335530030-5-13-2026-56-AS-NBRN-DUFQHB-20260526121052

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 335530030
Report Date: 05/13/2026
Date Signed: 05/13/2026 01:31:43 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/19/2025 and conducted by Evaluator Edith Conchas

COMPLAINT CONTROL NUMBER: 56-AS-20251119083236

FACILITY NAME:	CITY HOME SENIOR LIVING		FACILITY NUMBER:	335530030
ADMINISTRATOR:	SMITH, NGINA		FACILITY TYPE:	740
ADDRESS:	1672 GOLDEN WAY		TELEPHONE:	(951) 524-0039
CITY:	BEAUMONT	STATE: CA	ZIP CODE:	92223
CAPACITY:	6	CENSUS: 4	DATE:	05/13/2026
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Administrator Lorena Penne		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Staff do not ensure residents are provided adequate portions of food
Staff does not ensure facility has a sufficient supply of perishable and non perishable food
Staff does not ensure residents medical equipment is properly maintained
Staff dispensed medications not prescribed to residents
Staff did not discard discontinued medications
Staff did not prevent residents from developing pressure injuries
Staff do not seek medical care for changes in residents health conditions

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Edith Conchas and Lavette Farlow conducted an unannounced visit to the facility to commence a complaint investigation and deliver findings on the allegations stated above. LPAs observed the facility conducted interviews with staff, residents and witnesses.

Staff do not ensure residents are provided adequate portions of food.
Interviews with staff revealed that staff do provide sufficient food for residents and offer seconds to residents. During lunch time, LPAs observed a full meal was provided to residents with a bowl of soup, a sandwich and peas. Based on the interviews this allegation is UNSUBSTANTIATED.

Staff does not ensure facility has a sufficient supply of perishable and non-perishable food.
During today’s visit, LPAs observations the refrigerator and pantry. Based on LPAs observation there was sufficient supply of food for two days perishable and 7 days nonperishable for the number of residents in care.
Continue to LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Edith Conchas
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20251119083236

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CITY HOME SENIOR LIVING	FACILITY NUMBER: 335530030
	VISIT DATE: 05/13/2026

NARRATIVE

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Interviews with staff reveal food is ordered and delivered weekly. Based on the interviews this allegation is UNSUBSTANTIATED.

Staff does not ensure residents medical equipment is properly maintained
LPAs observed and interviewed staff and witnesses. Observations revealed 1 resident was using medical equipment and was functioning correctly. Interview with witnesses and staff reveal medical equipment for residents R5 and R2 has all the parts of their medical equipment to function correctly. Based on the interviews and observation this allegation is UNSUBSTANTIATED.

Staff dispensed medications not prescribed to residents
Interviews with staff reveal medication is audited by the administrator to ensure medication is given accurately before staff provide it to residents. LPA observation reveals medication was labeled and separated for each resident name in their own basket. Based on the interviews and observation this allegation is UNSUBSTANTIATED.

Staff did not discard discontinued medications
Interviews with S5 and S6 revealed that when a medication is discontinued it is relocate to another locked cabinet and notated that it is discontinued upon doctors’ orders and notify the other staff. S5 stated they crush the medications when there is an order that it is discontinued. Based on the interviews and observation this allegation is UNSUBSTANTIATED.

Staff did not prevent residents from developing pressure injuries
LPAs conducted interviews with staff and relevant parties. Based on interviews and record reviews it was revealed that R2 and R5 have in the past or presently experienced a pressure injury. Interviews and records review revealed they were between stage 1-2. LPAs observed Hospice nurse providing care and treatment and records indicated Home Health and hospice have been providing treatment. Interview revealed that R5 has a red mark that has opened in lower coccyx area and R2 has a pressure injury on R2’s foot. Staff have been monitoring it injury and staff have been treating it by elevating the R2 foot. Based on the interviews and observation this allegation is UNSUBSTANTIATED.

Continue to LIC9099-C

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Edith Conchas
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 56-AS-20251119083236

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CITY HOME SENIOR LIVING	FACILITY NUMBER: 335530030
	VISIT DATE: 05/13/2026

NARRATIVE

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Staff do not seek medical care for changes in residents’ health conditions.
LPAs interviewed staff, witnesses and conducted record reviews. Interviews with staff reveal when there are medical changes to residents in care we report it right away to administrator. Interview with W3 revealed they will notify hospice care staff and facility care staff immediately of any change in condition. Based on the interviews and observation this allegation is UNSUBSTANTIATED.

Based on the information above, the allegations are unsubstantiated. A finding of UNSUBSTANTIATED means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report LIC9099 was discussed, and a copy was provided to administrator Lorena Penne.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Edith Conchas
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

LIC9099 (FAS) - (06/04)

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