and utensils were in sufficient supply and in good repair. Knives and sharp items are located in the locked kitchen areas making it inaccessible to the residents in care. There was a sufficient supply of emergency food and water to meet all resident needs. Water temperature measured at 113.5-degree Fahrenheit meeting within the required limits. Resident bedrooms had the required bedding, furniture, and lighting. LPA's observed charged fire extinguishers mounted throughout the facility. LPA's observed an outdoor courtyard with a shaded seating area and sufficient space to allow outdoor activities. The facility is maintained at 77 degrees-Fahrenheit for the resident’s comfort. There is a posted activity plan for the whole month of September to encourage resident interaction. The facility has a designated computer room that maintain computers connected to internet easily accessible to the residents in care. LPA reviewed the facility's infection control plan which met department requirements. There are several centrally stored medication rooms located throughout the facility. A sufficient amount of PPE was observed in the locked medication room. (Continuation on LIC809C...) 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 Staff files reviewed have a criminal record clearance/ exemptions, valid first aid/CPR certification, health screenings, TB results, employee rights, and required trainings. Resident files included but are not limited to signed admission agreements, pre-appraisals, appraisals, physicians reports, TB tests, and personal rights. Facility sketch, personal rights, LTCO and emergency disaster plan is posted on a wall near the theater. According to Administrator, Monique, there are no firearms or ammunition on the premises. During today's visit, LPA's did not observe any immediate violations or concerns. An exit interview was conducted, and a copy of this report was reviewed and provided to the Administrator.

Administrator Moreira added R1 and R2’s family were kindly asked to step outside. Administrator Moreira reported law enforcement was called and issued Trespass Arrest Authorizations for three (3) of R1 and R2’s family members, including R1 and R2’s responsible person. LPA contacted law enforcement and verified the three (3) Trespass Arrest Authorizations are valid. LPA made several attempts to contact the reporting party and did not receive a response. R1 and R2 have since been relocated and were unable to be located for an interview. LPA interviewed one (1) resident who was identified as a possible witness. The resident corroborated witnessing R1 and R2’s family yelling profanities and behaving hostile towards Administrator Moreira and others around them. The resident reported they also asked R1 and R2's family to step outside to calm down and was yelled at by them. Based on the aforementioned, this agency has investigated the complaint alleging, “Staff are denying authorized representative access to the facility”. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided Administrator Moreira.

On 10/06/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20231003091855 and to check on the health, safety, and welfare of residents in care. LPA met with Assistant Executive Director, April Princesa and explained the purpose of the visit. During the visit, LPA toured the facility and observed no health and/or safety hazards . LPA interviewed staff and residents, reviewed resident #2 (R2) file and collected copied of pertinent documents. No deficiencies were cited during the visit. An exit interview was conducted, and a copy of this report was provided to April Princesa.

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that one-hundred fifty-nine (159) residents live at this facility. There are ninety-six (96) staff members present. The Assistant Executive Director, April Princesa conducted the tour and the Senior Executive Director, Robert Stansbury completed the facility tour. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Five (5) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration : LPA reviewed employee records. Five (5) record were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. (Continued on LIC809C) 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 (Continuation from LIC809) Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for sharps in the kitchen. Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 78 degrees for the resident’s comfort. Lighting is sufficient for safety. Water temperature measured at 108.0 degrees F. Laundry is done in the designated laundry room. The housekeeper supplies the detergent and cleaning supplies. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There is not a fireplace at this facility. There is a pool at the facility that is surrounded by a 5-foot gate and lock. Each resident has a key to unlock and access the pool. The facility had their last annual fire inspection by the Desert Fire Inspection on 03/14/2023. LPA reviewed the facility’s last disaster drills, which met the department's requirements. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. (Continued on LIC809C) 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 (Continuation from LIC809) Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked pushcart allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed if they were dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The fire extinguishers throughout the facility were last serviced and tagged on March 14, 2023. Pursuant to the Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to the Senior Executive Director, Robert Stansbury.

(CONTINUED FROM LIC9099 PAGE 1) Facility staff reviewed the assessments on each date mentioned with R1 however R1 did not sign the assessments at the discretion of the POA (for medical only) advice. R1’s inability to self-manage personal needs and resident expectations which must be followed to reside at the facility. Facility documentation reviewed and interviews revealed R1 and R2 is aware of the changes in Level of Care that R1 needs. This agency has investigated the complaint alleging "unlawful eviction". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided along with LIC 811- Confidential Names list.