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32 | Allegation 3: Staff does not ensure facility is free of pests.
Allegation 4: Staff does not ensure facility is free of rodents.
The Department conducted interviews with Staff Members 1–5 (S1–S5), who were asked whether staff ensure that the facility is free of pests and rodents. 5 out of 5 staff members reported that there is an ongoing problem with mice and roaches; however, they stated that an exterminator regularly services the facility by treating, spraying, and baiting both the interior and exterior areas.
The Department also interviewed Residents 1–9 (R1–R9). When asked whether staff ensure the facility is free of pests and rodents, 9 out of 9 residents stated that mice and roaches are present in their rooms and throughout the facility.
During the facility tour, the Department observed mouse traps placed along the outside perimeter of the building. The Department did not observe any roaches, mice, or droppings inside the facility. The Maintenance Director provided invoices from National Exterminator Company for August 2026, documenting services performed on 8/4/2026, 8/6/2026, and 8/10/2026. Each invoice has two check boxes on the bottom left stating the following; “Inspected and treated and needed,” and “No pest activity found at the time of service.” All three invoices have check marks next to “inspected and treated as needed,” indicating that the exterminators had found roaches and rodents during their inspections.
Continued 9099-C |
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32 | The investigation revealed the following:
Allegation 1: Staff does not ensure resident's call button is in good repair.
The Department interviewed staff members 1–5 (S1–S5). Staff were asked whether they ensured that residents’ call buttons were in good repair. 5 out of 5 staff stated that some residents’ call buttons were not working; however, wireless call buttons had been ordered and were delivered on 6/11/2026. When asked how long the call buttons had not been functioning and which rooms were affected, all five staff members reported that they could not identify specific room numbers, or which residents did not have working call buttons.
The Department also interviewed residents 1–9 (R1–R9). When asked whether their call buttons were in good repair, all nine residents reported that their call buttons have never worked.
During the onsite visit, the Department observed wireless call buttons that had been purchased and noted their presence in several rooms during the facility tour. However, when tested, the call buttons were not functioning. The rooms entered and tested were Rooms 1, 2, 14, 26, 76, and 78.
Allegation 2: Staff opens residents’ mail without resident's consent.
The Department interviewed staff members 1–5 (S1–S5) and asked whether staff open residents’ mail without their consent. 2 out of 5 staff members stated that Resident 1’s (R1) mail was opened in error, and R1 was immediately informed that their mail had been mistakenly opened when it was delivered to them.
The Department also interviewed residents 1–9 (R1–R9). When asked whether staff open their mail without consent, R1 stated that their mail had been opened without their permission, and that this was not the first occurrence. Residents 2–9 (R2–R9) stated that their mail had not been opened without their consent.
Continued 9099-C |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
09/25/2026
Section Cited
CCR
87303(i)(1)(A-C) | 1
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7 | 87303(a)Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria:
(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A)Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C)Identify the specific resident living unit.
This requirement was not met as evidenced by: | 1
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7 | The licensee agrees to inspect, repair, and ensure full functionality of all resident call buttons in Rooms 1, 2, 14, 26, 76, and 78, as well as facility wide audit of all call systems. Proof of repairs and functionality check will be submitted to Community Care Licensing by the POC 9/25/2026 |
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14 | Based on observations and interview, on 8/18/2026, LPA tested call buttons in rooms 1, 2, 14, 26, 76, and 78 and noted they were not in working condition, with residents confirming during interviews on 8/18/2026 that their call buttons have never worked. This poses a potential risk to residents’ health, safety and/or personal rights to residents in care. | 8
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Type B
09/25/2026
Section Cited
CCR
87468.1(a)(15) | 1
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7 | 87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (15) To send and receive unopened correspondence in a prompt manner. This requirement was not met as evidenced by:
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7 | The licensee has agreed to provide training to all staff members regarding residents’ rights to receive unopened correspondence. Additionally, the licensee will obtain a signed statement of understanding from each staff member confirming their comprehension of this regulation by the POC date of 9/25/2026 |
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14 | Based on interviews, on 8/18/2026 facility staff stated R1's mail was opened by facility staff in error. This poses a potential risk to residents’ health, safety and/or personal rights to residents in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
09/25/2026
Section Cited
CCR
87411(a) | 1
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7 | 87411 Personnel Requirements -General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, | 1
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7 | The licensee has agreed to hire staff members who are able to communitcate with the residents in care and provide all required trainings to ensure the health and saftey of the residents in care. The licensee will also provide the staff roster and proof of training for all staff members by the POC 9/25/2026 |
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14 | This requirement was not met as evidenced by: Based on interviews, on 8/18/2026 5 staff and 9 residents stated there is a problem with communication among the residents and staff which poses a potential risk to residents’ health, safety and/or personal rights to residents in care.
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Type B
09/25/2026
Section Cited
CCR
87303(a) | 1
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7 | 87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. | 1
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7 | The licensee will contact a licensed pest control vendor to assess, treat, and establish an ongoing pest management plan for all affected areas of the facility, including the kitchen and pantry. The licensee will ensure that all food storage areas remain clean, sanitary, and free of conditions that attract pests, in accordance with Title 22. Documentation of pest control services, corrective cleaning, and the facility’s updated pest management protocol will be submitted to Community Care Licensing by the POC date 9/25/2026 |
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14 | This requirement was not met as evidenced by: Based on interviews, on 08/18/2026 with the staff members and residents they have had problems with pest/rodents and on 8/12/2026 LPM Cifuentes observed roaches in the pantry in the kitchen area.
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