Palm Vista Senior Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual inspection utilizing the Compliance and Regulatory Enforcement (CARE) Tool. Upon arrival, LPA was greeted by the receptionist, who was informed of the purpose of the visit. Executive Director Stuart Montavo subsequently met with LPA and provided a tour of the community. The facility is licensed to serve one hundred fifteen (115) non-ambulatory residents, ages 60 and older, of which ten (10) may be bedridden. The facility is approved to retain no more than twenty (20) residents receiving hospice services. At the time of the inspection, there were no residents receiving hospice services. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool during today's inspection and observed the following: Physical Plant and Environmental Safety: The facility is centrally located within the City of Palmdale and provides Assisted Living and Memory Care services. The facility is a two-story property consisting of seventy (70) apartments in the Assisted Living section and twenty-five (25) apartments in the Memory Care section. LPA toured the facility and observed a front sports lounge, bistro, main dining area, and a private dining area available for residents seeking additional privacy. Public restrooms were available throughout the facility. Water temperatures were observed to be within the required range, and handwashing signs promoting proper handwashing practices were posted. (continued on 809C) LPA toured the Memory Care unit, where twenty-three (23) residents currently reside. LPA inspected five (5) resident apartments, including Apartments #2, #6, #12, #18, and #19. Apartments inspected contained the required furniture, linens, and adequate lighting. Water temperatures in resident grooming and bathing areas measured between 105°F and 120°F. LPA observed no hazardous items, chemicals, or medications accessible to residents in the Memory Care apartments inspected. LPA also observed a courtyard within the Memory Care unit that provided residents with outdoor space and adequate shaded areas for resident use. LPA also toured the Assisted Living area and inspected six (6) resident apartments, including Apartments #115, #111, #108, #213, #216, and #237. Apartments inspected contained the required furniture, linens, and adequate lighting. Resident bathrooms were equipped with grab bars adjacent to toilets and inside showers. Water temperatures in resident grooming and bathing areas measured between 105°F and 120°F. Carbon monoxide detectors and smoke alarms were observed in resident bedrooms and hallways. LPA also observed evacuation chairs positioned in the stairwells for emergency use. LPA observed an outdoor front lounge area and courtyard available for resident use. The outdoor areas provided adequate shaded seating and sufficient space for resident activities, including barbecues and social gatherings. A miniature golf putting area was also available for resident recreational use. Food Service: LPA toured both dining areas and the kitchens that serve the Assisted Living and Memory Care residents. LPA observed proper food storage, food preparation, and food handling practices throughout both kitchen areas. No chemicals, cleaning supplies, or other hazardous substances were observed in food preparation or food storage areas. LPA discussed with kitchen staff the process for monitoring and providing meals to residents with physician-ordered special diets. LPA observed the community’s daily and weekly menus, which were posted and available for resident review. Food menus were readily available throughout the community, and printed copies are available for residents upon request. The facility maintained at least a one-week supply of nonperishable food and a minimum two-day supply of perishable food. Soaps, detergents, and cleaning compounds were stored separately from food supplies. Freezers and refrigerators were clean and maintained at appropriate temperatures. Freezers measured approximately 0°F (-17.7°C), and refrigerators were maintained at or below 40°F (4.4°C). Planned Activities: LPA observed residents attending a church service during the visit. A September 2026 activity calendar was posted and included a variety of recreational activities and scheduled community outings. LPA observed adequate indoor and outdoor recreational space available for resident activities. (continued on 809C) Amenities: LPA observed that the community offers a variety of amenities for resident use, including a movie theater, equipped fitness gym, and an on-site beauty salon. These amenities provide residents with opportunities for recreation, exercise, personal care, and social engagement. LPA observed the amenities to be clean, well-maintained, and available for resident use. Resident Rights/Information: LPA observed the required postings displayed throughout the facility's common areas, including the Complaint Poster (PUB 475), Personal Rights, and the Nondiscrimination Notice. Internet access was also available for residents’ use. Health-Related Services & Records Ten (10) resident files were reviewed. Files contained current required documentation, including Admission Agreements, signed consents, Needs and Services Plans, Physician's Reports documenting TB results and ambulatory status, and signed Resident Rights acknowledgments. Residents' medications were reviewed. Medications were observed to be centrally stored in the facility's medication room in locked medication cabinets, locked medication carts. All medications observed were maintained in a secure manner and inaccessible to residents. Disaster Preparedness LPA received and reviewed documentation of the facility's most recent fire drills conducted on 09/10/2026 for both the AM and PM shifts by Fire Safety Services, Inc. LPA reviewed documentation indicating that a State of California Fire Marshal inspection was completed on 09/15/2026. LPA observed that the facility's LIC 610D, Emergency Disaster Plan, was in the process of being updated. Emergency disaster supplies, including potable water, nonperishable food, flashlights, batteries, and first aid supplies, were observed and appeared sufficient to meet the facility's emergency preparedness needs. Personnel Records & Training Six (6) staff files were reviewed and included criminal record clearances, CPR/First Aid, required training and TB screenings. Administrator Certificate for Stuart Montalvo was valid through September 27, 2027. An exit interview was conducted with Executive Director Stuart Montalvo. Based on observations made and records reviewed during today's inspection, the facility was observed to be in compliance with applicable Title 22, Division 6 regulations. No deficiencies were cited during today's inspection.the state’s words, verbatim · CDSS document, Sep 20, 2026

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provide resident adequate care or supervision to prevent frequent falls resulting in hospitalization.

Licensing Program Analyst (LPA) Evelin Rios and Licensing Program Manager (LPM) Mary Flores conducted an unannounced subsequent complaint visit regarding the above allegation. The investigation consisted of the following: On 02/24/26 LPA Rios conducted an initial complaint investigation and requested copies of the residents and staff rosters, copies of relevant documents for the investigation. LPA interviewed the Administrator, Resident Care Director, and two (2) staff, and conducted a physical plant tour of the facility. On 7/21/26 LPA and LPM conducted interviews with 8 residents and 8 staff. (Continue to LIC9099-C) Unsubstantiated The investigation revealed the following: Regarding allegation: Staff did not provide adequate resident care or supervision to prevent frequent falls which resulted in hospitalization. It is alleged a resident has fallen 3 times and one of the falls resulted in a head injury. Interviews with residents revealed 7 out of 8 residents stated staff are quick to respond when they have a fall, staff update their needs and care plan as needed, provide the necessary assistance as well as check on the residents more often after a fall occurs until there are no concerns. 1 out of 8 residents refused to be interviewed. Interviews with staff revealed upon observing a resident fall staff respond by going to the resident, informed the Med-Tech on duty, Medtech evaluates the resident, calls emergency respond services if necessary. When a resident has an open wound injury because of a fall or hit their head emergency responder services are called and the residents are sent out to the hospital. Documents reviewed revealed Resident #1(R1)’s physician’s report dated: 8/18/25 notes R1 has a non-ambulatory status and does not have any motor impairments. Incident report dated: 2/8/26 notes R1 was found on the floor in the patio laying in their back and blood was noted from the back of the head. The facility contacted emergency services and R1 was taken to the hospital. Needs and Care plan dated 8/21/25 notes no falls for R1. Needs and Care plan dated: 08/21/25 notes an update on 2/14/26 as R1 being a fall risk and requiring partial assist. Interventions are to monitor R1 and assist with compliance of use of mechanical aides. Needs and Care plan dated: 08/21/25 notes updates on 4/22/26 and 6/27/26 to redirect and provide safety education to R1. There were no incident reports prior 02/08/26 to note falls for R1. Although R1 sustained a fall that resulted in an injury based on documents reviewed there was no history of falls prior to that incident. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this report was provided to the ED.the state’s words, verbatim · CDSS document, Jul 21, 2026 · control 31-AS-20260218185246

Type of visit: Required - 1 Year

Licensing Program Analyst Melissa Spaeth conducted an unannounced visit and was greeted by the Administrator, Stuart Montalvo. LPA Spaeth stated the purpose of the visit was to conduct an annual inspection. The facility is licensed for 115 non-ambulatory residents of which 10 may be bedridden. The Administrator confirmed there are 93 residents. LPA and the Administrator toured the facility at 9:45 am until 10:30 am. Dining Hall/Kitchen - LPA observed a seven-day supply of non-perishable food and a two-day supply of perishable food. The dining area was prepared for the noon meal. The facility menu was also posted within the dining hall area. A snack bar is located outside the dining room and was stocked with coffee, tea and snacks. Emergency Food/Water Supply Room – LPA observed the emergency food and water. Common Areas – LPA observed the common areas are spacious and contain seating. Activity Room – The room contained tables and chairs along with games and other items. The activities calendar was also posted throughout the facility. Emergency Fire Drill – LPA observed a fire drill took place on 5/29/2025. Continued on 809-C Residents’ Apartments– LPA observed the resident apartments contained bed, linens, night stand, lamp, chest of drawers and a closet. The bathrooms contained walk in shower, sink, toilet, grab bars, and covered trash can. Water Temperature - The water temperature was tested at 10:20 am and was 116 degrees F. Memory Care Wing – LPA was escorted to the wing and observed the Administrator entered the security code on a ten key pad located at the wing entrance. LPA observed memory care staff assisting residents with a craft activity. The kitchen area was neat and clean. Meals are transported from the kitchen located in the assisted living section to the memory care section. Medication Rooms - LPA observed the memory care and assisted living med rooms were locked. Assisted Living Outdoor Courtyard- The courtyard contained comfortable seating and a shaded area. LPA Spaeth reviewed the residents’ records at 10:50 am until 11:45 am. LPA reviewed staff records at 12:00 pm until 1:00 pm. There are no deficiencies to report at this time. Exit interview conducted, and a copy of the report was giventhe state’s words, verbatim · CDSS document, Jun 25, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced case management visit and was greeted by the Resident Care Director and the Business Office Manager. LPA stated the purpose of the visit was to review residents' files. LPA confirmed LPA’s receipt of reports relating to an incident that occurred at the facility. LPA Spaeth toured the facility at 10:00 am until 10:45 am. LPA interviewed the Resident Care Director and Business Office Manager at 11:00 am until 11:15 am. LPA reviewed residents' files 11:20 am until 12:00 pm. LPA Spaeth requested and received copies of the staff work schedule, resident roster and residents' documents. There are no deficiencies to report at this time. Exit interview conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Apr 18, 2025

Allegation investigated: Staff charged resident for services not rendered Staff did not ensure that resident's incontinence care needs were met

On 3/26/2025 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth met with the Administrator, Stuart Montalvo. LPA explained the purpose of this visit was to review documentation, conduct interviews and deliver the findings. LPA Spaeth toured the facility at 10:00 am until 10:20 am. LPA interviewed nine (9) out of eighty-three residents at 10:45 am until 11:30 am. LPA also interviewed nine (9) out of forty-five staff members at 11:30 am until 3:00 pm. LPA reviewed residents’ records at 3:00 pm until 3:30 pm. LPA received copies of the Admissions Agreement, End of Shift Report, Billing Statement, Resident Move Out Form, Physician’s Report (LIC 602), Resident Assessment, and Needs and Services Plan. Continued on 9099-C Unsubstantiated Regarding the allegation: Staff charged resident for services not rendered. It’s alleged a resident was charged for services not received but the resident was billed for those services. During interviews with staff, S1-S9 unanimously confirmed the resident was provided with escort services to the bathroom and dining room. S1-S9 also confirmed a daily report is completed by staff which states how staff assist residents in care. LPA reviewed the resident End of Shift Report for R1 and observed staff did escort the resident to the bathroom and to the dining room. The Administrator, Stuart Montalvo stated the resident received a full refund for the care provided from February 24, 2025 until March 2, 2025. LPA Spaeth reviewed the Billing Statement which confirms the resident did receive the refund and LPA confirmed the refund was received. Regarding the allegation: Staff did not ensure that resident's incontinence care needs were met. It’s alleged a resident was not escorted to the bathroom. The Administrator and Jeisy Pinoargot, the Resident Care Director both confirmed the Needs and Services Plan is completed and presented to the resident and the family members prior to the move in date. LPA Spaeth reviewed the resident’s Needs and Services Plan and observed the resident would receive the recommended services. S1-S9 confirmed they provide the escort services to the residents in care. R2-R8 confirmed staff provide the incontinent services they need and also receive an escort to the bathroom. LPA Spaeth attempted to interview R1 but was unable due to their cognitive ability. Based upon interviews conducted and the review of resident documentation, the allegations are unsubstantiated. Exit interview conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Mar 26, 2025 · control 31-AS-20250310120255

Allegation investigated: Staff are not allowing resident to leave the facility

On 10/02/2024, Licensing Program Analyst (LPA) Melissa Spaeth initiated a complaint investigation for the allegation(s) listed above. LPA was greeted by the Administrator, Stuart Montalvo. LPA Spaeth explained the purpose of this visit is to interview staff, a resident and gather information regarding the complaint allegation(s). LPA Spaeth interviewed two staff members at 10:40 am until 11:00 am. LPA reviewed the residents' files at 12:15 until 12:45 pm. LPA received copies of the resident's documentation. LPA interviewed a resident at 12:30 pm until 1:00 pm. LPA Spaeth also toured the facility at 2:00 pm until 2:20 pm. Regarding the allegation: Staff are not allowing resident to leave the facility. It’s alleged a resident (R1) had a friend who requested to take R1 on 9/11/2024 to a local location for a walk; however, the facility staff called R1’s POA. The POA stated R1 could not accompany the friend on an outing. Continued on 9099-C Unsubstantiated The Memory Care Director and the Administrator both confirmed the POA was contacted on 9/11/2024 regarding a friend’s request to take R1 out of the facility. The POA stated the friend could visit R1 in the facility but did not want R1 to leave. Due to R1’s cognitive ability, the POA wanted to ensure R1’s safety. LPA Spaeth attempted to interview R1; however, R1 was unable to recall the incident. Based upon LPA’s interviews, the allegation is unsubstantiated. An exit interview was conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Oct 2, 2024 · control 31-AS-20240925121504

Type of visit: Required - 1 Year

Licensing Program Analyst Melissa Spaeth conducted an unannounced visit and was greeted by WHOM. LPA Spaeth stated the purpose of the visit was to conduct an annual inspection. The facility is licensed for 115 non-ambulatory residents of which 10 may be bedridden. LPA confirmed there are fifty-six residents in the facility. LPA was escorted by staff member (S1) for a tour of the facility at TIME Dining Hall/Kitchen - LPA was greeted by the chef at 10:15 am and observed a seven-day supply of non-perishable items and a two-day supply of non-perishable fresh fruits, vegetables and meats. The dining area was prepared for the noon meal. The facility menu was also posted within the dining hall area. A snack bar is located outside the dining room and was stocked with coffee, tea, yogurt, fruit and cookies. Emergency Food/Water Supply – The chef escorted LPA to the second floor to a locked room which contained emergency food and water. Common Areas – LPA observed the common areas are spacious and contain comfortable seating. The exercise room contained work out equipment for the residents. Activity Room – The room contained tables and chairs along with games and other items. The activities calendar was also posted throughout the facility. LPA observed a library activity and residents were reading within a common area on the first floor. Residents’ Rooms – LPA observed eight apartments which contained bed, linens, night stand, lamp, chest of drawers and a closet. The cleaning staff were busy cleaning various apartments. Continued on 809-C Residents’ Bathrooms – Bathrooms contained walk in shower, sink, toilet, grab bars, and covered trash can. The water temperature was tested at 9:20 am and was 116.2 degrees F.. Memory Care Wing – LPA was escorted to the wing at 9:20 am and observed the Business Office Manager entered a code on a ten-key pad located at the entrance of the wing. LPA observed memory care staff were serving breakfast to the residents in the memory care dining hall/activity room. The kitchen area was neat and clean. Meals are transported from the kitchen located in the assisted living section to the memory care section. The interior outside courtyard is furnished with comfortable seating along with a shaded area. Memory Care Medication Room - LPA observed the room was locked. Laundry Room – The laundry room contained washer and dryers. Assisted Living Medication Room - LPA observed the room was locked and contained the residents' medications. Assisted Living Outdoor Courtyard- The courtyard contained comfortable seating and a shaded area. Emergency Fire Drill – LPA observed a fire drill took place on 3/08/2024. Residents’ Records -LPA reviewed residents' records at 10:35 am until 11:55 am. The records were accurate and up to date. Staff Records - LPA reviewed five staff records at 1:15 pm until 1:40 pm,. The records were accurate and up to date. Staff interviews – LPA interviewed five staff members at 1:45 pm until 2:15 pm. Medication Review - LPA Spaeth reviewed four residents' medication at 3:00 pm until 3:10 pm. There are no deficiencies to report at this time. Exit interview conducted, and a copy of the report was given.the state’s words, verbatim · CDSS document, Jul 5, 2024

Allegation investigated: Staff unlawfully evicted a resident Staff is retaliating against a resident Staff did not follow a licensed physician orders Staff mishandled a resident's medications Staff did not afford a resident privacy while in care Staff unlawfully confiscated a resident's personal belongings Staff overcharged a resident for a service not received

On 4/19/2024 Licensing Program Analyst (LPA), Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by Jeisy Pinoargote, Resident Care Director. LPA explained the purpose of this visit was to conduct interviews and present findings. LPA conducted a physical tour at 9:45am to 10:10 am. The investigation consisted of the following: On 02/02/2024, LPA Spaeth initiated a complaint investigation. LPA reviewed resident files and interviewed two staff members. LPA received copies of the documentation. On 4/18/2024, LPA Spaeth reviewed resident documents, interviewed six residents. During today’s visit, LPA interviewed five (5) out of twenty-six (26) staff members. Regarding the allegation: staff unlawfully evicted a resident and Staff is retaliating against a resident. It’s being alleged that a 60-day eviction notice was given to R1 in retaliation of R1 not paying for services provided to R1. R1 was not available for interview and staff were unaware when the resident would be returning to the facility. The Administrator confirmed and provided documentation that R1 had not paid medication management amount due as of 8/22/2023. Also, R1 brought medication into the facility and Cont'd 9099-C Unsubstantiated did not notify staff. However, the Administrator stated the notice was revoked and R1 and R1’s family members were notified. Five (5) of the twenty-six (26) staff members confirmed residents receive the care needed and staff do not retaliate against a resident in care. Six (6) of the sixty-three (63) residents confirmed staff have not retaliated against them. R1 was not available for an interview. The allegations are unsubstantiated. Regarding the allegation: staff did not follow a licensed physician orders. It’s being alleged that R1 can manage their own medication. However, LPA observed the Physician’s report dated 2/26/2024 which states R1 needs assistance with medication distribution. Therefore the allegation is unsubstantiated. Regarding the allegation: staff mishandled a resident’s medication. It’s being alleged that staff did not give a resident their pain medication. LPA interviewed two medical technicians who stated have never refused to give a resident their pain medication. LPA viewed R1’s medication log and observed medication was always given to the resident. Six (6) out of the sixty-three (63) residents confirmed they receive their medication each day. Therefore the allegation is unsubstantiated. Regarding the allegation: Staff did not afford a resident privacy while in care and Staff unlawfully confiscated a resident's personal belongings . It’s being alleged that staff went into R1’s room and took medications from R1’s room. R1 was not available for interview. LPA interviewed the Administrator and the Resident Care Director who stated R1 invited them into R1’s room and observed the plastic sacks in R1’s room right in their sight. Both staff members observed the resident’s medications and R1 gave the medication to the Resident Care Director. Six out of the sixty-three (63) residents confirmed staff have always respected their privacy and staff have never confiscated a resident's personal belongings. Therefore the allegations are unsubstantiated. Regarding the allegation: Staff overcharged a resident for a service not received. It is being alleged that R1 was informed they could not use a scooter within the facility. It was also alleged that the Administrator told R1 since R1 could not provide insurance for a scooter R1 would have to pay for staff members escortingR1 to the dining hall. R1 was unavailable for an interview. LPA Spaeth reviewed R1’s September, 2023 billing statement. LPA did not observe a charge for that type of service. LPA interviewed two residents who use scooters. The two residents (R4 and R5) confirmed they are allowed to have a scooter. Therefore the allegation is unsubstantiated. Exit interview conducted and a copy of the signed report was given.the state’s words, verbatim · CDSS document, Apr 19, 2024 · control 31-AS-20240201160406

Allegation investigated: Facility staff did not accurately assess resident's needs. Facility staff did not communicate with resident's family. Facility staff did not ensure that resident's room was free of clutter in the walkways. Resident sustained pressure injuries while in care. Facility staff did not provide needed care and assistance to resident. Facility staff did not ensure that resident had hot water for showers Facility staff did not ensure that resident received medical attention while in care. Facility staff did not ensure that resident was being fed while in care.

On 4/18/2024 Licensing Program Analyst (LPA), Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by Jeisy Pinoargote, Resident Care Director. LPA explained the purpose of this visit was to conduct interviews and present findings. LPA conducted a physical tour at 9:45am to 10:10 am. The investigation consisted of the following: on 05/04/2023, LPA Spaeth initiated a complaint investigation. LPA reviewed resident files and interviewed seven residents. LPA received copies of the documentation. On 4/18/2024, LPA Spaeth reviewed resident documents at 10:30 am until 11:30 am. LPA interviewed residents and received copies of resident’s documents. The investigation revealed the following regarding the allegation: Facility staff did not accurately assess resident’s needs. It’s being alleged that facility staff did not accurately assess the care a resident (R1) cont'd 9099-C Unsubstantiated needed. LPA interviewed four (4) out of twenty-six (26) staff members who stated residents have stated the facility staff accurately assessed resident’s needs. LPA interviewed six (6) out of sixty-three residents who stated staff accurately assessed resident’s needs. Therefore the allegation is unsubstantiated. Regarding the allegation: Facility staff did not communicate with resident’s family members. It’s being alleged that the staff did not communicate to the residents and to their family members. LPA interviewed six (6) out of sixty-three residents who stated staff properly communicate with the resident and family members. Four (4) out of the twenty-six (26) staff members interviewed unanimously stated they communicate to the residents and their families. Therefore the allegation is unsubstantiated. Regarding the allegation: Facility staff did not provide needed care and assistance to the resident. It’s being alleged that the staff do not meet the resident’s needs. LPA interviewed six (6) out of sixty-three residents who stated staff provides the care they need. Four (4) out of the twenty-six (26) staff members interviewed unanimously stated they provide the care needed for each resident. It was also alleged that R1 was not taking medication and R1’s bed was soiled. Two med tech staff members confirmed R1 took medication as prescribed. R2 confirmed R1 and R2 lived in the same room and also confirmed that R1 had taken medication. R2 also stated staff changed R1’s bed when it was soiled. Six (6) out of sixty-three (63) residents who stated staff never miss giving their medication and if their bed is soiled, staff immediately change the linens. R1 did not want to be interviewed. Therefore the allegation is unsubstantiated. Regarding the allegation: Facility staff did not ensure that resident had hot water for showers.- It’s being alleged that there was no hot water at the facility and R1 did not shower for four weeks due to the lack of hot water. LPA interviewed six (6) out of sixty-three residents who stated there has not been any issues with the hot water. All six (6) residents confirmed they have not missed showering for four weeks. R1 did not want to be interviewed. Four (4) out of the twenty-six (26) staff members interviewed unanimously stated the facility has not had any hot water issues. The Administrator stated hot water was not available for one day when the facility opened but that the issue was repaired. Therefore the allegation is unsubstantiated. Regarding the allegation, Facility staff did not ensure that resident's room was free of clutter in the walkways. It was alleged that R1’s apartment was cluttered. During LPA’s visit on 5/04/2023, LPA observed R1’s apartment was not cluttered. Six (6) out of the sixty-three (63) residents stated their rooms have never been cluttered. Therefore the allegation is unsubstantiated. contd 9099-C Regarding the allegation, Resident sustained pressure injuries while in care…its alleged that a resident sustained pressure injuries while in care. LPA observed R1's documentation that R1 received wound care. Four (4) out of the twenty-six (26) staff members confirmed the residents received the care they need and residents have not developed wounds due to staff neglect. The Resident Care Director confirmed R1 received wound care but there are no residents at this time receiving wound care. Six (6) out of the sixty three (63) residents confirmed staff meet their needs and do not have any wounds. R1 refused to be interviewed. Therefore the allegation is unsubstantiated. Regarding the allegation, Facility staff did not ensure that resident was being fed while in care. It is alleged a resident (R1) did not receive meals because R1 would not go to the dining hall because R1 would be charged for staff assisting the resident to the dining hall. R2 confirmed since living in the room with R1, R2 went to the dining hall to pick up R1’s meals. Four (4) out of the twenty-six (26) staff members confirmed R2 picked R1’s meals every day. Six (6) out of the sixty-three (63) residents confirmed they receive three meals per day. Therefore the allegation is unsubstantiated. Regarding the allegation…Facility staff did not ensure that resident received medical attention while in care. It is alleged that staff did not provide transportation to R1 for doctor’s appointments. R2 confirmed they scheduled the trips to the doctor for R1. The Activities Director confirmed they drive residents to their doctor’s appointments. The Activities Director confirmed R2 made the reservations for R1 and R2 to be transported to doctor’s appointments. Therefore, the allegation is unsubstantiated. Exit interview conducted and a copy of the signed report was given.the state’s words, verbatim · CDSS document, Apr 19, 2024 · control 31-AS-20230502121813

Allegation investigated: Staff inappropriately forced resident into memory care

On 3/25/2024 Licensing Program Analyst (LPA), Melissa Spaeth and Licensing Program Manager (LPM), Troy Agard conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth and LPM Agard were met by Stuart Montalvo, Administrator. LPA explained the purpose of this visit was to gather additional information, conduct interviews and deliver the findings for this complaint. LPA conducted a physical tour at 9:45am to 10:10am. The investigation consisted of the following: on 07/06/2023, LPA Spaeth initiated a complaint investigation. LPA toured the facility and reviewed files. On 04/18/2024, LPA Spaeth and LPM Agard conducted interviews and reviewed additional records. Continued on 9099-C Unsubstantiated The investigation revealed the following… regarding the allegation: Staff inappropriately forced resident into memory care. It's being alleged that a resident is being placed in memory care that did not previously have a diagnosis of dementia for the sake of financial gains. During an interview with S1, they state R1 began to show signs of having moments of forgetfulness and confusion, episodes of incontinence and sundowning. S2 states R1’s placement is necessary due to their current needs. R1 was assessed by a physician in May of 2023 who noted a diagnosis of dementia. LPM Agard attempted an interview with R1 and observed signs of confusion. During a record review from 11:30am to 12:30pm, LPA and LPM reviewed R1’s physician report dated for 05/12/2023 which indicates R1 has a diagnosis of dementia. It was observed R1 had several needs and services assessments completed. R1 was initially assessed on 06/20/2023 and it shows R1 was independent in all activities of daily living. Resident was again assessed on 01/15/2024 and it indicates that R1 started to require support with some areas of their activities of daily living. LPA and LPM reviewed R1’s resident assessment conducted on 05/12/2023, 06/20/2023, 12/14/2023 and 01/25/2024 which indicated residents’ progression in their stages of dementia and their need for additional supports and services. All assessments and needs and services plan were observed to have verbal or written consent from R1’s power of attorney. Based on interviews, observation and a review of records the above allegation is unsubstantiated. Exit interview conducted and a copy of the signed report was given.the state’s words, verbatim · CDSS document, Apr 18, 2024 · control 31-AS-20230630143812