Tamalpais

Allegation investigated: Provider failed to notify residents and post a summary of the plans and application as required by Health and Safety Code Section 1779(e)

Complainant alleges that the Provider’s SNF Closure Application, resulted in violation of Health and Safety Code Section 1779(e) which states that, “Within 10 days of submitting an application for a certificate of authority pursuant to paragraph (3), (4), (7), or (8) of subdivision (a), the provider shall notify residents of the provider's existing community or communities of its application… A summary of the plans and application shall be posted in a prominent location in the continuing care retirement community so as to be accessible to all residents and the general public, indicating in the summary where the full plans and application may be inspected in the continuing care retirement community..” because provider failed to provide notification to residents nor posted a summary of the plans and the application in a prominent location in the community, within 10 days of the application. The Department’s investigation determined that the Department received notification in writing on June 5, 2023, of The Tamalpais’s intention and plan to convert its skilled nursing facility to assisted living and memory care; however, this application/notification was provided under HSC 1789. On September 5, 2023, the Department received an abbreviated application from The Tamalpais to delicense some of its skilled nursing facility (SNF) beds to be converted to RCFE beds. On September 12, 2023, provider sent out notification to Tamalpais residents and Resident Council with notification that the application has been filed, the notification also included the location at the community where the application, summary and plans were posted in compliance with HSC 1779(e); therefore, the Department finds the allegation “unsubstantiated”. LIC9099 delivered telephonically (Jennifer Walden, Allison Nakatomi and Paul Friesen), emailed, and signed copied emailed Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 9, 2023 · control 21-AS-20230831165745

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Hansen conducted an unannounced Health & Safety case management inspection and met with Terence Tumbale, Administrator. The purpose of this case management is to conduct a walk through of the newly renovated area of the 2nd floor consisting of Assisted Living & Memory Care units. There are 328 residents in the building. LPA observed 24 rooms have been remodeled, 2 dining/activity rooms at each end of the second floor, 1 large activity room, a director’s office, medication room, a relaxation room, clean & soiled linen closets, and storage rooms. LPA toured 6 rooms and observed water temperatures in resident’s rooms not within Title 22 regulations. LPA is requesting facility submit a 7-day log of water temperatures in tested rooms, so water temperature is within regulations prior to residents moving in. LPA has again requested an LIC200 be submitted to the department so that the department may initiate a new STD850 form be completed by the fire marshal to update the fire clearance on file prior to residents moving in. The Department will receive an LIC200 by COB 9/8/2023. Failure to submit may result in citation or civil penalties. No deficiencies cited during today’s inspection.the state’s words, verbatim · CDSS document, Sep 7, 2023

Allegation investigated: Provider is in violation of the Continuing Care Residence and Servies Agreement (HSC 1771(I))

Complainant alleges that the Provider’s proposed plan to close its skilled nursing facility (SNF) is in violation of H&SC section 1771(l) which states that, “… Care shall be provided under a life care contract in a continuing care contract in a continuing care retirement community having a comprehensive continuum of care, including a skilled nursing facility, under the ownership and supervision of the provider on or adjacent to the premises.” The Department’s investigation determined that the Department was notified in writing, in February 2023 of the intention to close the Skilled Nursing Facility at Sequoia Living, Inc., The Tamalpais. However the Department did not receive an application for the conversion until June 5, 2023. On June 22, 2023, the Department verified there are 202 residents with Life Care Contracts. Per the licensee, they have had discussions with residents regarding an intention to close the SNF and had send written notifications dated June 2, 2023 to the residents of the proposed closure date in September 2023, that closure has not yet occurred. (Con't.....) Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 5, 2023 · control 21-AS-20230410093217

Allegation investigated: The Provider failed to comply with H&SC section 1771.8(c)-(f) regarding the proposed 9.25% increase in monthly care fees.

AGPA Christina Hadley conducted an investigation into the facts surrounding this allegation. During the course of the investigation, the following information was determined: - On February 9th of 2022, - A Townhall Meeting was conducted to address the 2022 increase and financial status of Sequoia Living. - On September 15th, 2022, - A Townhall Meeting was conducted to discuss the financial structure of Sequoia Living and how monthly fee increases are calculated and the purpose of cash reserves. - On December 6, 2022, the SL Board met to vote on the 2023 increase. - On December 13, 2022 the proposed increase amount was shared with residents with an effective date of April 2023. - On January 19th, 2023, a Townhall meeting was conducted to discuss the 2023 increase and rationale. Over an hour was allocated for open questions and answers as well as an open invitation to submit questions weeks before the Townhall meetings occurred. (Cont....) Unfoundedthe state’s words, verbatim · CDSS document, Jun 14, 2023 · control 21-AS-20230126093548

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Shannan Hansen arrived at 8:50 AM to complete an unannounced annual inspection and met with Terence Tumbale, Administrator. There is a total of 224 residents. LPA reviewed centrally stored medication record, and conducted staff file review and interviews to complete this annual inspection. During staff file review it was revealed Staff (S1, S2, S3, & S4) did not have required current First Aid training/certificate (see LIC809-D). During inspection LPA followed up on medication error that was self reported to community care licensing on 4/21/2023. Resident given double dose of medication in error as staff did not check medication records. Conversation with Administrator indicated facility has scheduled medication training for staff. (see LIC809-D) LPA Hansen is requesting facility to update and submit the following documents by 5/13/2023 to SRRO: LIC 308 Designation of Facility Responsibility LIC 500 Personnel Record LIC 610 Emergency Disaster Plan (if changes) Copy of Administrator Certificate Proof of Liability Insurance Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..the state’s words, verbatim · CDSS document, Apr 25, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 28, 2023

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 requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above where resident was not assisted with medications per doctors orders, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 25, 2023

Plan of correction: Facility has scheduled to conduct additional training in Medication trainig for 4/28/2023. Administrator to submit training with staff signature and date to CCL by EOB 4/28/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c)(1) · Plan of correction due date: May 12, 2023

87411(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. Based on LPAs record review and interview the facility failed to ensure staff (S1, S2, S3 & S4) have first aid training which poses a potential health and saftey risk to residents in care.the state’s words, verbatim · CDSS document, Apr 25, 2023

Plan of correction: Administrator to submit proof of first aid training for S1, S2, S3, & S4 to CCL by POC 5/12/2023.

Type of visit: Required - 1 Year

License Program Analyst (LPA) Hansen arrived unannounced to conduct a required annual inspection of the facility. LPA was welcomed by front desk. LPA met with Administrator Terence Tumbale for the visit. There is a total of 22 assisted living residents and 202 independent living residents. There are two residents currently on Hospice. The facility is an eleven story CCRC with independent living and assisted living setting licensed by Community Care Licensing on all floors. The assisted living setting is on the second floor but currently due to construction have been temporarily moved. The facility also has a skilled nursing setting that is not licensed by Community Care Licensing. LPA toured the assisted living part of the facility on 4/24/2023 at 9:15 AM with administrator, Terence Tumbale; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 3/7/2023 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected, and inspection records are current. Facility service director Stewart Dalie stated that boiler is outside of building and kitchen stove is gas. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 110.4 degrees F and 114.8 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 8 of 8 assisted living & independent living resident’s bathrooms while touring facility on 4/24/2023 at 10:30 AM. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. LPA toured the kitchen area on 4/24/2023 at 11:00 AM with administrator Terence and Director of Environmental Services Stewart Dalie and learned that there are provisions made for individuals/residents with special dietary needs. Continue on LIC809-C Facility kitchen has a binder with resident’s names and their needs. Food is available for residents any time of the day. There is a daily activity schedule for residents. Toxins are stored in a locked housekeeping room. There was a supply of cleaners, hygiene products and paper products available for residents. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. At 11:50 AM LPA initiated a file review of five resident files and five personnel files but was unable to complete. LPA was also unable to review medication and will return at a later date to complete annual inspection. No deficiencies cited during today’s inspection.the state’s words, verbatim · CDSS document, Apr 24, 2023

Allegation investigated: Personal Rights-staff spoke inappropriately to residents in care

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Administrator, Terence Tumbale. Personal Rights-staff spoke inappropriately to residents in care – Reporting Party alleges resident’s personal rights were violated. On 1/26/2023 Community Care Licensing (CCL) received 3 self-reported SOC 341’s of alleged verbal aggression by staff to residents in care. Upon learning of this the facility Administrator immediately suspended staff pending an internal investigation. On 2/16/2023 LPA arrived at facility to open a complaint investigation. LPA obtained facility documents and conducted interviews with the following; three (3) resident, three (3) staff, a private care giver, and the Administrator. LPA reviewed documentation of Suspected Abuse Report (SOC341), and emails regarding the facility’s internal investigation. Based on interviews, record reviews and observations made, there is not enough information to prove or disprove the personal rights of residents were violated by facility staff speaking inappropriately to residents in care. Although the allegations may be true or valid, there is not a preponderance of evidence to prove that the allegations are, or are not, true. Therefore, the allegations are found to be UNSUBSTANTIATED. Exit interview conducted with Administrator Terence Tumbale and a copy of this report was given. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 30, 2023 · control 21-AS-20230208103553

Allegation investigated: Food Services Personal Rights (Staffing)

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Administrator, Terence Tumbale. Food Services – Per Reporting party, there has been a sharp decline in food services and food choices. This Department conducted unannounced site visits on 2/2/2023, 2/16/2023, and 3/7/2023, during these visits, toured the buildings and grounds, interviewed (2) two staff and (7) seven residents, reviewed and obtained records. The food supply and facility menus were observed by LPA at each unannounced site visit - the facility had adequate perishable and non-perishable food and menus were consistent with the requirements of Title 22 regulations. Based on interviews conducted by LPA, contradictory information was received related to food service and choices, although there is a consensus that there is plenty of fresh food options. Although the allegations may be true or valid, there is not a preponderance of evidence to prove that the allegation are, or are not, true. Therefore, the allegation is found to be UNSUBSTANTIATED. Continue on LIC9099-C Unsubstantiated Personal Rights (Staffing) – Complaint alleges facility has a reduction dinning staff, Health Center staff, and Clinic staff resulting in severely restricted services. LPA conducted unannounced site visits on 2/2/23, 2/16/23, and on 3/7/2023 where LPA toured the buildings and grounds, conducted interviews with (7) seven residents who reside in both the Assisted and Independent Living floors of the facility. LPA obtained documentation related to staffing and during each visit, LPA observed staff in the dining room, Health Center, and Clinic. Interviews concluded that although there may have been more staffing previously, the lack of staffing has not restricted services to residents. Although the allegations may be true or valid, there is not a preponderance of evidence to prove that the allegations are, or are not, true. Therefore, the allegations are found to be UNSUBSTANTIATED. Exit interview conducted with Administrator Terence Tumbale and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 30, 2023 · control 21-AS-20230126093548

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Hansen and Licensing Program Manager (LPM) Moellers conducted an unannounced case management and met with Executive Director Paul Friesen, Director of Nursing Ellen Pearson, & Minimal Data Set (MDS) Coordinator Jennifer Williard. The purpose of this case management inspection is to conduct a file review of 28 residents currently residing in the Skilled Nursing (SNF) portion of the facility. Facility is licensed as a Continuing Care Retirement Community(CCRC) that will be eliminating the skilled nursing facility (SNF) portion of the building. LPA Hansen and LPM Moellers provided copies of Title 22 Regulations: 87612-Restricted Health Conditions, 87615-Prohibited Health Conditions, 87618-Oxygen Administration - Gas and Liquidthe state’s words, verbatim · CDSS document, Mar 7, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Hansen conducted an unannounced case management and met with Terence Tumbale, Administrator. The purpose of this case management inspection is to follow up on 3 self reported SOC 341's submitted to Community Care Licensing (CCL). CCL received 3 self reported SOC 341 forms on 1/26/2023 reporting on 1/25/2023 and for the past two weeks S1 was reported by resident R1, R2, and R3, to have been verbally aggressive with residents. S1 has been suspended pending investigation. Submitted reports cross reported to Local Ombudsman, DOJ and responsible parties. LPA made copies of internal investigation notes, records, conducted interviews and made observations. Administrator agrees to inform LPA when internal investigation is complete and how facility is going to proceed regarding alleged abuse reported. During investigation LPA identified (S1) did not have criminal record clearance as required, to be working in a facility. Facility being cited under 87355(e)(1)(see LIC 809-D). ***An immediate civil penalty was assessed in the total amount of $500 The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Appeal of Rights Given ,the state’s words, verbatim · CDSS document, Feb 2, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Feb 3, 2023

87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance...as required by the Department... This requirement was not met as evidenced by: Based on records reviewed, Administrator did not ensure the above regulation due to staff (S1) working and providing services in the facility without a fingerprint clearance as required. This is an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 2, 2023

Plan of correction: (S1)'s last day working in the facility was 1/24/2023. Administrator to submit a written statement that they understand the regulation and will be in future compliance. Statement to be submitted to CCL by POC due date 01/03/2023. ***An immediate civil penalty was assessed in the total amount of $500

Type of visit: Required - 1 Year

License Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Required – 1 year Infection Control Inspection of the facility. LPA was welcomed by front desk who contacted Executive Director, Terrance Tumbale for the visit. There is a total of 241 assisted living residents and independent living residents in the facility. Two residents in Assisted Living are on Hospice. The facility is an eleven story CCRC with independent living and assisted living setting licensed by Community Care Licensing on all floors. The assisted living setting is on the second floor. The facility also has a skilled nursing setting that is not licensed by Community Care Licensing. LPA toured the facility on June 2, 2022 at 9:15 AM with Executive Director, Terrance Tumbale; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on March 7, 2022. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured at an acceptable range and within Title 22 acceptable regulation of 105 to 120 degrees in the 7th floor assisted living dinning hall, 2 assisted living and 2 independent living resident’s bathrooms while touring facility on June 2, 2022 at 9:45 AM. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. LPA toured the kitchen area with Executive Director and learned that there are provisions made for individuals/residents with special dietary needs. Food is available for residents any time of the day. There is a daily activity schedule for residents. Toxins are stored in a locked housekeeping room. There is supply of cleaners, hygiene products and paper products available for residents. (Report continued on LIC 809C) Infection Controle: Facility has submitted a mitigation program plan that has been approved, on 4/19/2021. All staff and visitors check in and log temperatures and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed at facility. Facility has PPE supply stored in basement. Staff had all PPE training required as well have been N95 Fit Tested. All but one staff have received their COVID booster shot and the one has an exemption letter on file and tests weekly. Facility conducted last disaster drills in 12/2021. LPA reviewed Licensing Information System (LIS) with Administrator who stated all is up to date, nothing needs to be changed. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA was presented with proof of CPR & 1st Aid certification for staff. LPA viewed Administrator Certificate for Terrance Tumbale #6051324740 Expiration 02/25/2023 No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the Facilities Executive Director, Terence Tumbale LPA Hansen is requesting Licensee to update and submit the following documents by 6/17/2022 to SRRO: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 610E-S Supplemental Emergency Disaster Plan LIC 9020 Register of Facility Resident’s Copy of Administrator Certificate Proof of Liability Insurancethe state’s words, verbatim · CDSS document, Jun 2, 2022

Type of visit: Annual/Random

License Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Required – 1 year Infection Control Inspection of the facility. LPA was welcomed by front desk who contacted Administrator, Terrance Tumbale for the visit. There is a total of 21 assisted living residents and 240 independent living residents and 35 in the skilled nursing facility. One resident in Assisted Living is on Hospice. The facility is an eleven story CCRC with independent living and assisted living setting licensed by Community Care Licensing on all floors. The assisted living setting is on the second floor. The facility also has a skilled nursing setting that is not licensed by Community Care Licensing. LPA toured the assisted living part of the facility on March 14, 2022 at 9:30 AM with Administrator, Terrance Tumbale; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on March 7, 2022. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured between 115.3 degrees F and 125.6 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 5 of 8 resident’s bathrooms while touring facility on 3/14/2022 at 09:30 AM. (see LIC 809-D). Administrator contacted facility service director Stewart Dalie to adjust water temperature while LPA was touring facility. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. LPA toured the kitchen area with Executive Director and learned that there are provisions made for individuals/residents with special dietary needs. Report continued on LIC 809C Food is available for residents any time of the day. There is a daily activity schedule for residents. Toxins are stored in a locked housekeeping room. There is supply of cleaners, hygiene products and paper products available for residents. Infection Controle: Facility has submitted a mitigation program plan that has been approved, on 4/19/2021. All staff and visitors check in and log temperatures and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed at facility. Facility has PPE supply stored in basement. Staff had all PPE training required as well have been N95 Fit Tested. All but 1 staff has received their COVID booster shot and the one has an exemption letter on file and tests weekly. Facility conducted last disaster drill in 12/2021. LPA reviewed Licensing Information System (LIS) with Administrator who stated that email needs to be updated. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA was presented with proof of CPR & 1st Aid certification for staff. LPA viewed Administrator NHA Certificate for Terrance Tumbale #6051324740 Expiration 02/25/2023 The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Appeal of Rights Given LPA Hansen is requesting Licensee to update and submit the following documents by 4/14/2022 to RPRO: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 610E-S Supplemental Emergency Disaster Plan LIC 9020 Register of Facility Resident’s Copy of Administrator Certificate Proof of Liability Insurancethe state’s words, verbatim · CDSS document, Mar 14, 2022

Allegation investigated: Facility is not following their Program Plan - AL and memory care residents are not receiving services as laid out in the facilities Program Plan. Food Services - facility is not following food service regulations

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of a subsequent complaint investigation resulting in delivering findings of the above allegations. LPA met with XXX ?Terence Tumbale, Administrator. During the investigation LPA reviewed records, made observations at the facility and conducted interviews. LPA investigated a complaint allegation; Facility is not following their Program Plan - AL and memory care residents are not receiving services as laid out in the facilities Program Plan. This facility does not have a memory care at this time. The facilities program plan for care of residents with dementia indicates in part; The degree of dementia is assessed by a team: Continued on 9099-C Unsubstantiated “Residents and Responsible Parties become involved in placement when staff or families recognize that a resident's dementia has become advanced to the point where he or she cannot live well with others, is a danger to him/herself, etc…” The facility will be undergoing renovations and the Administrator informed construction will begin at the beginning of April 2022, there were three resident meetings (9/14/2021, 9/20/2021, and 9/27/2021) where the facility discussed the Assisted Living and Memory Care (AL/MC) renovation and relocation. In addition, there was a zoom meeting set up by the Residents Care Director that took place on 10/7/2021 and another one with the CEO and Chief Development Officer. On 11/29/2021 there was a letter sent to all residents of A/L and their families regarding the change with a follow up call from the Resident Care Director (S7). LPA confirmed the five (5) residents requested to relocate prior to the move were notified and agreed to the relocation. On 12/9/2021 LPAs toured 2nd floor of facility where construction of memory care is soon to commence, and areas have started to be marked “off limits. Facility has had a full-time doctor (S5) for over ten years. In an interview with S5 LPA learned there was an agreement being put together for a new Medical Director who will be taking over when S5 retires although S5 will continue to be a consultant through January 2022. There is also an Infection Preventionist (S4) as well as a Director of Nursing Services (S6) who has been on leave but is returning on 1/3/2021 and has been employed since 2001”. Based on LPAs record review, interviews and observation no evidence to support facility is not following their program plan pending the renovations was obtained. Therefore, this allegation is unsubstantiated. LPA investigated the complaint allegation related to food service; facility is not following food service regulations. Complaint alleges the facility has no food director and they have cut back on food services. Records reviewed and interviews conducted revealed there has been a Dinning Services Director at the facility full time. According to the current Dinning Services Director (S1) who has been at the facility since 10/8/2021, “the food menu remains the same and the facility is not modifying unless they have Special Diets.” Administrator informed prior to S1 being hired facility had an interim Dinning Services Director (S2) from 8/10/2021 to 10/7/2021. Prior to interim Food Director S3 was the Dinning Services Director whose last day was 8/16/2021. Investigation revealed facility has a full time Food Director and prior to 10/7/2021 there was not a lapse in this position being filled. Continued on 9099-C Facilities Infection Preventionist (S4) informed facility has been working with Marin County Dept. of Public Health. Due to COVID the facility is not offering a buffet, but the dining room is currently open to seating with restrictions. Residents can dine in or request to have food delivered or pick up. Facility is following their plan of operations, “Three nutritionally balanced meals per day are provided in the dining room. In addition, will accommodate all special diets prescribed by your personal physician as a medical necessity and approved by the staff physician. Tray Service will be provided to your unit during an illness……” Although complainant alleges facility is not following food service regulation LPA did not obtain additional information to support. LPAs investigation did reveal changes to dining service related to COVID precautions. The allegation is unsubstantiated. A finding that the complaint allegation of; facility is not following their Program Plan - AL and memory care residents are not receiving services as laid out in the facilities Program Plan and Food Services - facility is not following food service regulations is unsubstantiated meaning that 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.the state’s words, verbatim · CDSS document, Dec 30, 2021 · control 21-AS-20211019114116