Hallmark of Bakersfield

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

Allegation investigated: Staff does not provide residents with adequate assistance. Staff have inappropriate interactions with residents in care. Staff left resident soiled in urine for an extended period of time. Staff do not shower residents due to insufficient staffing.

On 08/21/2026, Licensing Program Analyst (LPA) J. Duarte arrived unannounced to commence a complaint investigation. LPA met with Administrator Ashley Candelas. LPA explained the reason for today's visit. During the course of this investigation, LPA conducted a facility tour, reviewed records, and interviewed staff and residents. Based on interviews and records, residents are provided with adequate assistance, residents have call buttons and staff respond accordingly, staff change residents and respond to calls from residents to be changed, and the faciliy utilizes a shower log that staff follows. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator Ashley Candelas, and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 21, 2026 · control 24-AS-20260811092041

Allegation investigated: Staff mismanages residents' medications.

On 08/21/2026, Licensing Program Analyst (LPA) J. Duarte arrived unannounced to commence a complaint investigation. LPA met with Administrator Ashley Candelas. LPA explained the reason for today's visit. During the course of this investigation, LPA conducted a facility tour, reviewed records, and interviewed staff and residents. Based on interviews and records, the facility policy is to provide medication to residents and observe residents take their medication; however, two residents were observed to have their medication sitting on their table in small paper cups. The preponderance of evidence standard has been met; therefore, the allegation is SUBSTANTIATED. A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6, chapter 8, and a plan of correction was developed. A copy of this report and appeal rights were discussed and provided to Administrator Ashley Candelas, whose signature on this form confirms receipt of this document. Substantiatedthe state’s words, verbatim · CDSS document, Aug 21, 2026 · control 24-AS-20260811092041

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 22, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and records, the facility policy is to provide medication to residents and observe residents take their medication; however, two residents were observed to have their medication sitting on their table in small paper cups, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 21, 2026

Plan of correction: Administrator stated that regulation will be reviewed and med training has been scheduled for 09/02/2026. Administrator will provide documentation by POC due date of the trainning that was scheduled and the facility to provide proof of training conducted and sign in sheet of staff who participated in trainng to CCLD upon completion.

Type of visit: Case Management - Deficiencies

On 08/21/2026, LPA arrived unannounced to conduct a complaint investigation, relative to control #24-AS-20260811092041 and observed the following deficiencies. During the Course of investigation, LPA toured the facility with the Administrator and observed 12 out of 13 oxygen tanks in a resident room were not secured to the wall or in a stand. In addition, a staff was not associated to the facility and the facility did not have a signed LIC508. Deficiencies were cited. See LIC809D. A Repeat violation was assessed in the amount of $1,000 See LIC421IM. A background clearance was assessed in the amount of $100. See LIC421BG. An Exit interview was conducted, POC were developed, violations were assessed, and appeals rights were provided to Administrator, Ashley Candelas, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Aug 21, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87618(b)(3)(E) · Plan of correction due date: Aug 28, 2026

(3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall. This requirement is not met as evidenced by: LPA toured the facility with the Administrator and observed 12 out of 13 oxygen tanks in a resident room were not secured to the wall or in a stand, which poses/posed a potential health, safety or personal rights risk to persons in care. Photographs were taken.the state’s words, verbatim · CDSS document, Aug 21, 2026

Plan of correction: The faclity put in place stands and secured all oxygen tanks. POC cleared during visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(d) · Plan of correction due date: Aug 22, 2026

(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement was not met as evidenced by: A staff was not associated to the facility and the facility did not have a signed LIC508.the state’s words, verbatim · CDSS document, Aug 21, 2026

Plan of correction: Administrator associated staff to facility during vist.POC cleared during visit.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) J. Duarte, arrived at the facility unannounced to conduct the Required Annual Inspection. LPA met with Administrator Ashley Candelas. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Administrator and a tour of the facility was conducted with the Administrator. LPA toured six resident apartments and they were observed to have required furnishings. The restrooms had grab bars and slip resistant shower mats. The hot water temperature in the resident restrooms measured from 106 to 117 degrees F. LPA observed four oxygen tanks in R3's closet that were not secured in a stand or to the wall. LPA toured the activity room and observed residents coloring books, playing dominos, and talking with each other. The kitchen was toured, LPA observed a two day supply of perishable food and a seven day supply of nonperishable food. In addition, LPA observed an emergency supply of food stored in the pantry. The kitchen was clean and organized and the food being prepared is what was on the menu for the day. Cleaning supplies were in a locked storage closet. The facility has a laundry room and has detergent locked in a storage cabinet. The exterior was toured, the facility has a back patio with seating available for residents. There are two gates and the passageways to the gates were free of any obstructions. Facility has a pull station fire alarm and a fire panel and sprinkler system that was inspected on 01/31/2026. Fire extinguishers were observed with a service date of 12/31/2025. A fire drill was conducted on 01/27/26, per staff records. Continued on LIC 809-C. Continued from LIC 809. Medications were stored in a locked medication cart and in a locked medication room. Resident, medication and staff records were reviewed. The centrally stored log for R2 and R3 did not have a start date for some medications. A sample of resident files and staff files were reviewed and were observed to have required documentation. Deficiencies are being cited on the attached LIC 809 D report. An exit interview was conducted and Plan of Correction (POC) developed. A signed copy of this report and Appeal Rights were provided. Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below: Residential Care Facility for the Elderly (RCFE): · LIC 308 Designation of Facility Responsibility · -as applicable: LIC 309 Administrative Organization · -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources · -as applicable: LIC 402 Surety Bond · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly · LIC 9020 Register of Facility Clients/Residents · Copy of current Liability Insurance · Copy of current Administrator Certificate · Alternate contact information including name, telephone number, & email address. Please submit the above forms/information to Fresno CCL by: 04/16/26the state’s words, verbatim · CDSS document, Apr 8, 2026

Type of visit: Case Management - Deficiencies

On 02/23/2026, Licensing Program Analyst (LPA) J. Duarte, conducted a Case Management- Deficiencies found during a complaint investigation. LPA met with Administrator, Ashley Candelas. During the complaint investigation, LPA toured a sample of resident rooms. LPA observed R1's sliding glass door be secured closed with a wooden stick placed on the slider track, preventing the door being opened. In addition, LPA observed a reclining chair obstructing the sliding glass door exit. LPA reviewed a sample of resident medications and MARS and observed that medication for tomorrow morning was missing from the bubble packs for the sample of medications LPA reviewed. The administrator stated that the morning medication for the residents was transferred to a separate container to be ready to be dispensed/ administered to residents the following day. Deficiencies are being issued in accordance with the California Code of Regulations, Title 22, see LIC 809D. A Fire Clearance Civil Penalty was assessed in the amount of $500. An exit interview was conducted and Plans of Corrections were reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and left with Administrator, Ashley Candelas, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Feb 23, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Feb 24, 2026

87202(a) - Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by: LPA observed R1's sliding glass door be secured closed with a wooden stick placed on the slider track, preventing the door being opened. In addition, LPA observed a reclining chair obstructing the sliding glass door.the state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: .Administrator immediately removed the wooden stick that was preventing the sliding glass door from opening and repositioned the reclining chair to not obstruct the sliding glass door exit. In addition, Administrator stated that chimes will be installed. Administrator will obtain a quote and will let CCLD know when chimes have been installed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: Mar 2, 2026

87465(h)(5)- Incidental Medical and Dental Care Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by: LPA reviewed a sample of resident medications and MARS and observed that medication for tomorrow morning were missing from the bubble packs for the sample of medications LPA reviewed. The administrator stated that the morning medication for the residents were transferred to a separate container to be ready to be dispensed/ administered to residents the following day.the state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: Administrator stated that training will be conducted with staff regarding regulation 87465(h)(5). Administrator will provide proof of the topic of the training conducted and a list of all participants by POC due Date of 03/02/2026.

Allegation investigated: Staff did not report incident to responsible party

Licensing Program Analysts (LPA) J. Duarte and L. Xiong conducted an unnounced complaint investigation visit to the facility. During the course of this complaint investigation LPAs interviewed staff on duty and residents. LPAs obtained and reviewed facility records. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. The evidence from the investigation indicated that a report was not generated and sent to licensing for an incident that occurred on 11/18/25. Based on LPAs observations and interviews which were conducted and reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC 9099D.” Substantiatedthe state’s words, verbatim · CDSS document, Dec 18, 2025 · control 24-AS-20251211122424

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Dec 30, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by observation and interviews, R1 had a fall on 11/18/2025, and was not reported to the responsible party and licensing.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: Per Administrator, an inservice training will be conducted by the POC date.

Allegation investigated: Staff do not administer resident's medication in a timely manner Staff mismanage resident's medication

Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced for a complaint investigation. LPA was granted entry by Staff Monica Anayas. LPA contacted Administrator via telephone who advised Wellness Director Tiffany Luaces would respond to assist with the visit. LPA met with Tiffany Luaces. LPA interviewed staff and residents. LPA reviewed records. Based on records review and interviews, allegation Staff do not administer resident's medication in a timely manner, R1's medications show administered twice on the morning of May 6, 2025 once at 7:46 AM and at 9:42 AM for Buspirone and Carvedilol. Facility crossed out the 9:42 AM medication on these two and left the 7:46 AM medication. On May 16. 2025 Fluxotine shows it is supposed to be administered at 8 am and was not administered until 10:05 AM. On May 6, 2025 Losartan is supposed to be administered at 8 am and was not administered until 10:25 am according to records. Substantiated Based on interviews and records review, it is undetermined whether or not the allegation occurred. 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. Based on interviews and records review, allegation Staff mismanage resident's medication, R1's medication was not ordered in a timely manner where R1 missed the medication on May 1, 2025. Medication was administered May 2, 2025. 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. Refer to 9099D Civil Penalty was issued for repeat violation. An exit interview was conducted and a copy of this report was provided with plan of corrections and appeal rights.the state’s words, verbatim · CDSS document, Aug 16, 2025 · control 24-AS-20250606105352

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 18, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This regulation was not met as evidenced by R1's medications were not administered timely on several dates. For ex. R1's medications were to be administered at 8 am on May6, 2025 and were not administered until 10:25 am. R1's medication was not ordered timely causing R1's to miss the medication on May1, 2025 which poses an immediate health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 16, 2025

Plan of correction: Plan of correction Licensee agrees to conduct a medication training and will submit a date the training will occur and who is conducting the training by POC due date 08/18/25. Civil Penalty was issued for repeat violation.

Allegation investigated: Resident eloped from the facility due to lack of care or supervision from staff Staff did not give resident medication as prescribed

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA identified herself and explained the purpose of the visit with Administrator Ashley Candelas. LPA interviewed staff. LPA requested a copy of R1's file, MARS log and doctors order. Based on interviews and records review conducted, on 3/1/25 R1 was found down the street from the facility by Bakersfield Police Department patrolling the area. Bakersfield Police Department contacted ambulance due to R1 having a fall. R1was transported by ambulance to the hospital arriving at 11:03 PM. Interviews concluded staff did not check on R1 from 10 PM to 5:30 AM. Facility staff realized R1 was missing on 3/2/25 at 5:30 AM. Facility staff called 911 and contacted local hospitals, where R1 was located at the hospital. Substantiated 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 Penalties were issued. An exit interview was conducted and a copy of this report was provided with plan of corrections and appeal rights.the state’s words, verbatim · CDSS document, Mar 27, 2025 · control 24-AS-20250321154050

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Mar 28, 2025

87464 Basic Services (f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement was not met as evidenced by: Licensee did not ensure care and supervision for R1 who eloped from the facility on 3/1/25, which resulted in hospitalization which poses an immediate health safety and or personal rights risk.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Licensee installed additional alarms on the doors and have staff wear pagers from 10 pm to 8 am which pagers alert staff when any facility door opens. POC cleared during visit. LPA observed additional alarms and Administrator demonstrated how pagers work. Civil Penalties were issued.

Allegation investigated: Staff speaks inappropriately to residents in care

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA identified herself and explained the purpose of the visit with Administrator Ashley Candelas. LPA interviewed staff and residents. LPA toured the facility. LPA obtained copies of R1's file, R2's file, S1's file and the transportation schedule. Based on interviews conducted, staff spoke inappropriately to residents in care. R1 and R2 were in an arugment where staff responded to assist residents. S1 attempted to difuse the situation in an inappropriate manner. Consistant statements were made from residents. Substantiated 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. An exit interview was conducted and a copy of this report was provided with plan of corrections and appeal rights.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 24-AS-20250318132523

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 8, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by Licensee did not ensure S1 spoke approprately to residents in care which poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 19, 2025

Plan of correction: POC Licensee agrees to conduct a staff training on personal rights by POC date 04/08/25.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA)'s Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA met with Administrator Ashley Candelas. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Administrator. A tour of the facility was conducted with the Administrator. LPA Doucette observed 6 resident apartments. Residents' apartments were toured and inspected and observed to be clean. Hot water temperature was measured from 105.4 to 114.4 F. Residents were observed to be participating in activities in the activity room. Kitchen toured, supply of food observed to have a 2 day supply of perishable. Facility did not have a seven day supply of non perishable. LPA took photos. Medications were stored in a locked Medication cart and in a locked medication room. Cleaning supplies were in a locked storage closet. Facility has a pull station fire alarm and a fire panel and sprinkler system. Fire extinguishers were charged and had service dates of 12/19/24. Resident, medication and staff records were reviewed. R7 did not have a labeled prescription for aspirin from pharmacy. Facility did not have centrally stored logs. S1 verbally stated cycled medications are not logged and all cycled medications start on the 15th of every month. R7's D3, which was said to be a cycled medication did not start until February 19, 2025. Facility did not have hospice care plan identifying the duties of facility staff. S1 did not have all required 20 hour training. Staff did have CPR/First aid training. There was outdoor seating for the residents. See attached 809D. An exit interview was conducted with the Administrator. A copy of this report, plan of correction and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 5, 2025

The state marks this report as 8 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff mishandles the residents medications

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA identified herself and explained the purpose of the visit with Staff Stephanie Villanueva. LPA met with Administrator Ashley Candelas. LPA interviewed staff and residents. LPA toured the facility. LPA obtained copies of order and took photos of medication error. Based on records review R5 recieved a prescribed PRN on 11/3/24 at 8:07 PM and at 10:43 PM. PRN instructions state medication is to be given every 4 hours not more than twice within a 24 hour period. 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. A copy of this report was provided. An exit interview was conducted and a copy of this report was provided. Substantiatedthe state’s words, verbatim · CDSS document, Nov 7, 2024 · control 24-AS-20241028085831

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Nov 8, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by R5 was administered Acetaninophen on 11/3/24 at 8:07 PM and at 10:43 PM when the dr order states administer every 4 hours but not more than twice daily which poses an immediate health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: Plan of Correction POC Licensee agrees to do medication training 11/8/24 for all medication technicians

Allegation investigated: Staff does not prevent the spread of COVID. Staff does not ensure facility is in good repair. Staff does not ensure laundry needs are being met. Staff does not allow residents access to restroom. Staff does not provide nutritious foods.

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA identified herself and explained the purpose of the visit with Staff Stephanie Villanueva. LPA met with Administrator Ashley Candelas. LPA interviewed staff and residents. LPA toured the facility. LPA observed Rooms 108 and 215. LPA observed the elevator to be working. LPA obtained receipts for repairs and orders. LPA reviewed menu and took photos of lunch being served. Based on interviews and records review, facility is following Covid 19 protocols. LPA reviewed facility's infection control plan. Facility isolated the 4 Covid positive residents and sent 1 positive resident to the hospital and facility did not have any further positives. Facility also isolated all that were in close contact with positive residents. Unsubstantiated Based on interviews and reviewing records, facility elevator broke early morning of 8/22/24 and was repaired by 9:15 AM. Facility provided a receipt for the elevator company. LPA obtained a copy of the facility fire clearance dated 1/24/23 and a copy of the elevator permit which is checked annually and is current. Based on interviews and records review, Facility has had a broken washer, however facility has a back up washer and two back up smaller dryers. Administrator sent staff to the laundry mat to ensure residents laundry was completed in a timely manner. Administrator provided receipts for the laundry mat and the repairs to washer/dryer units. Based on interviews and observation, Facility has a sign on the lobby restroom stating "You may obtain the restroom key at the front desk". LPA took a photo. Residents have access to the lobby restroom however need to obtain the key from the front desk. Based on observation and interviews, facility staff is providing nutritious meals. LPA observed shrimp scampi asparagus, and garlic bread for lunch. LPA observed an alternative menu and observed a resident eating a salad at lunch. LPA took photos of lunch being served and the facility menu. Facility water is supplied by the City of Bakersfield. Based on records review and interviews, it is undetermined whether or not the allegation occurred. 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.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 24-AS-20240828100106

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Darius Williams conducted a continuation Annual Visit, from 3/6/2024, regarding review of facility files. LPA reviewed 5 resident files and 5 employee files. 5 of 5 resident files had documents requested by the LPA. LPA did request for Administrator to obtain clarification from a physician regarding a needs and services for Resident 3. Employee files had all documents requested by the LPA and initial training. LPA observed initial training regarding general Diabetes procedures, however there was not specific Diabetes training regarding Resident 3. Based on records review a deficiency is being cited on the attached LIC809D page. An exit interview was conducted and a copy of this report and appeal rights was provided.the state’s words, verbatim · CDSS document, Mar 26, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Darius Williams conducted an unannounced Annual inspection visit. LPA met with Administrator Ashley Candelass and discussed the purpose of the visit. LPA Williams began the tour in the facilities front desk. LPA observed an operational call light system at the front desk. Required facility postings were present. LPA observed residents in the activity room waiting to have their nails painted. The activities coordinator and calendar, identifying various activities, was also present. The dining room was next to the activities room and the LPA observed residents conversing and eating. There were seats and space to accommodate residents. LPA toured two floors. On each floor is a common area and two hallways, with residents rooms, branching out. LPA observed hallways and rooms to be clean and in good repair. Bathrooms are located in each residents room. LPA observed the medication room and chemicals to be locked and inaccessible to residents. First aid kit was present and had all required items. Smoke and carbon monoxide detectors were present and operational. LPA toured the back patio area that had seating to accommodate residents. LPA observed some seat covers to have dirt covering them; noted there has been high winds and storms in the area lately. Due to insufficient time LPA was not able to review files and facility documents. LPA will be returning at a later date to complete the Annual Inspection. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 6, 2024

Allegation investigated: Staff are preventing resident from having visits

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to open a complaint investigation. LPA met with facility staff facility Medication Technician, and explained the purpose of today's visit. LPA Hurt also read the report vis phone to Facility Wellness Director, Tiffany Luaces Regarding the allegation Staff are preventing resident from having visits. The facility has not sent any communication to Resident 1's Responsible Party excluding anyone from visiting Resident 1 at the facility. Based on the information received, we have found that the complaint is Unfounded, meaning that the allegation is false, could not have happened, and/or is without reasonable basis, therefore is dismissed. Exit interview conducted with, Medication Technician Melinda,Alfaro , and a copy of this report provided. Unfoundedthe state’s words, verbatim · CDSS document, Jan 27, 2024 · control 24-AS-20240125152348

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to conduct a Case Management visit. LPA met with facility staff facility Medication Technician, and explained the purpose of today's visit. LPA Hurt also read the report vis phone to Facility Wellness Director, Tiffany Luaces LPA Hurt toured the facility including entryway, and upstairs area of the facility. LPA reviewed four incident reports documenting Resident 1 displaying aggressive behavior towards facility Resident 2. On 01/23/24 Resident 1 nudged Resident 2 with her walker on the back of the legs as Resident 2 was getting on the elevator. Resident 1 proceeded to tell Resident 2 to remove her shirt that it belonged to her. The shirt belonged to Resident 2 and it has Resident 2's name on it. On 01/15/24 Resident 1 and Resident 2 were sitting in front of the lobby. Resident 1 approached Resident 2 and told that they were wearing their sweatshirt backwards, to take it off and put it on the right way. Resident 2 thanked Resident 1 and proceeded to remove the shirt to when Resident 1 snatched it from her and started yelling that it was theirs. Staff 1 intervened and let the residents know to start arguing. Resident 1 continued to argue with staff and use profound language. Staff 1 separated them and let management know. The facility could not provide an itemized list of Resident 1's personal belongings. The following Deficiencies are being cited Per Title 22 Regulations. Exit interview conducted with Facility Medication Technician, Melinda Alfano, and a copy of this reportthe state’s words, verbatim · CDSS document, Jan 27, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Feb 10, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. The following requirement has not been met as evidenced by: Resident 1 has violated the personal rignts on Resident 2 on several during several separate documented incidents, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2024

Plan of correction: Administrator will make a plan to keep Resident 1 from violating the rights of Resident 1, and sybmit proof to LPA by 02/10/2024.