The Leonard on Beverly A Clearwater Community

Allegation investigated: Staff pushed resident resulting in injury. Staff did not ensure resident received medical treatment in a timely manner.

On 08/27/26 at 10:30 am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Executive Director Trucy Flaherty (Staff #1/S1) as the purpose of today’s visit was explained. The investigation consisted of the following: On 08/27/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Residents #1-2 (R1-R2): Emergency ID forms, pre-appraisals, Physicians reports, needs and service plans, medication list, and copies of any incident reports and facility notes. On 08/27/26 from 11:00 am- 12: 30pm LPA conducted Interviews with Residents# 1-5 (R1-R5), and from 12:30pm- 1:40pm interviews were conducted with staff #1-5 (S1-S5). LPA conducted a review of R1's files, and facility notes. Unsubstantiated In the investigation revealed the following: Allegation: Staff pushed resident resulting in injury. It is alleged that a staff members pushed down a resident in care which resulted in shoulder pain. On 08/27/26 from 11:00 am- 12: 30pm LPA conducted Interviews with R1-R5 regarding the allegation above. 4 of the 5 residents interviewed denied the allegation above and report feeling safe and having no concerns about their safety. 1 of the 5 residents interviewed confirmed the allegation above and stated that a former employee caused resident to fall off their bed and hurt their shoulder. On 08/27/25 from 12:30pm- 1:40pm interviews were conducted with S1-S5 regarding the allegation above. 5 of 5 staff interviewed denied the allegation above and stated that there has not been any terminations within the last 2 months. LPA conducted a review of R1's file, and facility notes dated: 05/04/26- 08/24/26. Per facility note dated: 07/16/26 R1 has been complaining of shoulder pain, per POA there is no history of recent falls, and resident has had this issue chronically, physician was notified for request of pain medication. Note dated: 08/24/26 staff reached out to the R1's physician regarding continuous shoulder pain as Tylenol is not providing adequate relief. LPA reviewed service plan dated: 06/23/26: Full assistance with toileting, transfers and mobility as R1 has a history of falls. LPA conducted a file review and did not observe any incident reports related to the allegation above. Allegation: Staff did not ensure resident received medical treatment in a timely manner. It is alleged that resident in care requested to see a Doctor after obtaining an injury and staff did not assist. On 08/27/26 from 11:00 am- 12: 30pm LPA conducted Interviews with R1-R5 regarding the allegation above. 2 of the 5 residents interviewed denied the allegation above, 2 of the 5 residents interviewed did not have any knowledge of the allegation as they stated they have not had the need for medical attention, but believe the staff would assist. 1 of the 5 residents interviewed confirmed the allegation above and reported that resident is still waiting to see a Doctor. On 08/27/25 from 12:30pm- 1:40pm interviews were conducted with S1-S5 regarding the allegation above. 5 of 5 staff interviewed denied the allegation above, and stated that staff has not refused to seek medical attention for residents in care. 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 conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 27, 2026 · control 11-AS-20260821103410

Allegation investigated: Staff did not refund deposit. Staff did not provide a copy of the admission agreement.

On 07/01/26, the department conducted an unannounced subsequent complaint visit at the above named facility to further investigate the allegations listed above and deliver findings. The department met with Executive Director, Tracy Flaherty, and explained the purpose of the visit. The department was granted access to the facility. The investigation consisted of the following: On 04/23/26, the department received the following documents: staff roster, resident roster, Community Fee Receipt, and a Wells Fargo Bank personal check #102, made out to the facility from potential resident #1 (PR1). Additionally, the department conducted interviews with staff #1-#2 (S1-S2), and PR1. On 06/29/26, the department received a copy of the facility’s blank Admission Agreement, Resident Summary Ledger, and a Community Fee Receipt via email. Additionally, the department attempted to interview PR1. Unsubstantiated The investigation revealed the following: For the allegation: “Staff did not refund deposit.” It was alleged that a prospective resident paid a deposit to the facility to reserve a placement. The prospective resident reportedly notified facility staff on 03/05/26 that they no longer wished to move into the facility and requested a refund of the deposit. It was further alleged that, after not receiving the refund, the prospective resident followed up with the facility on 04/06/26 regarding the status of the refund. On 04/23/26, the department conducted interviews with S1-S2. Of those interviewed, 2 out of 2 staff denied the allegation. Interviews with S1 and S2 revealed that PR1 changed their decision about moving into the facility multiple times. S1 and S2 stated that PR1 made the final decision not to move into the facility on 04/06/26. According to S1 and S2, the facility initiated the refund process on that date and informed PR1 that the deposit would be refunded within 30 days. S1 further stated that PR1 received the refund by check on 04/24/26. On 04/23/26, the department conducted an interview with PR1, who stated that there was considerable back and forth between them and the facility regarding their decision to move in. PR1 acknowledged that they were unsure of the exact dates but believed they informed the facility on 03/05/26 that they no longer wished to move into the facility and requested a refund of their deposit. PR1 stated that they simply wanted their deposit returned. On 07/01/26, the Department attempted to conduct a follow-up interview with PR1 by telephone; however, PR1 was unavailable. On 07/01/26, the department reviewed the facility's Admission Agreement. On page 16, under Section D. Refund Policy, subsection 2. Refund of Unused Portion of Monthly Fee, the agreement states: "You or your estate will receive any refund that is due within thirty (30) days following the effective termination date." The Department also reviewed the Community Fee Receipt, dated 01/29/26, which documented that PR1 paid a $20,000.00 deposit to secure placement at the facility. The receipt further states that the deposit is fully refundable. Additionally, the Department reviewed the Resident Summary Ledger, which documented that the facility received PR1's $20,000.00 deposit via check #102 on 01/30/26. The ledger further documented that a refund in the amount of $20,000.00 was issued to PR1 on 04/24/26 via check #125. Based on the records reviewed, and interviews conducted, there is insufficient evidence to support the allegation. Although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed unsubstantiated. For the allegation: “Staff did not provide a copy of the admission agreement,” it is being alleged that the resident may have signed an admission agreement but can't recall and does not have a copy of it. On 04/23/26, the department conducted interviews with S1-S2. Of those interviewed, 2 out of 2 staff denied the allegation. S1-S2 stated that an admission agreement was never signed by PR1 as they never moved in to the facility. An interview conducted with PR1 on 04/23/26 revealed that they were not sure if they did not didn’t sign an admission agreement. Based on the records reviewed, and interviews conducted, there is insufficient evidence to support the allegation. Although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed unsubstantiated. No deficiencies were cited during this investigation. An exit interview was conducted and a copy of this report was provided to Tracy Flaherty.the state’s words, verbatim · CDSS document, Jul 1, 2026 · control 11-AS-20260417083834

Allegation investigated: Staff did not properly supervise resident while away from the facility.

On 06/24/2026, LPA Pamela Bunker conducted an initial visit to gather information regarding the allegation mentioned above. LPA met with Tracy Flaherty, Executive Director, and explained the purpose of today's visit. LPA was granted entry to the facility. The investigation consisted of the following: On 06/24/2026 at 12:30 p.m.., the Department requested and reviewed resident's records and obtained copies of the following documents: Personnel Report (06/17/2026), Resident Roster (06/24/2026), Admission Agreement (05/04/2026), Identification and Emergency Information (04/10/2026), Physician's Report (04/08/2026), Medical Assessment (06/12/2026), Consent Forms (03/09/2026), Functional Capability Assessment (06/24/2026), Preplacement Appraisal Information (05/04/2026), Appraisal, Needs and Service Plan (05/12/2026, Personal Rights (03/09/2026), Text Messages (05/23/2026), Interviews were conducted with Staff Members #1 and #4 (S1-S4) as well as with residents #1 through #3 (R1-R3). See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2. Investigation revealed the following: Allegation: Staff did not properly supervise a resident while away from the facility. On June 24, 2026, between 12:30 p.m. and 4:30 p.m., the Department conducted interviews with Staff #1 through Staff #4 (S1–S4). 4 out of 4 staff members reported that the staff properly supervise residents when they are away from the facility. Staff stated that the resident in question has mild dementia and that the physician’s order indicates the resident may be unsupervised. 4 out of 4 staff members also stated that residents are never left unsupervised and reported that they were not aware of the hair salon attendant running behind schedule or that there would be a one-hour wait before the resident’s appointment could begin. Staff reported that hair salon employees are not responsible for providing care or supervision to residents. Additionally, all four staff members stated that residents are provided with a safe, healthful, and comfortable environment, and that staff provide the necessary care and supervision to meet each resident’s needs. All four staff members denied the allegation. On June 24, 2026, between 12:30 p.m. and 4:30 p.m., the Department interviewed Residents #1 through #3 (R1–R3). When asked whether staff properly supervise residents while away from the facility, 3 out of 3 residents stated that staff do provide proper supervision and do not leave residents unattended. R1 reported that staff have never left her alone at the hair salon and that staff always wait in a chair until her appointment is finished. R1 also stated that when she schedules her hair appointments, she has never experienced a one-hour wait due to the salon being busy with multiple clients. 3 out of 3 residents stated that staff provide a safe environment and offer appropriate care and supervision based on each resident’s individual needs. Each resident confirmed that they feel safe in the facility and that staff maintain a respectful and supportive atmosphere. All three residents denied the allegation. See continued LIC9099-C page 3 Continued LIC9099--C page 3 On June 24, 2026, the Department also reviewed the resident records, including the physician’s report dated April 8, 2026, which indicates that the resident is able to leave the community unsupervised. In addition, staff received an email and text messages from the resident’s responsible party on May 23, 2026, providing instructions regarding the resident’s salon appointment and confirming that the resident may leave the community. Based on interviews, available evidence, observation, information received, and records reviewed, there was not enough sufficient evidence to support the allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. There were no deficiencies cited. LPA Bunker provided Tracy Flaherty, Executive Director, with copies of the LIC9099 and LIC9099-C Complaint Investigation Reports. An exit interview was conducted.the state’s words, verbatim · CDSS document, Jun 24, 2026 · control 11-AS-20260618084007

Allegation investigated: Staff forced resident to take insulin. Staff yells at other staff in the presence of residents.

On 06/17/2026, the department conducted an initial complaint visit to the facility and was greeted by Tracey Flaherty, Executive Director. The department explained the purpose of this visit was to gather information about the complaint, gather facility files, interview staff and residents, and deliver findings for the allegations mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4) and residents (R1-R3). The department received the following documents: Personnel Report (Dated: 06/01/2026), Resident Roster (Dated: 06/17/2026), ID/Emergency Information (Dated: 04/06/2026), Physician’s Report (Dated: 03/20/2026), Resident Service Plan (Dated: 05/15/2026) and Medication Administration Record (Dated: 06/01/2026-06/17/2026) from the facility. Report Continued On LIC9099-C Unsubstantiated The investigation revealed the following: Allegation #1- Staff forced resident to take insulin. The details of the complaint alleged that the facility staff violates residents’ right by forcing them to take their insulin against their will. On 6/17/2026, from 09:30am-12:30pm, the department interviewed staff (S1-S4) and residents (R1-R3) regarding the allegation. 4 of 4 staff denied the allegation that Staff forced resident to take insulin. All staff stated that they have never forced any resident to take any insulin or other medication against their will. Staff stated that the residents have a right to refuse medication and it is not the policy of the facility to force them to do anything. The department interviewed residents (R1-R3) about the allegation and 3 of 3 residents that were interviewed stated that the staff has never forced them to take any insulin or other medications against their will and have no knowledge of any other residents being forced to take medications. The department reviewed the ID/Emergency Information (Dated: 04/06/2026), Physician’s Report (Dated: 03/20/2026), Resident Service Plan (Dated: 05/15/2026) and Medication Administration Record (Dated: 06/01/2026-06/17/2026) and observed that there is one resident who takes insulin and they have glucose monitoring four times per day, injection monitoring three times per day, and are consistent in taking their insulin medication. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff forced resident to take insulin. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Report Continued On LIC9099-C Allegation #2-Staff yells at other staff in the presence of residents. The details of the complaint alleged that the facility administration is unprofessional, yells at staff members in front of residents, and forces them to perform functions above their professional scope. On 6/17/2026, from 09:30am-12:30pm, the department interviewed staff (S1-S4) and residents (R1-R3) regarding the allegation. 4 of 4 staff denied the allegation that Staff yells at other staff in the presence of residents. All staff stated that they have no knowledge of anyone in administration or anyone else yelling at staff members in the presence of their residents. They also stated that they have never forced anyone to perform duties that they were not trained to do; and they always conduct themselves in a professional manner while working at the facility. The department interviewed residents (R1-R3) about the allegation and 3 of 3 residents that were interviewed stated that they have never witnessed any staff member or executive being unprofessional in their presence. They also stated that they have not witnessed nor heard any staff member yelling at another staff member in the facility. Based on interviews, there is insufficient evidence to support the allegation that Staff yells at other staff in the presence of residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were observed and no citations were issued for this complaint investigation. An exit interview was conducted with Tracey Flaherty, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 11-AS-20260608185058

Type of visit: Prelicensing

On April 08, 2026, Licensing Program Analysts (LPAs) Ernand Dabuet, Perry Scott, and Lizeth Villegas conducted an announced visit to this facility. LPAs were greeted and accompanied by applicant Tracy Flatherty and Dee Navarro during the inspection. An application was submitted to CCLD on August 14, 2025. In the initial license application for a Residential Facility for the Elderly, ages 60 and above. The applicant requested a capacity of one hundred twenty-four (124) individuals, of which twenty-four (24) ambulatory, eighty-eight (88) non-ambulatory and twelve (12) bedridden. Structure: The facility consists of (80) units in the assisted living area and (20) in the memory care unit. Each room has its bathroom, kitchen, living room, bedroom, and laundry room. The six-story facility is situated in a residential/commercial neighborhood. The structure includes: living, bistro, main dining, private dining service area, discovery room, (2) fitness studio, library, theater, learning center, creative studio, exhibition kitchen, club room, (2) salons, (2) elevators, (7) guest restrooms, (8) administrative offices, and outdoor terraces. The terraces included tables and chairs, along with several water fountains and fire pits. The passageways, walkways, and steps are free from obstructions. Resident's Bedroom: Each resident unit has a bedroom. The facility had three (3) rooms with (1) a full-size bed, one (1) chair, one (1) night stand, one (1) dresser, and one (1) table lamp. All rooms had ample storage in the closets. The facility allows residents to either furnish their rooms with their own furniture or utilize furniture provided by contractors associated with the facility. Evaluation Report Continues Bathrooms: Each unit has a bathroom. All bathrooms have a working toilet, washbasin, and shower with grab bars. Each floor has public men’s and women’s restrooms. Linens & Hygiene Supplies: Beds have the required linen/supplies which include pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. The facility also provides linen and furnishings for residents who may require their own, as well as hygiene supplies. Emergency Phone Numbers, Exit Plan & Menu: Emergency phone numbers, exit plan, and menu are posted and readily available for review throughout the facility. There are fire extinguishers on each floor and in the kitchen and fully charged. All rooms have a telephone line available and internet services. All exit stairways had emergency evacuation chairs. Food Service: Dishes, cups, and flatware are stored in the kitchen, inspected, and in good condition. Knives, cutlery, and other sharp kitchen utensils are stored in drawers in the kitchen. Food supply is adequately stored in the kitchen and consists of perishables and non-perishables food. Smoke Detectors: Smoke and carbon monoxide detectors throughout the interior. Hardwired smoke detectors throughout the common areas and in each resident’s room. Carbon monoxide in each resident’s room. The facility is equipped with central air and heat throughout the common areas. Resident rooms all have individual air and heating available. Water Temperature: The water temperature ranged from 105.0 - 118.2 degrees F. throughout the kitchen and bathrooms. Toxins: All toxins are stored in storage closets on all floors with housekeeping. Evaluation Report Continues Appliances: Each unit had a stove burners, microwave, washer, and dryer in the assisted living units. The commercial kitchen also had small appliances which included a toaster, blenders, coffee makers, and microwaves. There are several commercial refrigerators in the kitchen. The refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. A freezer is at (45) zero degrees Fahrenheit. Medications, First-Aid Kit & Book: Several first aid kits are available and stored at the front desk, kitchen, and medication rooms. They have at least the following: a thermometer, tweezers, scissors, antiseptic, bandages, gauze, and a current first-aid manual. The resident’s medications will be stored in the memory care medication room and in the third-floor assisted living medication room. Resident & Staff Files: Records for staff and residents are stored inside the Human Resources office in locked cabinets. Reading Material, Games, Equipment & Materials: The facility has board games, books, magazines, and other recreational materials for resident use, stored in the activity, recreational, and library rooms. Pool/Jacuzzi & Pets: No jacuzzi or pool in the area. The facility's Plan of Operation allows pets. Fire clearance: A Fire Clearance inspection conducted on March 11, 2026 with approval for a capacity for (24) ambulatory, (88) non-ambulatory, and (12) for bedridden. Security: Currently the facility does not have interior surveillance cameras in common areas. Evaluation Report Continues Component II: (LPA) Dabuet conducted the Pre-Licensing inspection along with the information provided about how to operate the facility within substantial compliance with Component II PowerPoint. An exit interview was conducted, and a copy of this report has been furnished to the applicant, Tracy Flahterty. (LPA) Dabuet will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application. END OF REPORTthe state’s words, verbatim · CDSS document, Apr 8, 2026