Quality Care Assisted Living

Licensing Program Analyst (LPA) Shawna Doucette (LPA) conducted a visit to commence a complaint investigation. LPA discussed the purpose of the visit and the elements of the allegations with Caregiver/Office Staff Jan Krizia Adajar. Administrator Nancy Cudal gave permission for Caregiver/Office Staff Jan Krizia Adajar to sign for this report. LPA reviewed and obtained copies of R1's file. Based on interviews and records review R1 can leave facility unassisted per LIC602. Based on records review and interviews, facility reported to Bakersfield Police Department report number 2024-00146406 on 12/3/24. Based on record reviews and interviews, 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. A copy of this report was provided. UnsubstantiatedRead the full finding— CDSS inspection report, December 10, 2024 · control 24-AS-20241204234223

Licensing Program Analyst (LPA) Shawna Doucette (LPA) conducted a visit to commence a complaint investigation. LPA discussed the purpose of the visit and the elements of the allegations with Administrator Nancy Cudal. LPA interviewed Administrator. LPA obtained a copy of the electric bill showing a past due balance of $13,878.18. LPA received a photo of the PG & E Final notice posted at facility. Facility did not report to Licensing electric was going to be shut off. LPA requested copies of utility bills (water, garbage, electric, gas, phone) for July 2024, August 2024, September 2024 and October 2024 (or most current) submitted by 10/15/2024. LPA toured the facility and observed the power to be on and water was running. The facility was set at a comfortable temperature. SubstantiatedRead the full finding— CDSS inspection report, October 12, 2024 · control 24-AS-20241011073600

Licensing Program Analysts (LPA)'s Shawna Doucette conducted an unannounced complaint visit and was granted entry by Administrator Nancy Cudal. LPA's explained the purpose of the visit. LPA requested a copy of and reviewed the resident roster. LPA interviewed Administrator. Facility does not have a client by the name listed in this complaint. Based on LPA's interviews and record review, this agency has investigated the complaint alleging, Facility is not safeguard resident’s property, Resident is not getting is P & I funds and Facility uses intimidation to violate residents personal rights. We have found that the complaint was UNFOUNDED, which means it could not have happened, and/or is without a reasonable basis, therefore we have dismissed the complaint. An exit interview was conducted and a copy of this report was provided. UnfoundedRead the full finding— CDSS inspection report, October 7, 2024 · control 24-AS-20241003164659

Licensing Program Analysts (LPA)'s Shawna Doucette conducted an unannounced complaint visit and was granted entry by Administrator Nancy Cudal. LPA's explained the purpose of the visit. LPA requested copies of R1's file. LPA toured the facility. LPA interviewed resident and staff. Based on record reviews and interviews, 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. An exit interview was conducted and a copy of this report was provided. UnsubstantiatedRead the full finding— CDSS inspection report, October 7, 2024 · control 24-AS-20241003163936

Licensing Program Analyst (LPA) Shawna Doucette (LPA) conducted a visit to commence a complaint investigation. LPA discussed the purpose of the visit and the elements of the allegations with Administrator Nancy Cudal. LPA reviewed records and interviewed staff and residents. Based on records review and interviews, there is missing documentation for pain medication (PRN) being administered for R1. R1's June 2024 MARS log shows Olanzapine twice but does not show why one of the medications was not being administered. It is unknown if the medication was discontinued due to lack of documentation or missed for June 2024. Based on the Departments interviews and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Article 8, is being cited on the attached LIC 9099D. Civil Penalty issued for repeat violation. SubstantiatedRead the full finding— CDSS inspection report, September 10, 2024 · control 24-AS-20240627092941

Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced complaint visit and was granted entry by Administrator Nancy Cudal. LPA explained the purpose of the visit. LPA interviewed staff. LPA obtained copies of residents file. LPA interviewed R1's family. LPA toured the facility and checked R1's room. LPA observed clean clothing for R1. Based on observation and interviews LPA was unable to determine if there was a time R1 did not have clean clothing. During the course of the visit, LPA observed clean clothing in R1's closet and drawers. Based on record review and interviews, LPA was unable to determine if staff ensures resident attends scheduled appointments. After records review, staff notes show R1 refused a medical appointment on May 7, 2024 which was rescheduled for May 31, 2024. After conducting interviews, it was found R1 does refuse medical appointments sometimes. During today's visit, R1 was at a medical appointment. UnsubstantiatedRead the full finding— CDSS inspection report, July 9, 2024 · control 24-AS-20240508153114

Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced complaint visit and was granted entry by Staff Paula Maribel Brizuela. LPA contacted Administrator Ria Loria via telephone who gave permission for Staff Paula Maribel Brizuela to sign for the report. LPA interviewed staff and residents. LPA toured the facility. LPA reviewed staff file for S1. LPA obtained a copy of the staff schedule and the resident roster. LPA reviewed staff schedule and found S1 is working in the facility on 4/17/24, 4/19/24 and 4/20/24 and is not associated to the facility. LPA reviewed S1's file, which only consisted of the LIC 501. Facility did not have any other information for S1. SubstantiatedRead the full finding— CDSS inspection report, April 22, 2024 · control 24-AS-20240417130037

Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced complaint visit and was granted entry by Staff Paula Maribel Brizuela. LPA explained the purpose of the visit. Staff Paula Maribel Brizuela advised the Administrator is currently out of the country. LPA toured the facilty. LPA checked the food and took photos. LPA took photos of the menu. LPA requested staff training for kitchen staff. Facility could not provide staff training documents for food service. LPA interviewed staff. Facility does not have a 2 day pershiable and a 7 day non pershiable food supply. LPA took photos. Facility is serving won ton soup and eggrolls with jello for lunch during visit. LPA oberved a small bowl of soup with 3 wontons in each bowl, 3 egg rolls and 2 small slices of oranges. The menu states liver an onions, mashed potatoes, sweet green peas, dinner rolls, cake and an alternative of roasted chicken. For dinner the menu states chili dog with cheese diced onions, french fries, pickle sRead the full finding— CDSS inspection report, April 3, 2024 · control 24-AS-20240116151446

Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced complaint visit and was granted entry by Staff Paula Maribel Brizuela. LPA explained the purpose of the visit. Staff Paula Maribel Brizuela advised the Administrator is currently out of the country. LPA toured the facilty. LPA interviewed staff. Facility staff stated R1 did not have a roommate. Resident no longer resides at the facility. LPA requested a copy of R1's file. LPA reviewed the property list. Based on interviews and records review, it is not determined whether or not Staff did not ensure that resident's toileting needs are met and if Staff did not safeguard resident’s personal belongings. 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. A copy of this report was provided to Administrator via email. UnsubstantiatedRead the full finding— CDSS inspection report, April 3, 2024 · control 24-AS-20240129151358

Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced complaint visit and was granted entry by Administrator Ria Loria. LPA explained the purpose of the visit. LPA interviewed staff and residents. After conducting interviews, it was found facility phone calls for residents are being transferred to staff's personal cell phones. Based on the Departments interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Article 8, is being cited on the attached LIC 9099D. A copy of the this report was provided to the Administrator with appeal rights and plan of correction. SubstantiatedRead the full finding— CDSS inspection report, March 6, 2024 · control 24-AS-20240111220531

Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced complaint visit and was granted entry by Administrator Ria Loria. LPA explained the purpose of the visit. LPA interviewed staff. LPA obtained copies of R1 file and medical records showing R1 was in the hospital and then transferred to a higher level of care. Based on LPA's interviews, this agency has investigated the complaint alleging, Unlawful eviction. We have found that the complaint was UNFOUNDED, which means it could not have happened, and/or is without a reasonable basis, therefore we have dismissed the complaint. A copy of this report was provided to Administrator via email. UnfoundedRead the full finding— CDSS inspection report, March 6, 2024 · control 24-AS-20231222111549

Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced 10 day complaint visit and was granted entry by Staff Paula Maribel Brizula. LPA discussed the purpose of the visit. Staff Paola Maribel Brizula contacted Administrator Ria Loria via telephone who gave permission for Staff Paula Maribel Brizula to sign for this report. LPA interviewed both medication technicians. Based on interviews, it is not determined whether or not Staff are hiding medications in other substances without the resident's knowledge. 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. A copy of this report was provided to Administrator via email. UnsubstantiatedRead the full finding— CDSS inspection report, February 23, 2024 · control 24-AS-20240214153005

Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced complaint visit and was granted entry by Staff Paula Maribel Brizuela. LPA explained the purpose of the visit. Staff Paula Maribel Brizuela contacted Administrator Ria Loria who gave permission for Staff to sign for this report. LPA interviewed Staff. LPA reviewed medication log and centrally stored log. Centrally stored log was missing medications for R1. Based on interviews, R1 missed the medication for 4 days, 1/1/24 - 1/4/24. Based on the Departments interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Article 8, is being cited on the attached LIC 9099D. Civil penalty was issued. SubstantiatedRead the full finding— CDSS inspection report, January 9, 2024 · control 24-AS-20240105154108

Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced complaint visit and was granted entry by Administrator Ria Loria. LPA explained the purpose of the visit. LPA toured the facility and took photos of the food and the menu. LPA observed lettuce and 1 bag carrots only. LPA did not observe any fresh fruit. Administrator could not provide staff training or qualified staff to create a special diet menu for LPA to view. Facility menu had an old facility name on it "Golden Castle". LPA reviewed resident files. C1 did not have a diagnosis on C1's LIC602. C2 did not have a LIC 602 for this facility. See 9099C SubstantiatedRead the full finding— CDSS inspection report, October 18, 2023 · control 24-AS-20231017081313

Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced complaint visit and was granted entry by Administrator Ria Loria. LPA explained the purpose of the visit. LPA reviewed C1 and C2's medications and medication records. Facility had a centrally stored log for all medications that came from the Medicine Shoppe pharmacy, however did not have centrally stored log for medications that came from other pharmacys. LPA was unable to determine a start date or review centrally stored logs from the previous month. LPA reviewed the MARS log which was not current. LPA reviewed the medications which were in bubble packs and were administered up until todays date. Based on the Departments interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Article 8, is being cited on the attached LIC 9099D. A copy of this report was provided to staff with plans of correcRead the full finding— CDSS inspection report, October 18, 2023 · control 24-AS-20231004164333

Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced complaint visit and was granted entry by Staff Tracie White. LPA asked staff to contact Administrator Ria Loria. Staff contacted Administrator who advised it would take her 2 1/2 hours to respond to the facility and to have Staff Tracie White assist with the visit. LPA was unable to review resident records due to staff not having access to resident records. LPA interviewed staff and resident ad toured the facility. Based on interviews, staff does not have access to care plans or LIC602's. LPA was unable to review staff training. Based on the Departments interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Article 8, is being cited on the attached LIC 9099D. The Department found additional deficiencies during the course of the investigation, which will be addressed and cited on a separate 8Read the full finding— CDSS inspection report, September 27, 2023 · control 24-AS-20230922145354

Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced complaint visit and was granted entry by Staff Paula Maribel Brizuela. Administrator Ria Loria responsed to the facility and met with LPA. LPA discussed the purpose of the visit. LPA conducted interviews and obtained copies of residents files. LPA requested a copy of R1's last doctor visit on 7/8/23 through facetime. LPA reviewed R1's progress notes. On 08/05/23, R1 went to the doctor. R1 was diagnosed with a condition that can cause confusion and was placed on antibiotics. Due to this diagnosis, facility will not be evicting R1. Based on interviews and records review, it is not determined whether or not Staff are not preventing resident from harassing other residents. 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. A copy of this report was provided to Administrator. UnRead the full finding— CDSS inspection report, August 15, 2023 · control 24-AS-20230710121649

Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced complaint visit to deliver findings. LPA met with Staff Baula Maribel Brizuela and discussed the purpose of the visit. Administrator was not available for the visit. LPA spoke with Staff Oscar Chavez via telephone who assisted with the visit. The Department has investigated the allegationa: Neglect/ Lack of Care and Supervision resulting in resident being diagnosed with severe dehydration and staff not seeking medical attention for resident in a timely manner and Staff are not properly addressing scabies in the facility. According to interviews and records review the Department found, R1 did not recieve medical attention in a timely manner resulting in severe dehydration causing damage to R1's organs and causing other serious medical condtions due to neglect/lack of care and supervision, requiring R1 to be hospitalized. Staff did not seek medical attention for over a month. *Continued on 9099C SubstantiatedRead the full finding— CDSS inspection report, July 5, 2023 · control 24-AS-20230324154345

Licensing Program Analyst (LPA) L. Xiong conducted the complaint investigation visit to the facility. I met with Maribel Brizuela, staff and informed her the purpose of the visit. During the course of this investigation LPA reviewed facility files and interview of staff relevant to the complaint investigation. It was determined that the above allegations: Staff are not changing residents bedding, Facility a/c is in disrepair, and Facility laundry machines are in disrepair are UNFOUNDED. During the investigation, the file review and interviews indicated Laundry days goes in rotation and are only done on assigned day, A/C and laundry machines are fixed or replaced in a timely manner when they quit working. This agency has investigated the complaint alleging (Staff are not changing residents bedding, Facility a/c is in disrepair, and Facility laundry machines are in disrepair). We have found that the complaint was unfounded, therefore we have dismissed the complaint. UnfoundedRead the full finding— CDSS inspection report, February 10, 2023 · control 24-AS-20220608092801

Licensing Program Analyst (LPA) L. Xiong conducted the complaint investigation visit to the facility. I met with Maribel Brizuela, staff and informed her the purpose of the visit. During this visit LPA delivered investigation findings regarding the above allegations.The Department has investigated the complaint alleging: Administrator is not at the facility for the required hours, Residents are not being changed timely due to insufficient staffing, and Residents are not getting showered timely due to insufficient staffing. Based on the interviews conducted and/or records review the above allegations are UNSUBSTANTIATED. During the investigation, there no preponderance of evidence showing inadequate presence of administrator at the facility, residents not being changed and/or showered timely due to insufficient staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegatRead the full finding— CDSS inspection report, November 1, 2022 · control 24-AS-20211026103936

Licensing Program Analyst (LPA) L. Xiong conducted the complaint investigation visit to the facility. I met with Maribel Brizuela, staff and informed her the purpose of the visit. During the course of this investigation LPA reviewed facility files and interview of staff relevant to the complaint investigation. It was determined that the above allegations: Resident became ill from facility’s food, and Staff putting something in resident’s food/drink are UNFOUNDED. During the investigation, the file review and interviews indicated he wasn't sick from the facility food and/or staff putting anything into his food/drink. This agency has investigated the complaint alleging (Resident became ill from facility’s food, and Staff putting something in resident’s food/drink). We have found that the complaint was unfounded, therefore we have dismissed the complaint. UnfoundedRead the full finding— CDSS inspection report, November 1, 2022 · control 24-AS-20220404132517

Licensing Program Analyst (LPA) L. Xiong conducted the complaint investigation visit to the facility. I met with Administrator, Ria Loria and informed her the purpose of the visit. During the course of this investigation LPA reviewed facility files and interviewed persons relevant to the complaint investigation. It was determined that the above allegations: Staff are not administering medication(s) to resident according to physicians instructions, Resident is not being provided bedding while in care, and Staff restrained resident in a closet while in care are UNFOUNDED. Resident R1 was a new resident to the facility and due to her declining health and instability, resulting her making false statements/accusations. This agency has investigated the complaint alleging (Staff are not administering medication(s) to resident according to physicians instructions, Resident is not being provided bedding while in care, and Staff restrained resident in a closet while in care). We have found thatRead the full finding— CDSS inspection report, September 22, 2022 · control 24-AS-20211005132259

Licensing Program Analyst (LPA) Shawna Doucette and Vadim Gorban conducted an unannounced complaint visit to investigate and deliver complaint findings. LPA met with Administrator Ria Loria and discussed the purpose of the visit. The Department has investigated the allegation: Staff abandoned resident. LPA interviewed staff and resident. LPA obtained copies of R1's file. R1 is currently residing at the facility. Based on record review and interviews, it is unknown if the facility abandoned R1. 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. An exit interview was conducted and a copy of this report was provided. UnsubstantiatedRead the full finding— CDSS inspection report, August 5, 2022 · control 24-AS-20220503142815

Licensing Program Analyst (LPA) Shawna Doucette and Vadim Gorban conducted an unannounced complaint visit to investigate and deliver complaint findings. LPA met with Administrator Ria Loria and discussed the purpose of the visit. LPA interviewed staff and resident. LPA obtained copies of R1's file and reviewed records. LPA obtained copies of R1's shower schedule. Based on record review and interviews resident did sustain an injury while in care however the facility followed proper procedures by seeking medical attention for R1. Based on records review and interviews, it is undetermined if the resident was left unkept. 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. An exit interview was conducted and a copy of this report was provided. UnsubstantiatedRead the full finding— CDSS inspection report, August 5, 2022 · control 24-AS-20220519152727

Licensing Program Analyst (LPA) Shawna Doucette and Vadim Gorban conducted an unannounced complaint visit to investigate and deliver complaint findings. LPA met with Administrator Ria Loria and discussed the purpose of the visit. The Department has investigated the allegation: Staff will not allow resident to return to the facility. LPA interviewed staff. LPA obtained copies of R1's file. R1 returned to the facility on 5/27/22. R1 is currently residing at another facility as of 8/3/22. Based on record review and interviews, it is unknown if the facility abandoned R1. 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. An exit interview was conducted and a copy of this report was provided. UnsubstantiatedRead the full finding— CDSS inspection report, August 5, 2022 · control 24-AS-20220526090150