Northridge Valley Senior Living

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Allegation investigated: Staff wrongfully evicted resident

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an initial complaint visit and met with Executive Director Benedit Pak regarding the allegation that the facility wrongfully evicted a resident. To investigate the complaint, LPA conducted interviews and obtained and reviewed documentation on 08/04/2026, 08/05/2026, and 08/06/2026, during visits occurring between 9:00 a.m. and 2:00 p.m. The investigation included a review of records pertaining to Resident #1 (R1), including the Admission Agreement, billing statements, and other relevant facility documentation. Based on the information obtained, LPA determined that R1 was admitted to the facility on 05/29/2026. At the time of admission, the facility required payment of a prorated rent amount, a care plan fee, and a community fee. Documentation reviewed during the investigation showed that monthly rent for June and July had been paid; however, the prorated admission charges and community fee remained outstanding, resulting in an unpaid balance. (Cont'd LIC9099C) Unsubstantiated The Executive Director stated that the facility issued R1's representative a notice to pay outstanding fees, not an eviction notice. The Executive Director further advised that the facility would contact R1's representative to clarify the purpose of the notice and work toward resolving the outstanding balance. Based on interviews, documentation reviewed, and the allegation that the facility wrongfully evicted a resident is Unsubstantiated. Exit interview and copy of report provided to ED.the state’s words, verbatim · CDSS document, Aug 6, 2026 · control 31-AS-20260731133647

Allegation investigated: Staff did not adequately supervise residents resulting in residents ingesting non-food items

On 08/18/25, at 9:20am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Frances Norberte, Memory Care Director. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 08/18/25, LPA Saucedo asked for the census, staff, and resident rosters. On 08/18/25, at 10:30am, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Substantiated Regarding the allegation: Staff did not adequately supervise residents resulting in residents ingesting non-food items. It is being alleged that some residents in memory care were left unsupervised and were eating crayons and drinking water from a paint container. LPA interviewed four (4) out of four (4) staff that confirmed they have seen staff #1 (S1) from memory care leave the residents unattended. Four (4) staff confirmed that S1 from memory care walks around and leaves the residents unattended while the residents stay in the Activities Room for unknown amounts of time. One (1) staff confirmed that they have witnessed a resident eating crayons before. LPA attempted to interview residents in the memory care area of the facility but to no avail they were able to answer any of the LPA questions. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued, appeal rights was given and a copy of this report was given to the Memory Care Director.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 31-AS-20250813164015

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Aug 19, 2025

Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met by: Based on the LPA observation and interviews the licensee/administrator did not ensure the safety of the residents in memory care by leaving them unattended and residents eating crayons which poses an immediate Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Aug 18, 2025

Plan of correction: The Licensee/Administrator shall properly train the staff #1 (S1) to care and supervise the residents in memory care. POC 08/19/25

Type of visit: Case Management - Other

On 08/18/25, at 10:30am, Licensing Program Analyst (LPA) Gina Saucedo conducted a physical tour in the memory care area of the above facility. While conducting a physical tour, LPA asked about the planned activities that were supposed to be taking place. According to the Activities Plan Sheet, planned activities such as reading/educational hour and/or work out should have been taken place. There were no activities being performed for the residents in the memory care area. Staff also confirmed that there was no staff to conduct planned activities the day before (08/17/25). LPA obtained copies of the Planned Activities Sheet. An exit interview was conducted, a citation(s) was issued on a 809-D page for the above allegation(s), appeal rights and a copy of this report was given to the Memory Care Director.the state’s words, verbatim · CDSS document, Aug 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a) · Plan of correction due date: Sep 1, 2025

87219 Planned Activities(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities...This requirement was not met by: Based on the LPA observation and interviews the licensee/administrator did not ensure that Planned Activities were displayed on the Activites Plan Sheet were being performed which poses a potential Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Aug 18, 2025

Plan of correction: The Licensee/Administrator shall send a statement of why the activities that are displayed on the Plan Activities are not being performed. POC 09/01/25

Type of visit: Required - 1 Year

On 08/12/25 at 8:10AM, Licensing Program Analyst (LPA) Gina Saucedo arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with Frances Norberte, Memory Care Director and disclosed the purpose of the visit. LPA asked for the census, resident, and staff rosters and files. A physical tour was conducted at 10:05AM and observed the following: The entire facility has a total of 110 (one-hundred and ten) beds. Forty-three (43) are currently in the memory care unit and 44 (forty-four) in the Assisted Living area being occupied. All the rooms are on the second floor. The floor is divided by assisted living and memory care. The assisted living is on your left-hand side of the facility and the memory care is on your right-hand side of the facility. The second floor consists of a medication room which is in the memory care section. The memory care section has their own activity, dining hall, two (2) enclosed patio and enclosed gardens. There is also four (4) delayed egress on the doors in memory care. The assisted living side has their own activity room upstairs and another room downstairs. The assisted living side has access to the ground level which is the first floor which has the laundry room area, beauty salon, dining hall, kitchen access to the patio area, another activity room area and a staff lounge. The parking structure can be entered from this area and from the street area. LIC 809C-continued Random Bedrooms and Bathrooms were randomly selected to tour and were observed to have appropriate furniture, lightening, bedding, and televisions. Random Bathrooms were observed to have grab bars and non-skid mats. Hot water temperature was tested randomly for and measured 113-114-degree Fahrenheit. The random bedrooms and bathrooms had pull-cord alarms. The public bathrooms in the assisted living area had emergency pull-cord alarms. Fire extinguishers were observed throughout the facility and were fully charged on green with the same expiration dates- August 2025. There are fire extinguishers upstairs, downstairs, in the kitchen area and parking lot structure. Carbon Monoxide and fire sprinklers are located throughout the facility and are operable. Facility has a designated medication room that is inaccessible to residents where all the medication is stored and locked in the memory care side of the facility. The medication was revised randomly. The assisted living area: outside/backyard is accessible to residents with different areas for them to sit. There is appropriate outdoor furniture for the residents to sit on with proper shading. There is no bodies of water. Common Areas: These include the dining areas, beauty salon, and activities room. All common areas were observed to be cleaned and properly furnished. The activity room has a large television and has enough seating for several residents to watch the television and do different activities. Facility maintains a comfortable temperature of in between 74 and 77-degree Fahrenheit. There are several temperature thermostats throughout the facility. There are several common bathrooms throughout the upstairs and downstairs area. The staff and resident bathrooms are not shared. There are trash cans with lids and covid signs posted in the common bathrooms. There is toilet paper and napkins. The exit stairways leading to the downstairs area all have evacuation chairs. There are several hand sanitizers against the wall throughout the facility. LIC 809C-continued The Kitchen area was toured and observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. The chemicals are inaccessible to the residents which can be accessed via the kitchen area in a locked door. Against the wall of the kitchen towards the back is a Resident's Diet Plan Board. Administrative: The Insurance plan is current and dated 10/2025. There is a disaster plan, licensee certificate, YES sign, Resident Rights, and Rights of Resident Council against the wall facing the entrance of the facility on your right hand side. The Ombudsman sign is on your left hand side of the entrance of the facility. The last fire drill/emergency drill was conducted in July of 2025. An exit interview was conducted, citation(s) were issued, appeals rights, and a copy of this report was given to the memory care director. Citations were issued on Plan of Correction of Elopement of resident on 03/17/25 which was due on 03/31/25 and was never sent to Community Care Licensing/LPA and the garage area has hazardous materials such as bed mattresses and sofas next to parking spaces that need to be disposed of or stored in a storage area.the state’s words, verbatim · CDSS document, Aug 12, 2025

Allegation investigated: Staff are not properly addressing pest infestation in the facility

On 07/08/25, at 8:15am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Frances Norberte, Memory Care Director. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 07/08/25, LPA Saucedo asked for the census, staff, and resident rosters. On 07/08/25, at 8:25am, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff are not properly addressing pest infestation in the facility. It is being alleged that there was a cockroach in the hallway by one (1) of the resident's room in the memory care area of the above facility. During LPA's physical tour, LPA did not observe any cockroaches in the hallway, kitchen area and random rooms of the memory care area. LPA also interviewed three (3) staff that confirmed they have not seen any cockroaches in this area of the facility. One (1) staff confirmed that Pest Control comes several times a month so pest infestation can be prevented. In addition, LPA received the Pest Control Invoices of their monthly services from January 2025 to June 2025. LPA attempted to interview four (4) memory care residents but they did not understand what the LPA was asking. Therefore, based on the LPA's observations, record, review staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Memory Care Director. Regarding the allegation: Staff do not ensure the facility is properly maintained. It is being alleged that a big hole is on the wall for the garbage and the residents have been seen playing, opening and putting their hand and whole arm inside. During LPA's physical tour, LPA observed a garbage disposal that is against the wall and can be opened and closed by anyone, there is no lock. In addition, the garbage disposal is hazardous because anything can be thrown into it leading to the downstairs area. LPA interviewed three (3) staff that confirmed that the garbage disposal remains open at all times and not locked. LPA attempted to interview four (4) memory care residents but they did not understand what the LPA was asking. Let it be noted, this garbage disposal is in the memory care section of the above facility. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued for the above allegation(s), appeal rights was given and a copy of this report was given to the Memory Care Director.the state’s words, verbatim · CDSS document, Jul 8, 2025 · control 31-AS-20250702101204

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jul 9, 2025

87303(a) Maintenance and Operation (a) 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 by: Based on the LPA observation and interviews the licensee/administrator did not ensure the safety of both the staff and residents of the garbage disposal being opened and accessible to anyone which poses an immediate Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: The Licensee/Administrator shall buy a lock to keep the garbage disposal locked at all times and inaccessible to all residents. POC 07/09/25

Allegation investigated: Staff caused injury to resident in care

On 06/03/25, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Administrator, Karin Marin. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 05/16/25, the above complaint was referred to the Investigations Branch (IB) but was returned to the Regional Office (RO) on 05/19/25 for investigation. On 05/19/25, LPA Saucedo conducted an initial complaint and asked for the census, staff, and resident rosters. On 05/19/25, LPA Saucedo interviewed staff, residents and conducted a physical plant tour. LIC 9099C-continued Unsubstantiated Regarding the allegation: It is being alleged that resident #1 (R1) is being physically abused by staff. LPA interviewed two (2) staff that were present the morning of May 14th 2025. The two (2) staff that were present during the morning shift confirmed that there was blood on R1’s right arm and when they noticed it, R1 had a small skin tear. One (1) of the staff advised one (1) of medical technician staff about R1’s right arm and the medical technician applied first aid and bandaged R1’s arm. LPA received the end of shift summary from the medical technician stating skin care they had provided to R1. LPA also attempted to interview R1. Let it be noted, R1 is diagnosed with Dementia. When LPA asked R1 what happened to their arm, R1 touched their hand and said they had a cut. LPA asked R1 how they got the cut but R1 did not answer LPA. LPA also observed that R1 had two (2) more small skin tears on their left hand. LPA's review of R1's medical prescriptions also determined that R1 has been taking Latanoprost which can cause skin rashes. Based on the LPA's observations and record reviews, staff and resident interviews conducted, the allegation(s) for physical abuse is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) issued, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jun 3, 2025 · control 31-AS-20250516083811

Type of visit: Office

On this day at 11 am, a meeting was conducted by Assistant Program Administrator (APA) Stacy Barlow to verify Chapter 7 Bankruptcy Report filed by the Pacifica Senior Living as reported by the media. Present during the meeting are: Shelley Grace - Assistant Branch Chief, CCLD Craig Lundgren - Legal Counsel, CCLD Carl Knepler - Chief Executive Officer, Marlene Nelson - Director, Quality Assurance and Risk Management APA Barlow verified with Knepler information received by CCL from the media as follows: $25M lawsuit against the community located in Bakersfield Photography lawsuit against one of the properties lawsuit against a Skilled Nursing Facility (SNF) in the Healdsburg location Knepler states that despite the lawsuits, there is no financial impact to any of the properties, residents or staff of the company. Knepler added there are no vendor issues as well. Continuation on LIC809-C Knepler also states that management communicates with the staff and residents to make them aware of the changes. Signages have been changed. Knepler added that the bankruptcy did not affect any of the communities because Pacifica Senior Living Management was no longer the management company for any of the Pacifica Communities, that the communities had given notice to the department and residents back in October or November of last year of the changes in management companies. He said that the judgment in Bakersfield did not involve the operating entity, only the management company. He said there were no other suits pending against any of the Pacifica entities. APA requested the following documents be provided to CCL by today: Spread sheet of all facilities whose management company was/is Pacifica Senior Living Management Company management companies for each location letter provided to the residents notifying them of the changes At the conclusion of the meeting, APA emphasized to Knepler the importance of communicating with CCL any lawsuits that the company may have in the future. Knepler agreed with APA. A copy of this report was provided to Knepler.the state’s words, verbatim · CDSS document, Apr 4, 2025

Allegation investigated: Facility staff did not provide adequate supervision to resident in care.

On 03/17/25, at 9:20am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Frances Norberte, Memory Care Director. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 03/17/25, LPA Saucedo asked for the census, staff, and resident rosters. On 03/17/25, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Substantiated Regarding the allegation: Facility staff did not provide adequate supervision to resident in care. It is being alleged that resident #1 (R1) is housed in the memory care area of the facility and made it to the lobby area pass the egress doors. Let it be noted, the lobby area is part of the assisted living area of the facility. LPA reviewed R1’s file and it is documented that R1 has dementia and is housed in the memory care area of the facility. During LPA’s interview with R1, R1 denied leaving the memory care area but did state "they will not be staying at any facility and will try to leave and go home.” LPA interviewed three (3) staff that confirmed R1 has left the memory care area and made it to the lobby area. Staff #1 (S1) confirmed that R1 was informed by another staff that R1 was in the lobby are and needed to go back to the memory care area of the facility. Staff #2 (S2) confirmed that R1 has left the memory care area on multiple occasions and has been seen walking in the assisted living area of the facility. Staff #3 (S3) confirmed that they have seen R1 by their office which is outside of the memory care living area and located in the assisted living area of the facility. After LPA reviewed R1’s file it was determined that R1 was not given adequate supervision and did not have an updated appraisal. LPA attempted to interview six (6) residents in the memory care area, but they were not able to respond to LPA’s interview. Therefore, based on the LPA's record review, staff and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time. This report supersedes the previous report issued on 03/17/2025 to dismiss and change citations. An appeal was granted. Licensing Program Analyst (LPA) Gina Saucedo visited the facility to issue an amendment to the Licensing Report previously issued on 03/17/2025. The LPA met with Administrator and explained that the report was amended to correct the type of citation issued during the visit conducted on 03/17/2025. Citation CCR-87705(6)(A) is dismissed and Citation CCR-87411 (d)(3) is being changed to CCR-87468.2(a)(4). An exit interview was conducted, citation(s) were issued, appeal rights was given and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Mar 17, 2025 · control 31-AS-20250312143535

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(6)(A) · Plan of correction due date: Mar 31, 2025

Appeal was granted and deficiency was dismissed.the state’s words, verbatim · CDSS document, Mar 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a)(4) · Plan of correction due date: Jan 20, 2026

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications...This requirement is not met by: Based on the LPA observation, record reviews and interviews the licensee/administrator did not ensure proper supervision training for staff from the above facility which poses a potential Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Mar 17, 2025

Plan of correction: A training record of staff about personal rights of residents is to be sent to CCLD/LPA. Training of staff was provided to LPA at time of visit. POC Due Date and Cleard on:01/20/26

Allegation investigated: Due to water leakage there were molds on the floors and walls. Facility freezer is not maintaining the required temperature. Call buttons in residents rooms and bathrooms are missing.

Licensing Program Analyst (LPA) Leizl de la Cerra conducted an unannounced subsequent complaint visit to this facility to investigate the above allegation and deliver findings. At 10:30AM, LPA met with the facility executive director, Karen and explained the reason for the visit. Regarding the allegation: Facility freezer is not maintaining the required temperature. It has been alleged that on Dec. 4, 2024 the facility walk-in freezer is not maintaining the required temperature. To investigate this complaint, On 1/2/2025 at 11:00am, LPA conducted an initial complaint visit, LPA toured the physical plant, conducted interview with staff members and facility residents between 12:00PM to 4:00PM. LPA requested pertinent documents/records and conducted record reviews between 12:00PM to 4:00PM. Unsubstantiated During the initial visit on 1/2/25, LPA observed the walk-in freezer maintaining the required temperature of 0 degrees Fahrenheit, which is in compliance with the Title 22 Regulation, 87555 - General Food Service Requirements section. LPA took a picture of the temperature sensor which shows a -5 degrees F. LPA was also provided a copy of an invoice of a purchase of a new motor for the walk in freezer, invoice was dated Dec. 09, 2024. Furthermore, LPA interviewed four (04) facility staff members, S1, S2, S3 and S4 and all confirmed that on 12/04/2024, when the walk-in freezer was not working, all frozen items from the walk in freezer was transferred to the back-up freezer located in the dining area. LPA took a picture of the back-up freezer. During the subsequent visit on 2/20/25 LPA checked the walk-in freezer once again and observed the walk-in freezer maintaining the required temperature of 0 degrees Fahrenheit, which is in compliance with the Title 22 Regulation, 87555 - General Food Service Requirements section. LPA took a picture of the temperature sensor which shows a -5 degrees F. Therefore, based on interviews, record reviews and observations, this allegation is Unsubstantiated. Regarding the allegation: Due to water leakage there were molds on the floors and walls. It has been alleged that on August 27. 2024 the facility had a water leak which allegedly resulted to the floors and walls having mold. To investigate this complaint, On 1/2/2025 at 11:00am, LPA conducted an initial complaint visit, LPA toured the physical plant, conducted interview with staff members and facility residents between 12:00PM to 4:00PM. LPA requested pertinent documents/records and conducted record reviews between 12:00PM to 4:00PM. During the initial visit on 1/2/25, LPA observed no molds on the wall or the floors of where the the leak happened and the surrounding area close to the water leak. LPA conducted interviews with five (05) staff members, S1, S2, S3, S4 and S5 and five (05) residents, R1, R2, R3, R4 and R5 and all confirmed that they did not observe any molds on the floor or the walls. Interviews with S1 and S2 revealed that when both staff members assessed the leak, immediate clean up and repair was done. LPA was provided pictures of the repair of the affected areas. Furthermore, on 1/2/25 the maintenance director, (S1) used a moisture meter which can identify areas where there are high moisture levels. LPA observed S1 utilize the moisture meter on all areas affected of the water leak and LPA observed the moisture meter displayed 0% moisture content. Therefore, based on observations, interviews, and record reviews this allegation is Unsubstantiated. Regarding the allegation: Call buttons in residents rooms and bathrooms are missing. It has been alleged that two call bells haven't been installed in the shared rooms in Memory Care and some of the bathrooms in Memory Care doesn't have a call bell. To investigate this complaint, On 1/2/2025 at 11:00am, LPA conducted an initial complaint visit, LPA toured the physical plant, conducted interview with staff members and facility residents between 12:00PM to 4:00PM. LPA requested pertinent documents/records and conducted record reviews between 12:00PM to 4:00PM. During the initial visit on 1/2/2025 LPA conducted an interview with Memory Care Unit staff, S5 and it was revealed that there are a total of 11 rooms that are shared. LPA conducted a physical tour of each of the 11 rooms and LPA observed that each of these shared rooms have one (1) call button in the bedroom area and one (1) call button in the bathroom. All the bathrooms in each of the 11 shared rooms have call buttons. On 2/20/25, LPA's interview with administrator, S7 revealed that residents are provided with a call pendant. S7 also informed LPA that as stated in the facility's program plan for residents in dementia care unit, the facility develops an individual care plan for each resident, there is also a planned activity program to ensure continual observation of each resident and facility staff initiates an hourly check to each resident during night time. Furthermore an invoice was provided to LPA that shows a purchase of waterproof neck/ call pendants provided for the residents to use. Therefore, based on observations, interviews, and record reviews this allegation is Unsubstantiated. No deficiency cited during today's visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Feb 20, 2025 · control 31-AS-20241227112439

Allegation investigated: Licensee not ensuring there is a written plan of activities available to residents

On 01/22/25, at 10:35am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Irina Selezne, Resident Services Director. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 01/22/25, LPA Saucedo asked for the census, staff, and resident rosters. On 01/22/25, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Licensee not ensuring there is a written plan of activities available to residents. It is being alleged that there has not been a planned activities calendar since October 2024. During LPA's physical tour, LPA observed a planned activities for the month of January 2025 and daily planned activity brochures. In addition, LPA observed staff that was recently hired conducting an exercise group with about fifteen (15) residents. LPA confirmed the activity being conducted with the daily activities brochure date and time for accuracy. LPA interviewed two (2) staff that confirmed there is daily activities for the residents that want to attend and the activities for the month of January 2025 is displayed. LPA interviewed seven (7) residents that confirmed there is different activities everyday. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jan 22, 2025 · control 31-AS-20250121100857

Allegation investigated: Licensee not ensuring facility has an administrator on the premises a sufficient number of hours

On 01/13/25, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Resident Care Director, Francis Norberte. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint. The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 9:50am, LPA toured the physical plant. During the tour, LPA interviewed residents and staff. 9099C-continued Substantiated Regarding the allegation: Licensee not ensuring facility has an administrator on the premises a sufficient number of hours. It is being alleged that an administrator has not been on site. During LPA's physical tour, LPA asked for the administrator on site and LPA was informed by Staff #1 (S1) that there has not been administrator since December 2024. LPA asked S1 who has been covering or doing administrator duties and S1 stated several people have been doing different administrator duties at the above facility. LPA continued their physical tour and interviewed five (5) additional staff who confirmed that there has been no administrator at the above facility. LPA interviewed seven (7) residents who confirmed that there has been no administrator at the above facility since December 2024. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is SUBSTANTIATED at this time. An exit interview was conducted, a citation(s) was issued for the above allegation(s), appeal rights and a copy of this report was given to the Resident Care Director.the state’s words, verbatim · CDSS document, Jan 13, 2025 · control 31-AS-20250106161520

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Jan 27, 2025

87405Administrator - Qualifications and Duties(a)All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section... there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met by: Based on the observation and staff/resident interviews the licensee did not ensure an administrator to be at the above facility for sufficient number of hours to permit adequate attention to the management and administration of the facility which poses a potential Health, Safety or Personal Rights risks to person in care.the state’s words, verbatim · CDSS document, Jan 13, 2025

Plan of correction: The Licensee shall hire or designate an administrator by POC:01/27/25 and send all paperwork to Community Care Licensening Department/LPA Saucedo.

Type of visit: Case Management - Other

On 01/13/25, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit (31-AS-20250106161520) and was greeted by Resident Care Director, Francis Norberte. While interviewing residents, LPA was informed that there was also no Activities Director. While conducting the physical tour, LPA asked to speak to the Activities Director and was informed there is no current activities director. LPA interviewed six (6) staff that confirmed there is no Activities Director and the previous Activities Director left November of 2024. An exit interview was conducted, a citation(s) was issued for the above allegation(s), appeal rights and a copy of this report was given to the Resident Care Director.the state’s words, verbatim · CDSS document, Jan 13, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(f) · Plan of correction due date: Jan 27, 2025

87219 (f) Planned Activites: In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities...The responsible employee shall have had at least one year of experience in conducting group activities and be knowledgeable in evaluating resident needs, supervising other employees, and in training volunteers. This requirement is not met by: Based on the observation and staff/resident interviews the licensee did not ensure an activities director/one full time staff member to be at the above facility which poses a potential Health, Safety or Personal Rights risks to person in care.the state’s words, verbatim · CDSS document, Jan 13, 2025

Plan of correction: The Licensee shall hire or designate an activities director by POC:01/27/25 and send employee qualifications to Community Care Licensening Department/LPA Saucedo.

Allegation investigated: Staff are not safeguarding resident belongings Staff are not providing residents with napkins at meals

On 10/23/24, at 9:40am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Executive Director, Ivy Sharpe. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather additional information, conduct staff and resident interviews and deliver findings for this complaint. The initial investigation was conducted on 10/08/24 by LPA Gina Saucedo. On 10/23/24, LPA Saucedo asked for the census, staff, and resident rosters. On 10/23/24, LPA Saucedo interviewed staff, residents and conducted a physical tour. 9099C-continued Unsubstantiated Regarding the allegation: Staff are not safeguarding resident belongings. It is being alleged that one (1) of the residents has been missing several clothing throughout their stay at the above facility. During LPA’s physical tour and record review, LPA was able to verify that resident #1 (R1) has a lot of clothing in their room with their name written on their clothing. Furthermore, staff revealed that R1’s belongings (clothing) have changed because R1 gained weight and their responsible party was aware of their weight change and bought new clothing for R1. Two (2) staff confirmed that in the memory care living area their name must be written on all personal belongings including their laundry bag so all their property can be safeguarded. Seven (7) out of eight (8) residents confirmed that they are not missing any personal belongings and their property has been documented previously and kept in their file. Therefore, based on the LPA's record reviews, staff and resident interviews the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff are not providing residents with napkins at meals. It is being alleged that the facility has not provided napkins at mealtimes, and residents are having to use their clothing or just their hands. During LPA’s physical tour, LPA observed that both the memory care residents and assisted living residents do have clothed napkins during mealtimes and the memory care residents have bibs around their chest area, so their clothing does not get food stains on them. Three (3) staff confirmed that clothed napkins are provided to the residents during mealtimes for both memory care and assisted living residents. Two (2) staff did confirm that the memory care residents have a clothed napkin or bib around their chest area to prevent food from falling on their clothing. Furthermore, two (2) staff did confirm that disposable napkins are provided for special events. Seven (7) out of eight (8) residents did confirm that napkins are provided to them during mealtimes. Therefore, based on the LPA's record reviews, staff and resident interviews the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Executive Director.the state’s words, verbatim · CDSS document, Oct 23, 2024 · control 31-AS-20241007122633

Allegation investigated: Staff are not ensuring residents are provided with toiletries Staff are not providing adequate housekeeping services to residents Staff are not ensuring that facility dining area is kept clean

On 08/06/24, at 8:40am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Administrator Ivy Sharpe. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint. The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 9:15am, LPA toured the physical plant. During the tour, LPA interviewed residents and staff. 9099C-continued Unsubstantiated Regarding the allegation: Staff are not ensuring residents are provided with toiletries. It is being alleged that resident's rooms are not kept clean or stocked with toiletries, such as toilet paper and wipes. Seven (7) out of eight (8) residents were interviewed and they confirmed that they do receive toiletries either daily, every other day or/and weekly. Seven (7) out of eight (8) residents did confirm that their room is clean. Nine (9) out of nine (9) staff confirmed that residents are provided with toiletries. During LPA's physical tour, LPA observed toilet paper and wipes in all the rooms that were toured and the rooms were cleaned. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff are not providing adequate housekeeping services to residents. It is being alleged that the floors and bathrooms are not being cleaned in most of the rooms. Seven (7) out of eight (8) residents were interviewed and they confirmed that the staff do provide adequate housekeeping services. Five (5) out of six (6) staff confirmed that they have designated days of the week in which they clean the resident rooms. Some staff also confirmed that if additional cleaning is needed they will clean the room regardless if it's the resident's designated day. During LPA's physical tour, LPA observed the housekeeping and caregivers cleaning the rooms and providing services to the residents. The floors and bathrooms were also clean. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff are not ensuring that facility dining area is kept clean. It is being alleged that the dining room is not cleaned up after breakfast so when residents return to the dining area for lunch, the tables are sticky with syrup and food residue, and the floor still contains food items. Seven (7) out of eight (8) residents were interviewed and they confirmed that they do eat in the dining area and it is always clean. Five (5) out of six (6) staff confirmed that the dining area is kept cleaned. During LPA's physical tour, LPA observed the dining area to be clean. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Aug 6, 2024 · control 31-AS-20240802121141

Type of visit: Required - 1 Year

On 07/24/24 at 9:25AM, Licensing Program Analyst (LPA) Gina Saucedo and Licensing Program Manager (LPM) Troy Agard arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo and LPM Agard met with the Administrator, Ivy Sharpe and disclosed the purpose of the visit. LPA asked for the census, resident, and staff rosters and files. A physical tour was conducted at 11:15AM and observed the following: The entire facility has a total of 110 (one-hundred and ten) beds. Forty-three (43) are currently in the memory care unit and 44 (forty-four) in the Assisted Living area being occupied. All the rooms are on the second floor. The floor is divided by assisted living and memory care. The assisted living is on your left-hand side of the facility and the memory care is on your right-hand side of the facility. The second floor consists of a medication room which is in the memory care section. The memory care section has their own activity, dining hall, enclosed patio and enclosed garden. There is also a delayed egress on the doors. The assisted living side has their own activity room upstairs. The assisted living side has access to the ground level which is the first floor which has the laundry room area, beauty salon, dining hall, kitchen access to the patio area, another activity room area and a staff lounge. The parking structure can be entered from this area. Random Bedrooms and Bathrooms were randomly selected to tour and were observed to have appropriate furniture, lightening, bedding, and televisions. Random Bathrooms were observed to have grab bars and non-skid mats. Hot water temperature was tested randomly for and measured 110–115-degree Fahrenheit. The chemicals are inaccessible to the residents which can be accessed via the kitchen area in a locked door. LIC 809C-continued Fire extinguishers were observed throughout the facility and were fully charged on green with the same expiration dates- July 2025. There are fire extinguishers upstairs, downstairs, in the kitchen area and parking lot structure. Carbon Monoxide and fire sprinklers are located throughout the facility and are operable. Facility has a designated medication room that is inaccessible to residents where all the medication is stored and locked in the memory care side of the facility. The medication was revised randomly. The assisted living area: outside/backyard is accessible to residents with different areas for them to sit. There is appropriate outdoor furniture for the residents to sit on with proper shading. There is no bodies of water. Common Areas: These include the dining areas, beauty salon, and activities room. All common areas were observed to be cleaned and properly furnished. The activity room has a large television and has enough seating for several residents to watch the television and do different activities. Facility maintains a comfortable temperature of in between 74 and 75-degree Fahrenheit. There are several temperature thermostats throughout the facility. There are several common bathrooms throughout the upstairs and downstairs area. The staff and resident bathrooms are not shared. There are trash cans with lids and covid signs posted in the common bathrooms. There is toilet paper and napkins. The Kitchen area was toured, and LPA and LPM observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. There is a large freezer divided into two (2) compartments. The kitchen area was clean at the time of the tour. Administrative: There is no annual fee that is due right now. The Insurance plan is current and dated 2025. There is a disaster plan, licensee certificate, YES sign, Ombudsman, Theft and Loss Policy, Resident Rights, and Rights of Resident Council. against the wall facing the entrance of the facility. The last fire drill conducted was on 06-/2024. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Jul 24, 2024

Type of visit: Required - 1 Year

On 03/10/24 at 7:55AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with Resident Care Director Frances Norbete and disclosed the purpose of the visit. Lisa Villasenor, the administrator was called and arrived about an hour and half later. LPA asked for the census, resident, and staff rosters. A physical tour was conducted at 9:35 AM and observed the following: The entire facility has a total of 110 (one-hundred and ten) beds. Forty-three (43) are currently in the memory care unit. All the rooms are on the second floor. The floor is divided by assisted living and memory care. The assisted living is on your left-hand side of the facility and the memory care is on your right-hand side of the facility. The second floor consists of a medication room which is in the memory care section. The memory care section has their own activity and dining hall. There is also a delayed egress on the doors. The assisted living side has their own activity room. The assisted living side has access to the ground level which is the first floor which has the laundry room area, beauty salon, dining hall, access to the patio area and another activity room area. Random Bedrooms were randomly selected to tour and were observed to have appropriate furniture, lightening, bedding, and televisions. Random Bathrooms were observed to have grab bars and non-skid mats. Hot water temperature was tested randomly for and measured 115–118-degree Fahrenheit. There is one facility laundry area on the first level with chemicals inaccessible to the residents. LIC 809C-continued Fire extinguishers were observed throughout the facility and were fully charged on green with different dates. There are fire extinguishers upstairs, downstairs and in the kitchen area. Carbon Monoxide and fire alarms are located throughout the facility and are operable. Facility has a designated medication room that is inaccessible to residents where all the medication is stored and locked in the memory care side of the facility. There are always two (2) med-tech staff in there during the daytime for each side-memory care and assisted living. Medication was revised randomly. The assisted living area: outside/backyard is accessible to residents with different areas for them to sit. There is appropriate outdoor furniture for the residents to sit on with proper shading. There is no body of water. Common Areas: These include the dining areas, beauty salon, and activities room. All common areas were observed to be cleaned and properly furnished. The activity room has a large television and has enough seating for several residents to watch the television and do different activities. Facility maintains a comfortable temperature of 69.-72-degree Fahrenheit. There are several temperature thermostats throughout the facility. There are several common bathrooms throughout the upstairs and downstairs area. The staff and resident bathrooms are not shared. There are trash cans with lids and covid signs posted in the common bathrooms. There is toilet paper and napkins. The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. The dining area is located next to the kitchen where different residents were having breakfast with proper feeding utensils/plates/cups. Administrative: There is no annual fee that is due right now. The Insurance plan is dated as of 09/2023. There is a disaster plan, licensee certificate, designee and Infection control binder. The last fire drill conducted was on 02-12-2024. An exit interview was conducted, no citations were issued, and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Mar 10, 2024