Drake Terrace

Allegation investigated: Staff did not seek medical attention for resident in a timely manner

At approximately 10:55AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a complaint investigation regarding the above allegation and met with Hospitality Services Director, Arlene Samonte, and Care Services Director, Tess Estilo. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The Department investigated the following allegation, "Staff did not seek medical attention for resident in a timely manner." Complaint alleged that Resident 1 (R1) had symptoms of shortness of breath and coughing for multiple days before facility contacted emergency services. Review of facility’s incident report stated that on 02/15/2026, R1 reporting experiencing shortness of breath despite already receiving their inhaler and nebulizer treatments. Facility staff contacted emergency services Continued on LIC9099C Unsubstantiated Continued from LIC9099 Review of facility procedure for, “Vital Sign Readings to Determine the Need for Medication,” stated the following: · Facility Procedure: residents, who are physically and mentally capable of reading vital signs may take their blood pressure and pulse readings; a Physician or registered nurse (RN); a licensed vocational nurse (LVN) under the direction of an RN or physician. · Per document, unlicensed care staff may not take vital signs but may assist with self-evaluation of vital signs. Interview conducted with Care Services Director stated that R1's PRN "as needed" supplement oxygen was discontinued after they returned from a skilled nursing facility in 2025. Care Services Director further stated that prior to R1's discharge from the hospital in February 2026, the facility received correspondence stating that R1 no longer required scheduled oxygen or oxygen as needed. Review of R1's facility documents showed that on 12/13/2024 and 12/16/2024, R1 received physician orders for supplemental oxygen and for an oxygen concentrator. Review of R1's medication authorization record (MAR) indicated that R1 received their oxygen from 12/17/2024 to 02/20/2025. Review of R1's paperwork showed that R1 was admitted to the hospital on 02/20/2025 for acute respiratory failure. R1's discharge paperwork dated 02/26/2025, stated that R1 briefly required supplemental oxygen during their stay but was weaned off to room air. Review of R1's physician medication lists for 04/10/2025, 01/27/2026, and 02/21/2026 did not show any orders for supplemental oxygen. Based on record review, interviews conducted, and observations made, this allegation is Unfounded. A finding of Unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. Copy of report discussed and provided to Hospitality Services Director and Care Services Director. Signature on form confirms receipt of documents. Continued from LIC9099 and R1 was transported to the hospital. Review of R1’s physician orders dated 01/27/2026 stated that R1 had the following routine and PRN “as needed” medication orders for shortness of breath: · Breyna 160-4.5MCG HFA AER AD: Inhale 2 puffs by mouth twice daily for asthma exacerbation – rinse mouth after use · Ipratropium-albuterol outer UD 0.5-3MG/3 Ampul-neb: 1 vial (3ML) via nebulizer inhalation every 8 hours as needed for shortness of breath Review of R1’s medication administration record (MAR) for February 2026 stated that on 02/13/2026, 02/14/2026, and 02/15/2026, facility staff administered R1’s PRN or “as needed” nebulizer treatment for shortness of breath. Review of documentation stated that after receiving their nebulizer treatment on 02/13/2026 and 02/14/2026, R1 reported to facility staff that the treatment helped. On 02/15/2026, documentation stated that R1 was given their nebulizer treatment during the morning shift and later reported to facility staff that they still didn’t feel well. Review of R1’s care tracking log stated that on 02/15/2026, R1 complained of discomfort and requested for their inhaler. Per care log, after receiving their inhaler, R1 reported to facility staff to still to be in discomfort. R1 was then offered their nebulizer treatment. Facility staff checked on R1 an hour later and R1 reported that they were feeling better. Care Tracking Note for 02/15/2026 continued to state that R1 requested another second nebulizer treatment from facility staff, stating that they were having trouble breathing. Facility staff then contacted emergency services for further evaluation. Review of Facility's Policy and Procedure for "Change in Resident Status," indicated that community staff have the responsibility to provide care to each resident and summon medical attention when there is a change in status. If the change in status progresses to a crisis, then facility should contact emergency services. Based on record review and observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Hospitality Services Director and Care Services Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 8, 2026 · control 21-AS-20260220152924

Allegation investigated: Facility charged a resident for services not rendered Did not meet resident care needs Facility did not seek timely medical Reporting requirements Not responding to resident call pendants

At approximately 8:35AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a complaint investigation regarding the above allegations and met with Resident Care Coordinator, Ivon Vargas. Care Services Director, Tess Estilo, arrived during visit at approximately 9AM. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The Department investigated the following allegations, "Facility charged a resident for services not rendered, Did not meet resident care needs, Facility did not seek timely medical, Reporting requirements, and Not responding to resident call pendants." "Facility charged a resident for services not rendered" and "Did not meet resident care needs" - Complaint alleged that the facility overcharged R1 for services that were not contracted on or received. Per complaint, R1 moved to the facility in 2024, and were assessed at a Level 5 for care at $7,645/month. R1 was then Continued on LIC9099C Unsubstantiated Continued from LIC9099 still at a Level 5 but the cost of care was $4,785/month. Per complaint, R1 is now at Level 4 for care and is being charged $3,700/month. However, facility charged R1 $4,400 for care when R1 should have been charged $3,700. Review of R1's documents showed that R1 moved to the facility on 09/27/2024. R1's initial care plan dated 10/02/2024, was documented to be $4,830.00/month. R1 was reassessed on 11/03/2024. This care plan was shown to be signed by the facility and responsible party on 11/05/2024 and was for $3,700/month. Review of R1's file showed that R1 had an assessment for "Level Assisted Living Custom" on 11/03/2024 with an effective date of 11/05/2024 at $4,410/month. Per Care Services Director (CSD), this assessment occurred due to the system update that happened with the facility's assessment care tool. Per interview with CSD, residents are on a point based system. The discrepancy occurred because the facility updated their care assessment tool system which implemented additional points and new levels of care. It was identified that with the system update, the tool automatically reassessed R1 and allotted care points based on the new levels of care. This increased R1's total amount of points and increased the amount due per month. Email correspondence provided to the Department showed that the facility notified R1's responsible party of the clerical error on 09/05/2025, stating that the facility identified that R1's care plan had increased. Per email, the facility credited R1 and their responsible party based on the original care plan that had been received. Review of R1's statement showed that the facility issued a rent credit for "care discrepancy for 11/2024 to 09/01/2025" in the amount of $7,810.00 which was applied to R1's overall statement balance. Complaint also stated that R1 was not receiving services such as escorting or attending activities and only recently started attending activities in Fall 2025. Review of R1's care plan dated 11/05/2024 and 9/22/2025, both stated that R1 required assistance with escorts and was to receive activity reminders. Interviews conducted with facility staff stated that R1 is escorted to meals and activities when they wanted to attend. 6 of 6 staff members stated that R1 is escorted to the dining room for only for lunch and dinner because they prefer not to eat breakfast. 6 of 6 staff members stated that R1 will attend activities that they like to do such as movie night, bingo, music, or exercise class but will refuse if it's an activity they do not like or don't want to participate in. Review of R1's Activities of Daily Living (ADL) log for 2024 and 2025 showed tasks such as escorting and reminders for activities as completed. It was observed that the 2025 log showed incomplete tasks from 02/21/2025 to 04/10/2025 because R1 was out of the community. Based on record review, interviews conducted, and observations made, these allegations are Unsubstantiated. Continued on LIC9099C Continued from LIC9099C “Not seeking timely medical and Reporting Requirements” - Complaint alleged the following: facility did not inform R1's responsible party or primary care physician that R1 had lost 10 pounds, that facility did not seek medical care for R1 timely after they had a fall on 02/20/2025, and that facility did not report R1's fall to Community Care Licensing (CCL). Interview conducted with CSD stated that the facility provides a service to take resident vitals and weights monthly. If it is observed that a resident had a weight fluctuation of plus or minus five pounds, then the facility would notify the resident’s primary care physician and responsible party. Per CSD, R1 was not in the community for a period of time as they were at a skilled nursing facility. Review of R1’s facility weight log recorded R1’s weight in February 2025 as 141.2lbs. Review of R1’s care log notes indicated that R1 was out of the community from 02/20/2025 to 04/09/2025 and stated that R1 was expected to be discharged from a skilled nursing facility on 04/09/2025. Care log notes stated that R1 returned to the community on 04/10/2025. Review of R1’s physician’s report dated 04/06/2025 showed that their weight was 132.8lbs, and their skilled nursing facility discharge paperwork dated 04/10/2025 showed that their weight was 137.1lbs. R1’s facility weight log showed that they refused to have their weight taken on 05/01/2025 but had their weight taken during a physician’s visit on 05/06/2025 which recorded their weight as 130lbs. On 06/19/2025, R1’s weight was recorded as 125.7lbs. Review of facility documents showed that facility contacted R1’s responsible party and primary care team on 06/19/2025 to inform them of the weight change. Per notes dated 06/23/2025, R1’s primary care team responded to facility staff stating that they discussed the weight loss with R1’s responsible party and sent physician orders to the facility on 06/20/2025. Review of R1’s documents showed that facility received physician orders for a Glucerna Shake to be consumed twice a day on 06/20/2025. Complaint alleged that R1 did not receive timely medical care on 02/20/2025 and that R1's fall was not reported to Community Care Licensing. Per complaint, R1 had a fall around 4:00AM on 02/20/2025 and wasn’t sent to the hospital until 8:00AM on the same day. Complaint stated that R1 should have been sent to the hospital at 4:00AM and stated that 911 wasn't contacted until after R1's responsible party arrived to the facility after 8AM. Interview conducted with Witness revealed that video surveillance footage showed that the ambulance was called after facility staff called R1's responsible party on 02/20/2025. Department was unable to review video surveillance footage to confirm when the ambulance arrived as it was no longer available. Continued on LIC9099C Continued from LIC9099C Community Care Licensing (CCL) received an incident report for R1 on 02/27/2025. Review of R1's incident report stated that at approximately 07:40AM, R1 was observed to be weak, with tremors, and had profuse sweating. Paramedics were called and R1 was transported to the hospital, and R1's primary care physician and responsible party were notified. Review of email correspondence showed that the facility and responsible party communicated about R1's incident on 02/20/2025. Per Title 22 Regulations, Reporting Requirements, 87211(a)(1)(D), an incident report should be submitted to CCL, for "Any incident which threatens the welfare, safety or health of any resident..." Review of R1’s care log notes stated that on 02/20/2025, R1 was observed on the floor by facility staff at approximately 4:20AM. Per care log notes, R1 denied pain or discomfort at the time of the incident. R1's care log for 02/20/2025 further reported that R1 was sent to the emergency room after they were observed to be weak, shaking, and sweating later in the day. 4 of 6 staff interviews and interview conducted with CSD stated that R1 can communicate their needs and say if they are in pain or if something is wrong. Review of R1's Physician's Report dated 02/27/2025 stated that R1 is able to communicate their needs. Based on record review, interviews conducted, and observations made, these allegations are Unsubstantiated. "Not responding to resident call pendants." Complaint alleged that there have been instances of no response or lengthy responses when R1 presses their pendant. There was no additional information provided on when these instances occurred. Interviews conducted with facility staff revealed conflicting statements. 3 of 7 staff interviews stated that R1 has said they have waited for a long time to receive help but these interviews also stated that R1 says they have been waiting for a long time but hasn't. 4 of 7 staff interviews stated R1 has not reported long or lengthy response times. Interviews also revealed conflicting statements on what a facility staff member's response time should be. Per interviews, staff stated that pendant call times were to be responded to within 3-7 minutes, with the maximum time being 10 minutes. LPA was unable to pull pendant call records to review as they were unavailable. Based on interviews conducted, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Care Services Director. Signature on form confirms receipt of documents. Continued from LIC9099 Review of facility records showed that the Santa Rosa Regional Office received an eviction notice for R1 on 10/21/2025 for non-payment of fees. Facility correspondence showed that on 11/04/2025, the facility rescinded their October 2025 eviction notice and re-issued an eviction notice to R1 and their responsible party on 11/21/2025 for non-payment of fees. Per interview with Hospitality Services Director (HSD), an error was found in the amount that R1 owed in October 2025. An internal investigation was conducted by the corporation where it was found that R1 still had an overdue balance with non-payment of fees. Therefore, a secondary eviction notice for non-payment of fees was issued in November 2025. Per Title 22 Regulations, Eviction Procedures, 87224(a) and 87224(c): 87224(a) the licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5)...Thirty (30) days written notice to the resident is required…(1) Nonpayment of the rate for basic services..." and 87224(c) The licensee shall, in addition to either serving the required thirty (30) days notice…on the resident, notify or mail a copy of the notice to quit to the resident's responsible person.” Based on record review, interviews conducted, and 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. Exit interview conducted. Copy of report discussed and provided to Care Services Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 27, 2026 · control 21-AS-20251024233242

Type of visit: Required - 1 Year

At approximately 8:55AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Vice President of Operations (VPO), Wade Vest, Executive Director Specialist (EDS), Kelly Reynolds, Care Director, Tess Estilo, and Administrator, Arlene Samonte. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for a total capacity of 130 individuals, where 81 individuals can be Non-Ambulatory and 15 can be Bedridden. Facility has an approved hospice waiver for 10 individuals. Upon arrival, LPA was informed that there were 90 residents in Assisted Living, 13 residents in Memory Care, and 28 Independent Living residents for a total of 131 residents in care. LPA was also informed that there were 31 staff members on-site. At approximately 9:30AM, LPA reviewed Facility Staff Roster and found that all staff were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with VPO and EDS and observed the following: Facility is a 3 story building for Assisted Living and Memory Care, and has separate Independent Living units on the property. Facility was clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility has emergency water and food present if facility needed to shelter in place for 72 hours. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 12 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility has emergency chairs in facility stairwells. Facility's fire extinguishers were last inspected April 2025. Facility's smoke and carbon monoxide detectors were last inspected July 2025 and facility's sprinkler system was last inspected August 2025. Continued on LIC809C Continued from LIC809 Facility's last emergency/disaster drill was conducted October 2025. Administrator's Certificate for Arlene Samonte (6068960740) was current with an expiration date of 03/26/2026. LPA began resident file review. LPA followed up on an incident report and SOC341 report received on 10/27/2025. Reports stated that on 10/23/2025, it was discovered that Staff Member 1 (S1) transferred monetary funds to their personal account from Resident 1's (R1's) account. LPA obtained documentation related to the incident. LPA discussed the following topics with VPO, EDS, Care Services Director, and Administrator: Reporting Requirements PIN regarding 911 protocols PIN regarding dementia regulations LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to VP of Operations, Executive Director Specialist, Care Services Director, and Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 30, 2025

Allegation investigated: Staff did not meet the needs and services of a resident while in care Staff had inaccurate record keeping for a resident Staff overcharged a resident for services not received

At approximately 8:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations. Care Services Director, Tess Estilo, arrived during visit at approximately 9:00AM and Administrator/Hospitality Services Director, Arlene Samonte, arrived during vist at approximately 9:15AM. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The Department investigated the following allegations, “Staff did not meet the needs and services of a resident while in care, Staff had inaccurate record keeping for a resident, and Staff overcharged a resident for services not received”. “Staff did not meet the needs and services of a resident while in care” - Complaint alleged that Resident 1 (R1) was doing their own care and R1 was seen many times on FaceTime calls to be dressing themselves or Continued on LIC9099 Unsubstantiated Continued from LIC9099 be in dirty clothes worn from the day before. Per Complainant, the timing of R1’s care was not consistent and that on these FaceTime calls, R1 was observed waiting for help with dressing in the mornings and evenings. Complainant also alleged that R1 was to be escorted to meals using their wheelchair but that R1 would walk themselves to the dining room without assistance or facility staff would walk next to R1 while they used a walker. Complainant also stated that there was a doctor’s order from September 2024 for R1’s wheelchair to be used. LPA was unable to verify Facetime Calls. R1’s Physician Report dated 09/12/2024, stated R1 was unable to bathe or groom themselves and was non-ambulatory. Review of R1’s wellness physician order dated 09/13/2024 stated that R1 was not to participate in facility’s fitness program. Order did not provide additional information on mobility aids. Review of Facility documents showed multiple updates to R1’s plan of care: · R1’s care plan dated 09/20/2024 stated that R1 needed caregiver assistance with bathing; they could dress and undress and select their own clothing but may need reminders/supervision and was independent with grooming and personal hygiene care. This care plan stated that they required mobility escorts with a walker as a mobility aid. · On 09/29/2024, R1’s care log noted that a phone call conference was held with R1’s responsible party. On 09/30/2024, R1’s care plan was updated to the following - R1 did not require assistance with the following tasks: bathing, dressing, and grooming. This care plan stated that they required mobility escorts with a walker as a mobility aid. · On 12/04/2024, R1’s care plan was updated again to show that R1 required help with the following tasks: assistance with bathing set-up, one person assist with dressing and grooming as scheduled. This care plan stated they required mobility escorts with a walker or wheelchair as a mobility aid. · On 12/17/2024, R1 was admitted to a hospice agency and received an updated care plan. Review of R1’s hospice care plan stated “activities permitted: up as tolerated. Transfer bed/chair; wheelchair, walker.” Email correspondence provided indicated that the facility was aware of concerns with R1’s care. Email dated 09/15/2024, stated that flexibility would be needed on the timing of R1’s care because facility staff wouldn’t always be able to see R1 at a designated time due to the possibility of assisting another resident. 6 of 6 staff interviews conducted stated that R1 had a history of refusing care. Per interviews, there were times when facility staff would show up to assist R1, and they would be already dressed or would refuse their assistance many times. Review of R1’s care log for September 2024 - December 2024 showed R1’s care tasks like escorts and dressing as completed with time and date stamps. Review of R1’s care log also showed documented refusals of care. Continued on LIC9099C Continued from LIC9099C “Staff had inaccurate record keeping for a resident” – Complaint alleged that facility staff were falsifying R1’s notes stating that R1’s care like dressing and escorting were completed. 6 of 6 staff interviews conducted stated that they keep track of their daily duties on a phone care application. Review of R1’s care log showed that when a task was completed, it would be date and time stamped. Per interviews conducted, if a task is not completed or if a resident refuses care, there is a section in the care application where it can be notated. Interview with Care Services Director stated that if there were incomplete tasks identified, they would be reviewed and flagged by themselves and the Resident Care Coordinator. Review of R1’s care log for September 2024 - December 2024 showed documented refusals of care. “Staff overcharged a resident for services not received” - Complaint alleged that facility overcharged R1 for care services due to long-term care insurance paperwork not being completed by the facility. Interview conducted with Resident Relations Director stated the following: During a resident’s initial assessment, the facility would confirm if a resident had long-term care insurance. It would be documented in the resident’s care plan on who was responsible for managing the paperwork. If the facility was responsible, then a fee would be charged. Interview conducted with Care Services Director stated that the facility communicated frequently with the long-term care insurance company through phone calls. Interview also stated that the facility did not assist with the paperwork since it was requested to not be included in R1’s care plan. Email correspondence dated 09/04/2024 showed a request was sent to the facility for help with forms from a long term care insurance company. Additional emails provided dated 09/27/2024 showed that a request was made to remove R1’s long term care paperwork from R1’s care plan. Email dated 09/29/2024, showed that the facility did not include assistance with long-term care paperwork to R1’s care plan since it was not established and therefore no care points were added. Interview conducted with involved parties stated that R1’s family was responsible for filling out the long-term care insurance forms. Based on record review, interviews conducted, and observations made, these allegations are Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator/Hospitality Services Director and Care Services Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 10, 2025 · control 21-AS-20250527142002

Type of visit: Case Management - Annual Continuation

At approximately 9:05AM, Licensing Program Analysts (LPAs) Felias and Frank arrived unannounced to continue a Required 1 Year visit and met with Executive Director, Shawn Mooney, and Assisted Living Director, Tess Estilo. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for a total capacity of 130 individuals, where 81 individuals can be Non-Ambulatory and 15 can be Bedridden. Facility has an approved hospice waiver for 10 individuals. Upon arrival, LPAs was informed that there were 92 residents in Assisted Living and Memory Care with 23 Independent Living residents for a total of 115 residents in care. LPAs was also informed that there were 34 staff members on-site. At approximately 9:45AM, LPAs reviewed Facility Staff Roster with Executive Director and Assisted Living Director and found that all staff members on site were background cleared and associated to the facility per regulation. LPAs reviewed resident files and resident medication. Files were all found to be well organized, thorough and contained the required documentation. During medication review, LPAs observed that 2 of 8 resident medications were not documented on the log as required. Review of facility's log indicated that facility understands how to document medications appropriately. Discussion with Executive Director indicated that they are audited by their pharmacy monthly (technical assistance issued, LIC9102, regulation 87465(h)(6)). LPAs also followed up on incident reports that were self-submitted to Community Care Licensing (CCL). Incident Report 1/SOC341: CCL received an incident report and SOC341 on 03/06/2024. Reports state that on 02/29/2024, Resident 1's (R1) family notified facility management of unusual transactions on their joint financial account. R1's family also reported that $40 were missing from R1's wallet. Facility made all appropriate notifications per regulation. Incident Report 2: CCL received an incident report on 03/07/2024. Report states that on 02/29/2024, facility medication technician observed that Resident 2 (R2's) prescribed medication was discontinued on their electronic medication authorization record (EMAR) and that facility did not have a copy of the discontinued medication. Report continues to state that facility verified R2's medication list, and R2 received a new order for their medication on 03/01/2024. Facility made all appropriate notifications per regulation. Continued on LIC809C Continued from LIC809 Incident Report 3: CCL received an incident report and SOC341 on 03/28/2024. Reports state that on 03/25/2024, Resident 3's (R3) financial adviser notified facility management of $120 and credit cards missing from R3's apartment. Facility made all appropriate notifications per regulation. Incident Report 4: CCL received an incident report on 04/30/2024. Report states that on 04/29/2024, Resident 4 (R4) was given the wrong medication for pain. Facility made all appropriate notifications per regulation (deficiency cited, LIC809D, regulation 87465(a)(4)). Incident Report 5: CCL received an incident report on 05/02/2024. Report states that on 05/01/2024, Resident 5 (R5) was being assisted by Staff Member 1 (S1). When S1 transferred R3 to their wheelchair, S1 pushed R5's foot rests on the wheelchair and hit R5 in their leg. R5 sustained a hematoma blister to their leg. On 05/02/2024, facility contacted emergency services for R3 to be further evaluated due to blister increasing in size. Facility made all appropriate notifications per regulation. Incident Report 6: CCL received an incident report on 08/20/2024. Report states that on 08/19/2024, Resident 6 (R6) had an unwitnessed fall outside of the community on the sidewalk. R6 was observed to be bleeding from their head. Emergency services were contacted and R6 was taken to the hospital to be further evaluated. Facility made all appropriate notifications per regulation. Incident Report 7: CCL received an incident report on 12/27/2024. Report states that on 12/18/2024, Resident 7 (R7) notified the front desk that they couldn't find their spouse, Resident 8 (R8). Per R7, they had left R8 with other residents of the community. Facility staff initiated their elopement protocol and R8 was found 300 feet away from the property. Report states that R8's wanderguard bracelet and alarmed doors were functioning appropriately. Report continues to state that facility conducted a care conference with R7 and R8's care plan was updated accordingly. Facility made all appropriate notifications per regulation. Review of R8's Physician's Report states that they are unable to leave the facility unassisted. (deficiency cited, LIC809D, regulation 87468.2(a)(4)). 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 (Deficiency Page), Confidential Names (LIC811), Plan of Corrections, Plan of Corrections Letter, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 6, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At approximately 9:25AM, Licensing Program Analysts (LPAs) Felias and Frank arrived unannounced to conduct a Required 1 Year visit and met with Executive Director, Shawn Mooney, and Assisted Living Director, Tess Estilo. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for a total capacity of 130 individuals, where 81 individuals can be Non-Ambulatory and 15 can be Bedridden. Facility has an approved hospice waiver for 10 individuals. Upon arrival, LPAs was informed that there were 97 residents in Assisted Living and Memory Care with 25 Independent Living residents for a total of 122 residents in care. LPAs was also informed that there were 36 staff members on-site. At approximately 9:45AM, LPAs reviewed Facility Staff Roster with Executive Director and Assisted Living Director and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 10:15AM, LPAs conducted a walk-though of the facility with Executive Director and Assisted Living Director and observed the following: Facility is a 3 story building for Assisted Living and Memory Care, and has separate Independent Living units on the property. Facility was clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 12 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected April 2024. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected May 2024. Facility's last emergency/disaster drill was conducted September 2024. Administrator's Certificate for Shawn Mooney (7021863740) is current with an expiration date of 03/10/2026. LPAs reviewed staff files. Files were all found to be well organized, thorough and contained the required documentation. Staff were found to have current First Aid and CPR certification. LPAs unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Dec 10, 2024

Type of visit: Case Management - Annual Continuation

At approximately 12:45PM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Residential Relations Director, Arlene Samonte, Assisted Living Director, Mary Ann De Lara, and Administrator/Executive Director, Shawn Mooney. LPA reviewed resident medication records. Medication was found to be centrally stored and secure. LPA also followed up on an incident report that was submitted to Community Care Licensing (CCL). Incident Report 1: CCL received an incident report on 12/04/2023. Report states that on 11/26/2023, Resident 1 (R1) was administered a medication that they did not have a prescription for. Resident was observed to not have any adverse effects. Facility made all appropriate notifications per regulation (this deficiency has been cited, see LIC809D, Regulation 87465(a)(4)). Facility conducted a in-service training covering Medication Related Errors and The Five Rights of Residents. LPA was provided with a copy of training documentation. LPA cleared deficiency cited today during visit. LPA also cleared the previous deficiency cited conducted on 12/20/2023 for Health and Safety Code 1569.625(b)(2) during visit. LPA was informed that the facility has a new Executive Director, Shawn Mooney. LPA and Executive Director discussed submitting Administrator paperwork to the Regional Office so they can be established as the Administrator on file. Until paperwork has been submitted, facility understands that Donna Daniel-Herr will continue to be the Administrator on file until paperwork has been reviewed and processed. LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Updated Liability Insurance Continued on LIC809C Continued from LIC809 LPA also requested for the following documents to be submitted: Administrator Documents · LIC 308 (Designation of Facility Responsibility) · Active and Current Administrator Certificate · First Aid Certificate · Administrator Resume · LIC 500 (Personnel Report) · LIC 501 (Personnel Record) · LIC 503 (Health Screening Report - personnel) · Proof of TB test · LIC 9182 (Criminal Record Exemption Transfer Request) · LIC 508 (Criminal Record Statement) · Copy of Driver's License or Passport that is not expired · Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations) Administrator documents to be submitted for Shawn Mooney by 02/01/2024. Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 02/16/2024. 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. Plan of Corrections reviewed and developed with Executive Director. Copy of report, LIC809D, Plan of Corrections, Plan of Correction Letters, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 17, 2024

Type of visit: Required - 1 Year

At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Executive Director, Donna Daniel-Herr and Assisted Living Director, Mary Ann De Lara. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for a total capacity of 130 individuals, where 81 individuals can be Non-Ambulatory and 15 can be Bedridden. Facility has an approved hospice waiver for 10 individuals. Upon arrival, LPA was informed that there were 93 residents in Assisted Living and Memory Care with 21 Independent Living residents for a total of 114 residents in care. LPA was also informed that there were 22 staff members on-site. At approximately 9:45AM, LPA reviewed Facility Staff Roster with Assisted Living Director and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 10:15AM, LPA conducted a walk-though of the facility with Assisted Living Director and observed the following: Facility is a 3 story building for Assisted Living and Memory Care, and has separate Independent Living units on the property. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 10 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. At approximately 11:30AM, LPA reviewed 5 resident files and 5 staff files. Resident Files were all found to be well organized, thorough and contained the required documentation. LPA observed that 4 of 5 staff files were missing all or parts of the required annual training per Health and Safety Code (this deficiency has been cited, see LIC809D, Health and Safety Code 1569.625(b)(2)). Continued on LIC809C Continued from LIC809 Facility's fire extinguishers were last inspected April 2023. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected February 2023 and October 2023. Facility's last fire/disaster drill was conducted October 2023. LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Dec 20, 2023