Autumn Ridge Assisted Living

Allegation investigated: Staff did not adequately supervise residents Staff did not report incident to appropriate parties

On this date, Licensing Program Analyst (LPA) M. Yang conducted complaint visit to deliver complaint findings. LPA introduced self, stated the purpose of the visit, and met with Administrator Karen Dhaliwal. During the course of the investigation, the department conducted interviews and reviewed records. Based on records reviewed, on 01/29/2026, S1 found R2 inside R1’s room. R2 and R1 were exposed from the waist down. The facility failed to implement and maintain adequate measures to prevent further incidents when R2 attempted to bring other residents into R2’s room. A review of available records indicates the facility delayed contacting Emergency Medical Services (EMS) and law enforcement. Documentation shows the incident occurred at approximately 0920 hours. However, the facility did not notify law enforcement until 1225 hours, and EMS was not contacted until approximately 1228 hours. Based on interviews conducted and records reviewed, the preponderance of evidence has been met. Therefore, the above allegations are found to be SUBSTANTIATED. An exit interview was conducted. A copy of this report and appeal rights were provided to the Administrator whose signature on this form confirms receipt of this report. Substantiatedthe state’s words, verbatim · CDSS document, Sep 22, 2026 · control 24-AS-20260521131822

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f) · Plan of correction due date: Sep 23, 2026

87464 (f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement has not been met by: Based on interviews conducted and records reviewed, on 01/29/2026, S1 found R2 inside R1’s room. R2 and R1 were exposed from the waist down. The facility failed to implement and maintain adequate measures to prevent further incidents when R2 attempted to bring other residents into R2’s room, which poses an immediate health and safety risk for the residents in care.the state’s words, verbatim · CDSS document, Sep 22, 2026

Plan of correction: Administrator agrees to provide a written statement of steps the facility will take to ensure that the regulations will be met by POC due date 09/2326. Administrator agrees to have all staff retrained in in-service training on care and supervision. Training materials and staff attendance rooster will be submitted to the Fresno CCL by 10/12/26.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Sep 23, 2026

87211 (c) All other instances of known, suspected, or alleged abuse of an elder or dependent adult not covered in subdivision (b), shall be reported to the long-term care ombudsman, the local law enforcement agency, and corresponding state licensing agency as required by Welfare and Institutions Code Section 15630(b)(1). This requirement has not been met by: Based on records reviewed, records indicates the facility delayed contacting Emergency Medical Services (EMS) and law enforcement. Documentation shows the incident occurred at approximately 0920 hours. However, the facility did not notify law enforcement until 1225 hours, and EMS was not contacted until approximately 1228 hours, which poses a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 22, 2026

Plan of correction: Administrator agrees to submit a written plan of how the steps the facility will take to ensure to meet the regulations. Written plan will be submitted to the Fresno CCL by POC due date 09/23/26. All staff will have retraining in an in-service training on reporting requirements by 10/12/26. Training materials and staff attendance rooster will be submitted to the Fresno CCL by 10/12/26.

Allegation investigated: Staff are not meeting the residents needs

On 09/15/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint investigation and deliver complaint findings. LPA met with Administrator Karen Dhaliwal and stated the purpose of the visit. During the course of the investigation, the facility was toured, interviews were conducted, and records were received. Based on interviews conducted, records reviewed, and observation, staff changes the residents’ brief every two hours and as needed. Residents that are wearing briefs are observed with clean and odor free. Based on interviews conducted and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be UNSUBTANTIATED. Exit interview was conducted. A copy of this report was provided to the Administrator, whose signature on this form confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 15, 2026 · control 24-AS-20260812142944

Type of visit: Case Management - Health Checks

On this date, Licensing Program Analyst (LPA) Yang conducted a case management- health & safety check at the facility regarding concerns received. Specifically, the Department received concerns regarding the locks on resident’s rooms. LPA toured the facility and all rooms. Locks were checked. No issues with locks on residents’ door. During visit, LPA was informed of Soc 341 by Administrator. LPA follow up with Soc 341, conducted interviews with staff and resident and toured the facility. Exit Interview conducted. A copy of this report was provided to the Administrator, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Aug 12, 2026

Type of visit: Required - 1 Year

On 07/14/26, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct the Required Annual Inspection. LPA introduce self, stated the purpose of the visit, and met with Administrator Karen Dhaliwal. LPA toured facility with Administrator. The facility was observed to be at a comfortable temperature at 73 degrees F, clean, in good repair, and no passageway obstructions or fire hazards. Last fire drill was completed on 6/29/26. Kitchen was toured. An adequate supply of perishable and non-perishable food was observed to be properly stored. Temperature was maintained at 33 degree F. in stand up refrigerator and stand up freezer temperature was maintained at -2 degree F. Fire extinguisher was observed throughout facility with a service date of: 06/13/25. Medications were stored and locked in medication carts. MARs and Centrally Stored Medication List were reviewed. Medications were checked. LPA toured a sample of residents’ room were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Bathrooms were toured and observed with securely fastened grab bars. Hot water temperature was tested and maintained at 111.7 degree F in room 401. 115.5 degree F in room 409. 112.4 degree F in room 303, 113.2 degree F in room 301. 111.7 degree F in room 201. 111.8 degree F in room 206, and 111.7 degree F in shower room. Chemicals were stored and locked in housekeeping closet. Washer and dryer observed operational and functioning during visit. Extra linens observed. 30-second delay egress was observed. (continued to Lic 809C) (continued from Lic 809) The outside was toured and observed to be free from debris. There was outdoor seating available for the residents in courtyard. Fire alarm and sprinkler systems observed throughout facility. A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D. An exit interview was conducted. LPA received copies of Lic 308, Lic 500, Lic 610E, and current liability insurance. A copy of this report and appeal rights was provided to Administrator, whose signature on this form confirms receipt of these reports.the state’s words, verbatim · CDSS document, Jul 14, 2026

Allegation investigated: Staff did not allow resident in care to use the telephone Staff spoke inappropriately to residents in care

On 06/02/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint investigation. LPA met with Administrator Karen Dhaliwal and stated the purpose of the visit. During the course of the investigation, the facility was toured and interviews were conducted. Residents confirm staff allow residents to use the facility telephone and do not speak to the residents inappropriately. Based on interviews conducted, the preponderance evident has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 2, 2026 · control 24-AS-20260528101611

Type of visit: Case Management - Other

On 05/22/26, Licensing Program Analyst (LPA) M. Yang conducted a case management visit. LPA introduced self, stated the purpose of the visit, and met with Administrator Karen Dhaliwal. The purpose of today's visit is to return R1 and R2’s file that were removed on 05/26/26 for the purpose of a complaint investigation. There are no citations issued during this visit. Exit interview conducted. Report signed on site and a copy provided to facility.the state’s words, verbatim · CDSS document, May 28, 2026

Allegation investigated: Resident was left unattended

On this date 01/12/26, Licensing Program Analyst (LPA) M. Yang conducted initial complaint investigation. LPA introduce self, stated the purpose of the visit, and met with Administrator Karen Dhaliwal. LPA discussed complaint and delivered complaint findings to Administrator. During the course of the investigation, the department conducted interviews, records were reviewed, and the facility was toured. Based on interviews conducted and records reviewed, R1's current physician report documents that the resident cannot leave the facility unsupervised. Interviews confirmed R1 had left the facility premises with R2 without staff supervision on 01/06/26, therefore, the preponderance of evidence has been met, the above allegation is found to be SUBSTANTIATED. An exit interview was conducted. A copy of this report and appeal rights was provided to Administrator, whose signature on this form confirms receipt of this report. Substantiatedthe state’s words, verbatim · CDSS document, Jan 12, 2026 · control 24-AS-20260107172854

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87413(a)(2) · Plan of correction due date: Jan 13, 2026

87413(a)(2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. This requirement is not met as evidenced by: Based on interviews and records reviewed, R1's current physician report documents that the R1 cannot leave the facility unsupervised. Interviews confirmed R1 had left the facility premises with R2 without staff supervision on 01/06/26, poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Jan 12, 2026

Plan of correction: Facility shall submit a plan detailing steps the facility will take to ensure the requirements are met by 01/13/26.

Allegation investigated: Resident sustained severe pressure injuries due to staff neglect Staff are not providing adequate food service to residents Staff are not providing residents authorized representative with resident's documents Staff are not ensuring the facility is clean

On 09/12/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to delivered complaint findings on the above allegations. LPA introduced self, stated the purpose of the visit, and met with Administrator Karen Dhaliwal. During the course of the investigation, the department conducted interviews, received copies of records, and toured the facility. Based on interviews conducted, records reviewed, and observations, R1 is received hospice care for pressure injury. Staff assist in feeding food for residents that requires feeding. Facility provided requested documents to resident’s authorized representative. Facility was observed inside and outside. Facility was observed to be cleaned and free of odor. Therefore, the preponderance of evidence standard has not been met, the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 12, 2025 · control 24-AS-20250715135159

Allegation investigated: Neglect/ Lack of care and supervision resulting in resident having scabies

On 08/22/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings. LPA introduced self, stated the purpose of the visit, and met with Administrator Karen Dhaliwal. During the course of the investigation, the Department conducted interviews, records were reviewed and toured the facility. R1 developed skin rashes that were not diagnosis as scabies. The facility has notified R1’s physician and treatment has been provided for R1’s skin rash. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided Administrator, whose signature confirms received of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 22, 2025 · control 24-AS-20250630150714

Allegation investigated: Staff do not ensure residents expired medications are discarded

On 06/17/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint investigation. LPA introduced self, stated the purpose of the visit, and met with Administrator Karen Dhaliwal and Licensed Vocational Nurse Diane Cramer. LPA delivered complaint findings. During the course of the investigation, the Department conducted interviews, toured the facility, and reviewed records. Discontinued medications were stored in medication room unlogged and not disposed. Interview with staff confirms expired medications and medications for former residents has not been logged and disposed back dated to March 2025. Based on observations and interviews conducted, the preponderance evident has been met, therefore the above allegation is found to be SUBSTANTIATED. An exit interview was conducted. A copy of this report and appeal rights was provided to the Administrator, whose signature on this form confirms receipt of this report. Substantiatedthe state’s words, verbatim · CDSS document, Jun 17, 2025 · control 24-AS-20250513154609

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i) · Plan of correction due date: Jun 18, 2025

87465 (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, (1) Name of the resident. (2) The prescription number and the name of the pharmacy. (3) The drug name, strength and quantity destroyed. (4) The date of destruction. This requirement is not met as evidenced by: Based on interview conducted and observations, medications for expired residents and discontinued medications were not record nor destructed backdating to March 2025, in which poses/posed a potential health and safety and personal rights risk to the resident in care.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: All medications to be disposed shall be destroyed and recorded. Administrator will submit documentation of steps facility will take to ensure disposed medications are record and destroyed properly and timely to Fresno CCL by POC due date 06/18/25.

Type of visit: Required - 1 Year

On 06/17/25, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct the Required Annual Inspection. LPA introduce self, stated the purpose of the visit, and met with Administrator Karen Dhaliwal and Licensed Vocational Nurse Diane Cramer. LPA toured facility with Administrator. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards. Last fire drill completed on 3/25/25. Fire extinguisher was observed throughout facility with a service date of: 06/13/25. Medications were stored in medication carts. MARs, Centrally Stored Medication List were reviewed, and medications were checked. LPA toured a sample of residents’ room were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Bathroom was toured and observed with securely fastened grab bars and non-skid mat. Kitchen was toured. An adequate supply of perishable and non-perishable food was observed to be properly stored. Temperature was maintained at 31 degree F. in refrigerator and freezer temperature was maintained at -7.4 degree F. Chemicals was stored and locked in housekeeping closet. Washer and dryer observed operational and functioning. Extra linens observed. The outside was toured and observed to be free from debris. There was outdoor seating available for the residents in courtyard. Fire alarm systems observed throughout facility. A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D. A civil penalty is being assessed see attached Lic 421IM. An exit interview was conducted. The following documents are requested and submitted to Fresno CCL by: 06/23/25. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current Administrator certificate, and current liability insurance. A copy of this report and appeal rights was provided to Administrator, whose signature on this form confirm receipt of these reports.the state’s words, verbatim · CDSS document, Jun 17, 2025

Type of visit: Case Management - Other

On 05/19/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct case management visit for the purpose of checking on the health and safety of the clients in care. LPA introduced self, stated the purpose of the visit and met with Administrator Karen Dhaliwal. LPA was informed Administrator, that excluded individual is not employed with facility and have been taken off schedule since 12/16/24. Individual is not associated with facility. No deficiency cited during visit. A copy of this report was provided to Administrator. Exit Interview.the state’s words, verbatim · CDSS document, May 19, 2025

Allegation investigated: Staff do not ensure that residents are provided with a safe environment. Staff are not properly trained. Staff do not provided adequate laundry services.

On 05/09/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint investigation. LPA introduced self, stated the purpose of the visit, and met with Administrator Karen Dhaliwal and Licensed Vocational Nurse Diane Cramer. LPA discussed the purpose of the visit and delivered complaint findings. During the course of the investigation, the Department conducted interviews, toured the facility, and reviewed records. Facility is doing resident’s laundry on laundry schedule date, after resident’s shower date, and as needed. Staff completed required trainings and are redirecting residents. Based on interview conducted, observation, and records reviewed, there was insufficient evidence to prove or disprove that staff did not ensure that residents are provided with a safe environment, staff not properly trained, and staff did not provide adequate laundry services. Therefore, the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was provided to the Administrator, whose signature on this form confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 9, 2025 · control 24-AS-20250508124643

Type of visit: Case Management - Deficiencies

On 05/09/25, Licensing Program Analyst (LPA) M. Yang conducted an unannounced case management deficiency inspection regarding incident reports that received from the facility. LPA met with Administrator Karen Dhaliwal and Licensed Vocational Nurse Diane Cramer. The purpose of the today's visit is to address a medication error. Facility reported medication checked was completed on 04/18/25 at 10:00PM, S1 inadvertently administered R1’s medication Hydrocodone-Acetaminophen 5mg-325mg to R2 on 04/18/15 at approximately 08:41PM. On 04/18/25 at approximately 03:30PM, S1 inadvertently administered R3’s medication Oxycodone-Acetaminophen 10mg-325mg to R4. A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D. A civil penalty is being assessed see attached Lic 421IM. Exit Interview conducted. A copy of this report and appeal rights was provided to Administrator, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, May 9, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: May 10, 2025

87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on interviews and records review, at approximately 03:30PM, S1 administered medication oxycodone-acetaminophen 10mg-325mg prescribed for R3 to R4 and at approximately 08:41PM, S1 administered medication hydrocodone-acetaminophen 5mg-325mg prescribed for R1 to R2, which poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, May 9, 2025

Plan of correction: S1 was terminated on 04/23/25. All medication technician staff will have in-serviced training which will also include administering medications. Licensee will submit documentation of training topics and attendance roster to the Fresno CCL office by POC due date 05/22/25.

Type of visit: Case Management - Deficiencies

On 05/09/25, Licensing Program Analyst (LPA) M. Yang arrived to conduct an unannounced initial complaint investigation and met with Administrator Karen Dhaliwal. During the course of the investigation, LPA toured the facility and observed at 10:27AM, medication tablet unlock in R1’s room. Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. An exit interview was conducted. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, May 9, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 10, 2025

87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above when LPA toured the facility at approximately 10:27AM, observed one medication tablet on bedside tablet next to the resident unlock which poses an immediate health, safety or personal rights risk to person in care.the state’s words, verbatim · CDSS document, May 9, 2025

Plan of correction: Staff immediately removed medication from resident’s room.

Allegation investigated: Staff not responding to client's calls for assistance in a timely manner

On 04/16/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint investigation. LPA introduced self, stated the purpose of the visit, and met with Administrator Karen Dhaliwal. LPA delivered complaint findings. During the course of the investigation, the Department conducted interviews, toured the facility with Administrator and reviewed records. Administrator stated that call pendants are responded to within 10 to 15 minutes. Administrator and LPA observed a sample of residents' call pendant in which were not responded to in a timely manner upon activation. Based on observation and records reviewed, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Under California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC 9099D.An exit interview was conducted. A copy of this report and appeals was provided to the Administrator, whose signature on this form confirms receipt of this report. Substantiatedthe state’s words, verbatim · CDSS document, Apr 16, 2025 · control 24-AS-20250411152911

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Apr 29, 2025

87411(d)(3) Personnel Requirements – General All personnel shall be given on the job training…This training and/or related experience shall provide knowledge of and skill…by safe and effective job performance, Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement was not met: Based on observation and records reviewed, at approximately 01:37PM, LPA and Administrator observed resident call pendant not being responded by staff in a timely matter upon activation. Call log record total average staff responds to residents’ call in one day is above 49.78 minutes from 04/01/25 to 04/16/25, which poses a potential health and safety and personal rights risk to the person in care.the state’s words, verbatim · CDSS document, Apr 16, 2025

Plan of correction: Administrator will have in-service training for all staff regarding answering residents pendant alert call in a timely matter. Documents of staff in-service training and rooster of attendance shall be submitted to Fresno CCL by due date 04/29/25.

Allegation investigated: Staff allows resident to smoke while oxygen tank(s) are in use. Staff allows resident to have access to a lighter. Unqualified staff disposing medications.

On 03/24/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct complaint investigation. LPA introduced self, stated the purpose of the visit, and met with Administrator Karen Dhaliwal. LPA deliver complaint findings on the above allegations. During the course of the investigation, the Department conducted interviews, toured the facility, and reviewed records. Resident was observed requesting for cigarette from staff and staff lighting cigarette for resident outside. The department observed resident smoking outside in designated area. Disposed medications are disposed by medication technicians and management staff into a pharmaceutical container. Based on interviews conducted, observations, and records reviewed, preponderance of evidence standard has not been met, therefore, the above allegations are found to be UNSUBTANTIATED. An exit interview was conducted. A copy of this report was provided to the Administrator, whose signature on this form confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 24, 2025 · control 24-AS-20250318164041

Type of visit: Case Management - Deficiencies

On 03/24/25, Licensing Program Analyst (LPA) M. Yang arrived to conduct an unannounced complaint investigation and met with met with Administrator Karen Dhaliwal. Upon arrival to facility, LPA approached the automatic front door and observed front automatic door locked. A deficiency and an immediate Civil Penalty of $500 was assessed. See Lic 421IM is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6. An exit interview was conducted. A copy of this report and appeal rights were provided to Administrator, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Mar 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Mar 25, 2025

87202(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above when LPA arrived at the facility the front automatic door was locked, which poses/posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 24, 2025

Plan of correction: Administrator immediately unlocked the front door. POC cleared during visit.

Allegation investigated: Licensee does not ensure that facility's appliances are maintained in good repair

On 03/12/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint investigation. LPA introduced self, stated the purpose of the visit, and met with Administrator Karen Dhaliwal. During the course of the investigation, LPA conducted interviews, toured the facility, and reviewed records. Refrigerators were observed operational and in good repair. Refrigerator temperature was maintained at 36 degrees F. Frozen food was observed stored in refrigerator. A freezer was observed in the facility kitchen non-operational. Based on observation, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBTANTIATED. A copy of this report and appeal rights was provided to the Administrator, whose signature on this form confirms receipt of this report. Substantiatedthe state’s words, verbatim · CDSS document, Mar 12, 2025 · control 24-AS-20250311151837

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(21) · Plan of correction due date: Mar 13, 2025

87555 (b)(21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures. This requirement is not met as evidenced by: Based on interviews conducted, observation, and records reviewed, the facility did not have a working freezer for over two weeks to store frozen food, which poses/ posed a potential health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Mar 12, 2025

Plan of correction: Facility has a new freezer that arrived on 03/11/25 and not being put in use to store frozen food. New freezer will be plug in and utilized by POC due date.

Type of visit: Case Management - Deficiencies

On 11/07/24, Licensing Program Analyst (LPA) M. Yang conducted an unannounced case management- deficiencies inspection regarding incident reports that received from facility. LPA met with Administrator Karen Dhaliwal. The purpose of the today's visit is to follow up on the three incident reports that was reported to department. First incident that had occurred on 09/18/24 where R1’s medications was not administered. S1 had put all R1’s medications on hold without a doctor’s order on 08/25/24. Second incident occurred on 10/22/24, S2 administered R5’s medication to R2. The third incident occurred on 10/24/24, S4 had administered R4’s medication to R3. A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D. Exit Interview conducted. A copy of this report and appeal rights was provided to Administrator, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Nov 7, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Nov 8, 2024

87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on interviews and records review, on 09/18/24, R1’s medications were not administered to the resident and was put on hold. R1's medications was placed on hold by S1 without a doctor’s order on 08/25/24. On 10/22/24, S2 administered R5’s medication Lorazepam 1 mg to R2. On 10/24/24, S4 administered R4’s medication Hydralazine HCL 25mg to R3, which poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: S1, S2 and S4 was retrained on medications regulation which will include administering medications. Copies of trainings materials and proof of staff retrained will be submitted to department by 11/08/24.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) M. Yang conducted an unannounced visit to the facility for purpose of a Pre-Licensing evaluation. LPA arrived entered to the facility met Licensee Jonathan Johnson, Administrator Maria Barajas, Operation Manager, and Administrator 2 Mory Jaime. LPA conducted an announced Pre-licensing and Component III inspection for Change of Ownership. Fire clearance was granted for 50 non-Ambulatory and 4 bedridden for total of 54 capacity. The facility has two wings: east and west. Smoke detectors and carbon monoxide detectors were observed during inspection. Fire extinguisher observed throughout the facility on each wing with service date of 06/06/24. LPA observed a 2-day supply of perishable foods and a 7 day supply of non-perishable foods. A salon and activity room were observed. LPA observed an extra supply of bed linens and personal hygiene products. Sample of residents’ bedrooms were observed to have required furnishings and lighting. Temperature maintains at 31 degrees F in refrigerator 1 and 36 degrees F in refrigerator 2. Sample of residents’ bathrooms are observed with securely fastened grab bars and non-skid mat. Bathrooms observed operational and functional. Hot water measured ranged between 107.2 degrees F to 109.9 degrees F. Facility washer and dryer observed operating during inspection. Chemicals observed stored and locked in locked closets on each wing. Delayed egress doors observed. Exterior toured and observed free of debris. Adequate outdoor seatings observed available for the residents. First aid kit was observed and contained all required items. Medications observed locked in medication cart in the medication room. A sample of resident files were reviewed to have Admission Agreements, Physician Reports, and Pre-Appraisal. A sample of staff files were reviewed to have a criminal record clearance, fingerprinted clearance, and good health screening. Component III was conducted during today's pre-licensing visit. I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.the state’s words, verbatim · CDSS document, Aug 9, 2024

Type of visit: Office

Facility Type: Residential Care Facility for the Elderly Application Type: Change of Ownership Capacity: 54 Census (if any clients in care): 28 COMP II Participants: MARIA BARAJAS, JONATHAN JOHNSON Interview Method: Telephone interview On July 29, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jul 29, 2024