Incident investigation·October 3, 2025

On 10/3/2025 at 9:00AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit in regards to a self report incident received on 9/24/2025. LPA met with Operations Specialist, Dimple Kamdar and explained the reason for the visit. Based on the report received on 9/24/2025, it is alleged that S1 and S2 are abusing residents. It is also alleged that S2 and S3 are not providing adequate care to residents. Executive Director (ED) Theresa Truong was also suspended for failure to escalate the alleged incidents of abuse. ED has since been terminated. During visit, LPA requested copies of S1-S3 personnel record including but not limited to any and all disciplinary actions/ write ups, most recent training records, job positions held, schedules for all of 2024 and 2025; Records of all staff for 2024-2025, staff schedules, all write ups related to care; Transcripts of the allegations of abuse made by an anonymous caller, ED full termination record. During the visit LPA observed residents room floors dirty and bathrooms unclean with dry fecal matter on the toilet in room 11. Operations Specialist states that they are actively looking for a new maintenance and house keeping. LPA also observed that there are not enough caregivers on shift. On 10/3/2025 there were 3 caregivers available, five out of twenty-three residents require a two person assist, facility states they are also hiring more care staff. LPA also observed facility common area/ activities area furniture (ie chairs and couches) in disrepair and damaged. LPA will cite for the deficiencies observed today on return visit. Exit interview conducted. A copy of this report provided.