California Mission Inn - Rose Manor.

(continued on 9099C) Residents in adjacent rooms stated they do not hear sounds in the middle of the night. R1 stated that the sounds are coming from the adjacent room to the north side of resident's room. However, that room has been vacant since the beginning of the day on May 12, 2026 by 11:00am . Asked if R1 heard any sounds yesterday or this week coming from the unoccupied room, resident stated resident thinks resident heard sounds. R1 stated R1 will try to record the sounds next time. R1 could not identify the person(s) who are making the sounds or noise. There is no evidence to support this allegation. Allegation: Staff interrupted the sleep of a resident in care. It is alleged that resident was intentionally awaken when resident arrived at facility after being out on lengthy journey. LPA interviewed four (4) staff and all four (4) staff denied the allegations. LPA interviewed six (6) clients and all six (6) could not corroborate the allegation. R1 could not identify the person(s) who woke R1 up. Other residents interviewed stated they are not awakened in the middle of the night or anytime they are sleeping. There is no evidence to substantiate this allegation. 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, therefore the allegations are UNSUBSTANTIATED. No deficiencies were cited during this investigation. Exit interview was conducted. A copy of this report was provided.

(continued from 9099) LPA interviewed five staff (5) and all five (5) staff denied the allegation. LPA interviewed seven (7) residents in adjacent rooms to R1 and four (4) of seven (7) residents could not corroborate the allegation. Two (2) residents stated that they had a loud verbal disagreement recently, that is was only one day. They stated it had nothing to do with R1, and that it has not occurred again. Both residents stated their issue has been resolved between them. LPA explained this to R1 and R1 stated she understands. There is not enough evidence to substantiate this allegation. Staff does not ensure resident's room is clean and sanitized. It is alleged that R1 room is not being clean and sanitized. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. Several staff stated that resident has canceled room cleaning when scheduled and have refused to allow entry to housekeeping staff at times. LPA interviewed seven (7) residents and six (6) of seven residents could not corroborate the allegation. R1 admitted that R1 has cancelled scheduled room cleanings several times and stated that R1 does not want staff in R1 room when R1 is not present because things have gone missing before. LPA tour R1 room and it appeared clean. R1 stated outside service cleans room. There is insufficient evidence to support this allegation. Staff do not ensure the facility is properly maintained. It is alleged that R1 stove is uncleaned, toilet is leaking and cover for drawer is loose and needs repair and facility has not addressed the issues. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. One staff member stated that as soon as they get a work order, they are on it right away. Records reviewed show that R1 requested to have her toilet repaired on 2/25/2026 and staff asked which dates would work for R1. Records show toilet was repaired on 02/27/2026 and R1 confirmed this. R1 alleged that there was a natural gas leak in room and called the Gas company. Gas company arrived and discovered that R1 does not have any appliance that uses natural gas and they did not detect any gas leak. One staff member stated that staff used a little spray of W40 to loosen bolt on toilet to repair it and that is what resident smelled. R1 agreed that was the smell after being told. On 03/04/2026, R1 alerted staff that there was a cover that came off a drawer and the facility had that repaired on 03/04/2026. There is insufficient evidence to substantiate this allegation . 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, therefore the allegations are UNSUBSTANTIATED. No deficiencies were cited during this investigation. Exit interview was conducted. A copy of this report was provided.

(continued from 9099) The investigation consisted of LPA taking a tour of facility, interviewing two (2) staff (S#1-#2), reviewing and obtaining R1 admissions agreement, physician's report, staff and resident rosters, and R1 care plan. The investigation consisted of LPA taking a tour of facility, interviewing five (5) staff (S#1-#5), Six (6) residents (R#1- R#6), reviewing and obtaining R1 admissions agreement, physician's report, staff and resident rosters, AR form, R1 care plan and other pertinent documentation related to the investigation. The investigation revealed: Regarding Allegation: Staff did not provide meals to resident. It is alleged that staff did not provide meals for resident one day. LPA interviewed five (5) staff and all five staff were aware that resident missed all three meals on 12/01/2025. Several staff stated that resident usually went to the dining hall on the fifth floor to eat meals. Culinary supervisor noticed she had not seen resident that day and asked another staff member if she knew about the resident.. The staff member answered with “resident is OK” and never checked on resident. Resident was receiving escorts to meals when she first arrived at the facility on care plan that was created on 06/19/2024. Effective 04/15/2025 an updated care plan was created and removed wellness checks and meal escorts to the dining room. The resident should have no expectation for staff to check on resident or to deliver a meal tray to resident’s room on this day according to the services agreed upon by the resident and facility on 04/15/2025. There is insufficient evidence to support this allegation. (continued) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (continued) Allegation: Staff neglect/lack of supervision caused resident to remain on floor for at least 12 hours. It is alleged that staff neglected resident after a fall that resulted in resident being on the floor for twelve hours. Resident had wellness checks removed from care plan effective 04/15/2025. The resident was provided with a call pendant to press in case resident required assistance; however, resident did not press the pendant at any time during the time resident spent on the floor. According to the care plan effective 04/15/2025, the resident should have no expectation of a wellness check on 12/01/2026. 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, therefore the allegations are UNSUBSTANTIATED . No deficiencies were cited during this investigation. Exit interview was conducted. A copy of this report was provided.

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required - 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to the Administrator Jared Green and Maria Roleda, Wellness Director, assisted LPA with the visit. On today's date, LPA inspected the following domains 1.Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility still practices the infection control with hand washing. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirements : The current plan of operation is completed. The facility has a Dementia Waiver in place. A Hospice Waiver for 20 residents is approved. A fire clearance for 85 non-ambulatory residents, of which 9 may be bedridden, is in place. Liability Insurance in the amount of at least ($1,000,000) per occurrence and total amount of aggregate ($3,000,000) is in place. 3. Physical Plant/Environmental Safety: The facility consists of a 5-floor building. The first through fourth floors consist of residents rooms and the fifth floor is the dining area. The common areas are located on the first and third floors. LPA inspected random rooms and are clean and have required furnishing. Bathrooms were clean, toilets and water faucets worked properly and were properly supplied, have functional fixtures, and have secure grab bars. Emergency pull cords were observed in every resident room. (See LIC 809C for continuation) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (continued from 809) Showers were free of mold/ mildew and non-skid mats or strips were properly in place. The hot water temperature was tested between 109.4 and 115.8 F which is within the Title 22 regulation of 105.0 – 120.0 degrees F. LPA also inspected the carbon monoxide detectors in the facility, are working properly. The facility has a telephone service on the premises. 4. Staffing: The facility has sufficient staffing to provide care and supervision to residents. 5. Personnel Record-Training: All the staff are over 18 years old and they are fingerprint clear and associated with the facility. LPA inspected four (4) staff files, and they all have the required documents which include heath screening, TB test result, required training hours, updated first aid and CPR certificate. The facility administrator is Jared Green and his administrator certificate expiration date in 4/14/26. 6. Resident Record-Incident Reports: LPA inspected four (4) residents files and they all have the required documents in file which included: admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records. 7. Resident's Right : LPA observed the required posters posted on the board on the first floor in the TV/Living room which include Long Term Care Ombudsman, Community Care Licensing Complaint and Personal Right Poster. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physician. 8. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted, and LPA reviewed the calendar for the facility. 9. Food Service: The facility has sufficient 2 days perishable and 7 days non-perishable food supply and the emergency food supply are stored and locked in emergency food supply room. 10. Incidental Medical and Dental: LPA inspected four (4) residents medication, and the medication is centrally stored and locked in the Wellness Center room, and they are accurate and updated and also contain 30 days’ supply of medication. The facility will also provide transportation to residents' medical and dental appointments. 11. Disaster Preparedness: The facility has an Emergency Disaster Plan (LIC610E) posted but needs updated to show one evacuation site out of the area. The last fire drill was conducted on 09/16/2025 and the last disaster drill was conducted on 06/06/2025. Records of resident Appraisal and Needs services plans are part of Emergency training. 12. Residents with Special Health Needs: No residents in the facility with prohibited health condition. Currently there are three (3) residents on hospice and two residents in home health. Individual Service Plan and appraisals are on resident's files for home health and hospice. No deficiencies were observed during the visit. Technical advisories provided. Exit Interview Conducted and a copy of the report was provided to Wellness Director Maria Roleda

Licensing Program Analyst (LPA) Kimberly Ramirez conducted required annual inspection. LPA met with Jessica Estrada (Wellness Coordinator) and discussed the purpose of today’s visit. Maintenance Director Andy Mendoza arrived shortly after to assist with the inspection. The facility is licensed for 85 non-ambulatory residents, age 60 and over, of which nine (9) may be bedridden. The facility has an approved hospice waiver for twenty (20) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected eight (8) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. Facility maintains a monthly waterlog to record water temperature throughout the facility. LPA Ramirez observe postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez tested emergency pull cord in room#216. Staff responded 5 minutes later to assist. LPA Ramirez observed evacuation chairs in stairways. LPA Ramirez observed video surveillance in rooms# 211 & 216. Video surveillance was placed at the request of the residents and family. LPA Ramirez will issue Technical Violation based on this observation. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). LPA Ramirez observed facility weekly and daily menu, which is approved by the facility certified dietary manager. LPA Ramirez observed kitchen staff preparing for lunch while wearing hair nets and gloves. LPA Ramirez observed several dinning room servers disinfecting tables and counters while wearing gloves and hair nets. See 809-C for continuation. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Planned Activities: LPA Ramirez observed an activities calendar for October of 2024 with various activities and outings for residents. LPA Ramirez observed sufficient outdoor space. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility computers with internet access and a facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA Ramirez observed evacuation chair in stairway. Last documented emergency drill was conducted on 09/17/24. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. Residents with Special Needs: Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Operational Requirements: The facility is licensed for 85 non-ambulatory residents, age 60 and over, of which nine (9) may be bedridden. The facility has an approved hospice waiver for twenty (20) residents. LPA Ramirez reviewed facility liability insurance and auto registration for one (1) facility vehicle. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training only for four (4) out of the four (4) staff files requested. LPA Ramirez reviewed required annual training for staff working with dementia residents. LPA Ramirez was unable to review the following: CPR and First Aid, TB testing results, Health screening, fingerprint clearance, and job application. Staffing: Administrator Certificate for Jared Green and it expires 04/14/2026. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. No deficiencies were observed during this inspection. Exit interview was conducted with Jared Green and a copy of this report, LIC 9120 and appeals rights was provided via email.

Licensing Program Analyst (LPA) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to the Administrator Dwight Dunagan and assisted LPA with the visit. The facility is licensed to RCFE/Dementia for age range 60 and over. Approved for 85 non-ambulatory, of which 9 may be bedridden, approved hospice waiver for 20. Currently, there's two residents on home health, six residents on hospice but no bed ridden residents. On today's date, LPA inspected the following domains which include: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Record-Training, Resident Records/Incident Reports, Resident's Right, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness and Resident with Special Health Needs 1.Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility still practice the infection control with hand washing. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirements : The current plan of operation is completed. The facility has a Dementia Waiver in place. A Hospice Waiver for 20 residents is approved. A fire clearance for 85 non-ambulatory residents; of which 9 may be bedridden is in place. Liability Insurance in the amount of at least ($1,000,000) per occurrence and total amount of aggregate ($3,000,000) is in place. 3. Physical Plant/Environmental Safety: The facility is consisted of a 5 floor building. The first through fourth floors consist of residents rooms and the fifth floor is the dining area. The common areas are located on the first and third floor. LPA inspected Room#106, #116, #212, #205, #303, #301, #412, #414 and the rooms are clean and have required furnishing. Bathrooms were clean, toilets and water faucets worked properly and were properly supplied, have functional fixtures, and have secure grab bars. Emergency pull cords were observed in every resident room. (See LIC 809C for continuation) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Showers were free of mold/ mildew and non-skid mats or strips were properly in place. The hot water temperature were tested between 105 and 112.6 degrees F which is within the Title 22 regulation. LPA also inspected the carbon monoxide detectors in the facility and they are working properly. The facility has a telephone service on the premises. 4. Staffing: The facility has sufficient staffing to provide care and supervision to residents 5. Personnel Record-Training : All the staff are over 18 years old and they are fingerprint cleared and associated with the facility. LPA inspected four staff files and they all have the required documents which include heath screening, TB test result, required training hours, updated first aid and CPR certificate. The facility administrator is Dwight Dunagan and his administrator certificate expiration date 7/11/2024. 6. Resident Record-Incident Reports: LPA inspected 4 residents files and they all have the required documents in file which included : admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records. 7. Resident's Right : LPA observed the required posters posted on the board on the first floor in the TV/Living room which include Long Term Care Ombudsman, Community Care Licensing Complaint and Personal Right Poster. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physician. 8. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted and LPA reviewed the calendar for the facility. The facility does not have a resident council but regular town hall meeting. 9. Food Service: Currently the facility has 3 resident is on a modified diet with physician order in file. The facility has sufficient 2 days perishable and 7 days non-perishable food supply and the emergency food supply are stored and locked in emergency food supply room. Sanitation practices and kitchen cleanliness was observed. 10. Incidental Medical and Dental: LPA inspected four (4) residents medication and the medication are centrally stored and locked in the Wellness Center room and they are seemed accurate and updated and also contained 30 days supply of medication. The facility would also provide transportation to residents' medical and dental appointments. 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 11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610E) and its updated on 10/20/22. The last fire drill was conducted on 9/22/23 and the last disaster drill was conducted on 6/28/23. The facility has two temporary alternative shelter location. Records of resident Appraisal and Needs services plans are part of Emergency training. 12. Residents with Special Health Needs: No residents in the facility with prohibited health condition. Currently there are six resident on hospice and two residents on home health. Individual Service Plan and appraisals are on resident's files for home health and hospice. No deficiencies were observed during the visit. Exit Interview Conducted and a copy of the report was provided to Administrator Dwight Dunagan.

Investigation revealed the following: Regarding allegation, Staff does not adhere to posted food menus , it is alleged that facility is not providing facility residents the requested or posted meals. Interviews with Administrator Dunagan and facility staff revealed that staff adhere to posted menus at all times. They stated that residents also have the option of requesting an alternate meal from the bistro menu. Staff stated that the facility serves three full meals and provides two snacks on a daily basis. Staff also stated that residents can also request additional servings of any meal if they wish. Interviews conducted with 3 out of 5 residents revealed that facility adheres to the food menus. They also stated that they are given a copy of the weekly menu the week before so that they can make their own choices and turn it in to the front desk. LPA observed residents being served lunch during tour and verified that residents were served what was listed on the menu. LPA additionally toured the facility kitchen and observed an ample amount of food. There was enough food for 7 days non perishables and 2 day perishables. Based on interviews conducted with facility staff, facility residents, and LPA observations there was not enough supportive evidence to concur with the reported allegation. For allegation, Facility has inadequate food service , it is alleged that the facility residents are not receiving an adequate amount of protein and the servings are not enough for someone of a certain height. Protein servings are allegedly 1.5 ounces of chicken. Interviews with Administrator Dunagan and facility staff revealed that the facility provides adequate food service for all residents. They stated that the facility follows menus approved and developed by a registered dietician and the menus meet the residents nutritional needs. They stated that residents also have the option of requesting an alternate meal from the bistro menu and additional servings for any meal that they have. Staff stated that the facility serves three full meals and provides two snacks on a daily basis. Staff also stated that residents also have the option of requesting a half serving which will have a smaller serving of protein. Interviews conducted with 3 out of 5 residents revealed that facility food service is adequate. They stated that they are served an adequate amount of food including protein. They also stated that they are given two snacks a day. LPA observed residents being served lunch during tour and verified that residents were served what was listed on the menu. LPA observed that residents were served an appropriate amount of protein. LPA additionally toured the facility kitchen and observed an ample amount of food. There was enough food for 7 days non perishables and 2 day perishables. Based on interviews conducted with facility staff, facility residents, and LPA observations there was not enough supportive evidence to concur with the reported allegation. 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 For allegation, Staff do not serve nutritious meals, it is alleged that residents are not being given nutritious options such as broccoli. Staff have allegedly stated that they are unable to provide the meal items due to the facility not having them. Interviews with Administrator Dunagan and facility staff revealed that the facility provides nutritious meals for all residents. They stated that the facility serves well balanced and nutritious meals that include servings of protein, carbohydrates, fruits and vegetables. They also stated that the facility follows menus approved by a registered dietician. They also stated that residents can request certain foods or different meal options on the weekly menu and that is collected at the front desk and is followed by kitchen staff according to resident's preferences. Residents also have the option of requesting an alternate meal from the bistro menu and additional servings for any meal that they have. Staff stated that the facility serves three full meals and provides two snacks on a daily basis. Interviews conducted with 3 out of 5 residents revealed that facility food service is adequate. They stated that they are served nutritious and well balanced meals. They also stated that they are given two snacks a day. LPA observed residents being served lunch during tour. LPA observed that residents were served protein, fruits and vegetables. LPA additionally toured the facility kitchen and observed an ample amount of food. There was enough food for 7 days non perishables and 2 day perishables. Based on interviews conducted with facility staff, facility residents, and LPA observations there was not enough supportive evidence to concur with the reported allegation. For allegation, Facility meals are served more than fifteen (15) hours apart , it is alleged that dinner is served too early. Dinner is scheduled for 3:30pm and residents are not given snacks. It is also alleged that residents do not receive their next meal until the following morning at approximately 9-9:30am. Interviews with Administrator Dunagan and facility staff revealed that the facility does not serve meals more than 15 hours apart. They stated that dinner is served from 4:30pm to 6:00pm and breakfast is served from 7:30am to 9:00am. They also stated that residents can also request food from the Bistro Menu when they want and residents are given 2 snacks per day. Interviews conducted with 3 out of 5 residents revealed that meals are not served more than 15 hours apart. They stated that they are satisfied with the food service and do not have any concerns regarding the times that the meals are serve. They also stated that they are given two snacks a day. LPA observed lunch service at approximately 12:00pm. LPA additionally toured the facility kitchen and observed an ample amount of food. There was enough food for 7 days non perishables and 2 day perishables. Based on interviews conducted with facility staff, facility residents, and LPA observations there was not enough supportive evidence to concur with the reported allegation. 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, therefore the allegations are UNSUBSTANTIATED . Exit interview held. A copy of the report was provided to Administrator Dwight Dunagan.