River Bluffs Memory Care Community

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

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

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

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 dthe state’s words, verbatim · CDSS document, Mar 5, 2025 · control 24-AS-20250226141132

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

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 andthe 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 athe state’s words, verbatim · CDSS document, Sep 24, 2024 · control 24-AS-20240916165135

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are blocking the facility's exits Staff spoke inappropriately towards a resident while in care

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the initial 10 - day complaint inspection. LPA met with and explained the elements of the allegations with Administrator (AD) Donna Hurley. Immediately upon arrivial to the facility, AD and LPA toured the facility. LPA observed that passageways and emergency exits were free of obstruction. Based on observation and staff interviews, the exits were not blocked during this visit. Interviews were conducted with 3 Care Providers who worked the day RP identified overhearing a staff member speak inappropriately to Resident (R1). The CPs interviewed deny being aware of or hearing the inappropriate conduct. See LIC 9099-C for continuation of this report Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 26, 2023 · control 24-AS-20231024092235