Health inspection·May 16, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few supervision with functional mobility (a person's ability to move safely and independently within their environment) such as turning left and right in bed, transferring from sitting to standing position, and transferring from bed to chair. During a review of Resident 1's Nursing Progress Notes (PN), dated [DATE], timed at 3:40 AM, Licensed Vocational Nurse (LVN) 2 indicated at 11 PM, there was a female visitor (unknown) in Resident 1's room. The PN indicated at 11:10 PM, the visitor was crying, and LVN 2 asked the visitor to leave the facility due to, suggested visiting hours are over. The PN indicated at 11:15 PM, Resident 2 (Resident 1's roommate) informed LVN 2, someone [was] in [Resident 1's] room [and] was using [Resident 1's] phone and talking to [Resident 1]. The PN indicated at 11:38 PM, Family Member (FM) 1 arrived at the facility inquiring who had visited Resident 1. The PN indicated at 12:28 AM, Police Officer 1 arrived at the facility and spoke to Resident 1 about the unknown visitor. The PN indicated at 3:30 AM, FM 2 requested to take Resident 1 home. During a review of FM 1's written notification to the facility, dated [DATE] at 3:34 AM, the notification indicated FM 1 notified the facility of FM 1's decision to remove Resident 1 from the facility due to an incident where a stranger was allowed into [Resident 1's] room, compromising not only [Resident 1's] safety but also the safety of other patients in the facility. 2. During a review of Resident 2's AR, the AR indicated the facility originally admitted Resident 2 on [DATE] with diagnoses that included DM 2 and hypertension (high blood pressure). During a review of Resident 2's H&P, dated [DATE], the H&P indicated Resident 2 did not have memory loss and had the capacity to make medical decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills were intact. The MDS indicated Resident 2 did not experience hallucinations or delusions. During an observation on [DATE] at 5:05 AM of the facility's main entrance, there was one security camera on the edge of the building facing the facility's parking lot and the front main entrance door. The facility's main entrance door was locked, and no receptionist was observed at the front desk. There was a doorbell at the front of the facility, the doorbell was pressed and was working. During an observation on [DATE] at 6:16 AM in the facility's lobby, Resident 1's room was the first immediate room past the double doors located in the first hallway and to the left side of the lobby. During an interview on [DATE] at 7:27 AM with the Administrator (ADM), the ADM stated, there was a security camera monitoring the main front entrance door that all facility staff and visitors must use to enter and exit the facility. During a concurrent observation and interview on [DATE] at 9:55 AM, with Resident 2, in Resident 2's room. Resident 2 stated, Resident 1's bed was located across from Resident 2's bed. Resident 2 stated there was an unknown visitor on [DATE] who visited Resident 1 around 11 PM. Resident 2 stated, Resident 2 felt unsafe because the facility was not aware how the unknown visitor entered the facility. Resident 2 stated, as the conversation between the stranger and Resident 1 continued, Resident 2 realized Resident 1 did not know the stranger. Resident 2 stated Resident 2 saw the back of the unknown visitor's head who stood at the foot of Resident 1's bed. Resident 2 stated, the unknown visitor had long black hair, was young, and was tearful while interacting with Resident 1. Resident 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555107 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Care Center 3541 Puente Avenue Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated, Resident 2 heard Resident 1 tell the unknown visitor Resident 1 was not sure if Resident 1 knew the unknown visitor because Resident 1 did not remember the unknown visitor. During an interview on [DATE] at 11:02 AM with FM 2, FM 2 stated, FM 2 received a phone call from Resident 1 on [DATE] after 11 PM. FM 2 stated, when FM 2 answered the phone call, FM 2 heard someone crying horrifically and FM 2 thought [Resident 1) had died. FM 2 stated, FM 2 spoke to Resident 1 on the phone and Resident 1 told FM 2, I do not know who was the unknown visitor. FM 2 stated FM 2, I do not recognize the [unknown visitor's] voice. FM 2 stated, the unknow visitor said, it was not important, and it does not matter where [Resident 1 and the unknown visitor] met when FM 2 asked what the unknown visitor's relationship to Resident 1 was. FM 2 stated, Resident 1 told FM 2 the same nurse who brought the unknown visitor into Resident 1's room escorted the unknown visitor out of the room. FM 2 stated, I was worried for [Resident 1] because [the facility] let someone [unknown visitor] come in [the facility] unannounced. During an interview on [DATE] at 12:41 PM with Certified Nurse Assistant (CNA) 2, CNA 2 stated, the main entrance doors were always locked. CNA 2 stated, if there were visitors during the night shift, the visitors needed to ring the doorbell and the charge nurse, should be aware of who is coming in the facility. During an interview on [DATE] at 12:53 PM with FM 1, FM 1 stated, FM 1 received a phone call from FM 2 on [DATE] after 11 PM, and FM 2 stated there was an unknown visitor in Resident 1's room who was crying over the phone. FM 1 stated FM 2 did not think Resident 1 knew who the unknown visitor was because the unknown visitor initially told FM 2, she was Resident 1's neighbor then stated was Resident 1's niece. FM 1 stated, the facility put the entire facility in danger because the facility allowed an unknown visitor in, who did not have known family members in the facility, into the home of these residents. During an interview on [DATE] at 2:30 PM with CNA 3, CNA 3 stated, there should be no unknown visitors during the night shift. CNA 3 stated, we checked the logbook, and there were no visitor names during that time. CNA 3 stated CNA 3 did not know who opened the door for the unknown visitor and who showed [the unknown visitor Resident 1's] room. CNA 3 stated, it was scary if there were unknown visitors in the facility at night because unknown visitors might harm the residents by stealing their belongings or physically harming the residents. During an interview on [DATE] at 2:39 PM with LVN 2, LVN 2 stated on [DATE] there was a young unknown visitor in the facility near Resident 1's room. LVN 2 stated, LVN 2 did not know who the unknown visitor was and told the unknown visitor to leave the facility because visiting hours were over. LVN 2 stated, LVN 2 saw the unknown visitor come out of Resident 1 and Resident 2's room. LVN 2 stated the visitor did not sign the visitor logbook upon entering the facility. LVN 2 stated the unknown visitor should not be in a resident's room because it was dangerous. During an interview on [DATE] at 2:50PM with the ADM, the ADM stated no strangers, or unknown visitors should have entered the facility, especially during the night shift. The ADM stated it was important for all visitors entering the facility to sign the [visitor] logbook because it was important to keep track of who was in the facility. The ADM stated, there should not be unknown visitors in the facility because we do not want people who we do not know in[side] the building and it may be harmful to the staff and the residents. During a review of the facility's P&P titled, Accidents and Supervision, dated [DATE], the P&P (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555107 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Care Center 3541 Puente Avenue Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete indicated each resident will receive adequate supervision . to prevent accidents which include identifying hazards and risks and evaluating and analyzing hazards and risks. During a review of the facility's P&P titled, Resident Right to Access and Visitation, dated [DATE], the P&P indicated visitations will be person-centered, consider the residents' physical, mental, and psychosocial well-being, and support their quality of life. The P&P indicated the facility will provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions. The P&P indicated there were reasonable clinical and safety restrictions to protect the health and security of all residents and staff which included keeping the facility locked at night with a system in place for allowing visitors approved by the resident. Event ID: Facility ID: 555107 If continuation sheet Page 4 of 4