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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881318
Report Date: 05/23/2026
Date Signed: 05/23/2026 04:12:01 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/22/2024 and conducted by Evaluator Gabriela Castro
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240122113736
FACILITY NAME:ABUNDANT GRACE SENIOR LIVINGFACILITY NUMBER:
331881318
ADMINISTRATOR:ARZU, KANISHAFACILITY TYPE:
740
ADDRESS:43307 PUTTERS LANETELEPHONE:
(562) 551-1218
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:6CENSUS: 5DATE:
05/23/2026
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Kanisha Arzu, Administrator and Holy Martin House ManagerTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility staff restraining resident to furniture by material
Facility staff recording resident visit with visitors
Resident got food poising from food prepared by Facility staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 05/23/2026 to deliver findings related to the above allegations. LPA was greeted by facility staff Holy Martin and Elizabeth Goette. Administrator Kanisha Arzu was contacted via phone and explained the purpose of the visit. Administrator was available to LPA via phone.

The investigation included a review of the client roster, staff roster, R1 face sheets, R1 physician’s reports,admissions reports, Updated Resident Communication & Incident Report Summaries (March 2023 – July 2023), Admissions Agreement, communication logs between the facility and R1’s responsible party, staff task lists, and a facility walkthrough. In addition, LPA conducted interviews with three (3) staff members (S1–S3) and three (3) residents (R1–R3).

(continued on 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Gabriela Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 18-AS-20240122113736
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: ABUNDANT GRACE SENIOR LIVING
FACILITY NUMBER: 331881318
VISIT DATE: 05/23/2026
NARRATIVE
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Allegation: Facility staff restraining residents to furniture by material
It is alleged that facility staff restrained residents to furniture, including recliners, using fabric or other materials. During resident interviews, residents denied ever being restrained to a bed or recliner. R1 also denied ever witnessing staff restraining other residents to recliners. During staff interviews, staff denied the use of restraints at the facility and stated residents are not secured to furniture or chairs. Staff stated restraints are prohibited unless ordered by a physician and approved exception by licensing. Staff further stated the facility utilizes door alarms and monitoring devices to assist with residents identified as fall risks or wanderers. During the facility walk through, LPA observed recliner chairs throughout the facility and did not observe any type of restraint, fabric, ties, or materials attached to or being used on the recliners. During record review, LPA reviewed R1’s records, Updated Resident Communication & Incident Report Summaries, Admissions Agreement, and communication logs between the facility and R1’s responsible party. No documentation was found indicating the use of restraints, physician orders for restraints, or approval for restraint use at the facility.
Allegation: Facility staff recording resident visit with visitors

It is alleged that facility staff recorded resident visits with visitors. During staff interviews, staff stated the facility has cameras located in common areas of the facility for safety purposes, including the living room, kitchen, dining area, hallways, and outdoor front and back areas. Staff denied that visits are specifically recorded and stated residents, responsible parties, and visitors are informed about the cameras upon admission. During resident interviews, residents did not express concerns regarding cameras or being recorded during visits. During the facility walk through, LPA observed cameras located in common areas of the facility. During record review, LPA reviewed the Admissions Agreement, which documented the presence of cameras in the common areas of the facility. Documentation reviewed indicated R1’s responsible party signed the Admissions Agreement acknowledging awareness of the cameras.

Allegation: Resident got food poising from food prepared by Facility staff

It is alleged that a resident became ill due to food prepared by facility staff. During resident interviews, residents stated they liked the food served at the facility and denied becoming sick from the food. It was reported by S1 that R1 experienced dizziness, vomiting, and diarrhea and had difficulty keeping food down. S1 stated there was no direct diagnosis from a physician and that the information regarding symptoms was reported to the facility by R1’s responsible party. S1 stated the facility treated the symptoms as reported and made reports to hospice regarding R1’s history of dizziness and vomiting as communicated by the responsible party. Per S1, pre-placement documentation included notes reported by the reporting party. During staff interviews, staff denied concerns regarding food quality or residents becoming ill due to food prepared at the facility. Staff stated food is routinely monitored, expiration dates are checked daily, and food supplies are regularly inspected and replaced as needed.


(continued on 9099C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Gabriela Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20240122113736
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: ABUNDANT GRACE SENIOR LIVING
FACILITY NUMBER: 331881318
VISIT DATE: 05/23/2026
NARRATIVE
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During the facility walk through, LPA observed an adequate supply of fresh food. Food observed did not appear rotten or spoiled. Canned goods and bread observed during the visit were within expiration dates. During record review, LPA reviewed staff task lists which included instructions for staff to create grocery lists on Mondays and Thursdays and confirm there was no expired food present at the facility

Based on the investigation conducted, which included interviews with staff and residents, as well as a review of relevant records, there was insufficient evidence to support the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Gabriela Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3