Kern Village Assisted Living for Seniors

Allegation investigated: Staff allow residents to smoke marijuana in their room Staff come to work intoxicated affecting the care and supervision of residents

On 08/31/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint investigation. LPA met with Administrator Wendy Lee and stated the purpose of the visit. LPA delivered complaint findings on the above allegations during visit. During the course of the investigation, records were reviewed, the facility was toured, and interviews were conducted with staff and residents. Staff and residents confirmed a marijuana pipe was found in R1’s room. Interviews with staffs and residents confirmed staff did not observe R1 smoking marijuana in the room. Residents and staff confirmed no staff was intoxicated while providing care and supervision to residents at the facility. Based on interviews conducted, the preponderance of evidence standard has not been met, therefore, the above allegations are 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, Aug 31, 2026 · control 24-AS-20260826100017

Type of visit: Annual/Random

On 08/25/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA was greeted by Administrator Wendy Lee and granted entry into the facility. LPA introduced self and stated the purpose of the visit. LPA conducted tour with A1. Residents were observed in the common areas, bedrooms, and in the courtyard during inspection. The facility was observed to be at a comfortable temperature. The facility was observed clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Medications observed kept locked in medication cart in the facility office. Kitchen was toured. 2-days perishable food and 7-days non-perishable food were observed. Dishwasher was observed operational during inspection. Last fire drill was completed on 7/23/26. Fire extinguishers were observed throughout the facility with a service date of 05/04/26. Cleaning solutions observed stored and locked under kitchen sink and under staff bathroom sink. Refrigerator temperature was maintained at 39 degrees F and freezer temperature was maintained at 0 degrees F. Sharps observed locked in kitchen drawer. All bedrooms were observed to have required furnishings with adequate lighting and at comfortable temperature. Carbon monoxide and smoke detectors were tested and observed to be operational. Bathrooms were observed with grab bars and nonskid mats. All bathroom’s hot water temperature was tested. LPA observed chemicals stored and locked in the laundry room and in shed 1. (CONTINUED TO LIC 809C ) (CONTINUED FROM LIC 809) Outside of the facility toured and observed to be free of debris. Adequate outdoor seating was observed to be available for residents. Designated smoking area observed available for residents. LPA observed fence gates on each side of the courtyard locked. A sample of resident and staff files were reviewed. First aid kit observed with required items. A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. Exit Interview conducted. A copy of current Administrator Certificate was received. The following documents are requested and submitted to Fresno CCL by: 08/31/26. Forms requested: Lic 308, Lic 500, current liability insurance, Lic 610E, and current Administrator certificate. A copy of this report and appeal rights was provided to Administrator, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Aug 25, 2026

Allegation investigated: Staff spoke inappropriately to residents in care Staff did not allow residents to leave the facility

On 06/16/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint investigation. LPA met with Administrator Wendy Lee and stated the purpose of the visit. LPA delivered complaint findings on the above allegations during visit. During the course of the investigation, records were reviewed, the facility was toured, and interviews were conducted. Residents confirmed staff speaks to residents nicely and in a gently voice. Residents were allowed to leave the facility supervised by staff and unsupervised according to physician’s order. Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore, the above allegations are 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, Jun 16, 2026 · control 24-AS-20260608134743

Type of visit: Case Management - Other

On 06/16/26, Licensing Program Analyst (LPA) M. Yang conducted case management visit for the purpose on the health and safety of the residents in care. LPA introduce self, stated the purpose of the visit, and met with Administrator Wendy Lee. The purpose of today's visit is to follow up on information that was received at the Fresno Regional office. The issues included: cash handling, medication error, mishandling residents’ belongings, staff verbally and physically abuse residents. Interviews were conducted with residents, records were reviewed, and facility was toured. No deficiencies issued. No additional follow-up is required. An exit interview was conducted. A copy of this report was provided to Administrator, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Jun 16, 2026

Allegation investigated: Staff did not prevent residents from fighting

On 05/27/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint investigation and deliver complaint findings on the above allegation. LPA met with Administrator Wendy Lee and stated the purpose of the visit. During the course of the investigation, records were reviewed, facility was toured, and interviews were conducted. Due to the lack of supervision, R2 has wandering behavior and had wandered into R1’s room without supervision leading to a physical altercation where R2 was sent to the hospital for medical treatment. Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore, the above allegation is found to be SUBTANTIATED. Exit interview was conducted. A copy of this report and appeal rights was provided to Administrator, whose signature on this form confirms receipt of this report. Substantiatedthe state’s words, verbatim · CDSS document, May 27, 2026 · control 24-AS-20260521094940

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 28, 2026

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 in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on interviews conducted and records review, R1 and R2 had physical altercation where R2 was sent to the hospital for medical treatment after R2 had wandered into R1’s room without supervision, which poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, May 27, 2026

Plan of correction: Facility will submit a statement letter providing steps how the facility will ensure the residents who wanders are safe. Statement will be submitted to the Fresno CCL by POC due date 05/28/26.

Allegation investigated: Staff do not treat residents with respect. Staff are not ensuring activities are consistent.

On 02/25/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint investigation. LPA introduced self, stated the purpose of the visit, and met with Administrator Wendy Lee. During the course of the investigation, the Department conducted interviews, records were reviewed and toured the facility. Facility has variety of activities provided for residents. Allegation alleging staff did not treat residents with respect and alleging staff are not ensuring activities are consistent, although the allegation may have happened or is valid. Based on interviews conducted, the preponderance of evidence standard has not been met, therefore, the above allegations are found to be UNSUBTANTIATED. Exit interview conducted. A copy of this report was provided to Administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 25, 2026 · control 24-AS-20260218090257

Allegation investigated: Staff does not ensure residents are spoken to in an appropriate manner. Staff member worked while under the influence of alcohol impairing their ability to provide adequate care and supervision to residents in care.

On 02/25/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint investigation. LPA introduced self, stated the purpose of the visit, and met with Administrator Wendy Lee. During the course of the investigation, the Department conducted interviews, records were reviewed and toured the facility. Based on interviews conducted, allegation alleging staff did not ensure resident are spoken to in an appropriate manner and staff worked while under the influence of alcohol impairing their ability to provide adequate care and supervision to the residents, the preponderance of evidence standard has not been met, therefore, the above allegations are found to be UNSUBTANTIATED. Exit interview conducted. A copy of this report was provided to Administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 25, 2026 · control 24-AS-20260218090740

Allegation investigated: Staff member(s) worked while under the influence of alcohol.

On 1/28/26 at 12:30pm Licensing Program Analyst (LPA) J. Leffall conducted an initial complaint visit to open and to deliver findings on above allegation. LPA met with Activities Coordinator (AC) Adeana Pearson. The Department conducted interviews with staff, and residents. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is Unsubstantiated. No deficiencies were issued. Exit interview conducted. A copy of this report was distributed to Administrator which confirms signature of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 28, 2026 · control 24-AS-20260120101836

Allegation investigated: Staff are not mitigating the spread of infectious outbreaks in the facility

On 09/16/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint investigation and deliver complaint findings on the above allegation. LPA introduced self, stated the purpose of the visit and met with Administrator Wendy Lee and Lead Medication technician Elizabeth Eisenhauer. During the course of the investigation, interviews were conducted, facility was toured, and copies of records were obtained. R1 tested positive for TB and placed on quarantine. Facility had infection control procedure was in placed. Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore, the above allegation is found to be UNSUBTANTIATED. An exit interview was conducted. A copy of this report was provided to the Administrator, whose signature on this form confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 16, 2025 · control 24-AS-20250908142349

Type of visit: Required - 1 Year

On 09/16/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA was greeted by Administrator Wendy Lee and granted entry into the facility. LPA introduced self and stated the purpose of the visit. LPA conducted tour with A1. All 22 residents were present during inspection. The facility was observed to be at a comfortable temperature. The facility was observed clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Kitchen was toured. An adequate supply of perishable and non-perishable food was observed. Dishwasher was observed operational during inspection. Medications observed kept locked in medication cart in the facility office. MARs were reviewed and medications were checked. Cleaning solutions observed stored and locked under kitchen sink and under staff bathroom sink. Refrigerator temperature was maintained at 38 degrees F and freezer temperature was maintained at 0 degrees F. Sharps observed locked in kitchen drawer. Fire extinguishers were observed throughout the facility with a service date of 05/05/25. All bedrooms were observed to have required furnishings with adequate lighting and at comfortable temperature. Bathrooms were properly equipped. Bathrooms hot water temperature was tested at 112.8 degrees F in room 11, 110.4 degrees F in room 10, and 112.6 degrees F in room 8. LPA observed chemicals stored and locked in the laundry room and shed 1. CONTINUED TO Lic 809C Outside of the facility toured and observed to be free of debris. Adequate outdoor seating was observed to be available for residents. Designated smoking area observed available for residents. LPA observed fence gates on each side of the courtyard locked. Carbon monoxide and smoke detectors were tested and observed to be operational. A sample of resident and staff files were reviewed to have all the required documents. A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. Exit Interview conducted. A copy of current Administrator Certificate was received. The following documents are requested and submitted to Fresno CCL by: 09/22/25. Forms requested: Lic 308, Lic 500, current liability insurance, Lic 610E, and current Administrator certificate. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Sep 16, 2025

Allegation investigated: Facility did not meet the needs of a resident in care.

On 08/01/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint investigation. LPA introduced self and stated the purpose of the visit. LPA met with Administrator Wendy Lee and delivered complaint findings on the above allegation. During the complaint investigation, interviews were conducted, received copies of records, and the facility was toured. R1 confirmed R1 received MRI from hospital visit. Follow up appointments were scheduled. Based on interviews conducted and records reviewed, R1 received x-rays and MRI for resident’s injury with follow up appointments, therefore the preponderance evidences has not been met, the above allegation is found to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 1, 2025 · control 24-AS-20250724154728

Allegation investigated: Staff cross contaminating resident’s food.

On 06/25/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to complaint investigation and deliver findings on the above allegation. LPA introduce self, stated the purpose of the visit, and met with Administrator Ashley Bell. The Department conducted interviews and toured the facility. Each residents’ food was placed in separate plates before serving. Residents with restricted diet or with food allergy are placed in separate plates. Food is prepared in sanitized area with specific cutting board for meat products and vegetables. Therefore, the preponderance of evidence standard has been met, the above allegations is found to be UNSUBSTANTIATED. Exit Interview conducted. A copy of this report was provided to Administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 25, 2025 · control 24-AS-20250624115141

Type of visit: Required - 1 Year

On 09/24/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA was greeted by Licensee (L1) Anthony Barbato and granted entry into the facility. LPA introduce self and stated the purpose of the visit. LPA conducted tour with L1. All 17 residents were present during inspection. The facility was observed to be at a comfortable temperature. The facility was observed clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. An adequate supply of perishable and non-perishable food was observed. Medications observed kept locked in medication cart in the facility office. MARs were reviewed and medications was checked. Cleaning chemicals observed stored and locked under kitchen sink. Refrigerator temperature was maintained at 38 degrees F and freezer temperature was maintained at -1 degrees F. Fire extinguisher was observed with a service date of 05/23/24. All bedrooms were observed to have required furnishings with adequate lighting and at comfortable temperature. Bathrooms were properly equipped. Bathroom hot water temperature was tested at 111.3 degrees F in room 11, 118.9 degrees F in room 8, 114.8 degrees F in room 5, and 106.1 degrees F in room 2. Carbon monoxide and smoke detectors were tested and observed to be operational. Washer and dryer was observed operational during inspection. LPA observed chemicals stored and lock in the laundry room. Outside of facility toured and observed to be free of debris. Adequate outside seatings were observed available for residents. A sample of resident and staff files were reviewed to have all the required documents. No deficiencies issued during this inspection. Exit Interview conducted. A copy of current Administrator Certificate was received. The following documents are requested and submitted to Fresno CCL by: 09/30/24. Forms requested: Lic 308, Lic 400, Lic 402, Lic 500, current liability insurance, and Lic 610E. A copy of this report was provided to Licensee, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Sep 24, 2024

Allegation investigated: Staff made inappropriate comments towards a resident Staff yelled at a resident while in care Uncleared individual is posing as a risk to the residents Staff does not provide the residents with privacy

On 0815/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegation. LPA introduce self, stated the purpose of the visit, and met with Facility Manager Ashley Bell. Staff and LPA attempted to reach Licensee Anthony Barbato. Administrator Kala Gibson was called via telephone. LPA delivered findings to Administrator via telephone and Facility Manager. During the course of the investigation, LPA conducted interviews and records were reviewed. Based on interviews conducted, the allegations staff made inappropriate comments towards a resident, staff yelled at a resident while in care, an uncleared individual was at the facility and staff does not provided resident with privacy, the preponderance of evidence standard has not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted with Administrator via telephone and Facility Manager. A copy of this report was provided to the Facility Manager, whose signature on this report confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 15, 2024 · control 24-AS-20240502095656

Allegation investigated: Staff did not comply with basic service requirements

On 0815/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegation. LPA introduce self, stated the purpose of the visit, and met with Facility Manager Ashley Bell. Staff and LPA attempted to reach Licensee Anthony Barbato. Administrator Kala Gibson was called via telephone. LPA delivered findings to Administrator via telephone and Facility Manager. During the course of the investigation, LPA conducted interviews. A food bank organization was contacted and provided information to the residents at the facility. No resident had signed up and received any food assistances form the program. Therefore, based on the interviews conducted, the preponderance of evidence standard has not been met, the above allegation is found to be UNSUBSTANTIATED. An exit interview was conducted via telephone with Administrator and Facility Manager. A copy of this report was provided to the Facility Manager, whose signature on this report confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 15, 2024 · control 24-AS-20240503095428

Allegation investigated: Staff left a resident soiled while in care Staff are not providing adequate care and supervision to a resident

On this date, Licensing Program Analyst (LPA) M. Yang delivered findings for the above allegations. LPA met with Licensee Representative Anthony Barbato. The Department conducted interviews, reviewed records, and toured the facility. Based on the interviews conducted, records reviewed, and observations made by the LPA on the 12/18/2023 facility visit, the above allegations are Substantiated. R1 was observed soiled while in care. Facility staff did not ensure R2 received his medications to treat his insulin-dependent diabetes condition and did not monitor the resident’s glucose level, which resulted in the resident’s hospitalization and death. Citations were issued on complaint #24-AS-20231228152212 for care and supervision and appeal rights were provided. Exit interview was conducted. Substantiatedthe state’s words, verbatim · CDSS document, Aug 2, 2024 · control 24-AS-20231214090626

Allegation investigated: Facility staff did not ensure resident received medications as prescribed resulting in hospitalization. Staff left a resident soiled while in care.

On this date, Licensing Program Analyst (LPA) M. Yang delivered findings for the above allegations. LPA met with Licensee Representative Anthony Barbato. The Department conducted interviews, reviewed records, and toured the facility. Based on the interviews conducted, records reviewed, and observations made by the LPA on the 12/18/2023 facility visit, the above allegations are Substantiated. R1 was observed soiled while in care. Facility staff did not ensure R2 received his medications to treat his insulin-dependent diabetes condition and did not monitor the resident’s glucose level, which resulted in the resident’s hospitalization and death. Citations were issued on complaint #24-AS-20231228152212 and appeal rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 2, 2024 · control 24-AS-20231220104001

Allegation investigated: Staff did not monitor resident's glucose level resulting in death

The Department conducted interviews, reviewed records, and toured the facility. Based on the interviews conducted and records reviewed, the above allegation is Substantiated. Facility staff did not ensure R2 received his medications to treat his insulin-dependent diabetes condition and did not monitor the resident’s glucose level, which resulted in the resident’s hospitalization and death. Citation for care and supervision are issued on the attached 9099-D. The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report to the facility, if any. Exit Interview was conducted and Appeal Rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 2, 2024 · control 24-AS-20231228152212

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Aug 3, 2024

Personnel Requirements - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This was not met as evidenced by: Based on the interviews conducted and records reviewed, facility staff did not monitor R2’s glucose level. The facility staff also did not ensure R2 received his medications to treat his insulin-dependent diabetes condition. This resulted in R2’s hospitalization and death, which poses an immediate Health and Safety concern.the state’s words, verbatim · CDSS document, Aug 2, 2024

Plan of correction: POC addressed during NCC.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(2) · Plan of correction due date: Aug 3, 2024

Administrator - Qualifications and Duties - Knowledge of and ability to conform to the applicable laws, rules and regulations. This was not met as evidenced by: Based on interviews conducted, Administrator did not ensure resident’s care needs were met, which poses an immediate Health and Safety concern.the state’s words, verbatim · CDSS document, Aug 2, 2024

Plan of correction: POC addressed during NCC.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Aug 3, 2024

Basic Service - Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications… This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, facility staff left resident soiled and failed to ensure resident received medications, which poses an immediate health and safety concern.the state’s words, verbatim · CDSS document, Aug 2, 2024

Plan of correction: POC discussed during NCC.

Type of visit: Case Management - Incident

On 07/30/24, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct a case management visit based on record review of incident report submitted. LPA met with Staff Destiny Wood. Staff telephone called to Administrator Kala Gibson who stated unable to attend meeting. Administrator Assistant Ashley Bell arrived later during visit. The purpose of the visit is to address incident that occurred where S1 sold narcotic to R1. LPA reviewed records and conducted interviews with staff and resident. The information provide will be reviewed; a follow up case management will be conducted if necessary. Exit Interview conducted. A copy of this report was provided to the Administrator Assistant, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Jul 30, 2024

Allegation investigated: Staff does not ensure first aid is provided for minor incidents that don't require medical treatment

On 07/17/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint inspection. LPA introduce self, stated the purpose of the visit, and met with Administrator Assistant (AA) Ashley Bell. Administrator Kala Gibson was called and stated unable to attend meeting. LPA delivered findings to AA and to Administrator via telephone. During the course of the investigation, the department conduct interviews. Interviews conducted confirmed, S1 refuse to assist resident with first aid. Based on interviews conducted, 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, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report and appeal rights was provided to the Administrator Assistant, whose signature confirms received of this report. Substantiatedthe state’s words, verbatim · CDSS document, Jul 17, 2024 · control 24-AS-20240715113659

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(j) · Plan of correction due date: Jul 22, 2024

In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated as having primary responsibility for assuring that each resident receives needed first aid and needed emergency medical services and for assisting residents as needed… This requirement was not met: Based on interviews conducted, it was confirmed, S1 refuse to assist resident with first aid which poses a potential health and safety and personal rights risk to the person in care.the state’s words, verbatim · CDSS document, Jul 17, 2024

Plan of correction: Licensee shall submit steps and documents of how the facility will assist the resident with first aid to Fresno CCL office by POC due date 07/22/24.

Allegation investigated: Staff forced a resident to bathe

On 06/11/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint investigation and deliver complaint finding on the above allegation. LPA introduced self, stated the purpose of the visit and met with Administrator Kala Gibson. During the course of the investigation, the Department conducted interviews, received copies of records, and toured the facility. Based on interviews that were conducted, S1 forces R1 to take showers. Based on interviews conductd, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. An exit interview was conducted. A copy of this report and appeal rights was provided to the Administrator, whose signature on this form confirms receipt of this report. Substantiatedthe state’s words, verbatim · CDSS document, Jun 11, 2024 · control 24-AS-20240603113122

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jun 21, 2024

To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews conducted, S1 uses social force on R1 to take showers which poses a potential health and safety risk for the person in care.the state’s words, verbatim · CDSS document, Jun 11, 2024

Plan of correction: All staff In-Service training on resident’s personal rights is to be completed. Staff rooster of attendance of in-service training and training materials is to be submitted to Fresno CCL by POC date 06/21/24.

Allegation investigated: Staff are mismanaging residents medication

On 06/11/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegation. LPA introduced self, stated the purpose of the visit and met with Administrator Kala Gibson. During the course of the investigation, residents’ medications were audit and MARs were reviewed, medications audit showed staff did not administered R1 and R2 medications as directed by physician. Based on observation, 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, Chapter 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, Jun 11, 2024 · control 24-AS-20240307144719

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jun 12, 2024

Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on records review and observation, R1 and R2 medications were not administered by staff as instructed by physician which poses an immediate health and safety risk for the person in care.the state’s words, verbatim · CDSS document, Jun 11, 2024

Plan of correction: Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation which will include auditing the MARS and medications to Fresno CCL office by POC due date 06/12/24. Licensee shall have all staff retrained Health-Related Services regulations 87465. Licensee will submit documentation of training topics which include process of administering medications with staff attendance rooster to the Fresno CCL office by 06/21/24.

Type of visit: Case Management - Deficiencies

On 06/11/24, Licensing Program Analyst (LPA) M. Yang arrived to conduct an unannounced initial complaint investigation and met with Administrator Kala Gibson. LPA conducted case management-deficiency visit with Administrator. During the course of the investigation, LPA toured the facility with Administrator. LPA observed bathroom door missing in shared bedroom. A Deficiency 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 the Administrator, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Jun 11, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 14, 2024

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation and interviews conducted, at 12:01PM, Room 7 a shared room, was missing a bathroom door and has not been replace for a while which poses a potential health and safety risk for the person in care.the state’s words, verbatim · CDSS document, Jun 11, 2024

Plan of correction: Licensee shall ensure the facility is in good repaired at all times. Licensee shall ensure that there is a door to the bathroom in Room 7 by POC due date. Proof shall be submitted to the department by the POC due date of 06/14/24.

Type of visit: Case Management - Health Checks

On 04/04/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct case management visit for the purpose of checking on the health and safety of the residents in care. LPA introduced self, stated the purpose of the visit, and met with Administrator Kala Gibson. During today's inspection, LPA conducted a tour of the facility. All passage ways were clear from obstructions. Residents were observed in sitting in dining area, smoking in the courtyard,and in bedrooms. No deficiencies cited during today's inspection. Exit interview conducted. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of these report.the state’s words, verbatim · CDSS document, Apr 4, 2024

Allegation investigated: Staff hit resident with an object Staff are not treating resident with dignity and respect Staff did not ensure the facility was free from odors

On 03/08/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegations. LPA stated the purpose of the visit and met with Administrator Kala Gibson. During the course of the investigation, LPA toured the facility, reviewed records, and conducted interviews. R1 confirmed staff did not hit resident with any object and staff did not mistreat resident. LPA toured the facility and observed designated smoking area outdoor. Facility was observed free from odor. Based on observations and interviews which were conducted, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report and appeal rights was provided to the Administrator, whose signature on this report confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 8, 2024 · control 24-AS-20240229134130

Allegation investigated: Staff refused to take resident to the hospital. Residents did not receive medications as prescribed.

On 02/12/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a subsequent complaint visit and delivered complaint findings on the above allegations. LPA introduced self, stated the purpose of the visit and met with Tasha Duncan. Administrator Kala Gibson was called and unable to attend meeting. During the course of the investigation, the Department conducted interviews. It was confirmed that R1 had requested to be taken to the hospital and the staff refused for the resident to go. R1’s medications and Medication Administration Record (MAR) were reviewed and observed resident’s medication were not administered to resident as prescribed on multiple occasions. Based on interviews conducted, records reviewed, and observation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 is being cited on the attached Lic 9099D. An exit interview was conducted. A copy of this report and appeal rights was provided to staff, whose signature confirms receipt of this report. Substantiatedthe state’s words, verbatim · CDSS document, Feb 12, 2024 · control 24-AS-20240108182624

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Feb 13, 2024

Personal Rights of Residents in All Facilities To receive or reject medical care or other services. This requirement was not met as evidenced by: Based on interviews conducted, the resident had requested to go to the hospital and the facility staff refused to call for the resident to be taken to the hospital, which poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Feb 12, 2024

Plan of correction: Licensee shall submit a written statement of the understanding the regulation and how it will be met by POC due date 02/13/24. In-service training for all staff will be completed for “Personal Rights.” In-service training documents with staff attendance shall be submitted to the Fresno CCL office by POC due date 02/26/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Feb 13, 2024

If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration…(2)… the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on interviews conducted, records reviewed and observation, R1’s medication and MARs were reviewed and observed that staff did not administer medication: Lidocaine 5% patch at 7AM for multiple dates in February 2024, on 2/9/24 7PM and 2/11/24 7PM. Medication Morphine 15mg was not administer on 2/9/24 8PM and 2/10/24 8PM. Morphine 15mg was administered on 2/10/24 and 2/11/24 after medications were changed on 1/29/24 to Morphine 30 mg. Medication Morphine 30 mg was not administer on 2/10/24, 2/11/24 8AM, and 2/12/24 8AM. Medication Valproic Acid 250 mg was not administered on 2/5/24 12PM and 2/11/24 8PM. Diclofenac Sodium 1% gel was not administered on 2/6/24 8AM and 2/7/24 8AM. Several medications not being administered to R1 poses an immediate health and safety risks to the person in care.the state’s words, verbatim · CDSS document, Feb 12, 2024

Plan of correction: Licensee shall submit a written statement detailing steps the facility will take to ensure the requirements of Health-Related Services are met. Statement shall be submitted to Fresno CCL office by POC due date 02/13/24. All staff will be retrained on Health-Related Services regulations which includes medication pass and medication checks. Training documents and record of staff attendance will be submitted to the Fresno CCL office by 02/26/24.

Allegation investigated: Facility is not providing a healthful environment for residents in care.

On 02/12/24, 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 Tasha Duncan. Administrator Kala Gibson was called and unable to attend meeting. During the course of the investigation, the Department conducted interviews and toured the facility. LPA observed mold in the resident’s bathroom shower floor and wall. Based on observation, 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, Chapter 6 is being cited on the attached Lic 9099D. An exit interview was conducted. A copy of this report and appeal rights was provided to staff, whose signature confirms receipt of this report. Substantiatedthe state’s words, verbatim · CDSS document, Feb 12, 2024 · control 24-AS-20240104103038

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Feb 26, 2024

Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met as evidenced by: Based on observation, in resident’s room 11, mold was observed in the bathroom shower floor and wall which poses a potential Health, Safety, and Personal Rights risk to the resident.the state’s words, verbatim · CDSS document, Feb 12, 2024

Plan of correction: Licensee shall ensure there are no molding in resident’s bathroom shower by deep cleaning or replace shower. Proof shall be submitted to Fresno CCL office by POC due date 2/26/24.

Type of visit: Case Management - Deficiencies

On 12/18/23, Licensing Program Analyst (LPA), M. Yang arrived unannounced to conduct a Case Management - Deficiencies inspection. LPA introduced self, stated the purpose of the visit and met with Administrator Kala Gibson. The purpose of today’s visit is to address incident report and SOC 341 that the department received on 12/12/23. It was reported that on 12/10/23, staff 1 (S1) slapped and scolded R1. LPA conducted interview with Administrator, reviewed submitted photos and records which confirm S1 had slapped R1’s arm multiple times leaving bruises on R1’s arm the next day. S1 demanded R1 to go to her room and scolded R1 that grabbing S1’s hand was not okay. A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached 809D. Exit Interview conducted. A copy of this report and appeal rights was provided to Administrator, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Dec 18, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Dec 19, 2023

87468.1(a)(3) Personal Rights of Residents in All Facilities To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement has not been met by: Based on interviews conducted, reviews of photos and records, on 12/10/23 S1 had slapped R1 on the hand multiple times leaving R1 bruises on the forearm. S1 scold and demanded the resident to go to the resident’s room which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 18, 2023

Plan of correction: S1 was terminated on 12/12/23. All staff have been retrained in-service training on 12/13/23. In-Service training on elderly abuse including emotional, physical, mental, and verbal. Rooster of staff attendance and training documents was received. POC cleared.