Lytton Gardens Community Care

On 2/4/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to follow up on a Decision and Order(exclusion) of S1. LPA Calandra was greeted by Anahi McKane, Manager of Assisted Living/Administrator and explained the purpose of the visit. According to the Administrator, S1 has never worked at the facility and is not associated on Guardian. No deficiencies cited during today's visit. An exit interview was conducted and a copy of this report provided.

On 1/30/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to follow up on a Decision and Order(exclusion) of S1. LPA Calandra was greeted by Anahi McKane, Manager of Assisted Living/Administrator and explained the purpose of the visit. According to the Administrator, S1 has never worked at the facility. During the visit, the Administrator spoke to Human Resources who stated they would disassociate S1 from the facility on Guardian. LPA requested copies of the current LIC 500-Personnel Summary Report and current staff schedule. No deficiencies cited during today's visit. An exit interview was conducted and a copy of this report provided.

On December 29, 2025, Licensing Program Analyst (LPA) Murial Han conducted a case management - other visit to confirm staff # 1 (S1) is not working at the facility. LPA met with the administrator and explained the purpose of today's visit. During today's visit, LPA toured the facility with the administrator who confirmed that S1 does not work at the facility. Based on the facility's monthly master work calendar for August, Septometer, October, November and December of 2025 and the LIC 500 (Personnel Report), LPA observed S1 was not on the schedule. No deficiency is cited today. This report is reviewed and discussed with the administrator. A copy is provided.

LPA interviewed S1 and S2 and they stated that they have observed an odor in R1's room because R1 preferred to pile up a lot of soiled pull-ups in the trash can before allowing them to empty it and they were only allowed to change R1's beddings when R1 asked them to do so. They stated that R1 managed his/her own care and R1 wanted to do everything independently. LPA interviewed R1 who stated that for the most part, staff members are courteous and they are providing the care and services that R1 needs. After the investigation, this allegation is deemed to be unsubstantiated. Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

On August 18, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. LPA met with the Manager, Anahi McKane, and disclosed the purpose of the inspection. The facility consisted of one building with two floors for assisted living units. The Manager informed the LPA that the facility had 41 residents in care at the time. LPA initiated a walk-through of the facility, accompanied by the manager. LPA inspected randomly selected five (5) resident rooms. The rooms were found to be clean, well-lit, and equipped with the required furniture. LPA inspected the private bathrooms in random rooms. The bathrooms contained soap, grab bars, towels, a trash can, and non-slip flooring. The hot water temperature at the sink faucets measured between 112.8°F and 116.6°F. LPA inspected the main food serving area and dining area and found it clean. All meals at the facility are prepared in a third party kitchen, Morrison Living, which is located next to the facility. The meals are brought from Morrison Living kitchen to the facility and are served in the dining area at the facility. The refrigerator was observed to contain milk, creamers, juices, yogurt, bread, and butter. The freezer was observed to contain ice cream. Cereal boxes and fresh fruits were observed on a table in the serving area. A weekly dining menu and an alternate fixed menu was available to residents. LPA inspected the fire extinguishers mounted on the hallway walls and found them fully charged, with the last service tag dated January 30, 2025. Continued on LIC809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The smoke detectors are tested quarterly by a third-party vendor, CodeRed Communications Inc., with the last service completed on 07/11/2025. The fire sprinklers testing is performed quarterly by Nor-Cal fire protection Inc., with the last service completed on 08/14/2025. The manager tested the carbon monoxide detector in the main hallway in LPA’s presence, and it was found to be functional. LPA inspected an auditorium on the first floor and observed 6 residents participating in workout activities. The auditorium and souyer room on the second room are used for resident activities. Activity calendar was posted one month is advance for the residents. All common areas were free from obstructions, and hallways were well-lit. LPA toured the outside courtyard and patio areas and found passageways in good condition, free of obstructions, and without any blocking or tripping hazards. These areas had patio tables, chairs, and shaded area/umbrellas for residents’ use. No accessible bodies of water or hazards were observed. LPA observed and inspected a locked centrally stored medication cart in the medication room. Medications were organized separately for each resident. Narcotics were locked. All medication bottles and bubble packs were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete. LPA reviewed six (6) staff personnel records and five (5) resident records. The LPA observed that 5 of 5 residents had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. 5 of 5 residents didn't not receive routine annual medical assessment. LPA observed that 6 of 6 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 6 of 6 staff members were associated with the facility. LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted quarterly, with the most recent drill completed on 05/15/2025. The following updated forms are requested to be submitted to CCLD by 08/25/2025: 1) LIC 500: Personnel Report 2) LIC 308: Designation of Facility Responsibility Continued on LIC809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 3) Certificate of Liability Insurance 4) Administrator Certificate(s) No deficiencies were cited during today's visit. An Advisory note was given. An exit interview was conducted with the Manager. A copy of this report was provided to the Manager,Anahi McKane, whose signature on this form confirms receipt of the report.

LPA interviewed (3) residents (R1-R3). R1 stated they had not had any complaints about the quality, temperature, or hygiene of the food served at the facility, and if the food had not been warm, they had asked the staff to microwave it. R1 stated they had been given plenty of meal preferences, their requests had been met, and they had no complaints. R1 stated that the dining staff had worn gloves. R2 stated that the quality of the food had been fair but could have been better; sometimes the soup had been too hot, and the creamers and milk had not been spoiled. R2 stated that dining servers had worn gloves. R3 stated that the quality of the food had been alright and that they could customize options available from an alternate menu. R3 stated they had picked up food and brought it to their room, had warmed food in the microwave if necessary, and had never received any spoiled food. R3 stated they were not sure if staff had worn gloves in the dining area, as they had not eaten in the dining area. LPA interviewed (3) staff members (S1-S3). S1 stated they had passed around the food, had not touched the food, had always worn gloves, and had thrown the gloves in the trash bin. S1 stated the food temperature had been checked by the server in the kitchen before it was put on the table in the kitchen, and they had served coffee as well. No resident had complained to them about the food quality, and they had checked the milk expiration date. S1 stated they had been placed at the facility by an agency and that they had held a CNA license. S2 stated they had been a caregiver, had helped in the dining area, had always worn gloves, and had thrown the gloves in the garbage. S2 stated the server from the kitchen had always checked the temperature and had put it on the counter when the food was hot and in a little cooler when the food was cold. S2 stated they had not made or handled food but had just served the food, and they had verified what residents had ordered before giving it to them. They had never heard from any resident about spoiled food. S3 stated the residents had been given a weekly menu and an alternative options menu, and the residents had received what they had ordered. If residents had changed their minds, they had tried to accommodate. S3 stated that they had used a third-party vendor to prepare food for the residents and that the server responsible for food quality and temperature checks had come from the vendor only. They had never had issues with the quality or the temperature of the food. S3 stated the staff had stored their food in the staff refrigerator and not in the resident-use refrigerator. LPA reviewed S4's certification and in-service records. S4 had a ServSafe California certificate that had been issued on 12/27/2024 and was valid for three years, a Food Safety and Quality Assurance in-service training dated 9/19/2024, a Food Handling and Temperature in-service training dated 10/7/2024, an Associate Food Safety in-service training dated 10/16/2024, a Hand Washing in-service training dated 10/31/2024, and a Hand Hygiene in-service training dated 11/22/2024. Continued on 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 12/19/2024, LPA observed the dining area during lunchtime service, where the server (S4) had been standing behind the counter, putting food on the counter for the staff to serve. Two staff members (S1 and S2) were observed serving the food. S1 and S2 had been wearing gloves while serving food to the residents at the dining tables in the dining area. Residents were observed eating and enjoying their lunch. LPA observed a standing refrigerator in the dining area that contained milk and juices for the residents. LPA also observed and a freezer in the dining area that contained ice creams for the residents. Regarding the allegation “Staff have not addressed roaches in the facility”, the Reporting Party (RP) stated, “have roaches (they know about it and have pasted pictures regarding that too)”. LPA interviewed (3) residents (R1-R3). R1 stated they had not seen roaches too often and that bugs had been present when it was hot. R2 stated that a roach had been found in their closet the previous week, pest control had come and taken care of it, and they had not seen any roaches afterward. R3 stated that German roaches had started about seven months earlier, and a new pest control company had been hired by the facility. R3 further stated they had not seen a single roach in the last 10 days and that the facility had finally solved the problem. LPA interviewed (3) staff members (S1-S3). S1 stated they did not remember seeing any roaches. S2 stated they had roaches before, but not currently, as the company had come and sprayed. S3 stated the pest control company had been coming every two weeks, had last come on 12/11/2024, and had put traps on the floors. LPA reviewed pest control reports for the past two months. The Ecolab Pest Eliminator invoice number 6995717, for a service date of 12/11/2024, with the Service Program of Cockroach/Rodent Program and Outside-In Large Fly Program, indicated the following Conditions Found/Action Taken: “No rodent activity was noted during the inspection and/or service, no ant activity was noted during the inspection and/or service, and cockroaches were noted in one apartment.” For invoice number 6790324, for a service date of 11/14/2024, with the Service Program of Cockroach/Rodent Program and Outside-In Large Fly Program, the Conditions Found/Action Taken indicated: “No rodent activity was noted during the inspection and/or service, no fly activity was noted during the inspection and/or service, and no cockroach activity was noted during the inspection and/or service.” Continued on 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 12/19/2024, LPA visited three residents' (R1-R3) rooms and observed baits had been placed in R3’s room. No roaches were seen in any of these three rooms. LPA observed the dining area during lunchtime service, where baits had been placed, no roaches were seen, and no posted pictures regarding roaches were observed at the facility. Based on observations, interviews conducted, and records reviewed, the department has determined that the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies were cited under the California Code of Regulations, Title 22. An exit interview was conducted with the Manager. A copy of this report was discussed and left with the Manager, Anahi McKane, whose signature on this form confirms receipt of this report.

According to Provider Information Notice (PIN) 22-28-ASC, effective 9/26/2022, it states that If there are differing requirements between the most current CDC, CDPH, CDSS, CDDS, Cal/OSHA, and local health department guidance or health orders, licensees should follow the strictest requirements. For the allegation of resident was threatened with eviction, Resident is not part of assisted living but resides in the independent living area. The issue with eviction is not governed by title 22. Based on interviews & records review, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is reviewed and copy is provided. page 2 of 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 R1 did not say who attacked him/her. S2 was able to review cameras in the area and stated that nothing happened. R1 just came down to tell S1 that he/she was hit. S2 looked at the camera in the hallways on the fourth floor and nothing happened. Based on interviews, the department has determined that although the allegations 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. Report is reviewed and copy is provided. page 2 of 2

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Anahi McKane. During visit, LPA Marrufo toured the facility inside and out. LPA toured the facility kitchen and dinning areas. LPA observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA reviewed the first aid kit and found it to be complete. LPA toured the outside exits and found them to be clear of obstructions. LPA reviewed 5 resident records and 5 Centrally Stored Medication and Destruction Records and found them to be complete. Due to time constraints, this annual inspection visit will need to be continued at a later time. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Anahi McKane and a copy of this report was provided.

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced case management visit and met with Administrator Anahi McKane. The purpose of the visit was to follow up with an SOC341 Suspected Adult/Elderly Abuse report submitted by the facility to CCL on 07/01/2024. The SOC341 report stated that on Sunday 06/30/2024 at 8 PM, staff S1 heard sounds coming from the living unit of resident R1 that sounded like R1's Private Duty Care Giver (PDCG1) was verbally abusing R1 and throwing around objects in R1's living unit. The SOC341 stated that R1 reported to facility staff that PDCG1 hit R1 in the lower right leg. During visit, LPA Marrufo reviewed three video recordings that Administrator Anahi McKane stated R1 took while standing outside of R1's living unit while PDCG1 was inside. LPA Marrufo could hear the sound of someone yelling and cursing from inside R1's living unit. LPA Marrufo interviewed R1 during visit. R1 stated during interview that PDCG1 was yelling and cursing at R1 and hit R1 in the lower right leg. During visit, LPA obtained copies of R1's Emergency Contact and Information Form, LIC602 Physician's Report, Resident Functional Evaluation, and the internal Incident Report submitted by R1 to Administrator Anahi McKane. LPA Marrufo requests that the facility submit copies of PDCG1's contact information and Home Care Organization documentation by 07/29/2024 No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Anahi McKane and a copy of this report was provided.

of out 2 interviewed staff stated to have observed COVID postings in Chinese and Russian translations, and then later observed that the Chinese and Russian postings were missing. The other interviewed staff stated COVID notices were posted on all the residents’ doors in the facility, including both Assisted Living and Independent Living residents. LPA Marrufo toured both the Lytton I and Lytton II buildings, and observed there to be COVID notification postings in various areas in each building in English, Chinese, and Russian. The Department does not have regulations or Provider Information Notices (PINs) that specify how facilities are required to notify residents about new COVID cases in the facility or require facilities notify residents in languages besides English. Based on information from interviews conducted with staff, records reviewed, and observations, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22 This report was reviewed with Anahi McKane and a copy of the report was provided. Page 2 of 2.

S2 states a resident has been taking the postings down. Based on interview with resident R1, it was confirmed that R1 did take down a posting of a notification of another COVID case to make a copy. R1 stated to have returned the posting after making a copy. The regulations do not state a time frame for making postings after a COVID case has been confirmed. The Department recommends as best practice to post a notice as soon as possible. Based on information from interviews conducted with staff and resident and review of records, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22 This report was reviewed with Administrator Doris Lee and a copy of the report was provided.

During interview, staff S1 stated to have placed copies of the posting on 2 out of 2 elevators in the Assisted Living Building Lytton II, left extra copies of the posting at the Front Desk, and posted them in 3 out of 3 elevators in the Independent Living Building I and in 3 out of 3 locked bulletin boards in Lytton I. During visit, LPA Marrufo observed the COVID Notice posted on the glass panel of the Front Desk in Lytton II, on 2 out of 3 locked bulletins, 1 Russian COVID Notification posting in 1 out of 3 elevators, and 3 out of 3 elevators had no English or Chinese postings. Administrator Lee, S1 and S2 stated that a resident has been removing the COVID postings. Based on interview with resident R1, it was confirmed that R1 did take down a posting of a notification in one of the Lytton I elevators to make a copy. R1 stated to have returned the posting after making a copy. The regulations do not state a time frame for making postings after a COVID case has been confirmed. The Department recommends as best practice to post a notice as soon as possible. Based on information from interviews conducted with staff and resident and review of records, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22 This report was reviewed with Administrator Doris Lee and a copy of the report was provided.

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Doris Lee. During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed the facility to have a visitor screening area. The visitor bathrooms had available soap and paper towels and a hand washing sign. LPA Marrufo observed the food supplies to include a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed a 30-day supply of PPEs. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Doris Lee and a copy of the report was provided.

Licensing Program Analyst (LPA) David Marrufo conducted a Required - 1 Year visit and met with Doris Lee and Anahi McKane. During visit, LPA Marrufo observed the visitor screening area. LPA observed the hallway bathroom near the entrance and observed there to be COVID-19 related posters and available soap and paper towels. LPA Marrufo observed more COVID-19 related posters throughout the facility. LPA observed the facility PPE storage and observed there to be a PPE supply of at least 30 days. LPA observed the kitchen area and observed there to be a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. LPA observed the dinning area and two resident common areas. No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Doris Lee and Anahi McKane and a copy of the report was provided.

Regarding the allegation of Facility staff are not giving resident's their mail in a timely manner, the Department investigation found the following: during interviews with staff, staff stated that there is a sign by the mailbox area reminding residents to check their mail daily. If residents receive a package that is too big for their mailbox, it is left on the front desk and staff bring the package to the residents room. Regarding the allegation of Facility staff are tampering with resident's mail, the Department investigation found the following: during interviews with staff, staff stated that each resident has their own mailbox key. The mailman is the one that puts the mail in the residents mailboxes, there is no way staff could tamper with residents mail. Regarding the allegation of Facility staff are damaging resident's personal property, the Department investigation found the following: during interviews with staff, staff stated that there has never been an incident of staff damaging residents personal property. One staff stated that if damage to residents personal property were to happen, their protocol would be to immediately notify the resident as well as the manager. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Doris Lee. A copy of this report was provided to Doris Lee via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC9099 and 9099-C was received. Doris Lee can print out the report and fax a signed copy to LPA at 650-266-8841 or email to LPA at Christopher.Hopkins-Clarke@dss.ca.gov .