Oakmont of Whittier

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

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. LPA met with Executive Director Blasia Lee-Lole. The Residential Care for Elderly (RCFE) facility serves residents ages 60 and over. There is a Memory Care Unit for cognitively impaired residents. The following were observed/inspected: Infection Control: The Infection Control Plan was reviewed. Operational Requirements: The facility has an approved fire clearance for 97 non-ambulatory residents, of which 7 may be bedridden. A hospice waiver for 15 residents is approved. Facility does not handle resident monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 3/1/2027. Physical Plant/Environment Safety: LPA toured the facility grounds. It is a 2-story building consisting of 74 resident rooms, 2 courtyards, 2 activity rooms, 2 dining rooms, private dining room, bistro, sitting area, music area, media room, staff lounge, kitchen, library, fitness center, massage room, beauty salon, wellness office, medication room, and administrative offices. Twenty four (24) resident rooms, common areas were inspected. Resident rooms have required furniture, bedding, linens, lighting, and bathrooms have non-skid surfaces and grab bars. Exit doors are free of any obstruction. Cleaning supplies and toxic substances are inaccessible to residents. The signal system was tested and is operational. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety. The facility is equipped with fire extinguishers, sprinklers, smoke detectors, and carbon monoxide detectors. The last fire inspection was conducted on 3/5/2026 by Cal Building Systems. *Beds in rooms 107, 109, 112, and 233 did not have mattress pads. A citation was issued. Staffing: A total of 71 staff members provides care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 7/14/2027. 10 staff files were reviewed. They contained 1st Aid/CPR training, personnel records, health/TB screenings, and training records. Staff have criminal background clearance. However, staff (S7 & S8) are not associated to the facility. A citation and civil penalty was issued. Resident Records/Incident Reports: Nine (9) resident files were reviewed. They contained Admission Agreements, Service Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, and centrally stored medication records. RCFE & Ombudsman complaint posters are posted. Planned Activities: Facility activity calendar was posted. Sufficient space to accommodate both indoor and outdoor activities was observed. Food Service: Food supply was checked in the kitchen and pantry storage areas, consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Residents have physician orders for modified diets. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Executive Chef has a current Food Handling Certificate. A technical violation was issued because the fixed kitchen food steamer has been in disrepair with a leak for weeks. It has been serviced but the issue has not been resolved. Incident Medical and Dental: Centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family or facility bus. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed and is updated. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 6/23/2026. Residents with Special Health Needs: There are currently 4 residents receiving hospice services. Three (3) residents receive home health services and no residents have prohibited health conditions. Individual Service Plans, Appraisals, and postural support physician orders are on file. Pursuant to Title 22 deficiencies were observed. Exit interview was conducted with Blasia Lee-Lole. A copy of report and appeal rights were issued.the state’s words, verbatim · CDSS document, Aug 7, 2026

Type of visit: Case Management - Other

Licensing Program Analyst, Tena Herrera arrived on 7/30/2026 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. On September 03, 2025, the Department concluded a complaint investigation regarding the following allegation: Facility staff caused injuries to resident during a transfer. The licensee was cited for California Code of Regulations (CCR) § 87468.1(a)(2) Personal Rights of Residents in All Facilities. At the time of the complaint visit on September 03, 2025, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced as facility staff were not properly trained to use a Hoyer lift and that failure to train staff resulted in resident sustaining a head laceration with 15 J-staples and a large scalp hematoma during a transfer. Today, 7/30/2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department determines constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on September 03, 2025, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Administrator Blasia Lee-Lole and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Jul 30, 2026

Type of visit: Office

An informal conference was held at the Monterey Park Adult and Senior Care Program Regional Office on 06/15/2026. Attendees included: · Tony Vasallo, Regional Manager · David Sicairos, Licensing Program Manager · Kimberly Ramirez, Licensing Program Analyst · Jen Sato, Senior Vice President of Health Services · Scott Carlson, Senior Vice President of Operations · Sepoora Ahmed, Vice President of Memory Care & Program · Blasia Lee-Lole, Administrator Purpose: The conference was held to review the deficiency issued under Complaint Control# 28-AS-20241113164508,concerning a resident injury sustained during a transfer. Background: The Department completed its investigation on 09/03/2025. A deficiency was cited for noncompliance with California Code of Regulations, Title 22, Division 6, Chapter 8, Personal Rights of Residents in All Facilities- 87468.1(a)(2). An immediate civil penalty of $500 was assessed. On 08/28/2025, the licensee was notified that an additional civil penalty per Health and Safety Code 1569.49(f) may be warranted based on findings that staff failed to properly assist Resident#1 (R1) while operating a Hoyer lift, resulting in a head injury to R1. During today’s conference it was discussed with the licensee that the Regional Office will assess civil penalties at a later date and time. SEE 809-C Conference Discussion: During the conference, facility representatives stated that since November 2024, six (6) trainings on how to operate a Hoyer lift and specific use of Hoyer lift for specific resident use have been conducted. The facility is continuing ongoing training on the use of the Hoyer lift as part of their annual training. Facility staff conduct weekly meetings and updating care plans according to resident needs. Facility staff have been reminded of observation of changes of conditions and ensuring all staff are updated on resident changes of conditions. Facility staff stated their expressed dedication to providing the best care and supervision to their residents and willingness to remain in compliance. Facility representatives stated this incident was an opportunity to discuss Hoyer lift safety and personnel training with their sister communities. Health and Safety Code section 1569.49 was provided to facility representatives during this conference. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 15, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit-Deficiencies on 05/26/2026. LPA was greeted by Administrator Blasia Lee-Lole and explained the purpose of the visit. Case Management findings: On 04/27/2026, LPA Ramirez attempted to contact facility Administrator Adriane Runge via telephone. LPA was advised that Administrator Runge was no longer the facility Administrator and Blasia Lee-Lole was appointed as the facility Administrator effective 02/19/2026. Later that evening, Monterey Park Regional Office received an email and attachments advising the department of notification of Administrator Association change. The attachment letter was dated 03/02/2026 and it revealed that effective 02/19/2026, the licensee (Oakmont Management Group) appointed Blasia Lee-Lole as facility administrator. On 05/26/2026, LPA Ramirez conducted a Case Management visit and requested proof that the licensee notified this department in writing, within 30 days of the hiring of a new administrator. The licensee was unable to provide LPA with requested documents at this time. Based on records reviewed, LPA Ramirez issued one (1) type B deficiency. Exit interview was conducted. A copy of this report, 809-D and appeals rights were provided.the state’s words, verbatim · CDSS document, May 26, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(g) · Plan of correction due date: May 26, 2026

Reporting Requirements(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. This requirement was not met as evidenced by: This department did not receive written notification within 30 days of a new administrator change. This poses a potential risk to the health, safety, or personal rights of persons in carethe state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: No further action is required. On 04/27/2026, LPA received documents needed to process administrator change.

Allegation investigated: Staff stole resident's funds.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced compliant visit LPA met with Executive Director Janeth Medrano and Memory Care Director George Cruz and explained the purpose for todays visit. The investigation consisted of the following: On 2/5/26 LPA Herrera conducted the initial 10-day visit, obtained copies of Staff and Resident Roster, information for police report, and conducted 2 Staff interviews (S1-S2). On 3/17/26 LPA obtained and reviewed a copy of Police Report. On 3/19/26 LPA obtained copies of the Staff and Resident rosters, toured memory care and R1's shared room, conducted interviews with 5 Staff (S1-S6) and 6 Residents (R1-R6). (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff stole resident's funds. It is alleged that R1’s bank card was stolen and it is believed that S3 may have stolen the card to make multiple purchases. LPA contacted local police department, spoke to the detective and obtained a copy of the police report, the police report and detective disclosed that there was not enough proof/evidence to link the charges made to R1’s card to any staff at the facility and the allegation was unsubstantiated. LPA interviewed 6 staff and each denied the allegation stating that they have never stolen any items or money from the residents nor have they ever witnessed another staff steal from the residents. S3 stated they have never stolen any money from residents and that this particular day in question S3 observed R1’s roommate with a wallet at their desk, the wallet belonged to R1 and it was confiscated, returned to R1 and reported to management immediately. LPA interviewed 6 residents and each denied the allegation, interview with R5 revealed that they had money missing upon moving in but did not believe staff had anything to do with it, staff encouraged R5 to file a police report and although the money was never found R5 stated that they believe they must have dropped it or misplaced it as this is something they do at times. R5 stated this is the only time this has ever happened. Based on statements and interviews conducted with staff/residents, review of police report and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 19, 2026 · control 28-AS-20260204140858

Allegation investigated: Staff did not prevent a resident from being sexually abused while in care. Staff did not safeguard resident's personal belongings.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 10/18/2025 to deliver findings regarding the above allegations. LPA Herrera conducted an initial complaint visit on 08/08/2025 and a need for further investigation was documented. During today’s visit, LPA Ramirez was greeted by Administrator Runge and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster, Staff#1 - 8 interviews (S1 – S8), Interviews conducted by Community Care Licensing Investigation Branch, Resident#2 – 4 interviews (R2- R4), Attempted Interview of Resident#1, 5 (R1, R5), Copies of the following documents for resident#1 (R1): Medical Assessment (LIC 602A), Preplacement Appraisal Information (LIC 603), Client/Resident Personal Property and Valuables (LIC 921), Admission Agreement and physical plant tour. SEE 9099-C Unsubstantiated The investigation revealed the following: regarding the allegation “Staff did not prevent a resident from being sexually abused while in care.” It is alleged staff did not prevent R1 from being sexually abused while in care. Interviews conducted by Community Care Licensing Investigation Branch did not corroborate this allegation. Eight (8) out of the eight (8) staff interviewed by LPA Ramirez, did not corroborate with this allegation. Staff interviews revealed R1 suffered from cognitive impairment and aggressive behaviors. Interview with S6 revealed prior to R1 relocating to the facility memory care unit, R1 revealed to S6 that they (R1) experienced a traumatic event when they were younger and S6 believed this traumatic event was re-manifested into R1’s memory and that’s why R1 made this allegation. S6 revealed they did not care for R1 once R1 moved to the facility memory care but, S6 would still go visit R1 and observed R1 to be well cared for by memory care staff. Four (4) out of the four (4) residents interviewed by LPA Ramirez did not corroborate this allegation. Despite several attempts to contact R1 by Community Care Licensing Investigation Branch and LPA Ramirez, all attempts were unsuccessful. 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. “Staff did not safeguard resident's personal belongings.” It is alleged staff did not safeguard R1’s hearing aid devices and walker. Eight (8) out of the eight (8) staff interviewed by LPA Ramirez, did not corroborate with this allegation. S8 revealed that R1’s hearing aids were charged in the memory care medication room; along with all other memory care residents’ hearing aids. S8 revealed they recalled R1’s hearing aids were believed to have been misplaced but were located shortly after in the medication room. S7 revealed that R1’s hearing aids were placed on R1 during the day and charged at night in the memory care medication room. S7 revealed that R1 would take off their hearing aids often and staff would place them on the charger. S7 revealed they were never told by any staff or by R1’s family that R1’s walker was missing. Review of R1’s Client/Resident Personal Property and Valuables (LIC 921), did not corroborate this allegation. LPA Ramirez made multiple attempts to contact R1 and R1’s responsible party but all attempts were unsuccessful. Four (4) out of the four (4) residents interviewed by LPA Ramirez did not corroborate this allegation. R2 revealed that they have never had any personal belongings missing. R3 revealed staff treated them well and they felt safe to leave expensive personal belongings out when staff clean their room. 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 cited during this complaint investigation. A copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 18, 2025 · control 28-AS-20250807161503

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent annual inspection visit on 10/18/2025 and was greeted by Gina Alvarez- Business Office Director and discussed the purpose of today’s visit. LPA Ramirez conducted initial annual inspection on 10/02/2025. Administrator Adriane Runge arrived shortly after to assist. LPA Ramirez identified herself and explained the purpose of the visit. Operational Requirements: The fire clearance is approved for ninety-seven (97) non- ambulatory resident, of which seven (7) may be bedridden. This facility may retain no more than fifteen (15) hospice residents. There were eight (8) residents under hospice care, during annual inspection. Staffing: Administrator Certificate (7003384740) for Adriane Runge with an expiration date of 06/05/2027 was observed. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for six (6) out of the six (6) personnel record reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for six (6) out of the six (6) personnel record reviewed. Resident Records/Incident Reports: LPA reviewed resident records for six (6) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 09/27/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in pantry. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication room and in bubble packs and/or original containers. LPA Ramirez observed Centrally Stored Medication and Destruction Record. The facility provides incidental medical services. No deficiencies were observed during this visit. Exit interview conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 18, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst’s (LPA) Kimberly Ramirez conducted an annual inspection on 07/08/2025. LPA met with Gina Alvarez- Business Office Director and discussed the purpose of today’s visit. Administrator Adriane Runge arrived shortly after to assist with tour. This facility is licensed to serve ninety-seven (97) non- ambulatory resident, of which seven (7) may be bedridden. This facility may retain no more than fifteen (15) hospice residents. There were eight (8) residents under hospice care, during annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: See 809-C for continued Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA observed carbon monoxide detectors and smoke alarms in hallways. Smoke alarms and carbon monoxide detectors were tested and observed to be operational. LPA inspected six (6) rooms; of which three (3) were located in memory care. All resident bedrooms contained the required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. Facility maintains a weekly waterlog to record water temperature throughout the facility. LPA Ramirez observed postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA observed evacuation chairs in stairways. Food Service: LPA observed sufficient supply of nonperishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with a maximum temperature of 40-degree F. (4 degree C). LPA observed facility weekly and daily menu, which is approved by the facility certified dietary manager. LPA observed kitchen staff preparing for lunch while wearing hair nets and gloves. LPA observed several dining room servers disinfecting tables and counters while wearing gloves and hair nets. Planned Activities: LPA observed a calendar for October of 2025 with various activities and outings for residents. LPA observed sufficient outdoor space in both assisted living section and in memory care. Residents Rights-Information: LPA observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility computers with internet access and a facility land line. Residents with Special Needs: LPA observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. Due to time constraints, LPA Ramirez will return at a later time to complete record review and interviews; required for annual inspection. No deficiencies were cited at this time. The Exit interview was conducted with Administrator Adriane Runge. A copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 2, 2025

Allegation investigated: Facility staff caused injuries to resident during a transfer.

**This Report Supersedes the previous superseaded report dated 8/28/25 as LPA did not assess civil penalties on the report and a copy of the 421IM will be provided during todays visit, additionally, deficiencies issued on 12/18/24 and 8/28/25 are being dismissed, no additional changes have been made to the report and findings remain the same** Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent compliant visit LPA met with Adriane Runge and explained the purpose for todays visit. The investigation consisted of the following: During initial visit dated 11/14/24 LPA obtained copies of Staff and Resident Roster, and obtained copies of medical documents and current incident report from Resident #1's file, due to time constraints the allegation needed further investigation. On 12/28/24 LPA obtained copies of Staff and Resident Roster, interviewed 6 Staff (S1-S6) and 10 Residents (R1-R10), Reviewed Training and Participants for proper use of Hoyer Lift, toured R1-R4's rooms and S4 demonstrated each Hoyer Lift. (continued on LIC9099-C) Substantiated The Investigation Revealed the Following: Allegation: Facility staff caused injuries to resident during a transfer. It is alleged that R1 sustained injuries to their head during a transfer using a Hoyer Lift, that was assisted by S2 and S3. LPA conducted interviews with staff and 3 out of 6 staff confirmed the above allegation. S2 and S3 both confirmed the above allegation and stated that when they were using the hoyer lift, it was giving them trouble, the wheels got stuck and R1 landed on their bed from the hoyer lift. Part of the hoyer lift, grazed R1's forehead and R1 landed on her pillow, moments later blood was observed on the pillow and it was seen that R1 had an injury to the back of their head, 911 was called immediately. LPA reviewed in-service training for staff on usage of hoyer lift and it was explained to LPA by S1 that there is no documentation or proof that training prior to this incident was held. Since incident there have been 2 in-service training's dated 11/27/2024 and 12/4/2024, during staff interviews it was revealed that S6 has not received training for the hoyer lift and use the hoyer lift to assist residents with transfers. LPA interviewed residents and 8 out of 10 residents denied the allegation and stated they have never sustained injuries while being assisted nor have the witnessed/heard of any other resident sustaining an injury while being provided assistance/transfer. 2 of the 10 residents interviewed have a cognitive impairment that did not allow for successful interview. Based on observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D. Immediate Civil Penalties will be issued today, in the amount of $500.00 due to Staff caused serious injury to resident. At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 87468.1(a)(2) and may be assessed at a later date. Exit interview held and a copy of this report, appeal rights and civil penalty assessment were emailed to Adriane Runge - Executive Director.the state’s words, verbatim · CDSS document, Sep 3, 2025 · control 28-AS-20241113164508

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 5, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by: Resident #1 (R1) sustained injuries to their head on 11/11/2024 during staff assistance with a transfer using a hoyer lift. R1 head laceration (J staples), and a large scalp hematoma as a result.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: This POC was already previously corrected as LPA receievd a copy of the in-service training information for staff that need training in Hoyer Lift, training is scheduled for 12/20/24 and 1/17/25 LPA receieved signatures of staff that have completed the training.

Allegation investigated: Facility staff caused injuries to resident during a transfer.

**This Report Supersedes report dated 12/18/24 as the wrong regulation was cited during visit, citation was issued for regulation, 80072(a)(2) Personal Rights and is being corrected to 87468.1(a)(2) Personal Rights no additional changes have been made to the report and findings remain the same** Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent compliant visit LPA met with Adriane Runge and explained the purpose for todays visit. The investigation consisted of the following: During initial visit dated 11/14/24 LPA obtained copies of Staff and Resident Roster, and obtained copies of medical documents and current incident report from Resident #1's file, due to time constraints the allegation needed further investigation. On 12/28/24 LPA obtained copies of Staff and Resident Roster, interviewed 6 Staff (S1-S6) and 10 Residents (R1-R10), Reviewed Training and Participants for proper use of Hoyer Lift, toured R1-R4's rooms and S4 demonstrated each Hoyer Lift. (continued on LIC9099-C) Substantiated The Investigation Revealed the Following: Allegation: Facility staff caused injuries to resident during a transfer. It is alleged that R1 sustained injuries to their head during a transfer using a Hoyer Lift, that was assisted by S2 and S3. LPA conducted interviews with staff and 3 out of 6 staff confirmed the above allegation. S2 and S3 both confirmed the above allegation and stated that when they were using the hoyer lift, it was giving them trouble, the wheels got stuck and R1 landed on their bed from the hoyer lift. Part of the hoyer lift, grazed R1's forehead and R1 landed on her pillow, moments later blood was observed on the pillow and it was seen that R1 had an injury to the back of their head, 911 was called immediately. LPA reviewed in-service training for staff on usage of hoyer lift and it was explained to LPA by S1 that there is no documentation or proof that training prior to this incident was held. Since incident there have been 2 in-service training's dated 11/27/2024 and 12/4/2024, during staff interviews it was revealed that S6 has not received training for the hoyer lift and use the hoyer lift to assist residents with transfers. LPA interviewed residents and 8 out of 10 residents denied the allegation and stated they have never sustained injuries while being assisted nor have the witnessed/heard of any other resident sustaining an injury while being provided assistance/transfer. 2 of the 10 residents interviewed have a cognitive impairment that did not allow for successful interview. Based on observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D. Immediate Civil Penalties were issued on 12/28/24, in the amount of $500.00 due to Staff caused serious injury to resident. At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(f) and may be assessed at a later date. Exit interview held and a copy of this report, appeal rights and civil penalty assessment were provided to Adriane Runge - Executive Director.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 28-AS-20241113164508

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Aug 28, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by: Resident #1 (R1) sustained injuries to their head on 11/11/2024 during staff assistance with a transfer using a hoyer lift. R1 head laceration (J staples), and a large scalp hematoma as a result.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: This POC was already previously corrected as LPA receievd a copy of the in-service training information for staff that need training in Hoyer Lift, training is scheduled for 12/20/24 and 1/17/25 LPA receieved signatures of staff that have completed the training.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Tena Herrera conducted a Case Management visit. LPA met Angela Boyd - Health Services Director and discussed the purpose of this visit. During the course of a complaint investigation for complaint # 28-AS-20241113164508, it was discovered that the administrator at the time of the complaint investigation, did not ensure that staff were properly trained on how to operate a hoyer lift, which resulted in injuries to a resident in care. During investigation of above referenced complaint LPA reviewed staff files and did not observe any training's on file on how to utilize a hoyer lift properly while assisting residents (citations were previously issued during complaint investigation dated 12/18/2024 for injuries resident sustained, however, lack of training was not addressed at that time). Today LPA is addressing the and issuing the deficiency. Deficiency lack of training is being issued please refer to the LIC809-D page for details. Exit interview conducted and a copy of this report and appeals rights were emailed.the state’s words, verbatim · CDSS document, Aug 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(h)(4) · Plan of correction due date: Aug 15, 2025

87405 Administrator - Qualifications and Duties (h) The administrator shall have the responsibility to: (4) Recruit, employ and train qualified staff, and terminate employment of staff who perform in an unsatisfactory manner. This requirement was not met as evidence by: During the course of a complaint investigation for complaint # 28-AS-20241113164508, LPA reviewed staff files and did not observe any training's on file on how to utilize a hoyer lift properly while assisting residents.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: Licensee/Executive Director to ensure all staff are properly trained in proper usage of hoyer lift, and ensure that moving forward all staff complete all required trainings. This POC is cleared as on 1/17/2025 LPA receievd a copy of the in-service training information and signatures of staff that have completed the training. Clearance letter will be emailed.

Allegation investigated: Staff did not ensure centrally stored medication was locked and inaccessible to residents. Staff falsified medication records. Staff did not provide adequate supervision resulting in resident missing their medication dosage. Staff left residents in soiled diapers for extended periods of time.

Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegations. LPA met with Gina Alvarez (Business Office Director) and discussed the purpose of today’s visit. Angela Boyd (Health Services Director) arrived at approximately 9:10 A.M.. LPA Irra conducted the initial visit on 05/19/25. During this visit, LPA obtained copies of the staff and resident rosters, interviewed Staff #2 (S-2), Staff #3 (S-3), Staff #5 (S-5) and Staff #6 (S-6), reviewed files for Resident #1 (R-1) through Resident #7 (R-7) and obtained relevant documentation. During the course of this investigation, LPA also interviewed Staff #1 (S-1) and Staff #4 (S-4) and interviewed Resident #1 (R-1) through Resident #6 (R-6). LPA was unable to interview R-7 as R-7 was not available during this visit. Refer to LIC 9099C for the continuation of this report. Unsubstantiated Allegation: Staff did not ensure centrally stored medication was locked and inaccessible to residents. It has been alleged that staff misplace residents’ medication which would later be found inside the residents’ rooms. Staff interviews revealed that residents medications are locked inside a medication cart which is stored inside the locked medication room. Interviewed staff indicated that residents’ medications are not misplaced nor later found in residents’ rooms. Interviewed staff indicated that they have not received any complaints/concerns pertaining to this matter. Resident interviews revealed that staff provide residents with their medication daily and in a timely manner. Interviewed residents indicated that staff provide supervision when medication is provided to ensure the medication is consumed by the resident. Interviewed residents indicated that they do not have direct access to medication as the medication is centrally stored inside a medication cart and is inaccessible to residents. Interviews do not corroborate this allegation. Allegation: Staff falsified medication records. It has been alleged that staff misplaced a R-1’s Oxycodone pill and rather than reporting the pill missing, staff allegedly “falsely reporting it as a miscount”. Staff interviews revealed that on 04/26/25, R-1's Oxycodone pill #16 was discovered inside the medication cart and not inside the bubble pack. Interviewed staff indicated that the foil of R-1's bubble pack for Oxycodone somehow was broken/punctured under pill #16 which caused it to fall out of the medication bubble pack and onto the medication cart. Staff interviews revealed that R-1’s Oxycodone pill #16 medication was not missing as it was found inside the medication cart, therefore, per staff interviews, this medication was not reported as a “miscount”. Interviewed staff indicated that controlled medications are counted by staff on a daily basis and are logged on the controlled medication shift count. Interviewed staff indicated that R-1 takes this medication on an as needed basis and the last administration was on 03/16/25. Interviewed staff indicated that they have not received any complaints/concerns pertaining to this matter. Interviews and reviewed documentation do not corroborate this allegation. Refer to LIC 9099C for the continuation of this report. Allegation: Staff did not provide adequate supervision resulting in resident missing their medication dosage. It has been alleged that staff dispensed a diabetic medication to a resident (R-2) but did not ensure that the resident (R-2) consumed it and left the room. Staff interviews revealed that staff provide adequate supervision when administering residents’ medication. Interviewed staff indicated that R-2 takes their medication in front of the medication technician. Interviewed staff indicated that they have not found any unconsumed medication inside R-2’s room. Interviewed staff indicated that they have not received any complaints/concerns pertaining to this matter. Resident interviews revealed that staff administrating medication provide supervision to residents during the medication distribution to ensure residents are consuming their medication. Interviewed residents indicated that staff do not just provide them with their medication and leave. Interviewed residents indicated that they do not have any concerns pertaining to this matter. Interviews do not corroborate this allegation. Allegation: Staff left residents in soiled diapers for extended periods of time It has been alleged that staff avoided changing residents’ briefs at the end of their shift and that residents were wet, soiled and waited an additional hour and a half to be changed. Staff interviews revealed that staff do not leave residents in soiled diapers for extended periods of time. Interviewed staff indicated that they conduct rounds every (2) hours and as needed to change residents with soiled diapers. Interviewed staff indicated that they do not wait until the end of their shift to change residents’ diapers nor wait an hour and a half to change residents' diapers. Interviewed staff indicated that they have not received any complaints/concerns pertaining to this matter. Resident interviews revealed that staff provide incontinence care in a timely manner. Interviewed residents indicated that staff do not leave them in soiled diapers for an extended period of time. Interviewed residents indicated that they do not have any concerns pertaining to this matter. Interviews do not corroborate this allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report and appeal rights were provided to Adriane Runge (Executive Director).the state’s words, verbatim · CDSS document, Aug 1, 2025 · control 28-AS-20250512155944

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Elizabeth Irra conducted a Case Management visit. LPA met Adriane Runge (Executive Director) and discussed the purpose of this visit. During the course of a complaint investigation,(allegation: staff falsified medication records for another resident pertaining to Oxycodone), LPA discovered through staff interviews that S-1 falsified medication administration records for R-1 pertaining to the administration of R-1’s Metamucil medication. Per staff interviews, R-1 was not provided with Metamucil on 05/03/25 and S-1 documented the medication as being administered to R-1. Per documentation review, this was reported to this Department via Special Incident Report. Per staff interviews, S-1 was terminated for failure to adhere to the facility’s Medication Administration Policy. Additionally, per documentation, S-1 also received a written “disciplinary action notice” on 02/12/25 pertaining to medication/documentation error. Deficiency cited. Refer to LIC 809D. Exit interview and a copy of this report and appeals rights were provided to Adriane Runge (Executive Director).the state’s words, verbatim · CDSS document, Aug 1, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 2, 2025

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This standard is not met at evidence by: R-1 was not provided with Metamucil on 05/03/25 and S-1 documented the medication as being administered to R-1.the state’s words, verbatim · CDSS document, Aug 1, 2025

Plan of correction: Administrator to provide staff training on medication administration including appropriate documentation of medication administration to staff and provide proof of training to LPA Irra. CORRECTED AT TIME OF VISIT. DOCUMENTATION PERTAINING TO TRAINING PROVIDED.

Allegation investigated: Facility staff did not dispense resident's medications as prescribed Facility staff handled resident(s) in a rough manner Facility staff yelled at resident(s) Facility staff did not observe proper food service sanitation practices Facility staff did not safeguard resident's personal belongings

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced compliant visit regarding the above allegations. LPA met with Adriane Runge Administrator and explained the reason for the visit. The investigation consisted of the following: LPA requested a staff/resident roster. LPA interviewed 7 residents and 7 staff. LPA conducted a tour of the dementia unit and observed the dining room area and medication room. LPA reviewed medication for 4 residents. LPA reviewed file for resident #1(R1) and requested a copy of admission agreement, medical assessment, individual care plan, medication sheet, physician’s orders, resident personal property and valuables, preplacement assessments, behavioral expression appraisal, charting notes, and incident report. The investigation revealed the following: Regarding allegation: Facility staff did not dispense R1’s medications as prescribed. (CONTINUED ON LIC 9099C) Unsubstantiated It is alleged staff gave R1 doses of medication without doctor’s consent. Interviews conducted with residents revealed 4 out of 7 residents stated their medication is provided as prescribed and 3 out of 7 residents were not able to provide information due to cognitive skills. Interviews with staff revealed medication technicians provide medication as prescribed by the physician. Documents review revealed, on 3/11/25 a medication clarification sheet was signed by nurse practitioner listing two orders of quetiapine, one for 25mg and another for 50mg. Medication administration record notes the same medications listed on medication clarification. Charting notes revealed, on 5/12/25 and 5/13/25 R1’s responsible party shared concerns about the medication dosage to medication technician. On 5/13/25 facility staff contacted nurse practitioner to address R1’s responsible party concerns. On 5/14/25 facility staff received new order of medication per R1’s responsible party request. Medication review did not reveal medication errors. Although the allegation may have happened the facility staff were providing medication as prescribed. Facility noted R1’s responsible party concern and address it with physician. 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. Regarding allegations: Facility staff handled residents in a rough manner and Facility staff yelled at resident. It is alleged staff aggressively sat a resident down and yelled at another resident. Interviews conducted with residents revealed 7 out of 7 residents stated that facility staff treat them well and respectfully. Interviews with staff revealed staff have not observed any other staff treat the residents in an aggressive manner or yelling at residents. Per administrator there have not been any incidents of staff treating residents disrespectfully report it. Training on Communication; Courtesy was provided to staff #2 on 4/22/25. 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. Regarding allegation: Facility staff did not observe proper food service sanitation practices. It is alleged staff serve food with dirty hands and without gloves. Interviews with residents revealed 4 out of 7 residents stated staff take measurements to observe sanitation practices and 3 out of 7 residents were unable to answer due to cognitive skills. Interviews with staff revealed staff use gloves and hairnets to serve the food provided to the residents and practice hygiene while providing care. (CONTINUED ON LIC 9099C) Interviews with staff revealed staff use gloves and hairnets to serve the food provided to the residents and practice hygiene while providing care. Training on basic hand hygiene was provided on 6/10/24 and About Infection Control and Prevention on 6/8/24 was provided to staff #2. 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. Regarding allegation: Facility staff did not safeguard resident’s personal belongings. It is alleged R1’s clothes have gone missing. Interviews conducted with residents revealed 3 out of 7 residents stated to take care of their personal care themselves. However, personal items have not gone missing. 1 out of 7 residents stated none of their personal belongings have gone missing. 3 out of 7 residents were unable to answer due to cognitive skills. Document review revealed R1’s personal property and valuables dated: 3/8/24 list clothing in general. However, there is not a specific number of items. During facility’s tour LPA observed R1’s room and observed R1’s clothing folded in one closet and personal belongings on another closet. 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 with Adriane Rugen Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 20, 2025 · control 28-AS-20250514152656

Allegation investigated: Facility staff caused injuries to resident during a transfer.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent compliant visit LPA met with Adriane Runge and explained the purpose for todays visit. The investigation consisted of the following: During initial visit dated 11/14/24 LPA obtained copies of Staff and Resident Roster, and obtained copies of medical documents and current incident report from Resident #1's file, due to time constraints the allegation needed further investigation. During todays visit LPA obtained copies of Staff and Resident Roster, interviewed 6 Staff (S1-S6) and 10 Residents (R1-R10), Reviewed Training and Participants for proper use of Hoyer Lift and toured R1-R4's rooms and S4 demonstrated each Hoyer Lift. (continued on LIC9099-C) Substantiated The Investigation Revealed the Following: Allegation: Facility staff caused injuries to resident during a transfer. It is alleged that R1 sustained injuries to their head during a transfer using a Hoyer Lift, that was assisted by S2 and S3. LPA conducted interviews with staff and 3 out of 6 staff confirmed the above allegation. S2 and S3 both confirmed the above allegation and stated that when they were using the hoyer lift, it was giving them trouble, the wheels got stuck and R1 landed on their bed from the hoyer lift. Part of the hoyer lift, grazed R1's forehead and R1 landed on her pillow, moments later blood was observed on the pillow and it was seen that R1 had an injury to the back of their head, 911 was called immediately. LPA reviewed in-service training for staff on usage of hoyer lift and it was explained to LPA by S1 that there is no documentation or proof that training prior to this incident was held. Since incident there have been 2 in-service training's dated 11/27/2024 and 12/4/2024, during staff interviews it was revealed that S6 has not received training for the hoyer lift and use the hoyer lift to assist residents with transfers. LPA interviewed residents and 8 out of 10 residents denied the allegation and stated they have never sustained injuries while being assisted nor have the witnessed/heard of any other resident sustaining an injury while being provided assistance/transfer. 2 of the 10 residents interviewed have a cognitive impairment that did not allow for successful interview. Based on observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D. Immediate Civil Penalties will be issued today, in the amount of $500.00 due to Staff caused serious injury to resident. At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(f) and may be assessed at a later date. Exit interview held and a copy of this report, appeal rights and civil penalty assessment were provided to Adriane Runge - Executive Director.the state’s words, verbatim · CDSS document, Dec 18, 2024 · control 28-AS-20241113164508

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80072(a)(2) · Plan of correction due date: Dec 19, 2024

80072 Personal Rights (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidence by: Resident #1 (R1) sustained injuries to their head on 11/11/2024 during staff assistance with a transfer using a hoyer lift. R1 head laceration (J staples), and a large scalp hematoma as a result.the state’s words, verbatim · CDSS document, Dec 18, 2024

Plan of correction: Licensee/Executive Director to have all staff that provide assistance with transfers be trained in proper usage of hoyer lift. LPA was provided with in-service training during visit on 12/18/2024, however, after conducting interviews it was revealed that not all staff the use the hoyer lift have been trained. Licensee/Executive Director to schedule all remaining staff that have not yet been trained an in-service training and email all in-service training information (attendee names, date/time of in-service and topics that will be covered) to LPA by POC due date. tena.herrera@dss.ca.gov

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Elizabeth Irra conducted an annual inspection visit. LPA met with Adriane Runge and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility has an Infection Control Policy (binder) in place. Operational Requirements: Facility is adhering to the operational requirements. This facility is approved for (97) non-ambulatory residents (7 of which may be bedridden and 15 of which may be under hospice). There are currently (47) residents in the assisted living facility and (25) memory care residents. Physical Plant & Environment Safety: LPA toured facility grounds. Fire smoke alarms and carbon monoxide detectors observed. The fire extinguishers are located throughout the facility and appear to be full (last service date 03/27/24). Signal system tested and operable. Last emergency drill was conducted on 08/29/24. Emergency evacuation chairs were observed at the stairways. Hot water temperature measured within regulations. The hot water supply measured at the following temperatures: 106.5* to 110.0*. Bathrooms have non-skid surfaces and grab bars. Staffing: Facility is adhering to staffing requirements. Refer to LIC 809C for the continuation of this report. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for S-1 through Staff #5 (S-5). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights. Resident Rights-Information: Resident rights are posted and included in Resident files. Planned Activities: This facility has an activity room and provides a variety of activities for the residents. Activity schedule is posted. Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Posted menu observed. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining areas have adequate seating in both the assisted living and memory care dining rooms. Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #7 (R-7). Resident files are maintained at the facility. Resident files have the required documents. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Assessment Summary, Resident Rights were observed. Disaster Preparedness: The facility has a Disaster Preparedness manual (binder) in place. Health Related Services/Incidental Medical Services: The medications are stored and locked (medication carts) inside the medication room. Exit interview conducted, copy of appeal rights and a copy of this report was provided to Adriane Runge.the state’s words, verbatim · CDSS document, Sep 26, 2024

Allegation investigated: Staff did not prevent a resident from falling on more than one occasion resulting in injuries. Staff left a resident on the floor for an extended period of time after falling

Licensing Program Analyst (LPA) Angelica Rea made another visit to issue the final results of the investigation. LPA met with Executive Director, Adriane Runge who assisted with today's visit. Regarding the allegation that : Staff did not prevent a resident from falling on more than one occasion resulting in injuries. The investigation consisted of interviews with Administrator, Staff #1- Staff #4, and Resident #1 - Resident #5. The investigation revealed that resident #1 experienced a fall on 4/1/24, and on 4/2/24. Resident #1 was sent to the hospital, and was hospitalized from 4/2/24 -4/7/24. Review of hospital documents indicate that resident #1 sustained minor injuries due to fall(s). Administrator and staff interviewed stated that all residents are checked on every two hours, or more frequently according to their care needs. Administrator and staff stated that if a resident falls, staff will assess the resident. Staff will call 911, if the resident needs to be sent to the hospital. Administrator and staff interviewed stated that resident #1 is not considered a "fall risk", and has not experienced experienced any falls recently. Unsubstantiated Residents interviewed were unable to corroborate the allegation. Residents interviewed stated that staff are attentive, and check on them often. Residents stated that if a resident fall, staff will assess them immediately. Although resident #1 experienced two falls, on 4/1/24 and 4/2/24, the standard of proof has not been met because the preponderance of the evidence does not demonstrate the facility was in violation of Title 22 regulations. Regarding the allegation that : Staff left a resident on the floor for an extended period of time after falling. The investigation revealed that resident #1 experienced a fall on 4/1/24, and on 4/2/24. Resident #1 was sent to the hospital, and was hospitalized from 4/2/24 -4/7/24. Review of hospital documents indicate that resident #1 sustained minor injuries due to fall(s). Administrator and staff interviewed denied the allegation. They stated that residents are checked on every two hours, or more frequently according to their care needs. Staff stated that when resident #1 fell, he was found by staff, assessed, and sent to the hospital. Staff stated that resident #1 was not left on the floor for an extended period of time. Residents interviewed were unable to corroborate the allegation. Residents interviewed stated that staff are attentive, and check on them often. sw3 Although the allegations may have happened or are valid, there is not preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy this report was provided.the state’s words, verbatim · CDSS document, Jul 30, 2024 · control 28-AS-20240403151031

Allegation investigated: Resident has sustained multiple unwitnessed falls while in care. Facility does not provide a safe environment for resident. Facility staff are not adequately providing resident assistance and supervision while in care. Facility staff are not ensuring that resident is adequately fed while in care. Facility staff are not ensuring that resident is adequately hydrated while in care. Resident's sensor alert device was not working properly.

Licensing Program Analyst (LPA) Angelica Rea conducted another visit to deliver the final results of the investigation. LPA met with Administrator, Janette Hill, who assisted with today's visit. An initial visit was conducted on 9/26/22. The investigation consisted of interview(s) with Administrator, Staff #1 - Staff #4, and Resident #1 - Resident #5, and tour of memory care unit. LPA also reviewed resident #6's file, and obtained copies of speciific documents. Resident #6 was not interviewed due to residents' cognitive level. Regarding the allegation that : Resident #6 has sustained multiple unwitnessed falls while in care. Administrator and staff interviewed stated that if a resident falls, the facility staff are trained to assess the resident, and determine if 911 needs to be called. Administrator and staff interviewed stated that resident #6 experienced two falls, and was properly assessed by staff. Resident #6 fell on 9/22/22, was assessed, was sent to hospital, and returned to facility. Facility submitted special incident report as required. Unsubstantiated Regarding the allegation that : Facility does not provide a safe environment for resident. The investigation consisted of interview(s) with Administrator, Staff #1 - Staff #4, and Resident #1 - Resident #5. Administrator and staff interviewed stated that the facility does provide a safe environment for resident(s). Staff interviewed stated that resident(s) are assessed upon admission and are regularly observed for changes in condition. Residents interviewed were unable to corroborate the allegation. Five out of five residents interviewed stated that the facility does provide them with a safe environment. Regarding the allegation that : Facility staff are not adequately providing resident assistance and supervision while in care. Administrator and staff interviewed stated that staff are providing adequate assistance and supervision. Staff interviewed stated that they check on residents frequently, and they assist residents according to the resident(s) care plan. Residents interviewed were unable to corroborate the allegation. Five out of five residents interviewed stated that staff are providing them with assistance and supervision. Regarding the allegation that : Facility staff are not ensuring that resident is adequately fed while in care, and facility staff are not ensuring that resident is adequately hydrated while in care. Administrator and staff interviewed, stated that the staff do ensure that resident(s) are adequately fed and hydrated while in care. They said that the facility provides a sufficient amount of food and beverages to resident(s) and they assist resident(s) with eating and drinking, if they need assistance. Residents interviewed were unable to corroborate the allegation. Five out of five residents interviewed stated that staff do ensure that they are receiving enough food and hydration at the facility. Regarding the allegation that : Resident's sensor alert device was not working properly. Administrator and staff interviewed stated that the sensor alert devices are in resident room(s) in memory care. Staff interviewed stated that the sensors detect motion, and alert the staff if a resident falls, or is moving around in the room. Staff interviewed stated that the devices are working properly. Residents interviewed were unable to corroborate the allegation. Five out of five residents interviewed stated that that the sensor alert devices are working properly. LPA observed that the sensor alert devices are working properly. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 12, 2024 · control 28-AS-20220922154642

Allegation investigated: Facility staff did not dispense medications to resident as prescribed.

Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegation. On today's visit, LPA met with Administrator, Janette Hill, who assisted with the visit. Regarding the allegation that facility staff did not dispense medications to resident #1 as prescribed, the investigation consisted of review of of resident #1 medication list, hospital discharge documents, special incident report dated 11/17/23, and interviews with Administrator, and Health Services Director, Leslie Lopez. The investigation revealed the following: Resident #1 was hospitalized during the period of March 2023 through August 2023. Resident #1 returned to the facility on 8/10/23, and transferred to the Memory Care Unit. It was recently brought to the facility's attention that resident #1's medication list was changed upon discharge from the hospital, but it was not updated upon resident #1's return to the facility. Substantiated Administrator, and Health Services Director stated that the facility has discontinued the medication(s) that should no longer be administered to resident #1, and has made corrections to medication list that had not been made upon resident #1's return to the facility. The facility also sent a special incident report to Community Care Licensing as required. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Ms. Hill. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 21, 2023 · control 28-AS-20231113141817

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Dec 21, 2023

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not being met as evidenced by: Resident #1 was still being administered the following medications : Losartan Potassium 25 mg tab, Melatonin 3 mg tab, it should have been d/c upon discharge from hospital in August 2023. This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 21, 2023

Plan of correction: Administrator stated that the facility has obtained d/c orders from resident #1's physician, and has stopped giving resident #1 the medications that were discontinued. Administrator and Health Services Director stated that a medication error and prevention training will be conducted, as well as a 3 way audit will be performed by the facility pharmacy, Pharmerica.