Atria Collwood.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Community Business Director Patricia “Kitty” Totorica and Resident Services Director Ashley Baino-Jaimes. LPA also met with Executive Director Julia Lopez, who arrived shortly after. Today's visit was in response to Licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 03/28/2026. [See LIC 811 Confidential Names List for a description of R1]. Per the report, R1 passed away on 03/27/2026. During today’s visit, LPA performed a brief facility tour and welfare check on remaining residents, finding no immediate safety concerns. LPA also collected copies of pertinent records. No deficiencies were observed or cited during this welfare check. An exit interview was conducted with Community Business Director Patricia “Kitty” Totorica, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today's visit.

[CONTINUED FROM LIC 9099] Records and interviews aligned to show: On 03/11/2026, Licensee served R1 with an eviction letter citing nonpayment of rent and fees. The effective date of the eviction listed in this letter was 04/24/2026, which was more than the required thirty (30) day minimum. The dollar amount demanded in this letter accurately represented the portion of the balance which R1 owed to Licensee, and which was also more than ten (10) days past due. The letter also contained the required text disclosures described in regulations, as far as the spirit of the law is concerned. Interviews of R1 and staff, corroborated by LPA observation, aligned to showed: During the pertinent review period, R1 received help in practice from facility direct care staff with medication storage and administration, and with emptying and managing their urinary catheter. Licensee assessed and billed R1 at the care and medication levels corresponding to practice. Prior to the issuance of the 03/11/2026 eviction letter, Licensee had made multiple attempts to communicate with R1’s Responsible Person (RP) to resolve R1’s past due balance, but the problem was not solved. As of the commencement of CCLD’s investigation, Licensee had not received any payment on R1’s account for the preceding two (2) months, and R1’s past due balance was actively growing. Based on records and interviews, a preponderance of evidence does not exist to show that Licensee pursued an unlawful eviction of R1. The allegation is therefore Unsubstantiated, and no deficiency was cited for it. LPA issued one (1) Technical Violation regarding letter formatting (refer to the LIC9102-TV page) and provided Technical Assistance (TA) regarding promoting a resident’s independence. An exit interview was conducted with Engage Life Director Naomie Peterson, to whom a copy of this report, the LIC9102-TV page, the LIC9102-TA page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

[Continuation from LIC 9099] A review of R1’s records revealed they were admitted to the facility on February 3, 2025. Prior to admission, R1 had undergone two hip and knee replacements and was diagnosed with Mild Intellectual Disorder (MID), macular degeneration, depression, hypertension, and anxiety. R1 was non-ambulatory, considered a fall risk, but was able to leave the facility unassisted. A review of R2’s records showed they were admitted on February 29, 2024, following a stay at a Skilled Nursing Facility (SNF) due to a hip fracture. R2 was non-ambulatory and diagnosed with MID, atrial fibrillation (A-fib), hypertension, chronic obstructive pulmonary disease (COPD), depression, anxiety, Hyperlipidemia, arthritis, alcohol use disorder (ETOH), and alcoholic hepatitis. Records also indicated R2 was easily agitated but generally kept to themselves. Interviews with S1 and the facility’s Executive Director (ED) described R2 as quiet and non-problematic, and both expressed surprise at the allegation. They confirmed that no further incidents had occurred. The ED, who was informed of the incident by R1, stated that R1 and R2 had crossed paths at the facility and were in each other’s way when R2 swatted R1 on the bottom. Additionally, Staff 3 (S3) reported that no staff witnessed the incident and that all residents were gathered in the dining hall for dinner at the time. A review of outside source records corroborated that R1 preferred the facility to handle the situation, and did not wish to press charges. An additional interview conducted with R1 corroborated and they confirmed no other occurrences have happened at the facility . The incident was self reported to the Department on February 8, 2025, the day of the incident. Based on interviews and records reviews the allegation was determined to be Unsubstantiated. An Unsubstantiated finding means, although the allegation may be valid there was not a preponderance of evidence to prove the violation had occurred. An exit interview was conducted with CBD Totorica, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided. Signature below confirms receipt of the reports.

It was also alleged that staff restricted R1’s access to personal belongings, specifically a television and phone. An interview conducted with the ED disclosed that R1’s family member picked up all of R1’s belongings. A resident record review showed no items listed on R1’s inventory list of personal belongings. Additionally, It was alleged that staff failed to transport R1 to medical appointments and began charging for transportation services. Per the facility admission agreement, the facility’s policy states transportation is provided at no cost within a 10-mile radius, with a $25 fee beyond that. Staff 1 (S1) stated in the past, new residents were not charged the $25 fee for transport over 10-miles to allow them time to adjust and understand the facility’s transportation policy, and schedule visits accordingly. Records showed that transportation was offered and provided to R1 in accordance with policy. It was also alleged staff speak inappropriately to residents in care. Interviews with staff and residents did not corroborate this allegation. All parties reported that staff did not speak inappropriately to R1. However, multiple sources (staff and residents) stated that R1 frequently used inappropriate language toward staff and residents, including political rants, blocked access to elevators and doorways, and made derogatory remarks. It was also alleged that two residents engaged in explicit behavior on the facility transport bus. However, the residents involved were not identified, and staff interviewed had no knowledge of the incident. Lastly, it was alleged the facility is not clean and sanitary . Specifically, It was alleged the ED brings their dog to the facility and the dog urinated and defecated around the facility, including the communal dining area. Interviews conducted with staff and residents, and a facility tour yielded no corroborating evidence. At the time of facility tour it was observed to be clean and sanitary. Additionally, during the tour cleaning staff were observed throughout the facility. During several unrelated visits, for long periods of time, LPA has met the ED’s dog and never observed the dog having an accident and has never received any complaints or negative feedback regarding the dog. There are several residents at the facility that have dog,, for residents that are unable to walk their dog the facility has/had dedicated staff to take them on walks to use the bathroom and is included int their care plan. In addition, facility policy states pets are not allowed in the communal dining area. Based on record reviews and interviews with facility staff and outside sources the above-mentioned allegations were determined to be Unsubstantiated. An Unsubstantiated finding means the preponderance of evidence to prove the violation/s occurred was not met. An exit interview was conducted with CBD Tortarico, to whom a copy of this report, and Licensee Rights (LIC 9058), will be provided. The signature below confirms receipt of the reports

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Julia Lopez. Today's visit was in response to an SOC341 Report, which licensee self submitted to the CCLD San Diego Regional Office (received on 10/24/2025). According to the SOC341, on 10/15/2025, Resident #1's (R1's) Outside Source (OS1) [See LIC 811 Confidential Names List for a description of select person identifiers used in this report.] reported R1 was missing money. The facility followed their theft and loss protocol and immediately investigated the report of missing money. During today’s visit, LPA performed a facility tour; R1 is currently at the hospital, and LPA was unable to interview R1. OS1 was unable to be interviewed at this time due to being out of town on vacation. LPA interviewed pertinent managers and collected relevant care records on R1 during the visit. According to their LIC602 Physician’s Report, R1’s documented on the LIC602, No Cognitive Impairment, and their doctor had determined that R1 was able to make their own decisions. The Needs and Services Plan (Care Plan), which the Licensee authored, reiterated that R1 is their own responsible party and is able to make their own decisions.”R1 needed assistance with activities of daily living. R1 was admitted to the facility on 10/14/25 and is currently at the hospital. [Continue 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 [Continued from LIC809] No immediate health or safety risks were observed and no deficiencies were cited during this visit. Additional case management will be provided for this incident, including subsequent visits and resident and outside source interviews, as needed. An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (03/22) were left with the Administrator Julia Lopez, whose signature on this form confirms receipt of these documents.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced Case Management visit. LPA met with Executive Director (ED) Lopez and discussed the purpose of the visit. During today's visit LPA obtained signatures on an amended complaint. An exit interview was conducted with ED Lopez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) will be provided.

[Continuation of LIC 9099] A review of R1’s facility records dated February 24, 2023, revealed R1’s Primary Care Physician (PCP) concurred that self-storage and administration is safe,” “and the “Resident agrees to keep medications in a locked cabinet or drawer and will lock apartment door when not in apartment. Further review of R1’s resident records showed R1’s history of non-compliance regarding safeguarding their medication when R1 was still deemed able to self-medicate. Records include the following but are not limited to; facility records dated March 10, 2023, revealed facility Staff1 (S1) documented that R1 had medications out in their room and S1 and Staff 2 (S2) both told R1 they needed to purchase a lock box to store their medications however R1 got upset and refused. On April 4, 2023, the Executive Director (ED) observed R1 had opened bottles of medications out in their room, the ED emailed R1’s PCP regarding non-compliance with self-medicating. A review of R1’s facility records also revealed on April 27, 2023, R1 had misplaced their medication and subsequently a new prescription was ordered and staff delivered them to R1 by 9:00 am the following morning. Additionally, on June 7, 2023, R1 reported they never received that same prescription that had been ordered twice, and facility staff were able to locate the bottle under R1’s bed. On March 25, 2025, the Department received a 3-Day eviction notice that disclosed R1 received a prescription of a 224 count of Narcotic Painkillers, on that same day, prior to access to their prescription had made suicidal threats to Staff 3 (S3) by means of taking their entire bottle of pain killers at once. Upon S3 notifying management safety measures were put in place, including a search of R1's room for the medication, that were not found and remain unaccounted for to date. The Resident Service Director (RSD) also revealed they found other medication bottles in R1’s room that contained medication that did not match the prescription label. An interview with the ED revealed they followed the facility protocol, removed all R1’s medications that were found from their room, placed R1 on 1:1 supervision, and contacted R1’s PCP for an updated Physician’s Report. However, the PCP only sent a letter that stated R1 can handle their own medication. A follow-up interview conducted with the ED, on July 12, 2025, revealed after multiple requests to the PCP, they have not sent an updated Physician’s Report to date. [Continued on LIC 9099C] This is an amended version of the original report delivered on July 15, 2025. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [Continuation of LIC 9099C] On June 23, 2025, the facility received a complaint that alleged a Personal Rights violation due to the facility staff taking R1’s medications, and after a thorough investigation by LPA Nguyen, that revealed R1 was not in-compliance with facility protocol regarding procedures of safeguarding Narcotic medication, and R1 was not taking their medication as prescribed, the complaint was determined unsubstantiated which allowed the facility to continue centrally storing R1’s medication and implement Medication Management, and had R1 re-assessed by a third party Physician’s Assistant (PA), that determined R1 was not able to manage their own medication. In the event R1’s PCP conducts a reassessment of R1 and deems them able to self-medicate, California Code of Regulations (CCR) Section 87463(e) supports the right and responsibility of Licensees to conduct their own care assessments parallel to medical assessment(s). When health/safety concerns and/or unresolved questions are identified, regulation requires Licensees to further communicate with the physician to obtain recommendations on these issues. However, Licensees retain some independence in forming the written record of care that the resident shall receive while living at the facility, particularly when provisions reasonably uphold resident health/safety in balance with resident rights.” The interview conducted with ED on July 12, 2025, as previously mentioned, revealed R1 remained non-compliant even after being placed on Medication Management. The ED revealed R1 continued to have their Prescriptions refilled and have picked them up from Pharmacies on their own. In addition, R1 has prohibited staff from removing them from their possession. R1 also continues to have their medication unsecured and sprawled around their room. Due to R1’s continued noncompliance with medication management R1 was given a 30-day eviction notice on June 4, 2025, and an amended version on June 13, 2025, which resulted in the current complaint regarding and unlawful eviction that was under investigation. Based on staff interviews and record reviews revealed a preponderance of evidence that R1 has displayed disregard to the facility’s policy regarding safeguarding their medication, therefore the complaint regarding an unlawful eviction was determined to be unsubstantiated. An UNSUBSTANTIATED finding means that there was not a preponderance of evidence to prove the violation occurred. An exit interview was conducted with Irma Miranda,, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) will be provided after the conclusion of the visit. This is an amended complaint from the original version dated July 15, 2025.

[CONTINUED FROM LIC 9099] Records and interviews of R1 and facility staff aligned to show: Leading up to the complaint time frame, R1 was diagnosed with depression and a chronic neurological condition which caused them constant and intense pain. R1, who was their own responsible person, was also responsible for storing and taking their own medications, which included opioids. On 05/25/2025, R1 told Staff #1 (S1) that they were in so much pain they wanted to kill themselves by ingesting an entire bottle of medication. S1 quickly escalated this information to facility manager Staff #2 (S2). S1 and S2 both told LPA they interpreted R1’s statement at that time as a credible plan to harm self, with access to method/means present. R1 told both S2 and LPA they were speaking dramatically and not literally on 05/25/2025, and had no desire to commit suicide. Records and staff interviews further showed: Licensee took quick action that day to safeguard R1, which included calling 911 and notifying R1’s assigned physician (P1). R1 declined to go to the hospital for a psychiatric evaluation. P1 told first responders via phone they supported R1’s decision. R1 thus did not go to the hospital. Licensee also utilized a third-party home-care agency to provide continuous one-on-one supervision of R1, pending a psychiatric assessment to clear R1 of suicide-risk. That same day, Licensee also requested from P1 an updated list of prescribed medications for R1, which Licensee needed to successfully reevaluate R1’s ability to accurately self-manage their medications per their prescriptions. However, P1 replied they were out of town, away from their computer, and could not timely send such a list. In lieu of a fast response from P1, and with R1’s consent, Licensee arranged for R1 to be evaluated face-to-face on 05/28/2025 by a mobile, third-party psychiatric nurse practitioner (P2), operating under the oversight of a physician assistant (P3). P2 and P3 were not entirely new providers; each healthcare professional had previously treated/visited R1 in the past. P2’s psychiatric assessment concluded that R1 had “low to moderate risk” of suicide. However, P3 subsequently authored an updated LIC602 Physician’s Report, indicating that facility staff should store and administer R1’s medications. On 06/02/2025, facility managers met with R1 to take over storage and management of R1’s medications. [CONTINUED ON LIC 9099-C, 2 of 3] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [CONTINUED FROM LIC 812-C, 1 of 3] On 06/03/2025, P1 evaluated R1 via a tele-medicine appointment, then sent a signed letter to Licensee essentially saying that while P1 was aware of what earlier transpired on 05/25/2025, they had been assigned to R1 over two years and believed R1 was “not actively suicidal.” P1 determined that one-on-one supervision was not needed, that evaluation by a psychiatrist was not needed, and that R1 should go back to independently storing and taking their own prescribed medications. Upon receipt of this letter, Licensee discontinued one-on-one supervision for R1. However, Licensee then requested from P1 an updated list of R1’s prescribed medications and an updated LIC602 Physician’s Report showing that R1 could self-manage medications (to override/overturn the earlier LIC602 completed by P3). As of 07/01/2025, Licensee had not received these documents from P1 and was thus continuing to centrally-store and manage R1’s medications. CCLD interviewed R1 twice for this case, a few days apart, finding: To the lay observer, R1 was alert, oriented, and articulate, with no signs of memory-impairment. R1 continued to deny intent to commit suicide. However, LPA identified areas of potential concern, requiring further research, assessment, and/or education w/ R1: 1) The pharmacy prescription label on R1’s bottle of Oxycodone immediate-release tablets for pain lacked clear dosage instructions, saying instead, “Please see attached for detailed instructions.” The corresponding pharmacy paperwork that arrived with this medication also said, “Please see attached for detailed directions.” When LPA asked R1 how they typically took their Oxycodone medication, R1 gave inconsistent answers regarding the time-spacing and maximum number of tablets they would consume per typical day; 2) During his 06/27/2025 site visit, LPA observed inside R1’s room an empty bottle which once contained Oxycodone extended-release tablets for pain. The prescription label showed one tablet was to be taken twelve (12) hours apart. R1 said they took this medication just twice per day. However, per the label, sixty (60) tablets were dispensed on 06/02/2025; that R1 ran out of tablets suggests there were days earlier in the cycle when R1 consumed more than two tablets per day; 3) Regarding their as-needed Clonazepam tablets for anxiety, R1’s statements showed they did not consistently adhere to the prescribed time-spacing instructions for this medication; 4) Regarding their as-needed Hydroxyzine tablets for itching, R1’s statements showed they did not adhere to the prescribed maximum daily dose for this medication; 5) LPA observed multiple bottles of wine/liqueur near R1’s bed. Staff interviews showed a recent increase in R1’s ordering of wine/alcohol from outside sources (which have been dropped off at the facility’s front desk). Per R1’s own statements, they are nearly continuously medicated with opioids during their waking hours. P1 should clarify for Licensee if alcohol is contraindicated with R1’s current medications. [CONTINUED ON LIC 812-C, 3 of 3] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [CONTINUED FROM LIC 812-C, 2 of 3] The totality of available evidence showed: R1’s verbalizations on 05/25/2025 raised a credible safety concern at that time, to which Licensee diligently responded. Licensee’s taking over control of R1’s medications starting 06/02/2025, following the receipt of P3’s written medical assessment on R1 recommending such, was also justified. As the primary care physician of R1 for over two years, P1’s authority in this case supersedes that of P3’s. P1’s signed 06/03/2025 letter to Licensee was indeed valid physician instruction. However, California Code of Regulations (CCR) Section 87463(e) supports the right and responsibility of Licensees to conduct their own care assessments parallel to medical assessment(s). When health/safety concerns and/or unresolved questions are identified, regulation requires Licensees to further communicate with the physician to obtain recommendations on these issues. However, Licensees retain some independence in forming the written record of care that the resident shall receive while living at the facility, particularly when provisions reasonably uphold resident health/safety in balance with resident rights. At the conclusion of CCLD’s complaint investigation, there remained unresolved questions and documentation which P1 needed to clarify/address for Licensee. Such information is needed to effectively evaluate if R1 can safely and accurately manage their own medications, or if R1 can be educated/coached to do such, if applicable. Based on records and interviews, a preponderance of evidence does not exist at this time to show that Licensee did not allow R1 to keep their own medication without just cause. The allegation is therefore Unsubstantiated, and no deficiency was cited for it. An exit interview was conducted with Executive Director Julia Lopez and Resident Services Director Ashley Baino-Jaimes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Further review of R1’s resident records revealed as of May of 2023, R1 had refused staff assistance with showering, including an Outside Agency (OS1) that would also assist R1. Facility records dated July 05, 2023, revealed R1 requested assistance with showering to be removed from their care plan and subsequently facility records showed on that same day, July 5, 2023, staff requested authorization (marked urgent) from R1’s Primary Care Physician (PCP) to allow R1 to shower on their own which was approved and signed on July 10, 2023. Interviews conducted with staff corroborated R1 would refuse assistance with being showered. in addition, interviews with other residents in care revealed no issues with staff assistance with bathing. Based on facility, resident, and outside source records reviews, and staff and resident interviews the Department determined the allegation to be unsubstantiated. This finding means there was not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted with Med-Tech Amy Barajas and a copy of this report and Licensee/Appeal Rights (LIC 9058) will be provided to staff at the conclusion of the visit.

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management Visit. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Julia Lopez. During the visit the LPA secured report signatures and delivered an amended report. An exit interview was conducted with Lopez, to whom a copy of this report, and Licensee Rights (LIC 9058), were provided.

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management visit. The LPA introduced himself and disclosed the purpose of the visit to Maintenance Director Omar Zamudio. During the visit, the LPA secured report signatures, and delivered an amended report. An exit interview was conducted with Zamudio, to whom a copy of this report, and Licensee Rights (LIC 9058), were provided.

[Continuation of LIC9099] During the interview with R1 they reported the ED misinformed the responding officer by stating since R1 was independent staff do not have access to their room, however R1 revealed caregivers, and housekeeping entered their room each week. A review of R1’s care plan dated October 2, 2024, corroborated R1 was independent and did not require care, however the facility's basic plan included standard laundry and housekeeping services that were provided each week. In addition, it was disclosed the ED informed the responding officer that this was the first theft allegation made against the facility however a facility file review revealed an additional complaint was filed regarding the theft of another resident’s property on June 23, 2023, and on June 21, 2023, a complaint was filed that alleged a staff member was found digging through a resident’s belongings. A review of facility records revealed, per the facility's Admission Agreement and Health and Safety Code, the facility shall maintain a log (for 12 months) of all reported theft over $25.00 be maintained at the facility however the facility did not produce the record for the Department. Additionally, interviews conducted with facility staff and residents revealed no concerns of theft at the facility nor experienced any of their property stolen while residing at the facility. One Resident interview revealed they heard that another resident had money stolen at the facility but could not recall the Resident's name and believed they were no longer living there. Based on interviews ad records reviews the allegation was determined to be Unsubstantiated. An Unsubstantiated finding means, although the allegation may be valid there was not a preponderance of evidence to prove the violation had occurred. An exit interview was conducted with Zamudio, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided. Signature below confirms receipt of the reports.

Based on R1’s physician’s report dated October 2023, R1 was able to communicate R1’s needs and follow instructions; however, R1 was not able to independently transfer to and from bed. R1 utilized the call pendant when R1 needed help; most of the staff verified that R1 knew how to use the call pendant, but others reported that R1 would forget to use it. R1 had a history of previous falls that had not resulted in any injuries. Interviews with caregivers, medication technicians and resident care coordinator reported R1 received fall-risk checks and status checks. One caregiver reported checking on R1 every fifteen (15) to twenty (20) minutes, whereas other caregivers checked on R1 every one or two hours. Additional staff reported that they would escort R1 to the dining area, placed R1’s walker near R1, and assisted R1 to a recliner, and or bed before leaving R1’s room. On July 20th, 2024, staff checked on R1 between 0600 and 0700 hours and reported R1 was not ready to get up yet. At 0745 hours, the facility’s Resident Care Coordinator found R1 on the floor. R1 reported pain and hitting R1’s head. The care coordinator then summoned emergency medical services and R1 was transported to the hospital for further evaluation. Interviews and review of hospital records confirmed R1 lived at the facility until R1’s fall on July 20th, 2024, when R1 sustained several fractures such as fractured rib, right shoulder and right scapula fracture, right wrist fracture, right clavicle fracture and right elbow fracture. A CT scan of R1’s head and cervical spine showed no evidence of fracture or brain bleed. R1 was later moved to a board and care, after the facility determined they would not be able to meet R1’s needs post fall. A review of R1’s hospice records noted R1 was placed on hospice care on July 22nd, 2024, due to senile degeneration of brain and noted comorbidities as dementia, hypertension, hyperlipidemia, Type II diabetes, gout, deep vein thrombosis, osteoporosis, obesity, venous stasis ulcers. A medical examiner’s report was requested, but there was no autopsy report available. Review of R1’s death certificate noted R1 expired on August 14, 2024, at approximately 0900 hours and R1’s cause of death was senile degeneration of brain, not elsewhere classified. There were no other underlying factors that contributed to R1’s death noted. Several contact attempts were made with R1’s Primary Care Physician (PCP) but were unsuccessful. Contact was made with a source, who assisted with providing information on behalf of R1’s PCP. R1’s PCP had not seen R1 since October of 2023, therefore, the PCP would not have known R1’s most recent mobility/ambulation status pertaining to R1’s falls. (See additional LIC 9099-C for continuation of report.) 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 obtained, R1’s fractures were not the cause of R1’s death. There was insufficient evidence to prove that facility neglected, or did not provide care and supervision to R1 that resulted in R1 falling on July 20, 2024. The allegation was unsubstantiated. An exit interview was conducted with Lopez, to whom a copy of this report, LIC 811 Confidential names list, and Licensee/Appeals Rights (LIC 9058), were provided.

[Continuation of LIC9099] The interview with S1 also disclosed that R1 had requested a cumulative itemized bill dating back to their admission with all itemized fees, to the day of their date of admission. S1 reported during the prior two months from the month the complaint was filed, they had accommodated R1’s request, which was not the standard facility procedure. S1 explained that their billing system was not set up to generate cumulative billing, it required a substantial amount of additional work, and the process was burdensome and time-consuming. A review of facility records, Licensing regulations, and Health and Safety (H&S) code revealed that residents have the right to their records within two days from requesting them, however this included records maintained on file by the facility, and required records per mandate. The records reviews showed that only itemized monthly billing are required, and there were no cumulative bills for residents in care covering the time from admission generated and/or maintained on file. Based on interviews and records reviews, the above allegation was determined to be Unsubstantiated. An Unsubstantiated finding means the standard of evidence was not met to prove there was a violation. An exit interview was conducted with DCS Soto, and a copy of this report and Licensee Appeal Rights (LIC 9058) were left for facility records.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit.  LPA was greeted by and met with Julia Lopez, Executive Director, to discuss the purpose of the visit. Today's visit is in response to a self reported incident regarding Resident 1 (R1). LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Julia Lopez, Executive Director, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22).  Their signature confirms receipt of these documents.

Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to conduct a Case Management visit regarding a Death Report by the Department LPA was greeted by Front Lobbyist Griselda Pacheco, identified herself, then met with Executive Director (ED) Lopez and Resident Service Director (RSD) Baino-Jaimes to whom was explained the purpose of the visit. Today's visit was in response to a Death Report received on December 30, 2024 by Community Care Licensing (CCL) regarding Resident1 (R1). LPA conducted a resident records request and interviewed staff. [See LIC 811 for confidential names]. No deficiencies were cited during today's visit. LPA notified RSD Baino-Jaimes follow up visits and or phone calls are necessary before a determination if a violation had occurred. An exit interview was conducted with RSD Baino-Jaimes and a copy of this report and Licensee/Appeal Rights (LIC9058 01/16) will be provided at the conclusion of the visit. Signature below confirms receipt of the report. LPA left to conduct other time sensitive work related visits during today's Case Management visit.

Interviews with multiple residents residing in the vicinity of R1 did not recall any similar incidents, nor concerns with R1. These residents recalled the gardening crew working in the area but did not have any concerns and mentioned feeling comfortable in their bedrooms. Interviews with several staff members did not recall any similar behaviors from R1 and did not recall other residents reporting any concerns. These staff did not recall receiving any complaints from residents regarding the gardening crew’s work disturbing the residents. An interview with Executive Director Lopez revealed there was an instance when R1 became upset a smoke alarm battery was low and kept chirping. The LPA attempted to interview the staff who was present during this incident on multiple occasions, but the LPA was not successful. An interview with the local Long Term Care Ombudsman office did not reveal any knowledge, nor concerns with R1, nor with the gardening crew disturbing the residents. Based on the information revealed during the investigation, there was not enough evidence to prove the alleged violation occurred, therefore, the allegation was Unsubstantiated. An exit interview was conducted with Executive Director Lopez, to whom a copy of this report, LIC 811, and Licensee/Appeals Rights (LIC 9058), were provided via email. An email read receipt confirms the documents were received by Lopez.

Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct a case management annual continuation visit to continue the annual inspection commenced on December 5, 2024. LPA was granted entry into the facility by Receptionist George Tellez, and met with Executive Director (ED) Julia Lopez to whom was disclosed the purpose of the visit. During today’s visit, LPA Correia, accompanied by ED Lopez, conducted a facility tour. Based on today's continuation of the inspection, no deficiencies are being cited at this time in the areas evaluated. An exit interview was conducted, and this report was discussed with ED Lopez. Copies of the report and Licensee Appeal Rights will be provided at the conclusion of the visit, and her signature on this form acknowledges receipt of the rights and a copy of the report. 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 Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct a case management annual continuation visit to continue the annual inspection commenced on December 5, 2024. LPA was granted entry into the facility by Receptionist George Tellez, and met with Executive Director (ED) Julia Lopez to whom was disclosed the purpose of the visit. During today’s visit, LPA Correia, accompanied by ED Lopez, conducted a facility tour. Based on today's continuation of the inspection, no deficiencies are being cited at this time in the areas evaluated. An exit interview was conducted, and this report was discussed with ED Lopez. Copies of the report and Licensee Appeal Rights will be provided at the conclusion of the visit, and her signature on this form acknowledges receipt of the rights and a copy of the report.

Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Correia met with front lobbyist Griselda Pacheco, identified herself and met with Executive Director (ED) Lopez to whom was explained the purpose of the visit. This facility serves one hundred and eighty-Five (185) residents 60 and above; all may be non-ambulatory. LPA conducted a resident and facility records review. Staff records review verified that all staff records were complete and compliant. Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA conducted a thorough review of In-service training procedures. At this time, due to time constraints the annual inspection will be completed at a later date. An exit interview was conducted with ED Lopez, to whom copies of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. Their signature on this form acknowledges receipt and a copy of the report was given to ED Lopez after the conclusion of the visit.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced case management visit at the facility. LPA gained access to the facility, identified herself, and met with Executive Director (ED) Julia Lopez to whom was explained the purpose of the visit. During today's visit LPA conducted a staff interview and secured resident records. Today's visit was in response to an Incident Report received on November 22, 2024, by Community Care Licensing (CCL) regarding Resident 1 (R1). No deficiencies were cited during today's visit.(See LIC 811 for confidential name). An exit interview was conducted with ED Lopez and a copy of this report and Licensee/Appeal Rights (LIC9058 01/16) will be provided at the conclusion of the visit. Signature below confirms receipt of the reports.

R1 stated that R2 should not be living there since R2 has "dementia." R1 stated that R2 entered R1's room which R1 usually keeps unlocked. R1 stated that R1 yelled from R1's bed "who is it" and R2 responded. R1 stated that R2 is completely "out of it." LPA interviewed R2 who stated that R2 recently moved into the facility and is still unfamiliar with the facility layout. R2 acknowledged having walked towards R1's room due to confusion over room numbers. R2 indicated that the door was slightly open, and R2 called out, but did not actually enter the room. R2 clarified that all interactions occurred at the door entrance. LPA reviewed R2's physician's report which indicated that R2's overall health was fair. Physician's report further revealed that R2 may have slight confusion at times but R2 does not have a dementia diagnosis. LPA interviewed outside agency (OA) who stated that they are familiar with the incident and they conducted their own investigation. OA stated that they determined that R2 was confused due to R2 being new to the facility. OA stated that they also determined that although R2 did approach R1's room R2 never entered R1's room. OA stated that the investigation was then closed. OA stated that they have been working closely with the facility and the executive director who has been doing a great job of making improvements throughout the facility. LPA interviewed Executive Director (ED) who stated that in a community setting it is hard to control residents getting lost. ED stated that R2 accidentally entered R1's room due to confusion and immediately walked out when R2 realized it was not R2's room. ED stated that R2 was new so R2's name was not their door yet which added to the confusion. Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid. An exit interview was conducted with Julia Lopez. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Julia Lopez whose signature below verifies receipt of these rights.

Licensing Program Manager (LPA) Debbie Correia conducted an unannounced case management visit to obtain signatures, and deliver two (2) amended reports. LPA identified herself to, and met with Driver John Rodriguez to whom was explained the purpose of the visit. During the visit, LPA delivered on two (2) amended version of reports originally delivered on September 19, 2024, and obtained signatures. An exit interview was conducted with Driver Rodriguez and copies of this report and Licensee Rights (LIC 9058 01/16) were provided at the conclusion of the visit. Their signature on this form acknowledges receipt of the rights and a copy of this report.

The interview with S1 also revealed transportation on Monday, Wednesdays, and Friday’s are typically reserved for outings, and errands, and Tuesday’s and Thursday are reserved for medical related appointments. Interviews conducted with the Executive Director (ED) corroborated S1’s statement regarding transportation on Monday, Wednesdays, and Friday’s are typically reserved for outings, and errands, and Tuesday’s and Thursday are reserved for physician and/or medical related appointments, and the details of the transport schedule are posted in resident rooms. The interview also revealed that facility staff are flexible with transportation and will accommodate resident's needs when there is a pressing matter. Interviews conducted with S2 and S3 both corroborated S1's statements regarding the facility's transportation systems in place. Interviews conducted with R1, R2, and R3 all revealed no issues with obtaining transportation by facility staff. The resident interviews all concurred the transport driver does a great job and will go out of their way to accommodate transportation for the residents and have not ever encountered an issue with their transportation needs. [See LIC811 for Confidential Names] Based on staff and resident interviews and facility records reviews, the finding regarding the above allegation was established to be unsubstantiated. This finding means although the allegation may have happened or could be valid there is not a preponderance of evidence to prove that the alleged violation occurred. LPA conducted an exit interview with Julia Lopez who was notified a copy of the Complaint Investigation Report (LIC9099) and Licensee Rights (LIC9058). This is an amended version of the original complaint delivered on September 19, 2024.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to obtain signatures on an amended report. During today’s visit, LPA was greeted by the Resident Service Assistant (RSA) Sharmaine Osea, identified herself, and discussed purpose of the visit. During today’s visit, LPA obtained RSA Osea signature on an amended version of a report originally delivered on August 29, 2024. An exit interview was conducted with and a copy of this report and the Licensee Appeal Rights (LIC 9058 3/22) were provided.

An interview conducted with Resident 2 (R2) revealed they have had trouble adjusting the temperature of their AC unit however maintenance was able to fix the issue. An additional interview conducted with Resident 3 (R3) corroborated they have their own unit and can adjust the temperature to their preference. During a facility tour LPA observed individual AC units in residents rooms that have temperature controls for resident use. [See LIC 811 for confidential names] Based upon the information obtained during the investigation it is determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the violation occurred and is therefore UNSUBSTANTIATED. An exit interview was conducted with RSA Osea whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights. (LIC9058 3/22). LPA Correia had to leave the facility and return at a later time to deliver findings.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced case management visit at the facility. LPA gained access to the facility, identified herself, and met with Executive Director (ED) Julia Lopez to whom was explained the purpose of the visit. During today's visit LPA conducted staff and resident interviews and secured records. Today's visit was in response to a Special Incident Report (SIR) received on August 25, 2024, by Community Care Licensing (CCL) regarding an incident that involved Resident 1 (R1) eloping from the facility on the prior day, August 24, 2024. A review of facility records revealed on August 24, 2024, R1 left the facility at approximately 11:15 AM and was found by a neighbor on the community corner who who activated 911 and R1 was picked by the local police department and brought to a family member's home who brought R1 back to the facility at approximately 9:00 PM. [See LIC 811 for confidential names] No deficiencies were cited during today's visit. LPA notified ED Lopez follow up visits and or phone calls are necessary before a determination if a violation had occurred. An exit interview was conducted with ED Julia Lopez and a copy of this report and Licensee/Appeal Rights (LIC9058 01/16) were provided at the conclusion of the visit. Signature below confirms receipt of the reports.

An interview conducted with Staff 2 (S2) revealed residents come to or call the front desk to request transport and S2 will review the calendar to check for availability and put the requesting resident on the calendar. In addition, interviews conducted with residents in care revealed no issues with the transport services at the facility and were aware there is a scheduling system. Resident 2 (R2) also revealed the facility driver does a really good job with accommodating and prioritizing transportation based on the resident’s needs. Interviews conducted with Resident 3 (R3) and Resident 4 (R4) also provided positive feedback regarding the transportation provided at the facility. A review of R1's resident records revealed agreement to the policy that the facility provides transportation however there must be a schedule maintained to meet all requests. A facility records review revealed the calendar was booked the day of August 27, 2024, and corroborated R1 was provided transportation the following day, August 28, 2024. [See LIC 811 for confidential names] Based upon the information obtained during the investigation it is determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the violation occurred and is therefore UNSUBSTANTIATED. An exit interview was conducted with Ashley Baino-Jaimes Resident Service Director (RSD), whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22). This is an amended report of the original report Dated August 29, 2024. During today's visit LPA left the facility and returned at a later time.

(Continued from LIC9099 p.1) Staff interviews revealed that specific canned fruit items such as canned apples and pears were sometimes combined with fresh fruit to accommodate resident chewing and swallowing needs. Resident interviews did not corroborate the allegation, residents informed that the facility offered a variety of fresh fruit and vegetables at each meal. No residents interviewed expressed concern regarding inaccessibility to fresh fruit. Review of facility records revealed invoices of food orders that included fresh kiwi, grapes, pineapple, strawberries, celery, romaine lettuce, bananas, potatoes, spinach, shredded cabbage, and green onions. Records review also showed monthly and daily menus with fresh fruit offerings. During an unannounced facility visit, LPAs directly observed the food supplies, preparation, and meals served to residents. LPAs observed a variety of fresh fruit, including pineapple, cantaloupe, bananas, cut watermelon, sweet potatoes, Russet potatoes, onions, oranges, apples, lemons, limes, shredded carrots, sliced mushrooms, romaine lettuce, celery, and tomatoes. LPAs observed posted signs in two locations of the kitchen advising of the specific fresh fruit to be served each day. LPAs also observed daily menus on dining room tables with the fresh fruit offerings, and a posted monthly menu that also included fresh fruit offerings. Additional records included notes from a monthly meeting between the Director of Culinary services and residents that address fresh fruit offerings and the Licensee's accommodation of such. Regarding resident communication and language barriers, staff interviews revealed that caregivers did not have issues communicating with residents or caring for their needs. No staff interviewed advised of a resident expressing concerns regarding a language barrier with another staff. Residents interviewed did not advise having communication issues with staff; residents informed that staff were friendly and assisted them with their needs with no language barrier. No records were found to corroborate that staff were unable to meet any resident needs due to a language barrier. During an unannounced facility visit, LPAs observed caregiving, housekeeping, and dining room staff communicating with residents. No communication issues were observed. During staff interviews, LPAs observed caregiving, housekeeping, and dining staff to communicate in a way that was understandable and the staff responses indicated that they understood what was being said. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Julia Lopez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Manager (LPA) Debbie Correia conducted an unannounced case management visit to deliver an amended report. LPA identified herself to Receptionist Griselda Pacheco and met with Business Director Kitty Totorica, and met with Business Director Kitty Totorica to whom was explained the purpose of the visit. During the visit, LPA delivered an amended version of a report and obtained signatures. An exit interview was conducted with Business Director Kitty Totorica and copies of this report and Licensee Rights (LIC 9058 01/16) were provided at the conclusion of the visit. Their signature on this form acknowledges receipt of the rights and a copy of this report.

Continued from LIC9099 On January 31, 2024 LPA Domingo interviewed Staff 1 (S1) and S1 provided information regarding plumbing repairs that were completed on January 23, 2024.  S1 stated that an alternative bathroom was provided for residents that needed repairs in their rooms.  S1 stated that the repairs were completed on the same day that the plumbing needed repairs. Outside Source 1 (OS1) was interviewed and stated that OS1 was aware of the repairs that were needed to resident rooms that the plumbers were working on.  OS1 stated that there were rooms available that had no plumbing issues for residents to temporarily use until the repairs were completed.  Resident 2 (R2) was interviewed and had no complaints or concerns regarding the plumbing issue that occurred on January 23, 2024.  R2 stated that the management made the residents aware of the repairs and provided alternative rooms, including bathrooms for residents to utilize during the repairs. Resident 3 (R3) was interviewed and R3 stated that the management informed the residents of the repairs and provided alternative rooms and bathrooms to use during the repairs. Based on interviews, LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Maintenance Director Omar Zamudio, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

R1 was able to ambulate by walking on her own and using a wheelchair on some occasions. A Physician’s Report, interviews with internal and external sources and an observation by the LPA, confirmed R1 was able to ambulate by walking, or using a wheelchair. Initial care plans noted R1 was receiving and being charged for escorting services. Additional care plans and invoices, along with an interview of the administrator, revealed R1 declined the continuation of escorting services due to the additional charge. The facility administrator agreed to remove the charge and service, as R1’s assessments did not indicate a need for such service. Interviews with internal and external sources, including the alleged staff that was present, did not report any concerns regarding lack of assistance from staff. Review of R1’s account history revealed the facility had begun to only charge for basic services, not including escorts or other care, since September of 2023. Based on the evidence obtained, there was not enough evidence to prove the alleged violation occurred, therefore, the allegation was Unsubstantiated. An exit interview was conducted with Executive Director Lopez, and Maintenance Director Omar Zamudio, to whom a copy of this report, LIC 811 Confidential names list, and Licensee/Appeals Rights (LIC 9058), were provided.

It was alleged that staff are not properly addressing pest infestation in the facility. Interviews revealed that they have not seen any ants or silverfish in R1's room or around the facility. Interviews with R1 revealed they saw two ants yesterday, 03/04/2024 and no ants today. LPA observation did not reveal ants on the dresser or on the trash can as R1 stated. There were no dead ants or any trace of ants or silverfish in the bedroom or the bathroom. Interview with R1 also revealed that they believe that if the housekeeper saw the silverfish they would have picked it up. "It was an accident that they missed it". Interviews did not provide supporting information that staff are not properly addressing pest infestation in the facility. It was alleged that the staff did not assist resident in a timely manner. Interviews revealed that the staff assists all residents in a timely manner. Interviews revealed R1 demands that the staff help them right at that moment. Interviews revealed that when the request is made, it will be completed by staff. Interviews revealed all of R1 needs are met and they will ask for assistance and the staff assist them. R1 made a complaint about the ants to the maintenance director about 3 weeks ago and they came right in and put ant bait around the room. Interviews revealed all requests are not of immediate action although R1 treats all request as an emergency. Interviews with other residents revealed the staff are kind and assist them with their needs and they do not have to wait a long time to be helped. There were no complaints of the staff not assisting residents or not being timely. Interviews did not provide supporting information that staff did not assist resident in a timely manner. It was alleged that the staff did not ensure to empty resident’s trash can. Interviews revealed the trash is emptied everyday. Interviews with R1 revealed their trash is emptied daily but sometimes its in the middle of the afternoon. Interviews revealed staff are usually doing their rounds in the am and into the afternoon. Interviews with staff revealed they all have been notified not to knock or go into R1's room until after 10am. Interviews revealed all trash is picked up daily and if a resident request that their trash be emptied again the staff have no problem emptying it again. Interviews did not provide supporting information that staff did not ensure to empty resident’s trash can. 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 upon the evidence gathered during this investigation, insufficient information was obtained to support the allegations of staff are not properly cleaning resident's restroom, staff are not properly addressing pest infestation in facility, staff did not assist resident in a timely manner and staff did not ensure to empty resident’s trash can. The Preponderance of Evidence Standard was not met. As such, the allegations are Unsubstantiated. An exit interview was conducted with Patricia "Kitty" Totorica, Business Director. and a copy of the report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Director, whose signature confirms receipt of receiving the documents.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Julia Lopez, Executive Director, to discuss the purpose of the visit. Today's visit is in response to the self reported incident of second degree burns regarding Resident 1 (R1 - see LIC811 Confidential Names List). LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Julia Lopez, Executive Director, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.

(Continued from LIC9099 p.1) Outside source interview revealed that external investigations have been conducted regarding the resident's laundry service and it was found that staff abide by the housekeeping and laundry schedule. Outside sources did not have concerns regarding laundry service or the resident being provided clean linens. LPA directly observed the bedding in question, and it was observed to be clean with no stains, debris, or odors indicating that it had not been washed. Regarding the allegation, "Staff yelled at a resident", staff interviews did not corroborate the allegation, informing that the staff in question had never yelled at a resident, or any other staff. Staff interview further revealed that a witness was present during the incident in question. LPA interviewed the witness who confirmed that no yelling was done during the incident, and all parties were calm and maintained composure the entire time. Interview with the resident in question did not corroborate the allegation. The resident in question was unable to recall the specifics of the event and informed that the staff member did not yell at them. Outside sources did not corroborate the allegation, informing that the resident in question had a pattern of perceiving that staff yelled at them but they did not. The outside source informed that external investigations have been conducted regarding similar complaints from this resident, and they have been found to be untrue. No records were found that gave evidence to the allegation. During unannounced facility visits, LPA has observed staff and resident interactions. No observations made corroborated the allegation. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Julia Lopez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

It was alleged that the staff does not ensure basic laundry service is provided in a timely manner. Interviews with housekeeping revealed that R1 gets their room cleaned weekly on Wednesdays. Interviews revealed that they clean the floors, toilet, sink and shower to remove excess hair, and they change the bedding about two times a month upon the residents request. Interviews with R1 revealed the staff come in and clean their room. Interviews with laundry attendants revealed that they wash the laundry weekly and for R1 it is on Tuesdays. The residents are supposed to have the laundry ready for the attendant to pick up and take, although interviews revealed R1 does not get their items ready and expect the staff to pick up all of their unclean laundry. There was an incident the other day regarding R1 and unclean rugs and R1 admitted that the staff took the rugs and cleaned them. Interviews revealed that staff needed a bag and gloves to pick up the soiled mats and was going to leave to get bags when R1 offered a few bags to the staff. Interviews did not provide supporting information that the facility does not ensure basic laundry service is provided in a timely manner. It was alleged that the staff mismanaged resident’s medication. Interviews revealed that R1 manages their own medications. Upon LPA observation R1 had all of their medications in their room. Interviews revealed that R1 ordered a refill of an Iron medication and thought it was delivered. R1 asked the staff about the medication and the staff explained to R1 that the medication had not been delivered and if it was, it would have been in their mailbox and delivered to them with the rest of their mail. Interviews with R1 revealed that they contacted Care Mark a mail order services through CVS and they admitted to R1 they messed up and did not deliver the medications although R1 thought they did. Interviews with staff revealed anything that comes in through the mail they put into the residents mailboxes and that they don't open the residents mail so they don't know what the residents are getting in packages. Interviews did not provide supporting information that the facility staff mismanaged resident’s medication Based upon the evidence gathered during this investigation, insufficient information was obtained to support the allegations of unlawful eviction, staff does not ensure basic laundry service is provided in a timely manner and staff mismanaged resident’s medication. The Preponderance of Evidence Standard was not met. As such, the allegations are Unsubstantiated. An exit interview was conducted with Executive Director, Julia Lopez and a copy of the report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Director, whose signature confirms receipt of receiving the documents.

Resident interviews did not corroborate the allegation, residents stated that staff were very gentle and respectful when assisting with their needs. Outside source interview did not corroborate the allegation, providing observations counter to the allegation and informing that staff provided good care to residents. No outside sources verbalized concern regarding resident care at the facility. No records were found to support the allegation. During three (3) unannounced facility visits, LPA directly observed residents being provided care by staff; LPA did not observe any staff member make physical contact with a resident in a way that was unwelcome or harmful. Regarding the allegation, "Staff did not treat resident(s) with dignity", it was alleged that two staff (S1, S5) yelled at and/or spoke disrespectfully to three (3) residents (R1, R2, R6). Interviews with staff revealed that while dynamic issues existed between specific residents and staff, no observations were made regarding staff members speaking rudely to residents or not honoring their dignity. Staff interviews further revealed that the incidents in question were internally investigated by management and did not result in staff being at fault for lack of dignity. Management informed that their investigations revealed lapses in communication, language barriers, and unreasonable/unrealistic expectations by residents. Resident interviews confirmed the staff information of specific dynamic issues, but did not corroborate the allegation; residents stated that staff were respectful and nice when speaking to them. The investigation revealed that the situations in question were related to residents requesting staff to perform duties outside of their job description and being declined. Outside sources interviewed did not corroborate the allegation, advising no concerns with staff treatment of residents. An outside agency investigation for this claim was conducted and resulted in no evidence that the allegation was valid. No records were found to support the allegation. During three (3) unannounced facility visits, LPA directly observed residents receiving assistance from staff, including the staff in question. No observations were made regarding staff speaking to residents in an undignified manner. Based on interviews, direct LPA observations and records review, the investigation did not yield sufficient evidence to conclude that staff handled resident(s) in a rough manner, or that staff did not treat resident(s) with dignity. Based upon the foregoing, the allegations are unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Executive Director Julia Lopez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

and would not pay for the additional care. The resident stated that the facility charged additional fees for “personal care.” Additionally, it was alleged that the facility said R1 made threats to kill relatives in another state. When interviewed, R1 denied making the statements. The facility self-reported the incident. Reporting noted that the facility called 911 because R1 wanted paramedics to check their blood pressure and blood sugar. The records reflect that upon assessment, responding medics checked R1’s vitals and they were normal. Due to the statements made, the facility also called police and a crisis team to evaluate R1. Reporting and statements concluded that R1 refused treatment and denied making the threat. R1 was not hospitalized. Interviews with staff and outside sources indicate that R1 did in fact make the statements. Following the incident, the facility admittedly applied one to one supervision of R1 without the resident’s consent. R1 told the facility they would not pay for the additional care and supervision. LPA conducted interviews and reviewed facility records associated with this incident. Records and interviews indicate that the facility did apply the additional services due to safety concerns for R1. However, records showed that R1 was not charged for the additional services. Additionally, the facility has policy to implement one to one supervision for safety reasons and it’s noted in R1’s Admission Agreement. Outside source interviews reported that R1 held an unrealistic expectation of the service they should be provided by the facility staff. LPA interviewed an outside source close to R1 and assisted R1 in their admission into the facility. The outside source told LPA that R1 became very demanding of them and facility staff. The source did not know but thought it was R1's health conditions were worsening that were causing R1's difficult behavior. At one point, this source asked the facility to remove them as an emergency contact to R1. Based upon the evidence gathered during this investigation, insufficient information was obtained to support the allegations. The Preponderance of Evidence Standard was not met. As such, the allegations are Unsubstantiated. An exit interview was conducted with Director, Lopez and a copy of the report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Director, Lopez, whose signature confirms receipt of receiving the documents.