Atria Tamalpais Creek

Type of visit: Case Management - Incident

09/17/2026, Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident visit and met with Executive Director, Corrine Tanchoco and Resident Service Director, Jocelyn Vahle. The purpose of the visit was to follow up two self-reported incidents and an SOC341 that was submitted to Community Care Licensing (CCL). CCL received an incident report on 09/04/2026 stating on 09/04/2026 at approximately 2pm resident (R1) left the community unassisted. Staff leaving their shift reported they had seen R1 down the street. Facilities PM shift went and found R1 two blocks from the community. CCL received another incident report on 09/09/2026 stating on 09/08/2026 at approximately 5pm, front receptionist had notified staff that resident (R2) had left the property. R2 was located half way up the block from the community. Deficiencies are being cited from regulation 87705(d). Per conversation with Executive Director and Resident Service Director, R1 and R2 immediately started receiving 1:1 private caregivers. Review of R1's physicians report, R1 is unable to leave unassisted due to dementia diagnosis. Review of R2's physicians report, R2 is unable to leave facility unassisted and is diagnosed with Mild Cognitive Impairment (MCI). Facility followed up with the two incidents, conducting in-service training regarding elopements on 09/04/2026 and 09/08/2026. continued on LIC809C LPA followed up on a SOC341 that was submitted to CCL on 09/09/2026. LPA reviewed residents (R3) careplan, physicians report, and discharge paperwork. Review of documents show R3 was declining and was transferred to a skilled nursing facility. Outside sources have followed up regarding the incident with no additional follow up needed. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D, LIC811, and Appeal Rights provided to Executive Director.the state’s words, verbatim · CDSS document, Sep 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: Sep 17, 2026

87705 Care of Persons with Dementia:(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure staff were aware when R1 and R2 left the building without assistance. This poses an immediate Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 17, 2026

Plan of correction: In-service training was conducted on 09/04/2026 and 09/08/2026. POC cleared at time of visit.

Allegation investigated: Licensee does not ensure license number is displayed on public website

On 07/09/2026, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of initiating and delivering complaint findings. LPA arrived and met with Maintence Director, Corey Mundy. During the course of the investigation, LPA reviewed records, conducted interviews, and made observations. Compliant alleges licensee does not ensure license number is displayed on public website. LPA’s review shows that the facilities license number is displayed on the front page of the facilities website. Therefore facility is in compliance with Title 22 Regulations. Based on observations made, this allegation is Unfounded. An allegation that is Unfounded, means that the allegation was false, could not have happened and/or is without a reasonable basis. Unfoundedthe state’s words, verbatim · CDSS document, Jul 9, 2026 · control 21-AS-20260703144857

Allegation investigated: Staff did not provide resident with proper notification prior to rate increase

On 07/09/2026, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of initiating and delivering complaint findings. LPA arrived and met with Maintence Director, Corey Mundy. During the course of the investigation, LPA reviewed records, conducted interviews, and made observations. Compliant alleges staff did not provide resident with proper notification prior to rate increase. Complaint stated that resident (R1) moved into the facility in December 2025 and the facility recently increased R1s rent after six months without providing the required 90 day written notice. Complainant states neither did they or R1 receive the rate increase notice. LPAs review of record review shows the facility mailed out a rate increase notice addressed to R1s responsible party on 03/23/2026, indicating the rate increase will be effective 07/01/2026. 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 9, 2026 · control 21-AS-20260703144857

Type of visit: Required - 1 Year

05/19/2026, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and met with Executive Director, Corrine Tanchoco. There are currently 103 residents in care. Out of 103 residents, 86 residents are in Assisted Living and 17 are in Memory Care. Facility has an approved fire clearance for 180 non-ambulatory of which 5 may be bedridden. Facility has a hospice waiver approved for 20. LPA and Executive Director toured the building and grounds. The facility was found to be at a comfortable temperature. Facility has multiple activity rooms, a salon, media room, and a gym. LPA observed a list of dietary restrictions for residents in the kitchen that is updated monthly and/or when a new resident moves in. Emergency food supplies were found to be sufficient. Activities for residents are posted monthly with sign up sheets for residents who wish to participate. Water temperature in sinks accessible to residents in care were measured in both Assisted Living and Memory Care and were found to be within range of 105 to 120 degrees F. LPA observed evacuation chairs at each stairwell. Fire extinguishers were last inspected 01/2026. Facility has fire alarms that are hard wired to the fire department and were last inspected on 05/06/2026. Facility conducts monthly fire drills with the last one being conducted 4/18/2026. Chemicals and toxins were found to be secured in a locked room. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Log. continued on LIC809D LPA conducted a review of 8 resident records, 4 in Assisted Living and 4 in Memory Care. All records had the required documentation. LPA conducted review of 8 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file. No deficiencies cited during today's inspection. Updated copies of the following documents were requested and are to be submitted to CCL by 06/19/2026: LIC500- Personnel Report LIC308- Designation of Responsibility Updated Certification of Liability Insurance Emergency Disaster Plan (review, update if needed) Exit interview conducted with Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 19, 2026

Type of visit: Case Management - Incident

03/24/2026, Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident visit and met with Executive Director, Corrine Tanchoco and Resident Service Supervisor, Omar Peraza Molina. The purpose of the visit was to follow up on self-reported incident that were submitted to Community Care Licensing (CCL). CCL received an incident report on 03/11/2026 stating on 03/10/2026, around 5pm, resident (R1) reported accidentally consuming peanut sauce during dinner in the dining room. R1 stated he has a peanut allergy and reported a scratchy throat. 911 was contacted and paramedics arrived to assess R1. Per conversation with Executive Director, R1 ordered the stir fry and the sauce in the stir fry contained peanuts to which R1 is allergic to per R1s physicians report (LIC602). Facility has a dietary board posted in the kitchens for cooking staff to review. Dietary board states R1 is allergic to peanuts. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D, LIC811, and Appeal Rights provided to Executive Director.the state’s words, verbatim · CDSS document, Mar 24, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(7) · Plan of correction due date: Mar 25, 2026

87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by: based on observations made and record review, the Licensee did not comply with the section above and did not ensure that R1 was provided their modified diet. This poses an immediate health & safety risk to the residents in care.the state’s words, verbatim · CDSS document, Mar 24, 2026

Plan of correction: Licensee to submit self-certification that in-service training will be conducted for dining/kitchen staff by POC due date of 03/25/2026. Training to include: Date, Topic, Name/Job, and Signatures. Proof of completed training to be submitted by 04/17/2026.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident visit and met with Executive Director, Corrine Tanchoco, Resident Services Director, Jocelyn Vahle. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). CCL received three incident reports on 12/04/2025. Incident report #1 states on 12/03/2025, during an incident investigation staff (S1) verbalized to staff (S2) that on 12/02/2025 during S1s shift training of a new staff (S3), S3 did not give resident (R1) narcotic medications. It was reported they attempted to pass the medication while R1 was in the dining room and another staff stopped them. They then took the medication back to the cart and locked it in the top drawer. Later when R1 was ready for medication they only dispensed R1s non narcotic medications and omitted the narcotics from administration. Incident report #2 states on 12/03/2025, S2 went to resident's (R2) room after getting report from staff that R2 was not feeling was and reported R2 was given two doses of medication the night before. R2 reported having new staff given them medication and then seeing their normal med tech. S2 called 911 and R2 was transported to the hospital for further evaluation. Incident report #3 states on 12/03/2025, at approximately 6:30am staff called and reported to S2 that resident's (R3) Alprazolam had been tampered with. It was observed on the #7 bubble pill that Alprazolam was removed and replaced with mirtazapine tablet and taped back up. LPA was informed S1 and S3 were both terminated as of 12/08/2025. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D, LIC811, and Appeal Rights discussed and provided to Executive Director.the state’s words, verbatim · CDSS document, Jan 6, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a) · Plan of correction due date: Jan 7, 2026

Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: Based on document review; R1 did not receive their narcodic medication, R2 received two doses of the same medication, and R3s mediciation were tampered with which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 6, 2026

Plan of correction: Facility conducted medication in-service training for medication technicians on 12/04/2025. Deficiency cleared at time of visit.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident visit and met with Resident Services Director, Jocelyn Vahle. The purpose of the visit was to follow up on a self-reported incident that was submitted to Community Care Licensing (CCL). CCL received an incident report on 10/27/2025. Report states on 10/20/2025 staff observed an opening on resident (R1) buttocks. Kaiser home health came out on 10/22/2025 and determined R1 has a stage 2 pressure sore. LPA obtained medical documentation. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Resident Services Director.the state’s words, verbatim · CDSS document, Nov 20, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident Visit and met with Resident Services Director, Jocelyn Vahle. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). Incident Report 1: CCL received an incident report on 07/07/2025. Report states on 07/04/2025 at approximately 5:30PM resident (R1) had a severe fall when visiting their home with a friend outside of the community. R1 had fell hitting their head. They called 911 and R1 was admitted to the hospital for further evaluation. Per conversation with Resident Services Director, R1 sustained a subdural hematoma and needed a Gastrostomy tube. R1 is no longer at facility as they required higher care. Incident Report 2: CCL received an incident report on 07/07/2025. Report states resident (R2) had an unwitnessed fall and was found on the floor besides their bed. Staff member helped R2 up and to the bathroom where she noticed a bruise on the side of her left eye. 911 was called, as well as R2s daughter, who suggested that R2 did not go to the hospital but to call hospice instead. Per conversation with Resident Services Director, R2s family refused for R2 to be transported to the emergency room. The hospice nurse came to check on R2 with no concerns. R2 is currently still on hospice. No Deficiencies Cited during visit. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Resident Services Director.the state’s words, verbatim · CDSS document, Sep 17, 2025

Type of visit: Required - 1 Year

05/15/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and met with Executive Director, Corrine Tanchoco and Resident Services Director, Jocelyn Vahle. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 108 residents in care. Out of 108 residents, 91 residents are in Assisted Living and 17 are in Memory Care. Facility approved/cleared for 180 non-ambulatory which 5 may be bedridden and hospice waiver approved for 20. LPA and Executive Director toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. LPA observed a list in the kitchen of residents who have food dietary restrictions. All rooms were furnished per regulation. Water temperature in sinks accessible to residents in care were measured and found to be within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 01/2025. Facility has fire alarms that are hard wired to the fire department and were last inspected on 05/05/2025. Facilities smoke detectors were last inspected on 05/05/2025. Facilities last fire/disaster drill was conducted on 05/08/2025. Facility has multiple activity rooms, a salon, and a gym. All are accessible to residents. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. continued on LIC809-C LPA conducted a review of 10 resident records (5 Assisted Living and 5 Memory Care). All records had the required documentation. LPA conducted review of 10 staff records/training. Upon a review of staff records, LPA found all staff to have required training and current 1st Aid & CPR certification on file. No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/16/2025: LIC500- Personnel Report LIC308- Designation of Responsibility Updated liability Insurance Exit interview conducted with Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 15, 2025

Allegation investigated: Staff not properly supervising resident resulting multiple hip dislocation at the facility.

On 02/26/2025, Licensing Program Analysts (LPAs) Loera and Deniz conducted an unannounced visit for the purpose of delivering complaint findings. LPA arrived and met with Executive Director, Corrine Tanchoco. During the course of the investigation, LPA reviewed records, conducted interviews with staff and outside parties, and made observations. Medical records were reviewed by the Departments Program Clinical Consultant. Compliant alleges, Staff not properly supervising resident resulting multiple hip dislocation at the facility. Based upon department interviews with staff, information provided was contradicting with a lack of corroborating evidence to support the allegation. On Residents (R1) Pre-Placement Appraisal dated 05/31/2024 notes R1 uses a walker to ambulate with and is considered non ambulatory (slow, help with bathing, dressing, and toileting). R1’s Functional Needs Service Plan that was signed by POA states under functional capabilities (3. fall risk) requires minimal assistance, (16. Transfer ability) does not require assistance, and (20. Escorting) does not require assistance. continued on LIC9099-C Unsubstantiated R1’s physician’s report (602) (dated 05/29/2024) mentions hip dislocation under diagnoses. This Department’s Program Clinical Consultant reviewed medical records from Marin General Hospital that show R1 had surgery on 08/18/2024 to correct the problem. Medical records revealed that after surgery on 08/19/2024 R1’s hip was corrected. Review of medical records show R1 sustained hip dislocations while doing day to day activities (walking, bending forward to pick something off floor, waking-up and trying to walk), all were non-trauma related. Medical Records also show per R1’s history, R1 underwent hip replacement surgery on 08/10/2016 after suffering a left femur fracture. R1’s hip dislocations cannot be attributed from staff neglect. 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.the state’s words, verbatim · CDSS document, Feb 26, 2025 · control 21-AS-20241017124159

Type of visit: Case Management - Incident

At approximately 1:40PM, Licensing Program Analysts (LPAs) Loera and Deniz arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Corrine Tanchoco. The purpose of the visit was to follow up on self-reported incident that was submitted to Community Care Licensing (CCL). CCL received an incident report on 11/20/2024. Report stated that on 11/19/2024, Business Office Director observed resident 1 (R1) walking in front of community and alerted Executive Director. Executive Director then escorted R1 back into the community and into memory care. Upon investigation R1 had gone out the back door of memory care around 1:55pm and was still observed in the camera at approximately 2pm. R1 was last seen making a right into the memory care backyard. R1 was not harmed or needing medical attention. Based on conversation with Administrator, R1 went out the back door of memory care while staff were outside in the parking lot during a shift change and observed R1 to open the door in the backyard of memory care, staff then assisted R1 back into the memory care building. Facility made all appropriate notifications per regulation. No Deficiencies Cited during visit. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator.the state’s words, verbatim · CDSS document, Feb 26, 2025

Type of visit: Case Management - Incident

At approximately 12:40PM, Licensing Program Analysts (LPAs) Loera and Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director, Corrine Tanchoco, and Resident Services Director, Jocelyn Vahle. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). Incident Report 1: CCL received an incident report on 08/15/2024. Report stated that on 08/15/2024, facility staff observed Resident 1 (R1) on the ground. Facility notified emergency personnel who determined that R1 did not need to go to the hospital. Facility made all appropriate notifications per regulation. Per conversation with Executive Director, R1 was on a respite plan with facility for 30 days, and has since moved out of the community. Incident Report 2: CCL received an incident report on 08/15/2024. Report stated that on 08/15/2024, Resident 2 (R2) called emergency services to be evaluated. Facility staff notified R2's responsible party. R2 was admitted to the hospital for a urinary tract infection (UTI) and received antibiotics. Facility made all appropriate notifications per regulation. Per conversation with Resident Services Director, R2 has been observed to be at baseline. No Deficiencies Cited during visit. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Executive Director and Resident Services Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 28, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 1:15PM to continue an annual inspection that was initiated on 07/07/2024. LPA was greeted by Resident Service Director (RSD), Jocelyn Vahle. LPA and RSD discussed the purpose of the visit. Medications and medication records were reviewed during visit. Medications were documented as per regulation. LPA observed residents engaged in various activities throughout the inspection. No deficiencies cited during inspection. Exit interview conducted. Copy of report discussed and provided to RSD. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 12, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:00AM to conduct an Annual Required inspection and was greeted by Executive Director, Corrine Tanchoco. There are currently 17 residents in Memory Care and 75 residents in Assisted Living. LPA and Executive Director initiated a tour of the facility around 9:30AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. LPA measured water temperatures in 8 sinks accessible to residents and all were within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Fire extinguishers were last serviced 01/25/2024. Facility has fire alarms that are hard wired to the fire department and were last inspected on 04/03/2024. Facilities smoke detectors were last inspected on 04/16/2024. Carbon monoxide detectors located throughout the facility were tested and operational during visit. Most recent disaster drill was conducted on 02/21/2024. Facility conducts fire drills monthly. 10 AL and 5 MC files were reviewed. Reviewed files contained required documents. 10 staff records were reviewed. Staff have required First Aid and CPR certificates. Training records were reviewed. Staff have required training. Administrator Certificate for Executive Director, Corrine Tanchoco (6003554740) expired on 02/26/2024 and is now on the departments pending list. LPA unable to complete inspection at this time. LPA to return at a later date to complete inspection.the state’s words, verbatim · CDSS document, Jul 3, 2024

Type of visit: Case Management - Incident

At approximately 1:00PM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a case management inspection. LPA followed up on Incident Reports that occurred on 03/08/2024 and 03/14/2024 and a self reported SOC341 (Suspected Dependent Adult/ Elder Abuse) that occurred on 02/28/2024. LPA met with Executive Director (ED), Corrine Tanchoco and Resident Service Director (RSD), Jocelyn Vahle. SOC341 dated 02/28/2024: SOC341 states that Staff #1 (S1) went into Resident #1s (R1s) apartment to provide a bathroom reminder. When R1 saw S1 approaching them, R1 became agitated and punched S1 in the throat. S1 called RSD to the apartment and R1 admitted to punching S1. R1 stated that they believed S1 was going to take them to the bathroom and sexually assault them. R1 stated that they were upset that staff comes into their room to change their incontinence briefs and touch their genitals. RSD and ED confirmed that R1 has been having an increase in agitation and hallucinations due to R1s Parkinsons diagnosis. Per R1's physicians report that was conducted before move-in, R1 has a diagnosis of Parkinsons disease, as well as confused/ disoriented behaviors. RSD and ED have since contacted R1s POA as well as R1s Primary Care Provider (PCP) due to a change in cognition. R1 now has a 1 on 1 caregiver in place which will continue until R1 has an evaluation with their PCP to make any necessary medication adjustments. Incident Report dated 03/08/2024: Incident Report states that R2s wallet was reported to be missing. R2 remembered last having their wallet on Thursday afternoon when they went out of the community with their family. R2 noticed their wallet was missing on Friday morning. R2s family member helped to search R2s apartment and it was located at the bottom of a moving box that had not yet been unpacked, and found that there was $300 in cash missing. Continued on LIC809C Continued from LIC809 R2s family filed a police report and the facility conducted an internal investigation. The internal investigation narrowed it down to one caregiver (Staff #2, S2) who had entered the room between Thursday and Friday. When S2 was questioned about the incident, their story was not consistent with what the facilities electronic key log revealed. S2 has since been terminated. Incident Report dated 03/14/2024: Incident Report states that R3 was found by a housekeeper (Staff #3, S3) outside of the memory care unit waiting for an elevator to go down. RSD reviewed security footage at the time of incident and found that a culinary staff (Staff #4, S4) let R3 out of the door without realizing they were a memory care resident. R2 was outside of the memory care unit for a total of 2 minutes. Per conversation with RSD and ED, R3 doesn't exhibit clear dementia symptoms to those who do not know them. Per review of R3s physicians report, R3 does not have a diagnosis of dementia, and does not indicate whether or not R3 can leave the facility unassisted. However, there is conflicting information with another medical document which reveals that R3 does have a dementia diagnosis. LPA confirmed with RSD that R3 cannot leave the memory care unit. LPA discussed with RSD getting an updated physicians report that reflects R3s dementia diagnosis. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on forms confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 27, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(j) · Plan of correction due date: Mar 28, 2024

87705 Care of Persons with Dementia (j)The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by allowing resident to exit the memory care unit unassisted.the state’s words, verbatim · CDSS document, Mar 27, 2024

Plan of correction: Facility conducted an all staff retraining the day of the incident, and ran a drill. LPA is requesting an updated 602 reflecting R3s dementia DX. Deficiency cleared during visit.

Type of visit: Case Management - Incident

At approximately 2:00PM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a case management inspection. LPA followed up on an Incident Report that occurred on 08/16/2023 and a self reported SOC341 (Suspected Dependent Adult/ Elder Abuse) that occurred on 12/24/2023. LPA met with Resident Service Director (RSD), Jocelyn Vahle, and discussed the purpose of the visit. Incident Report dated 08/16/2023: Incident Report states that Resident 1 (R1) was found on the floor by staff with a firm art piece next to them. R1's right wrist appeared to be cut in a horizontal direction and there were blood stains on their sleeve close to the wound. Facility called the paramedics and the police department followed. R1 was then transported to the hospital. Per conversation with RSD, after R1 arrived at the hospital they were evaluated by a psychiatrist and they were not placed on a 5150 hold as they did not meet the criteria. RSD had a conversation with R1s family about options for bringing R1 back to the facility with a 1:1 or bringing the resident back to live with their family. Ultimately, family decided to bring R1 back to their family home. R1 did not return to the facility. SOC341 dated 12/24/2023: SOC341 states that Resident 2 (R2) and Resident 3 (R3) are live in partners in the facilities Memory Care unit. R2 was observed to hit R3 with a closed fist on R3's left shoulder. R2 was upset that R3 did not want to get coffee with them. R2 became agitated when staff attempted to redirect them. R2 and R3's families were notified of the incident. Per conversation with RSD, R2 came into the facility with aggressive behaviors that were difficult for staff to manage. After the incident, R2 was taken to the physician by their daughter and it was found that R2 had a Urinary Tract Infection (UTI). R2 then had multiple medication adjustments and staff has seen a decline in aggressive behaviors since their medications have been adjusted and their UTI was treated. R2 has not been observed to be engaging in any inappropriate behavior towards R3 since the incident. Exit interview conducted. Copy of report, LIC811 (Confidential Names), discussed and provided to RSD. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 23, 2024