Incident investigation·April 1, 2026

At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived announced, to conduct a pre-licensing inspection due to an ownership change of this currently operating care facility for the elderly. During this inspection, LPA followed up on four SOC341, Report of Suspected Dependent Adult/Elder abuse forms and an incident report. LPA met with Executive Director Zenia Shah and reviewed records. Two of the SOC341 forms and the Incident report were regarding a medication error that occurred on 02/02/2026. LPA spoke with Executive Director about reporting requirements and that an SOC341 was not required for medication errors. The error involved two residents, R1, R2, and them reporting to the medication staff, S2, that they did not receive their medication that morning from the previous medication staff, S1. S2 reviewed the computer system and found the medication was marked as given. An internal investigation was conducted and discovered S1 did not give the medication but marked it as given in the system. The physician was notified and authorized the medication to be given, even though it was past the normal time. Facility conducted additional training for all medication staff to refresh procedural knowledge and additional audits were put into place to ensure medications are given as ordered. ***This is a repeat violation in a 12 month period. An immediate civil penalty is being issued in the amount of $250.*** An SOC341 was submitted regarding Resident, R3, leaving the building without staff escort and assaulting staff. LPA reviewed records and interviewed staff and observed R3 left the memory care door and entered the outside courtyard. Staff observed R3 in the courtyard and immediately followed R3 and requested they come back inside. Staff had visual line of sight with resident during this incident. The door leading to the courtyard has an audio alert device, but the volume was low. Facility maintenance is working to increase the alert volume. Continued on LIC809-C... An SOC341 was submitted regarding Resident, R4, telling staff, S3, that a caregiver, S4, had grabbed them and pushed them toward the bed, then left the room. The facility conducted an investigation and found that throughout the day, R4, told staff a different story, including that staff were throwing the children against the closet doors. The investigation showed that R4 would describe the caregiver they saw last as the perpetrator of each incident. 02/20/2026 at approximately 12:00PM, R4 used their call button to summon staff and when staff entered, R4 immediately stated "Ow, your're hurting me!" Staff did not enter the room and immediately notified their supervisor of the situation. R4 was examined and no signs of abuse were found. Care plan was updated to ensure 2 staff are present at all times when assisting R4. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Zenia Shah and Appeal rights were given.