Aegis Assisted Living of Fremont

Type of visit: Case Management - Health Checks

On 07/28/2026 at 1:00 PM, Licensing Program Analyst (LPA) P.Manalo arrived unannounced to conduct a health and safety check because of incident that occurred on 07/24/2026 involving residents and visitor that were armed. Local law enforcement was involved during the incident. LPA met with General Manager, Ryan Turner, Interim General Manager, Renato Alesiani, and Health Services Director, Leslie Ibo LPA informed the purpose of the visit. During the visit, LPA observed R1 and R2 as they were preparing to go out of the facility for an outing with W1. Alesiani stated that the facility provided trauma counselors and chaplain services to the residents , staff, and visitors. The private dining room where the incident took place is closed until remodeling is completed. LPA toured facility inside and out including but not limited to apartments, bathrooms, kitchen, multiple activity rooms, common area and courtyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature in the hallways is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms is adequate for the comfort and safety of the residents. The hot water temperature in the residents shared bathroom was measured at 110, 113.4, 113.2, 105.7, and 115 degrees Fahrenheit. Residents’ showers are equipped with grab bars and non-skid shower pans. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Continue to LIC809-C... Continued from LIC809.... Fire Alarm semi annual was last conducted in December 2025. Smoke alarm and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 06/24/2026. First aid kit was observed to be complete. Liability insurance is effective from 12/01/2025 to 12/01/2026. THE FOLLOWING DEFICIENCY WAS OBSERVED DURING VISIT: At 1:59 PM, LPA observed Lysol wipes and Lysol spray in R3’s room and Clorox wipes in R4’s room The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalties. Exit interview conducted with Aleisani. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 28, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 29, 2026

87309(a) Storage Space and Access ...disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observations and record review, the licensee did not comply with the section cited above by having Lysol wipes and Lysol spray in R3’s room and Clorox wipes in R4’s room which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 28, 2026

Plan of correction: By POC date, staff agree to lock the items and send proof to CCLD.

Type of visit: Case Management - Incident

On 07/23/2026 at 2:10 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident. LPA met with Interim General Manager, Renato Aleisani, and Health Services Director, Leslie Ibo. Health Services Director, Leslie Ibo, self-reported the incident on 06/25/2026. LPA received a self-reported incident report from facility that indicated on 06/21/2026, Resident 1 (R1) and Resident 2 (R2) were observed in bed together by a care staff during routine rounds in the morning. Incident report stated that the facility reviewed the Augi footage and it showed R1 entering R2's room. R1 removed R1's clothing, leaving the R1's brief on, and got into bed with R2. When staff observed the incident, both residents were separated and R1 was placed with a 1:1 private caregiver. Incident report stated that the incident was reported to the appropriate parties. During the visit, S1 stated that R1 is still currently receiving 1:1 private caregiver until hospice services or medication change has been initiated by family and/or physician. LPA attempted to interview R1 and R2, however, they were not available for interview. LPA attempted to review Augi footage, but S1 stated that the footages can only be reviewed if the date is 30 days prior the current date. LPA reviewed the following documents including but not limited to Physician's Report, communication log with family and doctor's, service plan, progress notes, private caregiver invoices, Medication Order, and Physician Fax Reports. No deficiencies cited during visit. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 23, 2026

Allegation investigated: Staff do not ensure food served is of good quality Staff do not ensure contaminated food is discarded Staff do not ensure floors and surfaces are kept in clean sanitary condition at all times Licensee does not ensure staff are properly trained in food service

On 06/17/2026 at 11:40 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to deliver the findings on the above allegations. LPA met with General Manager, Ryan Turner and Health Services Director, Leslie Ibo. LPA explained the purpose of the visit. During the course of investigation, LPA interviewed 13 staff, 9 residents, and witness. LPA reviewed and obtained documents including but not limited to Personnel Report (LIC500), Resident Roster, Staff Schedule for February and March, Weekly Menu for February and March, Personnel Record (LIC501), California Food Handler Certificate, maintenance invoice, and staff training. Continue to LIC9099-C... Unsubstantiated Continued from LIC9099… Allegation: Staff do not ensure food served is of good quality It was alleged that staff do not ensure food served is of good quality. On 03/25/2026, LPA interviewed 8 of 9 residents and confirmed the food being served to the residents is good. In addition, 8 of 9 residents do not have any issues with the quality of food that they receive for their meals. Interview with 7 of 13 staff indicated that the food quality being served to residents is good and has not observed any issues. S10 stated that there are times when vegetables and pasta would be undercook to residents’ preference, therefore, S10 will request for those food items to be cooked longer. S10 confirmed that the kitchen staff will replace the food items when requested before serving to residents. Based on interviews and observations conducted, the above allegation that staff do not ensure food served is of good quality 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, therefore the allegation is unsubstantiated. Allegation: Staff do not ensure contaminated food is discarded. It was alleged that staff do not ensure contaminated food is discarded. Interview with S6 indicated that the facility receives their food shipment twice a week and if S6 notices that there’s something wrong with the food items, S6 will take a picture and file a claim to the food vendor. Interview with 5 of 8 staff members indicated that if they observe rotten or spoiled food in the kitchen, they will discard it. Interview with R9 indicated that when R9 receives fruits from the kitchen, R9 always received fresh fruits and never rotten. Additionally, interviews with R4, R5, R6, R7, and R9 stated that there are no issues with the food that they receive from the kitchen. Based on interviews conducted, the above allegation that staff do not ensure contaminated food is discarded 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, therefore the allegation is unsubstantiated. Continue to LIC9099-C... Continued from LIC9099-C... Allegation: Staff do not ensure floors and surfaces are kept in clean sanitary condition at all times. It was alleged that staff do not ensure floors and surfaces are kept in clean sanitary condition at all times. On 03/25/2026, LPA observed the kitchen and observed it in sanitary conditions. LPA also observed kitchen staff sanitizing their workstations after each task. Interview with S1 indicated that every quarter, the kitchen staff will have overnight cleaners that will clean the kitchen, including the floors. A record review of the facility’s maintenance invoice dated from 03/13/2025 to 05/13/2026 showed that the facility had a deep cleaning that included the floors and surfaces of the kitchen every 3 months. Interview with S6 indicated that kitchen staff will mop and sweep the floor daily and the maintenance staff will conduct a deep cleaning of the floors every 3 weeks. S5, S7, and S9 stated that they will occasionally mop and/or sweep the floors during their shifts. Additionally, S2 stated that they frequently visit the kitchen throughout their shift and have not observed the kitchen floors and surfaces unsanitary. Based on interviews and record review conducted, the above allegation that staff do not ensure floors and surfaces are kept in clean sanitary condition at all times 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, therefore the allegation is unsubstantiated. Allegation: Licensee does not ensure staff are properly trained in food service. It was alleged that licensee does not ensure staff are properly trained in food service. On 03/25/2026, LPA reviewed a sample of staff files and 8 of 8 staff members all have a valid Food Handlers certificate. S1 stated that all staff members working in the kitchen will receive training on Relias and are required to have a Food Handlers certificate. Interviews with S3, S4, S6, S8 and S9 confirmed that they all maintain a Food Handlers certificate. S3 and S6 both stated that they will provide training for the kitchen staff, especially for the different types of diets each resident has. 4 of 7 kitchen staff that were interviewed indicated that they received kitchen training of some sort in the facility before they began completing tasks on their own. Continued to LIC9099-C... Continued from LIC9099-C... Based on interviews conducted, the above allegation that licensee does not ensure staff are properly trained in food service 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, therefore the allegation is unsubstantiated. No deficiencies cited. Exit interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 15-AS-20260320091415

Type of visit: Case Management - Legal/Non-compliance

On 06/17/2026 at 12:50 PM, Licensing Program Analyst (LPA) Patricia Manalo conducted a case management legal non-compliance visit and met with General Manager, Ryan Turner Health Services Director, Leslie Ibo. LPA explained to Turner and Ibo the purpose of the visit. This case management visit is conducted as follow up on the facility's compliance plan as a result of the Non-Compliance Conference (NCC) conducted on March 25, 2025. During the visit, LPA reviewed incident reports regarding the water leak in the dining room that occured on 06/03/2026 and the power outage on 06/09/2026 which resulted in R1 stuck in the elevator. Interview with R1 confirmed that R1 was stuck in the elevator, however, the facility staff contacted 911 right away. Both incidents were reported to the Department on a timely manner. LPA conducted a tour of the facility including Memory Care Units and the Dining room. LPA observed the elevator in operational and a portion of the dining area where the leak took place is blocked off from the residents. LPA will request for an update once the repair is concluded in the dining room. LPA reviewed R2's incident report that indicated falls that occured on 06/01/2026 and 06/04/2026. During both incidents, 911 and R2's responsible party was contacted. A review of R2's doctor's order indicated that due to the reoccurring falls, one of R2's medications is discontinued to help minimize the falls. LPA and Ibo discussed the facility's care plan will be for R2 No deficiencies cited. Exit interview was conducted and a copy of this report was provided via email.the state’s words, verbatim · CDSS document, Jun 17, 2026

Type of visit: Case Management - Legal/Non-compliance

On 02/03/2026 at 4:20 PM, Licensing Program Analyst (LPA) Patricia Manalo conducted a case management legal non-compliance visit and met with Health Services Director, Leslie Ibo. LPA explained to Ibo the purpose of the visit. This case management visit is conducted as follow up on the facility's compliance plan as a result of the Non-Compliance Conference (NCC) conducted on March 25, 2025. During the visit, LPA P. Manalo conducted an inspection of the Memory Care unit with Ibo. LPA reviewed R1 and R2's incidents dated on 01/07/2026 and 01/27/2026 that were reported to CCLD and residents' responsible party on a timely manner. Interview with Ibo revealed that when R1 had a witnessed fall and 911 was called when R1 verbalized that R1 was in pain. No deficiencies cited. Exit interview was conducted with Ibo and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 3, 2026

Type of visit: Case Management - Incident

On 02/03/2026 at 2:10 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director, Leslie Ibo, self-reported the incident on 01/27/2026. Incident report and interview with Ibo revealed that on 01/26/2026, R1 left the community with friends and did not return. Ibo revealed that the police officers involved during the incident allowed R1 to leave the community since police officers were unable to restrain R1 from leaving. During the visit, LPA interviewed Health Services Director, R1's Durable Power of Attorney (DPOA), and attempted to interview police officer for more information. Interview with Ibo revealed that R1 has not returned to the facility and facility staff are providing R1's friends with R1's medication everyday. Additionally, Ibo stated that education has been provided to R1's friends each time medication is provided. LPA obtained the following documents including but not limited to staff roster, resident roster, facility's visitor log, R1's physician report, service plan, resident emergency information face sheet, police contact information, R1's POA documentation, Medication Release Records, and SOC341. LPA may return at a later time. No deficiencies cited. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 3, 2026

Type of visit: Case Management - Incident

On 02/03/2026 at 2:10 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director, Leslie Ibo, self-reported the incident on 01/07/2026. LPA received a self-reported incident report from facility that indicated Resident 1 (R1) had and witnessed fall while R1's private caregiver was escorting R1 to the bathroom in R1's room on 01/03/2026. Incident report revealed that R1 attempted to push the private caregiver away which resulted in R1's fall. R1 was sent to the Emergency Room and was diagnosed with a hip fracture. R1 is currently at a skilled nursing facility (SNF). LPA reviewed the following documents including but not limited to R1's Physician's Report, communication log with family and doctor's, service plan, call pendant alert log, private caregiver contact information, Home Health Visit Communication form, staff roster/ schedule, staff contact information, and resident roster. Interview with Ibo indicated that a new physician report will be obtained and sent to CCLD when R1 is discharged from the SNF. Additionally, Ibo followed up with the SNF that revealed that there is no discharge date and R1 is undergoing physical therapy. LPA may return at a later time. No deficiencies cited during visit. Exit interview was conducted with Health Services Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 3, 2026

Type of visit: Required - 1 Year

On 10/07/2025 at 11:15AM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with General Manager, Ryan Turner and Health Services Director, Leslie Ibo and explained the purpose of the visit. LPAs toured the facility with General Manager, Ryan Turner, including but not limited to residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents shared bathroom were measured at 114.2, 109.6, 114.3, 112.2, 114, 109.2, and 109.4 degrees Fahrenheit. Hallway temperature measured at 72-73 degree. Residents’ bathrooms are equipped with grab bars with non-skid shower pan. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. At 11:45 AM, LPAs reviewed 8 residents records. At 2:02 PM, LPAs reviewed 8 staff records and 8 of 8 are associated with the facility. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was observed last serviced on 07/10/2025 and kitchen fire extinguisher was last serviced on 07/10/2025. Emergency Disaster Drill last updated on 09/24/2025. Fire Drill last conducted on 09/20/25. First aid kit was observed to be complete. Liability Insurance is effective from 12/01/2024 to 12/01/2025. Continue to LIC809-C... Continue from LIC809... THE FOLLOWING DEFICIENCY WAS OBSERVED DURING VISIT: At 12:42 PM, LPA observed the food supply in the same closet as the antibacterial liquid soap and water supply placed in the laundry room. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalties. Exit interview conducted with General Manager. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 7, 2025

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 08/18/2025 at 2:00 PM, Licensing Program Analysts (LPAs) P.Manalo and K.Nguyen arrived unannounced to conduct a case management visit. LPA met with General Manager, Ryan Turner, and explained the purpose of the visit. While LPAs was at the facility for another visit, LPAs observed the following deficiency: LPAs observed Tide Pod in the washing machine room in Memory Care 2. LPAs observed Sanitation Wipes unlocked in Memory Care 1. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Aug 19, 2025

87309(a)(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions,...which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having a tide pod and sanitzation wipes unlocked and accessible to residents which poses an immediate safety risks to person in care.the state’s words, verbatim · CDSS document, Aug 18, 2025

Plan of correction: The General Manager agrees to lock the items and send proof to CCLD by POC date.

Type of visit: Case Management - Incident

On 08/18/2025 at 12:20 PM, Licensing Program Analysts (LPAs) P.Manalo and and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 07/29/2025. LPAs met with Health Services Director, Brenda Silva and General Manager, Ryan Turner, and explained the purpose of the visit. LPA received a self-reported incident report from facility that indicated Resident 1 (R1) had an unwitnessed fall and incident report revealed that R1 sustained an avulsion fracture. LPAs reviewed the following documents such as R1's Physician's Report dated 05/13/2024, Physician's Fax, Report, After Visit Summary, Individualized Service Assessment, and email correspondence between facility and responsible parties. Interview with Health Services Director stated that the facility and R1's family are in communication regarding R1's care. No deficiencies cited during visit. Exit interview was conducted with Health Services Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 18, 2025

Type of visit: Case Management - Incident

On 08/18/2025 at 11:40 AM, Licensing Program Analysts (LPAs) P.Manalo and and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 07/17/2025. LPAs met with Health Services Director, Brenda Silva and General Manager, Ryan Turner, and explained the purpose of the visit. LPA received a self-reported incident report from facility that indicated Resident 1 (R1) had an unwitnessed fall and after visit summary stated that the resident had sustained a femur fracture. LPAs reviewed the following documents such as R1's Physician's Report, Individualized Service Assessment Plan dated 05/01/2025, 07/21/2025, 08/07/2025, and 08/18/2025, Facility Call Button Log, and After Visit Summary. Interview with Health Services Director stated that the resident was independent and Individualized Service Assessment dated 05/01/2025 stated that R1 will use their pendant to call on staff if assistance is needed. LPAs attempted to interview R1, however, R1 was unavailable during the the time. No deficiencies cited during visit. Exit interview was conducted with Health Services Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 18, 2025

Type of visit: Case Management - Legal/Non-compliance

On 08/18/2025 at 9:40 AM, Licensing Program Analysts (LPAs) Patricia Manalo and Kelly Nguyen conducted a case management-legal non-compliance visit and met with General Manager, Ryan Turner and Health Services Director, Brenda Silva. LPAs explained to Turner and Silva the purpose of the visit. This case management visit is conducted as follow up on the facility's compliance plan as a result of the Non-Compliance Conference (NCC) conducted on March 25, 2025. During the visit, LPA P. Manalo conducted an inspection of the Memory Care unit and reviewed Resident 1 (R1) and Resident 2 (R2) files. Health Services Director and LPAs had a discussion regarding the facility's fall prevention plan. No deficiencies cited. Exit interview was conducted with General Manager and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 18, 2025

Type of visit: Case Management - Incident

On 07/30/2025 at 10:25 PM Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported medication error that occurred on 07/20/2025. Health Services Director, Brenda Silva self-reported the incident on 07/24/2025. LPA met with Care Director, Maryrose Vinarao, and explained the purpose of the visit. General Manager was unavailable during today's visit. LPA received an incident report that on 07/24/2025 Resident 1 (R1) was given a PRN medication after the medication has been discontinued. During the visit, LPA reviewed R1's After Visit Summary, Medication List, Medication Administration Training, Physician's Fax Report, Individual Narcotic Record, and Email Correspondence with R1's family. Progress Notes indicated that the facility contacted the appropriate parties such as R1’s physician and family. Progress Notes also stated that R1 was placed on monitoring and did not show any side effects from the medication error. Interview with Care Director revealed that Staff 1 (S1) gave R1 the PRN medication before checking the Medication Administration Record (MAR). The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalty. Exit interview conducted with Care Director. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 30, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Aug 13, 2025

87465(c)(2) Incidental Medical and Dental Care (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: The licensee did not comply with the section cited above by giving R1 a discontinued PRN medication that posed a potential health and safety risk to person in care.the state’s words, verbatim · CDSS document, Jul 30, 2025

Plan of correction: Staff conducted a Medication Administration In-Service Training on 07/22/2025. Deficiency cleared during the visit.

Type of visit: Case Management - Incident

On 07/30/2025 at 12:00PM Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 07/07/2025. LPA met with Care Director, Maryrose Vinarao, and explained the purpose of the visit. LPA received a self-reported incident report from facility that indicated Resident 1 (R1) had an unwitnessed fall and after visit summary indicated that the resident had a wrist fracture. During the visit, LPA reviewed R1's Individualized Service Plan, Medication List, Transfer/Discharge Report and Order Summary Report from previous skilled nursing facility, and After Visit Summary dated 07/06/2025. A review of resident's Individualized Service Plan dated 06/22/2025 and Order Summary Report from previous skilled nursing facility revealed that the resident has a diagnosis of bone density and structure. No deficiencies cited during visit. Exit interview was conducted with Care Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 30, 2025

Type of visit: Case Management - Incident

On 07/10/2025 at 1:05 PM Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 07/03/2025. LPA met with Health Services Director, Brenda Silva, and explained the purpose of the visit. General Manager, Ryan Turner, gave authorization for Silva to sign the report. LPA received a self-reported incident report from facility that indicated Resident 1 (R1) had an unwitnessed fall and after visit summary stated that the resident was treated for a closed hip fracture. During the visit, LPA reviewed R1's Physician's Report dated 01/30/2023 and 07/09/2025, Individualized Service Plan, Individualized Service Assessment, and After Visit Summary dated 07/10/2025. A review of R1's Physician Report revealed that R1 has a diagnosis of osteopenia. R1's Individualized Service Plan dated 06/21/2025 showed that R1 is independent with most Activities of Daily Living's (ADLS). LPA spoke with R1 during the visit. R1 stated that R1 lost their balance and fell on the ground. R1 stated that R1 fell on R1's hips. R1 stated that staff arrived shortly after to assist R1. No deficiencies issued during the visit and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 10, 2025

Type of visit: Case Management - Incident

On 07/01/2025 at 2:25 PM Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported missed medication that occurred on 06/12/2025. Health Services Director, Leslie Ibo self-reported the incident on 06/19/2025. LPA met with General Manager, Ryan Turner, and explained the purpose of the visit. LPA received an incident report that on 06/12/2025 for Resident 1 (R1) that revealed that R1 was not administered the insulin dose in the morning because the second safety on the needle remained intact causing the missed dosage of the medication. R1 was then given the lunch dosage after the incident. LPA reviewed Physician’s Fax Report dated 06/12/2025, Insulin Staff Training, Progress Notes, Aegis Medication Incident Report and June Emergency Paper Medication Administration Record (MAR). Progress Notes indicated that the facility contacted the appropriate parties such as R1’s physician and family. Progress Notes also stated that R1 was placed on monitoring and did not show any side effects from the missed medications. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with General Manager Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 1, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 1, 2025

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by having a missed medication for R1's insulin which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: The facility conducted an Insulin Training on 06/18/2025 after the incident occured with all the Wellness Nurses. Deficiency cleared during the visit.

Type of visit: Case Management - Incident

On 07/01/2025 at 12:40 PM Licensing Program Analyst (LPA) P. Manalo conducted an unannounced Case Management visit regarding a self-reported restraint abuse that occurred on 06/23/2025. Health Services Director, Leslie Ibo self-reported the incident on 06/23/2025. LPA met with General Manager, Ryan Turner, and explained the purpose of the visit. LPA reviewed the following documents such facility’s Resident Incident Report, Physician’s Fax Report, Progress Notes, and SOC341. LPA also reviewed the AUGi monitoring system during today's visit. LPA interviewed Staff 1 (S1) and Staff (2). Interview with S1 revealed that S1 heard motion in R1’s room and checked the AUGi Monitoring System. AUGi system showed that R1 was laying down and the 1:1 caregiver was holding R1 down on the bed. S1 and another staff member proceeded to intervene. Interview with S2 and Progress Notes for R1 showed that the R1 did not sustain injuries during the assessment. General Manager stated that the private caregiver was sent home and will not be allowed at the facility anymore. LPA will have the facility send the 1:1 Private Caregiver Contract by 04/07/2025. No deficiencies cited during visit. Exit interview was conducted with General Manager and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 1, 2025

Type of visit: Case Management - Incident

On 05/06/2025 at 2:15 PM, Licensing Program Analysts (LPAs) P.Manalo and L. Fontanilla conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 04/29/2025. LPAs met with Health Services Director, Leslie Ibo, and explained the purpose of the visit. Health Services Director self-reported multiple fall incidents that occured with Resident 1 (R1) on 04/25, 04/26, 04/27. LPAs interviews with Health Services Director indicated that R1 has a 1:1 caregiver from 10 PM to 6 AM daily. Record reviews shows that the facility updated R1's Service Plan and Individualized Service Assessment after the incident of the multiple falls. R1 has also moved to the Memory Care Unit and hasn't fallen since the implementation of the their new plan. No deficiencies cited during visit. Exit interview was conducted with Health Services Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 6, 2025

Type of visit: Case Management - Legal/Non-compliance

On 05/06/2025 at 1:10 PM, Licensing Program Analysts (LPAs) Patricia Manalo and Luisa Fontanilla conducted a case management-legal non-compliance visit and met with General Manager, Ryan Turner and Health Services Director, Leslie Ibo. LPAs explained to Turner and Ibo the purpose of the visit. This case management visit is conducted as follow up on the facility's compliance plan as a result of the Non-Compliance Conference (NCC) conducted on March 25, 2025. During the visit, LPA P. Manalo conducted an inspection of the Memory Care unit with Turner and observed laundry baskets blocking two resident's door. The facility removed the baskets during the visit. A technical violation was issued during the visit. Exit interview was conducted with General Manager and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 6, 2025

Type of visit: Case Management - Incident

On 04/07/2025 at 2:04 PM Licensing Program Analysts (LPAs) P.Manalo and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 03/15/2025. LPAs met with Health Services Director, Leslie Ibo, and explained the purpose of the visit. LPA received a self-reported incident report from facility that indicated that the Resident 1 (R1) had an unwitnessed fall and after visit report indicated that the resident sustained closed compression fracture. LPAs reviewed the After Visit Summary dated 03/14/2025. The After Visit Summary indicated that there is no evidence of spine fracture and is due to age indeterminate. No deficiencies cited during visit. Exit interview was conducted with Health Services Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 7, 2025

Type of visit: Case Management - Incident

On 04/07/2025 at 1:25 PM Licensing Program Analysts (LPAs) P.Manalo and and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 03/15/2025. LPAs met with Health Services Director, Leslie Ibo, and explained the purpose of the visit. LPA received a self-reported incident report from facility that indicated Resident 1 (R1) had an unwitnessed fall and after visit summary stated that the resident had a closed T11 fracture. LPAs obtained the following documents such as R1's Physician's Report from move in date, Emergency ID Face Sheet, and After Visit Summary from 03/15/2025. LPAs record review indicated that R1's Physicians Report and Emergency ID Face Sheet indicated that R1 had sustained a unspecified fracture prior to moving in. No deficiencies cited during visit. Exit interview was conducted with Health Services Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 7, 2025

Allegation investigated: Staff did not provide adequate supervision resulting in resident sustaining multiple fractures while in care

On 02/20/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit to deliver the finding of the allegation. LPA explained the purpose of the visit with Executive Director/Administrator (ADM). During investigation, the department obtained the following documents from administrator – staff roster with contact information, LIC500, resident roster, admission agreement, physician's report, preplacement appraisal, hospice care plan, emergency information, responsible party (POA) information, home heath reports, incident reports. Health & safety check conducted see LIC 809 dated 04/11/24. Continued on next page, LIC 9099-C Substantiated ALLEGATION: Neglect/Lack of Supervision – Staff did not provide adequate supervision resulting in resident (R1) sustaining multiple fractures while in care. INVESTIGATION FINDING: Substantiated During investigation, the department conducted interviews of facility staff (Care Director (CD), Regional Health Services Director (RHD), S1, S2) & R1’s responsible party (POA) and reviewed resident (R1) documents. Review of R1’s incident reports showed R1 had sustained 5 documented falls at the facility since she was admitted in 2022. Staff (CD, RHD) both denied receiving reports from care staff that R1 needs a 1:1 caregiver citing R1 higher level of care. Despite having multiple fall prevention methods in place and staff expressing their concerns to management in not being able to provide adequate care, R1 continued to have un-witnessed and witnessed falls in the facility, twice sustaining serious fractures in her femur and pelvis, Based on observations and interviews which were conducted and record review(s), the department has substantiated the allegation that staff did not provide adequate supervision resulting in resident (R1) sustaining multiple fractures while in care. The preponderance of evidence standard has been met. Therefore, the above allegation was found to be substantiated. Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in resident sustaining multiple fractures while in care. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 20, 2025 · control 15-AS-20240409165559

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 20, 2025

To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by staff failing to provide adequate supervision resulting in resident sustaining multiple fractures while in care which posed an immediate risk to resident in care.the state’s words, verbatim · CDSS document, Feb 20, 2025

Plan of correction: Deficiency corrected during visit. In-service staff retraining on proper care and supervision conducted on 04/12/24. Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in resident sustaining multiple fractures while in care.

Type of visit: Case Management - Incident

On 02/20/25 at 2:43PM, Licensing Program Analyst (LPA) Daisy Panlilio arrived unannounced to conduct a case management visit in response to a priority 1 complaint received on 04/09/24. LPA met with Executive Director (ED) and explained the purpose of the visit. Reporting party (RP) stated that review of video footage on 03/03/24 showed a male memory care resident (R5) entered resident's (R1) bedroom at 0449 hours and stayed there until 0600 hours. RP stated that R1's bedroom had a motion sensor that would alert staff of any movements inside. RP stated that no staff came to remove R5 from R1's room. R5 left the room on his own at 0600 hours. RP also stated she observed memory care residents left unsupervised in the common room of the memory care unit while she was visiting R1 on May 2024. LPA interviewed ED who stated that he discussed the incidents with RP and conducted in-service staff retraining regarding proper care and supervision of residents with dementia on 04/12/24. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 20, 2025

Type of visit: Case Management - Incident

On 1/15/2025 at 11:15 AM Licensing Program Analysts (LPAs) P.Manalo and L. Fontanilla conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 01/13/2025. LPAs met with Health Services Director, Leslie Ibo, and explained the purpose of the visit. LPAs obtained the following documents such as R1's Physician's Report, Emergency ID Face Sheet, Physician's Fax Report Notification, Discharge Summary from 12/20/2024, Internal Progress Notes, Care Plan, Individualized Service Assessment, Medication Administration Record (MAR), Appraisal Needs and Services Plan, and Staff Schedule. LPAs requested a copy of the Death Certificate to be sent to CCLD on 02/15/2025. No deficiencies cited during visit. Exit interview was conducted with Health Services Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 15, 2025

Type of visit: Case Management - Incident

On 12/06/2024 at 8:55 AM Licensing Program Analysts (LPAs) P.Manalo and L. Fontanilla conducted an unannounced Case Management visit regarding a self-reported abuse that occured on 11/29/2024. Health Services Director self-reported the incident on 12/05/2024. LPAs met with Executive Director, Ryan Turner, and explained the purpose of the visit. LPAs interviewed R1, R2, Executive Director, and Health Services Director regarding the incident. R1 has dementia diagnosis and lives in the Memory Care Unit. R2 stated that S1 pulled R1's leg while R1 was in bed. LPAs interviewed Executive Director and Health Services Director who stated that S1 was terminated on 12/05/2024 and has been removed from the facility roster. LPAs obtained the following documents such as R1's Physician's Report, S1's Termination Paper, S1's Employee Files, Staff Roster, and Resident Report. No deficiencies cited during visit. Exit interview was conducted with Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 6, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPAs) Manalo and Clancy-Czuleger arrived unannounced to conduct a case management visit in response to the Unusual Incident Report (UIR) submitted by the facility. LPA's met with Leslie Ibo, Health and Wellness Director and Ryan Turner Executive Director and explained the purpose of the visit. Resident (R1) had a sudden death and was not on hospice. Health and Wellness Director (S1) stated that R1 was receiving morning adl’s with care staff when she started throwing up & loss consciousness. CPR was administered for about 45 minutes and tried to resuscitate. R1 had a history of colon cancer and colon diverticulitis, and had a diagnosis of dementia and hypertension. Police were called (badge #16133) and stated that the coroner does not need to visit the community. No deficiencies cited during today's visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 28, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPAs) Manalo and Clancy-Czuleger arrived unannounced to conduct a case management visit in response to the Unusual Incident Report (UIR) submitted by the facility. LPA's met with Leslie Ibo, Health and Wellness Director and Ryan Turner Executive Director and explained the purpose of the visit. Resident (R1) had passed away on 10/17/2024. On October 20, 2024, Health and Wellness Director (S1) started the process of medication destruction, when it was observed that an unused bottle of narcotics medications was missing. Medtech’s and nurses started to look for the medication. All medication carts and overflow cabinets were searched and still could not find the medications. An internal investigation was conducted, medtech’s and nurses was interviewed. The incident was reported to Fremont Police with the incident event number is P24125430. In-service with wellness team started on 10/22/2024 with the following topics: narcotic count, documentation, medication error, medication destructions and other topics. Regional Health Services Director and General Manager was notified regarding the incident. Our community started to have two staff signing off for the narcotics, nurses will audit narcotics weekly. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Oct 28, 2024

Type of visit: Required - 1 Year

On 10/28/2024 at 9:00AM, Licensing Program Analysts (LPAs) P. Manalo and J. Clancy-Czuleger arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Health Services Director, Leslie Ibo and explained the purpose of the visit. Administrator, Ryan Turner, arrived shortly after. LPAs toured the facility with Administrator, Ryan Turner, including but not limited to residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 115 and 114.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars with non-skid shower pan. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. At 9:45 AM, LPAs reviewed 8 residents records. At 10:45 AM, LPAs reviewed 8 staff records and 8 of 8 are associated to the facility. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was observed last serviced on 08/28/2024 and kitchen fire extinguisher was last serviced on 08/28/2024. First aid kit was observed to be complete. Continue LIC809C... Continue from LIC809... Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/04/2024: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 28, 2024

Type of visit: Case Management - Deficiencies

On 9/25/24 at 12:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver amended LIC9099D page from visit conducted on 9/24/24 . LPA met with Ryan Turner, General Manager and explained the purpose of the visit. LPA delivered amended LIC9099D. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 25, 2024

Allegation investigated: Staff locked residents in their room.

On 9/24/24 at 10:30 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings in regard to the allegation above. LPA met with Ryan Turner, General Manager and explained the purpose of the visit. During the course of the investigation LPA interviewed the RP, facility staff and reviewed facility documents. S2 stated that while doing her rounds in the memory care unit on 4/20/24 at approximately 8:00 p.m. she observed that someone had placed laundry baskets in front of 3 residents’ rooms essentially locking the residents in their rooms. S2 took pictures to document what she observed, removed the baskets, checked on the residents and called her supervisor. ***report continues on LIC9099C*** Substantiated ***report continues from LIC9099*** S1 stated that while conducting the investigation into the situation S3 admitted to placing the laundry baskets in front of the residents’ rooms to prevent them from wandering while she did her work. LPA reviewed S3’s personnel file and found the S3 was separated from the facility on 4/22/24 for “misconduct: locked the resident in the apt with cart outside the door.” LPA also reviewed the photos that S2 took of the laundry baskets blocking the residents' rooms. Based on LPA document review and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted, a copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 24, 2024 · control 15-AS-20240422104806

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Sep 24, 2024

87468.1 Personal Rights of Residents in All Facilities (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. Based on interviews the licensee did not comply with the section cited above by having a staff person lock residents' in their rooms using a laundry cart which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: Facility to conduct Personal Rights training and send proof to LPA by POC date.

Allegation investigated: Resident sustained an injury while in care Staff did not report the incident to CCL

On 08/19/2024 at 2:40 PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger and P. Manalo arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with General Manager Ryan Turner and HSD Leslie Ibo. On the allegation: Resident sustained an injury while in care. RP states that R1 was found on the floor in fetal position. When R1 was admitted to the ER imaging was done showing that R1 had traumatic subarachnoid hemorrhage with no acute fracture or malalignment identified. R1’s medical records state that this injury is constant with an accidental fall. Staff did not report the incident to CCL. The facility provided an incident report dated 6/4/2022 for R1 which details the incident of R1 getting sent to the hospital for a UTI and returning to the facility on 6/3/22 after being admitted to hospice. The incident report did not report the subarachnoid hemorrhage that was found at the hospital as a result of an unwitnessed fall. Continued on LIC9099-C... Substantiated ...Continued from LIC9099-A Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided. ....Continued from 9099 Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 has been cited. Exit interview conducted. A copy appeal rights, and this report provided.the state’s words, verbatim · CDSS document, Aug 19, 2024 · control 15-AS-20230703170031

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Aug 26, 2024

(a)Each licensee shall furnish to the licensing agency such reports... (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not met as evidenced by: Based on reports the licensee did not comply with the section cited above by not submitting an incident report involving an injury resident sustained from accidental fall.the state’s words, verbatim · CDSS document, Aug 19, 2024

Plan of correction: Licensee will submit a written certification indicating the understanding of reporting requirements. Civil penalty assessed of $250 for repeat violation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Aug 26, 2024

The licensee shall ensure that residents are regularly observed for changes in physical, mental, ... the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews and records review, the facility did not observe R1 close enough to know that he had a fall resulting in injury.the state’s words, verbatim · CDSS document, Aug 19, 2024

Plan of correction: Licensee will submit a written certification indicating the understanding of the regulation. Civil penalty assessed of $250 for repeat violation.

Allegation investigated: Staff did not seek medical attention to resident Staff did not report incident to CCL Staff did not communicate with the responsible party of incident

On July 10, 2024 at 9:10 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to deliver findings on the above allegations. LPA met with Ryan Turner Genral Manager and Kevin Hunter SVPO and explained the reason for the visit. The Department’s investigation included but was not limited to interviews with staff, residents, and the reporting party. The Department obtained copies of resident (R1) record, pictures of R1’s bruising, Medical Records, Text message exchange and Death Certificate. On the allegation: Staff did not seek medical attention to resident. Based on Interview On June 16, 2022, R1 had two unwitnessed falls that occurred around 0825 AM and 1120 AM. The information about these two falls was provided by S2 to her leadership (S1) about five days after the incident occurred. Continued on LIC 9099C... Substantiated ...Continued from LIC 9099 The first unwitnessed fall was discovered by S2; documents support that care staff (caregivers) helped R1 up and provided first aid to her finger. The second unwitnessed fall, S1 delayed reported that around 1120 hours, she observed R1 on the floor in front of a chair she was previously sitting on at around 1100 hours. Staff assisted R1 to her feet and, as per interviews, guided her back to the dining area before later presenting her to her family for a visit. Care staff did not notify the nurse on duty for additional assessment for both unwitnessed falls. On the allegation: Staff did not report incident to CCL. Based on interviews and records review the facility did not report to the department that R1 had 2 unwitnessed falls on June 16, 2022. In an interview with S1 said that for both falls reported by S2, facility was not able to find the incident reports or the COC report to provide to CCLD. On the allegation: Staff did not communicate with the responsible party of incident. Based on interviews and records review the facility did not report to R1’s family the residents change of condition or falls that occurred. In an interview with the investigator S1 confirmed that no one updated R1’s family about the investigation. Based on the investigation, above allegations are deemed Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 10, 2024 · control 15-AS-20230614155123

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Jul 12, 2024

The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by: Based on interviews and records review, the facility did not seek medical attention for a resident who had two falls.the state’s words, verbatim · CDSS document, Jul 10, 2024

Plan of correction: The administrator agreed to have an in-staff training to review regulation 87465(g). The facility will submit a copy of the training topic with attendees’ signatures and will be abided by going forward to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Jul 24, 2024

Each licensee shall furnish to the licensing agency such reports as the Department ... A written report shall be submitted to the licensing agency ... This report shall include... Any serious injury as determined by the attending physician... This requirement was not met and evidenced by: Based on interviews and records review, the facility did not report to the department that the resident had bruising and two unwitnessed falls.the state’s words, verbatim · CDSS document, Jul 10, 2024

Plan of correction: The administrator agreed to have an in-staff training to review regulation 87211. The facility will submit a copy of the training topic with attendees’ signatures and will be abided by going forward to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jul 24, 2024

The licensee shall ensure that residents are regularly observed for changes in physical, mental, ... the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews and records review, the facility did not for a resident who had two falls.the state’s words, verbatim · CDSS document, Jul 10, 2024

Plan of correction: The administrator agreed to have an in-staff training to review regulation 87466. The facility will submit a copy of the training topic with attendees’ signatures and will be abided by going forward to CCLD by POC date.

Type of visit: Case Management - Health Checks

On 04/11/24 at 12:40PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Health and Safety check due to the department receiving a priority 1 complaint. During the health and safety check, LPA observed a total of 27 staff members and 72 residents at the facility. LPA toured facility with general manager/administrator, including but not limited to bedrooms, kitchen, dining rooms, activities rooms, bathroom, outdoor garden and common areas. LPA observed residents comfortable in their surroundings, eating their lunch meals and relaxing in common areas with family and friends. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 11, 2024

Allegation investigated: Staff abused residents while in care. Staff violated residents personal rights.

On 11/15/2023, at 11:00 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a subsequent complaint investigation visit and to deliver findings on the above allegations. LPA was greeted by Madeline Williams, General Manager (GM), and Shashi Madahar, Health Service Director (HSD) and explained the purpose of the visit. During the course of the investigation, LPA interviewed four (4) residents and five (5) staff members . LPA obtained the following documents: Staff and resident roster, Staff contact information, Facility staff schedule (May and June 2023), Residents Identification and Emergency Information (ID), Progress notes (May 2023), Physicians reports, and Incident reports (May 2023) of a sample of 5 of 5 residents. Continue on Lic9099-C... Unsubstantiated Continue from Lic9099 It was alleged that staff abused resident while in care and staff violated residents personnel rights. Based on interviews conducted. All staff have stated that they have not witnessed any residents’ being abused nor their personnel rights being violated. All staff gave residents’ their personal phone and call button to call as they please. Residents’ stated during interview that they are treated well, and staff has not abused them nor violated their personnel rights. Residents’ also stated that staff allows them to use their personal phones, and use the call button for assistance if they need any type of help. LPA review R1’s medical record which indicated R1 sustaining a fall resulting in a hip fracture in November 2021. Based on Interviews and record review conducted, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegations are UNSUBSTANTIATED. Exit interview conducted with GM and HSD, and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 15, 2023 · control 15-AS-20230523081935