An informal conference was held with Licensee designees on 8-7-2025 to discuss previous citations issued prior to this date. Since the date of this conference, Licensee has received a total of five A citations and eight B citations. The regulated areas of which the citations occurred were: Personal rights, care and supervision, buildings and grounds, administrator qualifications, client records, health related services, and reporting requirements.

Citations issued by the Department since the last informal include:

8-13-2025: Type B - Section 80072(5) Personal Rights. R1 was told he could not attend an activity without a reasonable explanation.

9-3-2025: Type B – Section 80072(a)(1) Personal Rights. staff utilized inappropriate labeling of a resident based on behavior episodes – based off verbiage from an incident report

{Cont. on 809C}

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

9-3-2025: Type A – Section 80087(a) Buildings and Grounds. Based on observation, fenced area on left side of facility's property is missing multiple boards giving access to neighbor's yard containing an unfilled pool. Fenced area was accessible to residents in care

9-3-2025: Type B – Section 80064(a)(3) Administrator qualifications. R1 eloped from facility on 8-2-2024, and licensee did not ensure incident was reported to regional center per regional center reporting requirements.

10-7-2025: Type B – Section 80070(c)(1) Client Records. Based on interview and record reviews, facility staff sent a resident’s file contents to a family member of another resident’s family resulting in unauthorized access

10-23-2025: Type B – Section 80064(a)(3) Administrator – Qualifications and Duties. Based on record review, various areas of deficiencies were identified by an outside compliance agency on 5-21-2025 which violated applicable law and regulations including but not limited to: Medications, physical plant, and care and supervision.

10-28-2025: Type A – Section 80078(a) Responsibility for Providing Care and Supervision. Based on interview and record review, licensee did not ensure appropriateness of care and supervision in that staff did not utilize adequate safety measures and other protocols during R1’s behavior event.

11-7-2025: Type A – Section 80078 Responsibility for Providing Care and Supervision. Based on interviews and record reviews, R1 sustained rashes on armpit area, and Licensee did not ensure proper observation and follow up

12-5-2025: Type B – Section 80072(a)(2) Personal Rights. Based on interview and record review Licensee did not ensure safe and comfortable accommodations for a resident in that staff members transported a client in a manner described as reckless-like.

{Cont. on 809C}

12-5-2025: Type B – Section 80061(d) Reporting Requirements. Based on interview and record review, Licensee did not ensure the reporting of an alleged event involving a staff member slapping a resident.

12-5-2025: Type B – 80064(a)(3) Administrator-Qualifications and Duties. Based on interview and record review, program administrator received an allegation of abuse and did not follow regulatory procedures for proper reporting.

Topics discussed during today’s Non-Compliance Conference were:

· Care and Supervision

· Medication management

· Client Records

· Administrator qualifications and duties

· Reporting requirements

· Personal rights

· Buildings and Grounds

· Facility closure/transition process and status

The Licensee has agreed to the following for purposes of reaching substantial compliance:

· Facility program administrator will ensure compliance plan is being followed

· Licensee will ensure facility program administrator is physically present at facility for a minimum of 40 hours per week

{Cont. on 809C}

· Building and Grounds (Monthly physical plan inspection)

· Monthly audits of medication orders and skin/body check forms to ensure accuracy

· Continue to follow all closure/facility program transition procedures as set forth by Title 22 regulations and Regional Center requirements

· Submit an updated LIC 500 to include program administrator days and hours scheduled. Submit by 12-12-2025.

In regards to facility's planned closure, a plan was discussed regarding supervision for the remaining resident still currently residing at facility. Resident will continue planned staffing ratios currently in place which includes 2:1 staffing between 7am-11pm as well as lead staff on site 24/7. Beginning in November 2025, and additional 8 hour floater was added to assist resident with activity during the day. Licensee designees are currently in the process of arranging for a new day program for resident, and are now engaging resident into the community through various activities.

In addition, at this meeting the notified Licensee/Administrator was advised future non-compliance regarding the above and other regulatory components will result in additional citations, civil penalties, and further potential administrative action.

Community Care Licensing Department (CCLD) will do the following:

· Continue quarterly visits to ensure above compliance plan and other Title 22 and Health and Safety code requirements.

· Follow up with Licensee during the closure process to ensure compliance.

{Cont. on 809C}