Bentley Suites.

The investigation revealed the following: Allegation: Licensee did not maintain the liability insurance coverage requirements It is being reported that this facility does not have the proper liability insurance that is required. On 4/7/26, LPA Felisa Shirley reviewed the Certificate of Liability Insurance provided for Bentley Suites. Per the certificate, the effective date of coverage is 08/26/2025 thru ending date of 8/26/2026. This certificate indicates the coverage of limits one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate. However, this certificate states that this policy has sublimit in the categories of Bed Sore & Elopement, with 100,000 per occurrence and 300,000 being the maximum. A copy of the full Professional and General Liability Insurance Policy for Residential Care Facility was requested and received by the department on 3/30/2026. Per the full policy, one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate are covered, but there is a 10,000 deductible as well as sublimit of $100,000 per claim and 300,00 per yearly occurrence in the categories of Physical and Sexual Abuse, Elopement, Bedsores, Fall Hazards and an added Medical Payment Sublimit of $5,000 per claim, meaning this policy does not provide the required coverage of one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate for this facility. LPA interviewed staff 1 and staff 2 (S-1 and S-2). Of those interviewed 2 out of 2 denied the allegation. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. A deficiency is being issued and an exit interview is conducted with Muriel Cabacungan, Assistant Administrator. A copy of this report and appeal rights were provided.

The investigation revealed the following: Allegation: Licensee did not maintain the liability insurance coverage requirements It is being reported that this facility does not have the proper liability insurance that is required. On 4/7/26, LPA Felisa Shirley reviewed the Certificate of Liability Insurance provided for Bentley Suites. Per the certificate, the effective date of coverage is 08/26/2026 thru ending date of 8/26/2026. This certificate indicates the coverage of limits one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate. However, this certificate states that this policy has sublimit in the categories of Bed Sore & Elopement, with 100,000 per occurrence and 300,000 being the maximum. A copy of the full Professional and General Liability Insurance Policy for Residential Care Facility was requested and received by the department on 3/30/2026. Per the full policy, one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate are covered, but there is a 10,000 deductible as well as sublimit of $100,000 per claim and 300,00 per yearly occurrence in the categories of Physical and Sexual Abuse, Elopement, Bedsores, Fall Hazards and an added Medical Payment Sublimit of $5,000 per claim, meaning this policy does not provide the required coverage of one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate for this facility. LPA interviewed staff 1 and staff 2 (S-1 and S-2). Of those interviewed 2 out of 2 denied the allegation. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. A deficiency is being issued and an exit interview is conducted with Muriel Cabacungan, Assistant Administrator. A copy of this report and appeal rights were provided.

During a subsequent visit conducted on 04/08/2025, the department inspected R1's room, interviewed Staff S1, and interviewed Residents R2 and R3. On 04/01/2025, the department received a copy of the Kaiser Permanente medical records for R1’s 01/17/2025 hospital admission. The investigation revealed the following: Allegation: Facility is in disrepair The allegation alleges the elevator at the facility is not operational. During record review, LPA received and reviewed a service contract for a new company, Liftech Elevator Services, INC., (Dated 01/27/2025, 03/10/2026 ) . During the visit, LPA observed the lift to the second floor was not operating. LPA observed activities being provided on the first and second floor. Additionally, LPA observed staff taking trays of food up to the second floor for lunch. During interviews with Staff S1, S3-S4, were asked if the wheelchair lift is working properly, three (3) out of three (3) stated the lift has not been working since they returned from the evacuation. Additionally, S1, S3-S4, were asked how residents on the second floor are accommodated while the life was not operational, three (3) out of three (3) stated additional activities are provided on the second floor, and meals are taken to the residents on the second floor. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on observations, records reviewed and interviews, the preponderance of evidence standard has been met, therefore the above allegation Facility is in disrepair is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D. Deficiencies were issued and plans of corrections were discussed on LIC9099D. Note: *Citations that are not cleared by the POC due date of 04/03/2026 will have a $100 fine assessed for each day the citation is not cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. An exit interview was conducted with Muriel Cabacungan, Assistant Administrator, and a hard copy of this Complaint Investigation Report was provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 During a subsequent visit conducted on 04/08/2025, the department inspected R1's room, interviewed Staff S1, and interviewed Residents R2 and R3. On 04/01/2025, the department received a copy of the Kaiser Permanente medical records for R1’s 01/17/2025 hospital admission. The investigation revealed the following: Allegation: Resident sustained unexplained fracture resulting in hospitalization. The allegation alleges a resident was experiencing pain and when transferred to the hospital was diagnosed with a hip fracture. On 01/08/2025 the facility received orders from Los Angeles County officials to immediately evacuate due to Pacific Palisades fires. On 01/09/2025 R1 was picked up by family to stay with until the evacuation order was lifted. During interviews with Staff S1 and S2, stated R1 was not experiencing unusual pain prior to leaving the facility. During an interview with W1 stated when R1 was residing with them, R1 would scream and complain when attempting to use the restroom. Additionally, W1 stated R1 did not experience a fall while staying with them. On 01/15/2025, R1 returned to the facility and was assisted to their room. On 01/16/2025, staff S1 and S2 stated R1 would complain of pain when asked to move. Staff notified R1’s family and Witness W4, who came to the facility. R1 was transferred to Kaiser Permanente Medical Center to get medically evaluated. The medical records from Kaiser Permanente Medical center (01/17/2025) confirmed R1 was diagnosed with a right intertrochanteric femur fracture and right hip osteoporotic fracture. It was also noted R1 has a history of the following conditions: Osteoarthritis, spinal stenosis, moderately advanced degenerative changes of the lower lumbar spine and facets, with central canal stenosis at multiple levels, most prominent at L2-3 and L4-5, Neural foraminal narrowing predominately at L4 prominent at L5 and a previous left femur trochanteric hip fracture that was sustained back in 2023. Based on interviews conducted and records review, there is not enough evidence to place where and when R1 sustained a fall that would have caused the fracture. There is no evidence to support that the fall occurred at the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Resident sustained unexplained fracture resulting in hospitalization. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated Report Continued On LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Resident sustained multiple falls due to lack of supervision. The allegation alleges that a resident has experienced multiple falls due to lack of supervision. During the facility inspection, LPA observed sensors on R1’s floor in their room that notify staff when R1 attempts to or gets up. LPA observed a sensor pad on R1’s bed that notifies staff if R1 gets up. During record review, LPA received and reviewed Unusual Incident /Injury Reports for R1 dated 02/28/2024, 11/30/2024 and 01/02/2025, that report R1 was found on the floor in their room. In the Unusual Incident Report dated 01/02/2025, stated R1 was found on the floor, staff immediately assisted and checked for any visible injuries. Vitals were checked and were stable and there were no complaints of pain. Medical care was rendered immediately, and proper notifications were made. LPA received and reviewed R1’s Kaiser Permanente discharge paperwork dated 01/27/2025, that lists current medications for R1 is taking. Upon conducting research of the medication, LPA observed four (4) out of four (4) of the Continue taking medications have a side effect that may cause dizziness, lightheadedness, or fainting when getting up from lying or sitting position. One (1) out of four (4) medications may cause an increased risk of bone fracture of the hip, wrist, and spine, more likely to occur if over the age of 50. One (1) out of the four (4) may cause trouble with controlling body movements, which may lead to fall and fractures. During interviews with Staff S1-S4, stated R1 is considered a high risk for falls and precautions are taken such as rounds are conducted every 30 minutes and sensors have been placed in R1’s room to alert staff if R1 gets up unassisted. During interviews with Witness W4, who is a Registered Nurse and has been working with R1, denied witnessing any type of neglect/ lack of care on behalf of the facility staff. During interviews with Resident’s R2 and R3, two (2) out of two (2) stated staff are constantly checking on residents to see if they need anything and assistance is provided immediately. Additionally, Resident’s R2 and R3 stated they have not witnessed any type of neglect or lack of care and do not have any issues or concerns regarding the level of care provided by the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Resident sustained multiple falls due to lack of supervision. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated . No citations were issued. An exit interview was conducted with Muriel Cabacungan, Assistant Administrator, and a hard copy of this Complaint Investigation Report was provided.

On 7/9/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced annual comprehensive inspection. LPA was greeted by staff Maricar Hernandez. LPA explained the purpose of the visit and was granted access to the facility. Belen Taico Administrator arrived around 11:15AM and joined the visit. LPA conducted a tour of the facility, there were no obstructions inside or outside. LPA reviewed four (4) staff files, four (4) resident files with all required documents and certifications. LPA conducted an audit of four (4) residents’ medications, found no discrepancies. Last fire/Disaster drill conducted 5/16/25. LPA observed a 5-day supply of perishable & 7-day supply of non-perishable food items stored properly. LPA observed residents’ rooms and bathrooms, which appeared clean and operational, with required furnishings and lighting. Based on observations made during today’s visit, a citation was issued for violating the residents’ rights by having a surveillance camera in Resident 1 (R1) room. An exit interview was conducted, and this report was discussed and provided to Muriel Cabacungan- Hernandez at the conclusion of the visit with appeal rights.

Allegation: Staff refused to provide resident’s authorized representative copies of resident’s files. The allegation alleges that a written request was submitted on March 5, 2025, and the facility was contacted multiple times with the request, and the documents have not been provided. During the facility inspection, LPA observed resident file stored in the office. For residents who have moved out or have passed away the files were observed in a locked file cabinet in a second-floor storage room. During record review, LPA reviewed R1’s Admission Agreement that includes Personal Rights in Privately Operated Residential Care Facilities for the Elderly that states on number 21 that residents have the right “To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies.” Additionally, LPA received copies of emails between the Administrator and R1's Representatives offices indicating Invoice Ledgers for R1 were sent. LPA reviewed a letter dated 03/05/2025, that requests “a copy of all writings related to R1 within your care, custody and control. Copies shall include all “resident records’ for R1.” During interviews with Staff S1-S4, were asked if resident R1 was provided with documents requested, four (4) out of four (4) stated yes, R1 was provided with the documents from their file when they moved out. Additionally, S1 stated they emailed the Invoice Ledgers for R1 to the requesting person who is a representative for R1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 During interviews with Residents R2 and R3, were asked if there was a time they requested a document and did not receive it in a timely manner, one (1) out of two (2) stated they are provided with the documents right away. Additionally, one (1) out of two (2) stated they have not requested documents from the facility. During interviews with Residents R4-R6’s responsible parties W1-W3, were asked if when they have requested documents from the facility if they received them in a timely manner, three (3) out of three (3) stated they have had no issues and received them right away. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Administrator Assistant, Muriel Cabacungan, and a copy of this report and appeal rights were provided.

Investigation revealed the following: Regarding the Allegation, "Staff did not provide copies of resident's file to authorized representative". It has been alleged that on March fifth of the year 2025 (03/05/25) a formal letter was dispatched to Bentley Suites requesting photocopies of all documents pertinent to their client, R1, and that the authorized representative (AR) had not received any response. On 03/28/25 L PA conducted record review of communications from the AR of R1 to the facility. The communications record were listed as follows: at least four (4) electronic communication attempts (e-mail) from AR to the facility betw een the dates of 03/05/25 - 03/25/25. On 04/03/25 between 09:45AM and 10:45AM, LPA interviewed three (3) residents (R2-R4). R1 was not available for LPA interview. All three (3) residents (R2-R4) disagree with the allegation. On 04/03/25 between 11:00AM and 12:40PM, LPA interviewed two (2) staff (S1-S2). Both interviewed staff (S1-S2) stated that one witness (W1) has received all documentation of R1, as requested, and that W1 has signed R1's emergency ID as reception of documentation of R1 (dates unknown). S1 and S2 have confirmed they had not received electronic messaging from R1's authorized representative (AR). Staff three (S3) was not available for LPA interview. On 04/03/25 between 12:57PM and 1:07PM, LPA interviewed one witness (W1). W1 has stated that they had only received a paper clipped stack of paperwork pertaining to R1, for W1 to bring to R1's new care facility and that R1's AR had not received any response from the facility. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated . California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC9099-D. One deficiency has been cited, see LIC9099-D. An exit interview was held with staff one, Muriel Cabacungan (S1). A copy of this report, the deficiency cited, and facilities' appeal rights have been provided to Muriel Cabacungan (S1).

On 10/10/2024, at 10:15PM Licensing Program Analyst (LPA) Troy Watson conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Assistant Administrator Muriel Cabacungan. LPA Troy Watson explained the purpose of today’s visit. Facility is licensed for (44) non-ambulatory residents and (4) bedridden residentS. The facility has an approved hospice waiver for (15) residents.The facility consists of (22) resident bedrooms, (22) bathrooms, (1) living room, (1) dining room, and (1) kitchen and one laundry area. LPA Watson toured the physical plant with the Assistant administrator. There were no bodies of water or obstructions on the premises. A total of (22) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected the carbon monoxide detector and found that it wase in operable condition. The water temperature properly measured between: 114°F and 116°F, between the bathrooms and in the kitchen. Evaluation Report Continues LIC 809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA Troy Watson observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed. Sharps objects and cleaning agents were locked and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available at the property. All fire extinguishers were charged and were operable. A review of (7) residents' service files, (5) staff personnel files were reviewed. LPA checked (7) Medication Administration Records (MAR) and no discrepancies were found. The first AID kit was checked and contained the correct manual. Last facility disaster drill was held in August 2024. LPA observed the facility's infection control practices. And a copy of the liability insurance was on file. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Muriel Cabacungan.

Interviews revealed that 4 out of 11 staff, one witness and one (1) out of 3 residents have agreed with the allegation. Record reviews revealed that communications between an elevator service company and the above-mentioned facilities' Administrator (S5) have been in contact between the dates of 06/15/2024 and 06/28/2024 to repair the lift. Based on record reviews, LPA's observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated . California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D. An exit interview was conducted with Muriel Hernandez Cabacungan, Assistant Administrator (S1), and a copy of facilities’ appeal rights and this report has been provided.

Regarding Allegation #1 : Staff did not provide adequate supervision resulting in residents wandering away from facility. This complaint alleged that R1 wandered away from the facility. LPA Calderon interviewed with A1. A1 stated that on 07/26/2022 R1 followed a guest out the front door of the facility at 1 pm. Staff searched for R1 when unable to locate inside the facility and then called 911. According to the police report #22-76564, R1 was found blocks away from the facility and was unharmed. LPA Calderon interviewed with S1-S3. 3 out of 3 staff admitted that R1 did wander away from the facility on 07/26/2022 and was recovered with no injuries in tack. facility. LPA Calderon interviewed with R1-R3. R1 was not able to answer any questions due to health condition. R2-R3 acknowledged that R1 did wander away from the facility due to the failure of staff supervision. On 11/02/2023 LPA Calderon reviewed the physician’s report (dated 03/07/2022) for R1. The report indicated R1 has a wandering behavior and requires observation and supervision. Regarding Allegation #2 : Resident has lost significant amount of weight while in care. This complaint alleged R1 lost a significant amount of weight while in care. LPA Calderon interviewed with A1. A1 stated that R1’s weight on 03/07/2022 was 136 lbs. and that R1 lost 15 lbs. A1 stated that staff did not keep track of R1’s weight, but that A1 had called R1 sister to advise that the facility would need a new doctor’s order regarding R1 weight. A1 stated there were no responses from the R1 family for the new doctor’s order. A1 claimed that the weight loss was not due to overmedication of quetiapine. LPA Calderon interviewed with S1-S3. 3 out of 3 staff stated that most residents lose some weight until they get familiar with the facility and food and then usually gain weight. 3 out of 3 staff stated that R1 did lose some weight which is normal for a new resident. LPA Calderon interviewed with R1-R3. R1 was not able to answer any questions due to health condition. R2-R3 stated that new residents usually must get used to the food and lose some weight. R2-R3 reported that they also lost some weight at first but gained weight after getting used to the food being served. On 11/03/2022 reviewed food log notes (dated September 2022) for R1. The percentage of food consumed by R1 is logged in the log. It appears R1 ate 90% of his breakfast, 50% of his lunch, and 10% of his dinner. There were no logs of any changes to R1 weight. 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 interviews, observations, and supporting documents. The preponderance of evidence standard has been met; therefore, the allegation of Staff did not provide adequate supervision resulting in residents wandering away from the facility. Residents have lost a significant amount of weight while in care” is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citations issued (ref LIC9099D). A face-to-face meeting was conducted with Administrator Robin Aquino, and a hard copy was provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding Allegation #1 : Resident fell while in care resulting in injuries. This complaint alleged that R1 fell outside the facility and had bruising to R1’s face and a cut above the left eye. LPA Calderon interviewed with A1. A1 stated that there is no medical report or incident report regarding bruising to R1’s face or a cut above R1’s left eye. LPA Calderon interviewed with S1-S3. 3 out of 3 staff stated that R1 was not injured while inside the facility. 3 out of 3 staff do not recall R1’s having bruises or a cut above R1’s left eye. LPA Calderon interviewed with R1-R3. R1 could not answer any questions due to R1's health conditions. R2-R3 states that R2-R3 has not seen R1 fall and that R2-R3 had not fallen or been injured from any incident. On 11/02/2023 LPA Calderon reviewed incident reports (dated 7/26/2022 to 11/09/2022). The incident report (dated 7/26/22) revealed that R1 left the facility and was found by the police safe and not injured. There is no incident report or medical report that states R1 was injured inside the facility. Regarding Allegation #2 : Staff is mismanaging residents’ medication. This complaint alleged staff are over-medicating R1 with quetiapine. LPA Calderon interviewed with A1. A1 stated that the staff did not overmedicate R1 with quetiapine and that the staff gave medication to R1 only as prescribed by doctors’ orders. A1 stated that if the staff had overmedicated R1 with quetiapine R1 would not have wandered away from the facility on 07/26/2022. LPA Calderon interviewed with S1-S3. 3 out of 3 staff reported that R1 is given medications 2 times per day usually before mealtime. 3 out of 3 staff stated that the med-tech administers the medication and will document the Medication Administration Record (MAR) for R1. LPA Calderon conducted an interview with R1-R3 for this complaint. R1 was not able to answer any questions due to R1’s health condition and was unable to carry on a conversation. R2-R3 reported that staff gives medication 3 times per day and residents have noted that staff updates their records on what medication is given to a resident. On 11/02/2023 LPA Calderon reviewed the Centrally Stored Medication and Destruction record (dated 06/01/2022 to 10/10/2022) for R1. Quetiapine 25 mg, 1 tablet daily, 3 refills, there was no change in medication strength observed. 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 Regarding Allegation #3 : Staff did not seek medical attention for residents in care. This complaint alleged staff did not seek medical attention for resident in care. LPA Calderon interviewed with A1. A1 stated that staff take care of residents’ medical needs. A1 stated that staff give medical attention to all residents and if residents need help there are staff to take care of residents’ needs. A1 stated that there are no medical or incident reports to suggest R1 was injured inside the facility. LPA Calderon interviewed with S1-S3. 3 out of 3 staff reported that all staff provided the best care and medical attention possible for each resident. 3 out of 3 staff claimed that if a resident is injured staff will seek medical attention right away. LPA Calderon interviewed with R1-R3. R1 was not able to answer any questions due to health condition. R2 expressed that R2 is independent, but that stuff is there if R2 requires medical attention. R3 claimed staff are attentive and if the call button for assistance is activated, the staff provides immediate attention. On 06/08/2023 LPA Calderon and S1 toured the facility. It was identified by LPA Calderon that staff members assisted various residents with medical problems, cleaned beds, and answered the call button whenever it was used. Regarding Allegation #4 : Facility did not notify residents responsible party of an accident in a timely manner. This complaint alleged facility did not notify residents responsible party of an accident in a timely manner. LPA Calderon interviewed with A1. A1 stated that there were no medical or incident reports noting any injuries to R1. A1 claimed that if R1 or any other resident was injured staff does call the resident family members to update the resident family on status. A1 claimed that R1 was not injured, and no call was made to authorized representatives. A1 indicated that when R1 wandered away from the facility on 07/26/2022, a staff and A1 called R1's family to update them on R1's status. LPA Calderon interviewed with S1-S3. 3 out of 3 staff stated that S1-S3 are fully trained and are mandated reporters. As mandated reporters, any injuries must be reported timely to the administrator. This includes reporting to family representatives when an incident occurs. LPA Calderon interviewed with R1-R3. R1 could not answer any questions due to health condition. R2 expressed being independent and able to handle their own daily needs. R3 reported that family representatives are given status as required. On 11/02/2023 LPA Calderon reviewed incident reports for R1 dated 07/26/2022 to 11/09/2022. LPA Calderon observed staff reported the incident to the R1 family timely. 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 Regarding Allegation #5 : Staff use zip ties to lock facility gate. This complaint alleged staff used zip ties to lock the facility’s front gate. LPA Calderon interviewed with A1. According to A1, residents from this facility live together without being segregated including some who are independent and some who require assistance with daily living activities due to memory loss. A1 stated that at no time has staff used any type of zip ties to secure the front door to the facility. A1 claimed that before R1 wandered from the facility on 07/26/2022 the front door had a normal lock. A1 stated that at no time did staff put a zip tie on the front door. A1 reported that since 07/26/2022 the facility’s front door has a security code that only staff knows to prevent residents with wandering behavior from leaving the facility. LPA Calderon interviewed with S1-S3. 3 out of 3 staff denied ever using zip ties to secure the front door. 3 out of 3 staff reported that the front door currently has a security code to prevent residents with dementia from leaving without staff assistance. LPA Calderon interviewed with R1-R3. R1 was not able to answer any questions due to health conditions. 2 out of 2 residents stated that they have never observed a zip tie used on the front door, but since 07/26/2022 maintenance changed the front door with a security passcode. 2 out of 2 residents claimed that some residents have dementia, and the

Licensing Program Analyst (LPA) David España is conducting a case management-other visit due to LPA observations on 12/13/2023 deficiencies not related to a complaint that is being investigation today. (Control # 11-AS-20231205153025) LPA met with S#1 who assisted with visit. Upon arriving at the facility, LPA met with S#1 and S#2 who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct inspections. On 12/13/2023 Licensing Program Analyst (LPA) David España confirmed there were Thirty-Six (36) total residents in care. LPA confirmed there are Ten (10) total staff employed as of 12/13/2023. LPA confirmed there is only One (1) resident in care who receives oxygen as of 12/14/2023. LPA confirmed there are Six (6) total staff working at the time of visit 12/14/2023. LPA confirmed there are Twenty-Two (22) total residents in care with dementia at the time of visit 12/14/2023. LPA confirmed there are Twelve (12) total residents in care with wheelchairs at the time of visit 12/14/2023. LPA confirmed there are Seventeen (17) total residents in care with diapers at the time of visit 12/14/2023. The LPA also reviewed the following documents provided by Muriel Cabacugan Assistant Administrator (S1): Staff roster and Client roster. Observation on 12/13/23 at 10:25am made while conduction a walkthrough of the physical plant, LPA observed Room #16 and Room #15 front doors and Room walls with large holes in the drywall that needs maintenance. LPA and S#1 observed Room #3 window bathroom screen missing. LPA and S#1 observed bathroom window not working (did not stay on its track). LPA and S#1 also observed Room #14 and Room #13 had a strong urine odor in both rooms. LPA and S#1 observed private room #12 missing window screen next to the bathroom. LPA and S#1 observed outdoor walkways with materials with little accessibility towards exit of facility (back of facility). LPA and S#1 also observed materials with little accessibility entering the laundry area towards side of facility. Continued on LIC 809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA and S#1 observed during tour observed front and side of facility, and the left-hand side of the facility, noted overgrown grass with no access to the length of the facility. LPA and S#1 noted debris and yellow overgrown grass. LPA interviewed S#1 about access to the side of facility, and S#1 stated there was no door access to the area. LPA noted that flammable grasses blanketed the side of the facility. Lastly, LPA and S#1 observed in the front yard with overgrown plants. LPA and S#1 toured the back side of the facility and noted that the trash bins were not closed. LPA and S#1 observed flies and insects within the facility. LPA and S#1 additionally noted pigeons and pigeon cages within the facility. The following deficiency is being cited in accordance with California Code of Regulations, Title 22, Division 6 Chapter 8 Article 05. Physical Environments and Accommodations 87303 (a-e) Maintenance and Operation and Title 22, Division 6 Chapter 8 Article 05. Physical Environments and Accommodations 87303(f) (1-2) Maintenance and Operation on the LIC 809D. Exit interview was conducted with facility representative and appeal rights as well as report was provided.

On 11/04/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with care staff Hazel Luguevarra. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to serve (44) non-ambulatory elderly residents of which (4) may be bedridden ages 60 and above. The facility is approved for (15) hospice residents. Currently, the facility has (5) hospice residents. Rooms #1, #3, #4, and #5 are cleared for bedridden residents. The facility is a two-story structure located in a residential neighborhood. It consists of the following: (22) resident bedrooms. Each room has a bathroom in the room, an activity room, dining room, a kitchen, storage closets, an administrative office, and an open patio area. LPA toured the physical plant. There were no bodies of water on the premises. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #1, #2, #7 #10, #17, and #19. Bathrooms were operational. A comfortable temperature was maintained in the facility at 72 - 74 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguishers were fully charged, and smoke detectors and carbon monoxide were operable in each resident's room. The facility has a certificate of liability insurance effective 08/26/23 - 08/26/24. The facility is current on annual license fees. (Evaluation Report continues LIC 809-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The facility maintains for each resident Centrally Stored Medication Destruction Record and PRN Log. LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA conducted an audit of resident #1-#6 (R1-R6) service files, and staff #1-#6 (S1-S6) personnel files were in maintained in place. LPA conducted (2) residents and (2) staff interviews. DEFICIENCIES: During resident file review between 11:30 AM - 12:15 PM, resident #4 is identified as bedridden in room #7 is in a room not cleared for bedridden. - Type A (Civil Penalty) Hot water temperature for rooms #1 & #2 ranged at 161.2-165.9 at 12:34 PM. - Type A Furnishing of bed mattress, wheelchair, and other furniture obstructing passage way adjacent to room #10 at 12:45 PM. - Type A Bathroom baseboards were rusted and filled with mold in room #19 at 12:47 PM. - Type B Open powder bleach found under bathroom sink in room #7 accessible to residents in care at 12:53 PM. Type A Facility has not conducted a quarterly fire drill consistently. Last drill was performed June 2023. - Type B According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D). An exit interview conducted with Hazel Luguevarra, and a copy of the report and appeal rights provided. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *