Riverstone Terrace Senior Living Memory Care

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Staff are not grooming residents in care.

On 09/18/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint investigation. LPA met with Administrator Douglas Rice and stated the purpose of the visit. LPA delivered complaint findings on the above allegation during visit. During the course of the investigation, records were reviewed, and interviews were conducted. Based on interviews conducted, observation, and records reviewed, the facility failed to provide grooming services to the residents in care. Four residents were observed with overgrown toenails with no documentation between residents or resident’s responsible party and the facility to arrange for grooming services. Therefore, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBTANTIATED. 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. Substantiatedthe state’s words, verbatim · CDSS document, Sep 18, 2026 · control 24-AS-20260918085127

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 24, 2026

87464(f)(1) Basic services shall at a minimum include: 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, observation, and records reviewed, the facility failed to provide grooming services to the residents in care. Four residents were observed with overgrown toenails with no documentation between residents or residents’ responsible party and the facility to arrange for grooming services, which poses/posed a potential health and safety risk for the residents in care.the state’s words, verbatim · CDSS document, Sep 18, 2026

Plan of correction: The facility will provide a plan how the facility will ensure the residents’ grooming needs will be met. The written plan will be submitted to Fresno CCL by POC due date 09/24/26. Facility will provide proof of grooming service has been completed for four of the residents that were observed with overgrown nails. Proof will be submitted by 09/24/26.

Allegation investigated: Licensee is not following adequate infection control protocols

On 09/9/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint investigation. LPA met with Administrator Douglas Rice and stated the purpose of the visit. LPA delivered complaint findings on the above allegation during visit. During the course of the investigation, records were reviewed, the facility was toured, and interviews were conducted. Residents were isolated, PPE supplies were available for residents and staff, and staff disinfected facility and worn PPE per infection control plan when infection disease was present at the facility. Based on interviews conducted, the preponderance of evidence standard has not been met, therefore, the above allegation is found to be UNSUBTANTIATED. 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 9, 2026 · control 24-AS-20260902100404

Type of visit: Required - 1 Year

On 06/23/26, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct the Annual Inspection. LPA met and toured facility with Administrator Douglas Rice. Facility has sufficient furnishings inside and outside for resident use. LPA observed exits to have a 15-second delay egress. The facility was observed to be at a comfortable temperature, clean, and no passageway obstructions or fire hazards. Residents were observed seating in common areas. Facility is equipped with pull stations and fire sprinklers throughout the facility. Fire extinguisher was observed throughout the facility with a service date of: 09/09/2025. LPA toured kitchen. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer, refrigerator, and pantry. Food are prepared at Riverstone Terrance Senior Living and kept warm during transport to the resident during each meals in a cart. Chemicals stored and locked in house keeping’s room. A sample of resident bedrooms was toured. Hot water temperature was tested and measured to be maintained at 96.2 degrees F in room D7, 91.9 degrees F in room D7, 91.9 degrees F in room A6, 93.7 degrees F in room B8, and 99.5 degrees F in room C6. LPA observed securely fastened grab bars in bathrooms. Nonskid strips in residents’ showers. Flooring in the laundry room was observed in disrepair near the washer and dryer. Medications are kept lock in medication cart. A sample of residents’ files was reviewed. Courtyard was toured and observed with available seating for residents with shade. Carbon monoxide was observed operational during visit. Technical Support Program (TSP) assistance was offered. Administrator will make a decision and reach out the department regarding acceptance. A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6 see attached 809D. Exit interview was conducted. The requested documents are to be submitted to the department by 06/26/6: Lic 308, Lic 500, Lic 610E and current liability insurance. A copy of this report and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Jun 23, 2026

Type of visit: Case Management - Deficiencies

On 11/25/25, Licensing Program Analyst (LPA) M. Yang conducted case management- deficiency visit to the facility. LPA introduce self, stated the purpose of the visit and met with Resident Service Director Casey Gonzales and Administrator Douglas Rice. The purpose of the visit is to address incident that was reported on 11/17/25 where R1 AWOL from the facility on 11/14/25. The facility was contacted by the resident’s family and informed the resident had contacted the family that the resident was not located inside the facility. The facility was not aware that R1 went AWOL until R1’s family contacted and informed the facility. Therefore, as mentioned, R1 went AWOL from facility. As a result, a deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D. An immediate civil penalty of $500.00 was issued, see Lic 421IM. An exit interview was 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 25, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 26, 2025

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required…. This requirement is not met as evidenced by: Based on interviews and records review, staff did not provide care and supervision when R1 went AWOL on 11/14/25, and facility was not aware until the facility was notified by R1’s family which poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Nov 25, 2025

Plan of correction: Administrator agrees to have AWOL policy and procedures upated to ensure the requirements and procedures will be in place to ensure facility are aware of the reisdents whereabouts. POC will be submit to Fresno CCL by POC due date 11/26/25.

Type of visit: Case Management - Health Checks

On 10/09/25, 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 Resident Service Director Casey Gonzales who stated Administrator Douglas Rice is unavailable. The purpose of the visit is to conduct a health and safety visit on the resident’s in care. It was informed that R1 was sent out to the hospital with a swollen eye. Interviews were conducted, records were received, and the facility was toured. The information provide will be reviewed; a follow up case management will be conducted if necessary. An exit interview was conducted. A copy of this report was provided to Resident Service Director, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Oct 9, 2025

Type of visit: Case Management - Deficiencies

On 09/08/25, Licensing Program Analyst (LPA) M. Yang conducted case management visit to the facility. LPA introduce self, stated the purpose of the visit, and met with Administrator Douglas Rice. The purpose of the visit is to conduct a health and safety visit on the resident in care. The department was notified of a complaint that was submitted on staff not administering prescribed medications to resident at facility Riverstone Terrace Senior Living. R1 did not reside at Riverstone Terrace Senior Living and reside at facility. A case management visit was conducted at facility to be investigated on the allegation. Interviews were conducted, records were received, and the facility was toured. R1’s medications were checked, and MARs were reviewed. An exit interview was 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, Sep 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(d)(3) · Plan of correction due date: Sep 9, 2025

87465(d)(3) The date and time …medication was taken, the dosage taken, and the resident’s response shall be documented and maintained in the resident’s facility record. This requirement was not met as evidenced by: Based on observations, records reviewed, and interviews conducted, not all R1’s medication was record in R1’s Medication Administration Record (MAR), which poses/ posed a potential health and safety risk for the person in care.the state’s words, verbatim · CDSS document, Sep 8, 2025

Plan of correction: All prescribed medications shall be recorded on resident MARs. Staff record all R1’s medication into R1's MAR during visit. POC cleared during visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(6) · Plan of correction due date: Sep 9, 2025

87465 (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year… This requirement is not met as evidenced by: Based on interview conducted, observation, and records reviewed, all R1’s current medications were not record in Centrally Stored Medication (Lic 622) record, poses/posed a potential health and safety and personal rights risk to the resident in care.the state’s words, verbatim · CDSS document, Sep 8, 2025

Plan of correction: All resident’s current medication shall be recorded on Lic 622. Staff record all R1’s medication onto Lic 622 during visit. POC cleared during visit.

Allegation investigated: Staff did not properly supervise resident, resulting in resident sustaining a fracture Staff do not assist resident with personal care Staff do not ensure that residents' dietary needs are met

On 08/06/25 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 Douglas Rice. During the course of the investigation, the Department conducted interviews, records were reviewed and toured the facility. Water and food are provided for R1. Staff assist in feeding R1 during mealtimes. Adequate staffing was observed and provided at the facility providing care for residents. Based on interviews conducted, records reviewed and observation, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided to the caregiver, whose signature confirms received of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 6, 2025 · control 24-AS-20250606095355

Type of visit: Case Management - Annual Continuation

On 08/06/25, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to continue Annual Inspection. LPA met with Administrator Douglas Rice. A sample of staff files were reviewed. A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6. Exit Interview conducted. The following documents are requested to be submitted to the department by 08/12/25: 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 the report.the state’s words, verbatim · CDSS document, Aug 6, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Aug 7, 2025

87355 (e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by: LPA observed S1 not fingerprinted cleared and S2 who is fingerprinted cleared, not associated to facility were observed providing care for residents at the facility, which poses an immediate risk to the health and safety of the residents.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: S1 and S2 was removed from the facility schedule immediately.S2 is not permitted back until fingerprint is cleared and associated. S2 is not permited back to the facility until assocaited. POC cleared during visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(c)(1) · Plan of correction due date: Aug 7, 2025

87411 (c)(1) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on records reviewed and interview conducted, S1 do not have First Aid, this poses an immediate health and safety risk for the residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Licensee shall ensure that staff have current First Aid training. Proof of S1’s First Aid training is to be submitted to the Fresno CCL by 08/07/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(5)(A) · Plan of correction due date: Aug 12, 2025

87303(e)(5)(A) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above when LPA and A1 observed in room A5, room B6, and room C9 with no nonskid mat or nonskid strip in bathroom showers, this poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Proof of non-skid mat or strips in room A5, room B6, and C9 showers shall be submitted to the Fresno CCL by POC due date 08/12/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(c) · Plan of correction due date: Aug 12, 2025

87412(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Based on records reviewed and interviews, administrator informed LPA that all staff have no trainings record on file. Two out of four staff file reviewed, staff do not the required trainings on file, which poses a potential health and safety risk for the person in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Facility shall review regulation section 87412 and ensure that all staff have the required training. Statement of how the facility will met the regulations and include date all staff trainings will be completed and training records will be on file. Statement shall be submitted to the Fresno CCL by POC due date 08/12/25.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1796.45 · Plan of correction due date: Aug 19, 2025

HSC 1796.45 Affiliated home care aides hired on or after January 1, 2016, shall submit to an examination 90 days prior to employment, or within seven days after employment, to determine that the individual is free of active tuberculosis disease. This requirement is not met as evidenced by: Based on records review and interview conducted with Administrator, S1, S2, and S3 do not have a TB result on file which poses a potential risk to the health and safety of the residents.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: All staff have a TB result on file prior or within 7 days after employment. S1, S2, and S3’s TB result shall be submitted to the Fresno CCL office by POC due date 08/19/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(F) · Plan of correction due date: Aug 19, 2025

87411(F) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Based on record review and interview conducted with Administrator, the licensee did not comply with the section cited above when LPA reviewed staff files and observed no health screening were on file for S1, S2, and S3, which poses a potential health or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Proof of S1, S2, and S3’s health screening to CCL by POC due date 08/19/25.

Type of visit: Required - 1 Year

On 07/24/25, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct the Annual Inspection. LPA met and toured facility with Administrator Douglas Rice. Facility has sufficient furnishings inside and outside for resident use. The facility was observed to be at a comfortable temperature, clean, and no passageway obstructions or fire hazards. Residents were observed seating in dining area. Facility is equipped with pull stations and fire sprinklers throughout facility. Fire extinguisher was observed throughout the facility with a service date of: 09/12/2024. LPA toured kitchen. Food are prepared in assisted living facility and transfer in food warmer to facility during meals. LPA observed exits to have a 15-second delay egress. LPA toured a sample of resident bedrooms and was observed to have the required furnishings and with adequate lighting. Medications were stored in a locked medication room in a medication cart. MARs were reviewed and medications were audited. Kitchen was toured. All meals are prepared at Assisted Living facility and transferred to the facility by staff during mealtimes. Midnight snacks are stored and available in the kitchen. A sample of resident bedrooms was toured. Bathrooms’ hot water temperature was tested maintained within range between 105.0 to 113.5. LPA observed securely fastened grab bars in bathrooms. Nonskid mat/ strips was not observed in room A5, room B6, and room C9. A sample of resident files were reviewed. Due to time constraints, LPAs will return at a later date to finish the inspection tool and issue citations. Exit interview was conducted. A copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jul 24, 2025

Type of visit: Case Management - Deficiencies

On 03/27/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced at the facility to conduct a case management visit. During the visit, the LPA met with the facility Benched Executive Director Angelina Rodriguez and stated the purpose visit is to issue a civil penalty related to the substantiated complaint allegation filed on July 31, 2018, complaint # 24-2018080731160804 while licensed as Pacifica Senior Living Bakersfield Memory Care, facility #157204131. Please note that Pacifica Senior Living Bakersfield Memory Care changed their name to Riverstone Terrace Senior Living Memory Care effective January 10, 2025, the licensee did not change. On December 7, 2018, the Department completed an investigation into a complaint alleging staff failed to provide adequate care and supervision, resulting in resident sustaining severe burns, and staff failed to obtain timely medical care for resident The licensee was cited for violating Health and Safety Code 1569.312(a), Basic Services Care and Supervision. At the time of the complaint visit on December 7, 2018, the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidence by information gathered through medical records and interviews that the licensee did not ensure R1 received the required care and supervision, which resulted in an elopement and RI sustaining severe burns to the upper extremities, arms, legs, and feet. RI eloped from the facility on July 22, 2018, in temperatures over 100°F. Medical records show R1 was diagnosed with second and third-degree burns, requiring surgery and skin grafts. Today, 03/27/25, the Department is issuing a civil penalty per Health and Safety Code § 1569.49 for violation that the Department constitutes as serious bodily injury in the amount of $10,000.00. Exit interview conducted. A copy of the report issued. Appeal rights provided. Benched Executive Director Angelina Rodriguez and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Mar 27, 2025

Allegation investigated: Facility did not seek medical attention for a resident in care

On 01/14/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to delivered complaint findings on the above allegation. LPA introduced self, stated the purpose of the visit and met with Administrator Douglas Rice. The department conducted investigation. Based on the records reviewed and interviews conducted, on 04/20/2024, at approximately 1140 hours, R1 sustained a fall and S1 found her on the floor next to her bed. Facility staff failed to abide by the discharge instructions. Staff also failed to contact emergency medical services until approximately 1956 hours, upon R1’s daughter’s request. Therefore, the preponderance of evidence standard has been met, the above allegation is found to be SUBSTANTIATED. 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 appeal rights was provided to the Administrator, whose signature on this form confirms receipt of this report. Substantiatedthe state’s words, verbatim · CDSS document, Jan 14, 2025 · control 24-AS-20240911151955

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(3) · Plan of correction due date: Jan 15, 2025

87411(d)(3) Personnel Requirements - General Skill and knowledge required to provide necessary resident care and supervision… This requirement was not met as evidence by: Based on records review and interviews conducted, R1 sustained a fall and S1 found R1 next the resident’s bed. Staff failed to abide by the discharge instructions. Staff failed to contact emergency medical services until R1’s daughter instructions which poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: Facility shall review regulations 87411 and submit a written statement on steps facility will take to ensure regulations is met. Written statement is to be submitted to Fresno CCL by POC due date 01/15/25. All staff in-service training on providing resident care and supervision. Staff attendance rooster and topics of training material shall be submitted to the department by 02/03/25.

Type of visit: Case Management - Deficiencies

On 01/14/25, Licensing Program Analyst (LPA) M. Yang arrived to unannounced to conduct case management deficiency visit and met with Administrator Douglas Rice. During the course of the investigation for complaint 24-AS-20240911151955, staffs were interviewed during the complaint investigation. Five staff that were interviewed were found not to be associated with the facility during the time of the complaint investigation. A deficiency is being cited and an immediate Civil Penalty were assessed. See Lic 421BG is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6. 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, Jan 14, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Jan 15, 2025

87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: During course of a complaint investigation for complaint 24-AS-20240911151955, it was found that S1, S2, S3, S4, and S5 were not associated to the facility which poses an immediate risk to the health and safety of the residents.the state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: S1 is no longer employed with the facility effective 11/01/24. S3 is immediately removed from the premise. S1, S2, S3, S4, and S5 is not permitted on the premise until associated. Proof of S2, S3, S4, and S5 associated to the facility shall be submitted to the department by 1/15/25.

Type of visit: Required - 1 Year

On 07/09/24, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct the Annual Inspection. LPA met with Administrator (A1) Angela Ohanian and Memory Care Director Kellie Porter. LPA toured facility with A1. Residents were observed seating in common areas. Facility has sufficient furnishings inside and outside for resident use. The facility was observed to be at a comfortable temperature, clean, and no passageway obstructions or fire hazards. Facility is equipped with pull stations and fire sprinklers throughout facility. Fire extinguisher was observed throughout the facility with a service date of: 09/15/2023. LPA toured a sample of resident bedrooms and was observed to have the required furnishings and with adequate lightening. Medications were stored in a locked medication room in a medication cart. MARs were reviewed and medications were audit. LPA toured kitchen. All meals are prepared at Assisted Living facility and transferred to facility by staff during mealtime. Bedrooms have Bathrooms hot water temperature was tested and within range between 111.5 to 118.2. LPA observed securely fastened grab bars and non-skid surfaces/mat in shower. A sample of resident and staff files were reviewed to have all the required documents. A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6. Exit interview was conducted. The following documents are requested and submitted to Fresno CCL by: 07/15/24. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, and currently liability insurance. A copy of this report and appeal rights was provided to Administrator.the state’s words, verbatim · CDSS document, Jul 9, 2024

Allegation investigated: Staff lock residents in their rooms. Staff are not following proper food safety procedures. Facility kitchen is in disrepair.

On 05/03/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit, and met with Administrator Angela Ohanian and Memory Care Director Kelly Porter. During the course of the investigation, LPA conducted interviews, reviewed records, and tour the facility. Residents’ bedroom doors have lock doorknob. Residents are able to exit bedroom when doorknob is lock. Food was observed transferred in portable food warmer and properly stored. Facility kitchen stove is observed disrepair. Records were reviewed and verified that repaired has been in progress. Based on the observation, records reviewed, and interviews conducted, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided to the Administrator, whose signature confirms received of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 3, 2024 · control 24-AS-20240423162001

Allegation investigated: Resident sustained fracture while in care.

On 05/03/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver findings on the above allegation. LPA introduced self, stated the purpose of the visit, and met with Kelly Porter, Memory Care Director. During the course of the investigation, interview was conducted, and records were reviewed. An internal report dated 01/21/24 indicates that “no new fractures happened” following a visit to the ER. Based on records reviewed and interview conducted, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided to the Memory Care Director, whose signature confirms received of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 3, 2024 · control 24-AS-20240424144836

Type of visit: Case Management - Deficiencies

On 04/25/24, Licensing Program Analyst (LPA) M. Yang arrived to conduct an unannounced initial complaint investigation and met with Memory Care Director Kelly Porter. LPA toured the facility and conducted interviews. During the course of the investigation, LPA observed knives and cleaning chemicals stored in kitchen unlocked. Deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6. An exit interview was conduct. An exit interview was conducted, and a copy of this report and appeal rights was provided to the Memory Care Director, whose signature confirms received of this report.the state’s words, verbatim · CDSS document, Apr 25, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: Apr 26, 2024

The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above when LPA, Memory Care Director, and Maintenance staff observed kitchen door in disrepair and unlock. Residents were present in the dining area when knives and cleaning chemicals were unlocked in the kitchen accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Maintenance staff immediately repaired the kitchen door. POC cleared during visit.