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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on the allegations listed above. LPA met with facility Cognitive Care Director, Ashley Mendoza , and explained the purpose of today's visit. Regarding the allegation that staff did not report incident to Licensing, Licensing Program Analyst (LPA) conducted interviews and reviewed facility records related to the reported resident fall incident involving resident 1.LPA reviewed a completed Unusual Incident/Injury Report documenting the resident experienced an unwitnessed fall on 01/31/2026 resulting in hospitalization. Facility records reflected the facility completed a written incident report and provided a fax cover sheet and confirmation report indicating a nine-page report was transmitted to the Licensing office on 02/05/2026 with a successful transmission result. Although the incident report was not located in the facility’s electronic Licensing file at the time of LPA review, recoRead the full finding— CDSS inspection report, May 6, 2026 · control 24-AS-20260210143137

On 03/04/2026, Licensing Program Analyst (LPA) J. Duarte arrived unannounced to deliver findings. LPA met with Administrator Paul Rocha. Interviews and documentation revealed that Med Techs assist resident with injectable medication using a hand over hand technique and LVNs also assist residents in administering injectable medication. Based on interviews conducted and documentation, the allegation: “Unqualified staff injecting residents with medication,” is UNSUBSTANTIATED. 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. No deficiencies issued. Exit interview conducted. A copy of this report was discussed and provided to facility Administrator Paul Rocha, whose signature on this form confirms receipt of this document. UnsubstantiatedRead the full finding— CDSS inspection report, March 4, 2026 · control 24-AS-20251222095613

On 03/04/2026, Licensing Program Analyst (LPA) J. Duarte, arrived unannounced to conduct interviews and deliver findings. LPA introduced self, stated the purpose of the visit and met with Executive Director and Administrator Paul Rocha. The Department conducted interviews and reviewed records. Based on the interviews conducted and records reviewed, the allegations; residents develop multiple pressure injuries due to staff neglect, residents develop multiple UTI's due to staff neglect, staff handle residents in a rough manner, staff do not ensure residents' hygiene needs are being met, staff do not provide adequate supervision to residents resulting in falls, and staff do not ensure to provide residents' with fluids are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur or did not occur; therefore, the allegations are Unsubstantiated. No deficiencies were issued. An exit interview wRead the full finding— CDSS inspection report, March 4, 2026 · control 24-AS-20260105161419

On 12/04/24, Licensing Program Analyst (LPA) M. Medina conducted an unannounced subsequent complaint visit to conduct additional interviews and deliver findings. LPA introduced self and stated purpose of visit and allowed entrance. LPA met with Executive Director/Administrator, Paul Rocha during visit. This Department investigated the allegation of questionable death and staff. During the investigation, this department obtained a copy of Resident 1 (R1) death certificate. Based on record review of R1's death certificate, it was determined R1's cause of death was respiratory arrest. Facility has Point Click Care (PCC) system that monitors and tracks all residents toileting, brief changes, and any assistance with activities of daily living (ADLs) provided by staff on shift. This Department has found that the above allegations are UNFOUNDED, meaning they were false, could not have happened, and/or were without reasonable basis. We have therefore dismissed the complaint. No deficiencies isRead the full finding— CDSS inspection report, December 4, 2024 · control 24-AS-20240507171907

Licensing Program Analyst L. Padgett arrived unannounced to deliver amended investigative findings on the above allegation. LPA met with Paul Rocha and explained the purpose of the visit. The Department investigated the complaint alleging: Staff do not prevent inappropriate interactions between residents. During the course of the investigation the Department conducted interviews with staff and witnesses and reviewed resident and facility records, including incident reports, resident care notes, physician’s report pertaining to Residents R1 and R2. The Department determined that staff on duty did not prevent sexually inappropriate non-consensual interactions between the two residents in the Memory Care Unit. Per Department’s investigation: On 10/24/2023, in the Memory Care Unit of the facility resident R1 was found in resident R2’s bedroom; resident R2 had his arm around resident R1’s waist and resident R1 was pushing resident R2 away. Resident R2’s genitalia was exposed out of his brieRead the full finding— CDSS inspection report, March 18, 2024 · control 24-AS-20231027143209

The Department interviewed staff, resident, and reviewed records. In the case of: Resident had multiple falls and sustained injuries while in care based on interviews conducted, although resident did sustain falls, the Facility did due diligence in following required protocol. Facility RN conducted a Neuro assessment after the falls and the resident was placed on 30 min checks for 72 hours. Incident report was submitted to the Department regarding falls. In the case of Staff failed to seek medical attention for resident in a timely manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted. UnsubstantiatedRead the full finding— CDSS inspection report, May 17, 2022 · control 24-AS-20220321142901

Licensing Program Analyst (LPA) Katie Brown arrived at the facilirt unannounced to deliver the complaint investigation findings. LPA explained the purpose of the visit and the elements of the allegations with Administrator Paul Rocha. The Department investigated the allegation: Resident fell while in care. The facility submitted a Special Incident Report (SIR) to CCLD reporting that Resident R1 sustained a fall. Based on Records Review of the SIR, Physician’s Report, Facility Assessment and Facility Call System Record, it was determined that even though the resident fell while in care, it was not due to lack of care and supervision provided by the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. The allegation is UNSUBSTANTIATED. See LIC9099-C for continuation UnsubstantiatedRead the full finding— CDSS inspection report, May 3, 2022 · control 24-AS-20211222165036