River Bluffs Memory Care Community

Allegation investigated: Staff did not provide a refund upon resident’s death

On 8/04/2026, Licensing Program Analyst (LPA) M. Medina conducted an unannounced subsequent complaint visit. LPA arrived, stated purpose of visit, and allowed entrance to facility, Administrator, Donna Hurley was not available to meet with LPA during today's visit, LPA met with Health Services Director, Alexis Martin During the subsequent visit, LPA conducted additional interviews and received additional documentation. Based on LPA review of documentation and interviews conducted, family for Resident 1 (R1) did receive a refund but payment was rendered on 7/15/2026. This date of payment was approximately six (6) months after R1 passed away and their personal belongings were packed by facility. Interviews indicated that payment was rendered by facility two times but was sent to incorrect addresses on file and the third time a check was mailed never cashed. Based on information gathered, interviews and record review the above allegation is UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Nothe state’s words, verbatim · CDSS document, Aug 4, 2026 · control 24-AS-20260709110654

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with, Licensee, Donna Hurley, Continual Administrator's Certification expires 02/19/2027. There are currently 34 residents who reside at this home and there is 7 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested in multiple rooms between 113 degrees and 116 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA observed medication for Resident 1 documented on Centrally Stored Medication record with start date of 05/20/2026 despite resident being hospitalized and not administered any medication. There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with, Licensee, Donna Hurley and copy of report left at facilitythe state’s words, verbatim · CDSS document, May 21, 2026

The state marks this report as 7 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provide clean clothing to resident in care in a timely manner

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint investigation. LPA met with and discussed the allegation with Administrator (AD) Donna Hurley. Investigation findings were delivered during this visit. This Department investigated the allegation above. Multiple staff were interviewed with consistent reporting of Resident (R1's) preferences, behavioral expressions, and ADL needs. Additionally, If R1 was in a Case Management/therapy visit, staff would be reluctant to interrupt. File review was conducted, Service Plan 10/25/25 notes R1 requires assist required for dressing from staff. Based on interview and record review the above allegation is UNSUBSTANTIATED. 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. There were no citations issued. An exit interview was conducted, and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 28, 2025 · control 24-AS-20250725101336

Allegation investigated: Facility does not ensure resident is free from physical abuse

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the initial complaint investigation. LPA met with and discussed the allegation with Administrator (AD) Donna Hurley. Investigation findings were delivered during this visit. Interviews were conducted of facility staff which included Caregivers, Med Tech, Activity Director and Administrator. Interview statements were consistent, R1 has not reported abuse and there have been no reports or observations of skin markings or bruising. R1's Hospice Case Manager visits regularly and stated there have been no changes or irregularities in R1’s skin condition. When asked, R1 denied experiencing any kind of physical abuse and praised the staff. This Agency has investigated the allegation listed above. We have found that the allegation is UNFOUNDED, therefore we have dismissed the allegation. There were no citations issued. An exit interview was conducted, a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Aug 28, 2025 · control 24-AS-20250822151010

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Katie Brown conducted a Case Management in conjunction with a complaint visit (Control Number 24-AS-20250822151010). LPA met with and discussed the reason for this Case Management with Administrator (AD) Donna Hurley. During this visit, LPA toured the facility, selecting resident rooms to enter. Upon entering the room of R1 and R2, LPA observed a hospital bed with 2 - 1/2 side rails attached to one side of the bed. During this visit, a Physician's Order was obtained, and the rails were placed properly on the hospital bed. A deficiency is being cited in accordance with the California Code of Regulations on the attached LIC 9099-D. An exit interview was conducted, and Plan of Correction was developed. A copy of this report and Appeal Rights were provided to AD.the state’s words, verbatim · CDSS document, Aug 28, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Aug 29, 2025

87608 Postural Supports (a) Based on… Postural supports may be used under the following conditions.(3) A written order from a physician indicating the need for the postural support shall be maintained... This requirement was not met as evidenced by: Licensee did not ensure there was a written physician's order indicating the resident's need for a postural support (1/2 side rails) for R1's hospital bed. There were 3 1/2 side rails attached to the bed, there should only be 1 per side This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: AD obtained a complete written physician's order for R1's 1/2 siderails during the visit. The extra (3rd) side rail was removed to ensure the postural support was used safely and properly. DEFICIENCY CLEARED DURING VISIT

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Administrator (AD) Donna Hurley and Alexis Martin. During this visit, LPA toured the facility inside & out. Resident rooms and common areas were clean, in good repair and contained required equipment, furnishings and lighting. LPA observed required items in bathrooms which were clean with faucets delivering hot water as required. LPA observed hygiene items, paper products, towels, extra bedding, and linens which were stored and available for use. The kitchen was found to be clean, with necessary items and appliances. LPA observed required food supply, emergency food, water, and paper products. Medications are centrally stored. Cleaning/disinfecting supplies and chemicals are locked and stored separate from food. Doors and passageways are unobstructed throughout the facility including outdoors. First aid kits contained required items. LPA walked the outdoors to find the grounds well-kept with clear walkways with sitting areas. Fire extinguishers were found to be charged and serviced 6/2/25. LPA conducted resident and staff file reviews. Emergency Disaster and Infection Control procedures and plans were reviewed during the inspection. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D. A Repeat Violation Civil Penalty is being assessed on the attached LIC421M. An exit interview was conducted and Plan of Correction (POC) developed. A signed copy of this report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jun 4, 2025

Allegation investigated: Facility failed to maintain bathroom cleanliness

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a complaint investigation. LPA explained the reason for the visit and the elements of the allegations with Wellness Director Alexis Martin (LVN) as Administrator (AD) Donna Hurley was unavailable at the time of visit. During this visit, LPA toured the facility with LVN. LPA was provided a resident roster and randomly selected rooms to observe. LPA observed the bathrooms of 12 currently occupied resident rooms and bathrooms. LPA observed multiple restrooms found to be unsanitary as evidenced by unclean toilets, toilet seats needing repair and briefs not being disposed of properly. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with Alexis Martin. Substantiated Continued from LIC9099 - Unsubstantiated report. The invoice was provided and notes that "General Monthly Service" was provided on this date. The invoice does not note service specific to roaches in resident rooms. Based on LPA observation, interview and record review the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was left with Alexis Martin.the state’s words, verbatim · CDSS document, Mar 5, 2025 · control 24-AS-20250226141132

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Mar 19, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times..... (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met as evidenced by: Licensee did not ensure that resident bathrooms are clean, safe, sanitary and in good repair. LPA observed multiple resident toilets that were unsanitary and unclean. 2 toilet seats are broken requiring replacement and a soiled resident brief was found on the floor in a resident bathroom.the state’s words, verbatim · CDSS document, Mar 5, 2025

Plan of correction: Administrator has agreed to provide inservice to all staff on the maintenance of resident bathroom requirements. A sign in sheet will be provided containing the name and signature of all appropriate staff attending the inservice. LVN ordered new toilet seats during the visit. A receipt and written statement that the repairs have been made as well as a receipt copy will be provided. The poc will be submitted to CCL via email by poc date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Katie Brown is at the facility to conduct a Case Management visit in conjunction with a complaint investigation. LPA met with Wellness Director Alexis Martin (LVN) as Administrator (AD) Donna Hurley was unavailable at the time of visit. During this visit, LPA observed the following: 1. A sharp cooking knife was left in a drying rack in the facility kitchen. The knife was not secured or locked. 2. A bottle of bleach was left out on the counter of a laundry room counter. The room was unlocked and the door found ajar. 3. A housekeeping cart was left unattended in the hallway leaving cleaning and disinfecting supplies accessible. The items listed above were immediately removed and locked as required. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 809-D, Section Storage Space and Access. The deficiency was cleared during this visit. An exit interview was conducted and a signed copy of this report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Mar 5, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Mar 6, 2025

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives..., are in locked storage and are not left unattended if outside the locked storage.This requirement was not met as evidenced by: Licensee did not ensure a sharp cooking knife in the kitchen, bottle of bleach in a laundry room and an open housekeeping cart were locked and inaccessible to residents in care. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 5, 2025

Plan of correction: During the visit, the knife was removed and locked, bleach and housekeeping cart containing cleaning supplies were locked and secused. DEFICIENCY CLEARED DURING VISIT

Allegation investigated: Facility staff did not seek timely medical attention for resident who ingested incorrect medication

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint visit and deliver investigation Findings. LPA met with Welness Director, Alexis Martin. This Department investigated the allegation: Facility staff did not seek timely medical attention for resident who ingested incorrect medication. Interviews reveal that the staff are not aware of a medication error or emergency where a resident needed medical attention. The facility did not submit a Special Incident Report to CCL reporting an incident. The Reporting Party did not identify the resident who ingested the wrong medication, therefore a medication audit and file review could not be conducted. Based on interview and record review the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was signed and left with Alexis Martin. Unsubstantiated This Department investigated the allegation: Licensee does not ensure facility is adequately staffed to meet resident's toileting needs. The facility was toured 7/25/24 and 9/24/24. Residents were observed throughout the common areas and in rooms dressed, appearing clean with no odors. Staff interviews did not reveal concern about staff meeting resident needs. Resident care plans note each residents assistance level for toileting and other ADLs. The staffing schedule was reviewed for July 2024. We have found that the allegations are UNFOUNDED, therefore we have dismissed the allegations. There were no citations issued. An exit interview was conducted and a copy of this report was signed and left with Alexis Martin.the state’s words, verbatim · CDSS document, Sep 24, 2024 · control 24-AS-20240717095726

Allegation investigated: Staff yells at residents in care Staff is racist towards a resident in care Staff did not ensure residents clothing was changed Staff changed a resident in an aggressive manner Staff are not meeting the needs of a resident in care

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the initial complaint investigation. LPA also delivered investigation findings during the visit. This Department investigated the allegations listed above. LPA toured the facility and found residents dressed in clean clothes with no odors noticed. Bedding was found to be clean as well. Multiple Care Providers (CPs) and Med Techs (MTs) from both AM and PM shifts were interviewed. All staff members interviewed denied seeing or knowing about any of the allegations listed above occurring at the facility. Multiple resident interviews were attempted. The residents were unable to answer or participate in conversation due to Dementia. Record reviews were conducted and revealed that R1's ostomy and catheter bags are changed or drained daily and as needed by trained staff. Based on interview and record review the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was left with Alexis Martin, whose signature confirms receipt of these documents. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 24, 2024 · control 24-AS-20240916165135

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Administrator (AD) Donna Hurley and Wellness Director (WD) Alexis Martin. AD re-certification was confirmed to be in process during the visit. During this visit, LPA toured the facility inside & out Resident rooms are found to be in good repair and contained required furnishings and lighting. The resident bathrooms was clean and in good repair with faucets delivering hot water within required limits, grab bars and non-skid shower floors observed. LPA observed required hygiene items, towels, extra bedding, and linens were stored and available for use. The kitchen was clean, with necessary items and appliances. LPA observed required food supply and paper product storage. Cleaning/disinfecting supplies, knives and sharps are locked and stored separate from food. Medications are locked and centrally stored in a medication cart. The First aid kit contained required items. There are visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. The Fire extinguishers were serviced by Valley Fire Co. on 4/5/2024. LPA conducted resident and staff file reviews. A medication audit was also conducted Emergency Disaster Plan and Infection Control Plans were reviewed during this visit and found to be updated. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 809-D in the area of: Hospice Care Waiver and Incidental Medical and Dental Care. An exit interview was conducted and Plan of Correction (POC) developed. A copy of this report was signed by AD and Appeal Rights were provided. LPA requested the following updated forms faxed to CCLD by 5/22/2024: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Surety Bond (Lic402), Emergency Disaster Plan (LIC610E), Client Roster (LIC 9020), Proof of current Liability Coverage.the state’s words, verbatim · CDSS document, May 15, 2024