Almavia of San Rafael

Allegation investigated: Personal Rights

At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a complaint investigation regarding the above allegation and met with Executive Director, Tracy Freudendahl. During the course of the investigation, the Department made observations and conducted interviews. There is an allegation of "Personal Rights." Complaint alleged that the Executive Director brings their dog to work and allows the dog to be off leash and wander the facility. Per report, the residents do not like the dog because the dog snaps at residents and staff members. Interview conducted with Executive Director (ED) stated that their dog, Winston, is a service dog. Per ED, they are currently taking care of Winston for a family member. ED further stated that they have not observed Winston to snap at residents, family members, or facility visitors. Continued on LIC9099C Unfounded Continued from LIC9099 Interview conducted with Resident Care Director stated that they have not heard of any complaints about Winston, and have not observed Winston to snap at residents, family members, or facility visitors. Resident interviews were conducted. 4 of 4 resident interviews stated that Winston was a wonderful dog and they did not see Winston snap, growl, or be aggressive towards themselves or others at the facility. These interviews revealed that Winston was primarily seen in the Executive Director's office. These interviews also stated that sometimes Winston would be in the facility lobby to greet residents, but he was always with the Executive Director. During visit conducted on 08/27/2026, LPA observed two residents greet the Executive Director in their office and ask if they could pet Winston and give him treats. During these resident interactions, LPA observed that Winston did not bark, growl, lunge, or act in an aggressive way towards the residents. During the length of the visit, Winston stayed in the corner of the Director's office, or would sit by the Executive Director. It was also observed that Winston had their leash attached to them at all times and was not "off-leash". Based on 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 Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 29, 2026 · control 21-AS-20260819151158

Type of visit: Case Management - Legal/Non-compliance

At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Legal/Non-compliance visit and met with Executive Director, Tracy Freudendahl. The purpose of today's visit was to conduct the facility's quarterly Non-Compliance inspection. During an office meeting on 06/19/2026, facility was placed on a Non-Compliance Plan for 2 years to address the following concerns: Substantiated Complaint Investigation: Complaint 21-AS-20251222134309 Observation of a Resident Exceptions for Health Conditions During the office meeting, the Department requested for facility to submit an updated policy on observed changes of a resident and how they will be assessed and who is responsible for reporting changes and contacting emergency services, if needed. This policy was submitted to the Department on 06/22/2026. LPA obtained copies of training packet and proof of staff signatures for staff members hired between June - September 2026. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 29, 2026

Allegation investigated: Unqualified staff providing care to residents Staff did not serve food in a healthful manner

At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a complaint investigation regarding the above allegations and met with Executive Director, Tracy Freudendahl. During the course of the investigation, the Department reviewed documents, conducted interviews, and made observations. The following allegations were investigated, "Unqualified staff providing care to residents and Staff did not serve food in a healthful manner." Complaint alleged that a child (C1), approximately 8 or 9 years old, had been providing care to residents. Per report, the child had been taking resident meal orders and delivering food to the residents. Report also stated that the meals have not been served in a healthful manner because the child is not changing gloves after they clean the tables. Report also stated that the child worked in the kitchen and also cleaned facility closets. Review of C1's file showed that they were 13 years old and had received training at the facility on 07/22/2026 Continued on LIC9099C Unsubstantiated Continued from LIC9099 C1's documentation also showed that they volunteered at the facility from 07/22/2026-07/31/2026, and had the proper documents required for volunteers. Interview conducted with Executive Director (ED) stated that C1 did the following tasks: cleaned facility storage closets, served and delivered food to residents, cleaned tables, and helped with landscaping at the front of the facility. Per ED, C1 was supervised at all times when they were at the facility and was supervised by the Executive Director, the Business Office Manager (BOM), the Maintenance Director, the Head Chef, and the dining room servers. Interview conducted with the Resident Care Director (RCD) stated that they observed C1 to be supervised by the Head Chef and the BOM. RCD stated that they did not observe C1 serving meals and was unable to state if C1 was changing their gloves appropriately. Interview conducted with the Assistant Food Service Director, stated that C1 worked primarily in the dining room to help bus and clean tables, and deliver meals to the residents. Assistant Food Service Director stated that they observed C1 to change their gloves appropriately. Interview conducted with the Head Chef stated that C1 helped with the following tasks: organize facility storage, how to date produce and facility deliveries, helped serve meals in the dining room, and helped plate desserts. Per interview, C1 was interested in how to become a server, and would shadow and observe the dining room servers. This interview stated that the Head Chef provided safety training to C1 which included training on gloves. Interview also revealed that C1 would occasionally take residents' meal orders while in the dining room, and a dining room server would be there to supervise. Per Head Chef, they observed C1 to change out their gloves appropriately per the training that was provided. Review of Title 22 Regulations showed that there is no regulation that prohibits an individual under the age of 18 to volunteer at a licensed Residential Care Facility for the Elderly (RCFE). Per Title 22 regulations, 87411(j), volunteers may be utilized and shall be supervised. Continued on LIC9099C Continued from LIC9099C Based on record review, interviews conducted, and observations made, the allegations of, "Unqualified staff providing care to residents," and "Staff did not serve food in a healthful manner," are Unsubstantiated. A finding that a 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 Executive Director/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 8, 2026 · control 21-AS-20260729084558

Type of visit: Office

On 06/19/2026, a Non-Compliance meeting was conducted at the Santa Rosa Regional Office. The following individuals were present in the meeting: Acting Regional Manager, Kimberley Mota, Licensing Program Manager, Victoria Bertozzi, Licensing Program Analyst, Caitlynn Felias, Executive Director, Tracy Freudendahl, Corporate Director of Heath Services, Sophia Allwood, Vice President of Operations, Carla Sanchez, Assistant General Counsel, Colleen Freeman, and HansonBridgett Partner, Joel Goldman. The purpose of today’s meeting was to address areas of concerns identified by the Department. The following areas were discussed during today's meeting: Substantiated Complaint Investigation: Complaint 21-AS-20251222134309 Observation of a Resident Exceptions for Health Conditions During visit conducted on 02/03/2026, Facility was issued a $500.00 civil penalty for a violation of Regulation 87466, Observation of a Resident. **Licensee has been informed that the issuance of an additional civil penalty is under review. Additional civil penalty may be assessed based on a violation that the Department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident.** Facility to submit updated policy surrounding how observed changes of a resident will be assessed and who is responsible for reporting changes and contacting emergency services, if needed. Policy to be submitted to the Department by Monday, 06/22/2026. Continued on LIC809C Continued from LIC809 Facility's Non Compliance Plan will be in place for 2 years with an end date of June 2028. Department will review Facility's Compliance Plan after 1 year to review progress when requested by the facility. The Department discussed having the Technical Support Program (TSP) work with Licensee on the addressed concerns. No Deficiencies Cited. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 19, 2026

Allegation investigated: Personal Rights Facility did not provide resident explanation of additional services when initiating a new level of care

At approximately 8:30AM, Licensing Program Analyst (LPA) Felias, arrived unannounced to deliver findings for a complaint investigation regarding the above allegations and met with Executive Director, Tracy Freudendahl, Interim Resident Services Director, Elvira Suciu, and Resident Care Director, Isabel Saunders. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Personal Rights, and Facility did not provide resident explanation of additional services when initiating a new level of care.” Complaint alleged that the facility was forcing Resident 1 (R1) to take medications multiple times a day and that R1’s care plan was changed from a Level 2 or 3 when it should be a Level 0. Per report, R1 is independent and does not need additional care or help with their medications. Complaint also stated that R1 Continued on LIC9099C Unfounded Continued from LIC9099 was being mentally brutalized and psychologically tortured due to being forced to take medication, having facility staff knock on their door three times a day for medications, and being charged $900 per month for care they did not need. “Personal Rights” – Interview with Resident 1 (R1) stated that it is wrong that facility staff are coming into their room to bother them about medications. Per R1, they have told facility staff that they don’t want medication, but facility staff keep coming to their room and keep pushing them to take medication. R1 stated that after refusing, facility staff leave with the medication. Review of facility’s policy under “The Six Rights” stated that the seventh right that a resident has is the “Right to Refuse.” Per facility document, residents may refuse medication at any time for any reason, but facility staff should try at least three times. Review of facility documents showed that R1 has been refusing their medications and facility has been notifying their primary care physician of the refusals. Review of R1’s file indicated that the facility received communication from R1’s Psychiatrist on 03/20/2026. Per communication, the facility has been directed to continue administering R1’s medication per physician orders based on R1’s medical history and to keep R1 on the facility’s medication management program. “Facility did not provide resident explanation of additional services when initiating a new level of care” – Review of R1’s file showed that they moved to the community on 02/14/2026. Per facility documents, R1’s initial level of care was assessed at a Level 1 on 02/12/2026. R1’s care included being on the facility's medication management program, having showers two times per week, escorts, and reminders. Per facility email correspondence, R1’s level of care would be reassessed after 30 days for accuracy. On 03/10/2026, R1’s level of care was lowered to a Level A and included being on the facility's medication management program. Further review of R1’s Level A care plan showed that R1 signed the document on 03/10/2026, indicating that they were informed of the care changes made. Review of R1’s financial transaction report indicated that from February 2026 to May 2026, R1 has not been charged an additional $900/month. 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 Executive Director, Interim Resident Care Director, and Resident Care Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 8, 2026 · control 21-AS-20260408113148

Allegation investigated: Staff do not answer residents calls for assistance timely

At approximately 8:55AM, Licensing Program Analyst (LPA) Felias, arrived unannounced to deliver findings for a complaint investigation regarding the above allegation and met with Executive Director, Tracy Freudendahl, Resident Services Director, Elvira Suciu, and Resident Care Director, Isabel Saunduvs. During the course of the investigation, the Department requested and reviewed documents and made observations. The following allegation was investigated, “Staff do not answer residents calls for assistance timely.” Complaint alleged that on 02/22/2026, Resident 1 (R1) did not receive help in the morning. Report stated that facility staff did not arrive even though R1 pressed their pendant and waited. Continued on LIC9099 Substantiated Continued from LIC9099 R1’s facility pendant call logs for 02/21/2026 through 02/23/2026 were requested. Review R1’s pendant log for 02/21/2026 and 02/22/2026 showed evidence of late response times. The following was observed: · On 02/21/2026, R1’s pendant was pressed at 4:07AM and was not cleared until 5:00AM. Log reported that 52 minutes had lapsed. · On 02/22/2026, R1’s pendant was pressed at 12:30AM and was not cleared until 7:35AM. Log reported that 424 minutes had lapsed. · On 02/22/2026, R1’s pendant was pressed at 7:57AM and was not cleared until 8:57AM. Log reported that 60 minutes had lapsed. · On 02/22/2026, R1’s pendant was pressed at 7:54PM and was not cleared until 8:42PM. Log reported that 48 minutes had lapsed. Based on record review and observations made, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), 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, Apr 16, 2026 · control 21-AS-20260225083835

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 27, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities:(a) In addition to...Section 87468.1... residents...shall have...following personal rights: (4) To care, supervision, and services that meet their...needs and are delivered by staff that are sufficient in numbers, qualifications & competency...Requirement was not met as evidenced by: based on record review, Licensee did not comply with section cited above & did not ensure that R1's pendant call was responded to timely. This poses a potential health/safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 16, 2026

Plan of correction: Licensee to conduct in-service training regarding expectations on answering resident pendant calls timely. Training to include: Trainer, Date of Training, Topic, Job Title, Staff Names and Signatures. Training to be submitted for review and approval by POC due date of 04/27/2026.

Type of visit: Required - 1 Year

At approximately 8:55AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Executive Director, Tracy Freudendahl, Interim Resident Care Director, Elvira Suciu, and Resident Care Director, Isabel Saunduvs. Facility serves older adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has a total capacity for 160 residents and an approved fire clearance for 130 non-ambulatory residents, of which 40 residents can be bedridden. Facility has an approved hospice waiver for 20 individuals. Upon arrival, LPA was informed that there were 116 Residents in care and 35 staff members on-site. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Interim Resident Care Director and Resident Care Director and observed the following: Facility is a 3-story building for Assisted Living and Memory Care. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. Emergency evacuation chairs were observed at facility stairwells. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. 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 November 2025. Facility's fire and sprinkler system was last inspected April 2026. Facility's emergency disaster plan was last reviewed and updated on 03/18/2026. During walkthrough, LPA observed multiple instances of expired food in the facility's art and crafts room. LPA, Interim Resident Care Director, and Resident Care Director, disposed of all items. LPA also observed over the counter (OTC) medications in two resident rooms. Continued on LIC809C Continued from LIC809 Review of facility's medication management program indicated that these two residents are receiving assistance with medications and therefore the medications should have been centrally stored. LPA discussed the following with Executive Director, Interim Resident Care Director, and Resident Care Director: 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. 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, Plan of Corrections, Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 16, 2026

Allegation investigated: Dietary needs not being followed Reporting requirements Medication mismanagement Resident care plan not being followed

At approximately 1:30PM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a complaint investigation regarding the above allegations and met with Executive Director, Tracy Freudendahl. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Dietary needs are not being followed, reporting requirements, medication mismanagement, and resident care plan not being followed.” “Dietary needs not being followed.” - Complaint alleged that Resident 1 (R1) is allergic to shellfish and was served a meal with shellfish at least three times. Per complaint, R1 was served shellfish in May 2025 and September 2025. Review of facility’s diet list dated March 10,2025 identified R1 to be allergic to shellfish. Continued on LIC9099C Substantiated Continued from LIC9099 Review of R1’s electronic progress notes also listed R1 to have a seafood/shellfish allergy. Based on record review, this allegation is Substantiated. “Reporting Requirements” – Complaint alleged that R1’s responsible party was not notified of a fall or bruising found on R1 in September 2025. Per complaint, R1 had two falls in September 2025. R1’s primary contact was unavailable in September 2025 and the facility was to call the secondary contact listed for R1. Complaint also stated that R1’s secondary contact was informed of R1’s falls in September 2025 by voicemail. Review of facility documents showed that on 09/18/2025, R1 was found on the floor by facility staff. Per document, R1 denied hitting their head and denied any complaints of pain. Facility staff notified R1’s responsible party and Primary Care Physician. Review of Physician Communication dated 09/18/2025 showed that facility informed R1’s Primary Care Physician of the fall. Review of facility documents showed that on 09/25/2025, R1 was observed to have bruising on their back while having their clothes changed. Per document, R1 informed facility staff that they had fallen earlier in the day but did not report it to facility staff. Review of facility’s internal incident report and physician communication dated 09/25/2025 showed that R1’s responsible party and Primary Care Physician were notified. Interview conducted with R1’s secondary contact revealed that they received a voicemail regarding R1’s falls in September 2025. This interview further revealed that they were not informed of any bruise on R1 and that they did not receive a written report from the facility regarding R1’s falls. During the course of the investigation, it was revealed that R1 was served a meal containing their food allergen in May 2025. Interview conducted with facility staff confirmed that the incident occurred. It was observed that an incident report was not submitted to Community Care Licensing as required for this incident. It was also observed during a medication audit that multiple errors occurred in the administration of medication for R1. These medication errors were also not reported to Community Care Licensing as required. Based on record review, observations made, and interviews conducted, this allegation is Substantiated. “Medication Mismanagement” – Complaint alleged that R1 did not receive their “as needed” or PRN nystatin powder for groin rash as required, did not have a urinary analysis test completed timely, and did not receive their PRN epinephrine pen after having an allergic reaction. Complaint also stated that R1 did not receive their levothyroxine medication correctly. Complaint stated that R1 did not receive their “as needed” or PRN nystatin powder for groin rash as required. Review of R1’s facility documents stated that R1 is able to communicate their PRN or “as needed” needs and can inform facility staff when they need or want a medication. 5 of 6 staff interviews reported that R1 has the ability to communicate if they need or Continued on LIC9099C Continued from LIC9099C want a medication while 1 of 6 staff members stated they believed R1 could not communicate their needs. Review of R1's medication list dated 02/13/2025 stated that R1 is able to determine and clearly communicate their need for prescription and nonprescription PRN medications. Review of R1’s medication authorization records (MAR) for their PRN nystatin powder showed that R1 would refuse to have the powder applied stating that they didn’t need it. Complaint stated that R1 did not have a urinary analysis test completed timely. Complaint stated that R1’s primary care physician faxed a urinary analysis test to the facility on 09/24/2025 but that the facility did not collect the sample until 09/28/2025. Review of R1’s facility file shows that facility sent a fax request to R1’s physician on 09/20/2025 for a urinary analysis test due to observing signs and symptoms of confusion, urine odor, and signs of anxiety. Review of R1’s progress note did not state when R1’s order was received or when the urine sample was collected by the facility. The urinary analysis order stated by the complainant to have been faxed to the facility on 09/24/2025 was unable to be found in R1’s file. Email correspondence provided to the Department showed that a copy of the urinary analysis order was provided to the facility on 09/27/2025 with the urine sample collected on 09/28/2025. Complaint also alleged that facility did not administer R1’s epinephrine pen after R1 had an allergic reaction on 09/08/2025. Review of R1’s medication records showed that they were prescribed an epinephrine pen on 07/05/2023, which states “Inject 0.3 mL intramuscularly as needed for severe allergic reaction. Inject into thigh at the first sign of severe allergic reaction or as directed. Review of R1’s incident report received on 09/15/2025 stated that on 09/08/2025, R1 complained of feeling itchy and had visible signs of redness. Report stated that R1 was served a meal containing their food allergy. Report further stated that facility staff contacted R1’s responsible party who transported R1 to the hospital for further evaluation. Interviews conducted with facility staff members revealed conflicting information on who is allowed to administer epinephrine pens to residents if needed. 4 of 6 staff members stated that only nurses are allowed to administer epinephrine pens while 2 of 6 staff members stated that both medication technicians and nurses are allowed to administer an epinephrine pen. 1 of 6 staff members stated that medication technicians received training on how to administer an epinephrine pen. There was no documentation available to show that training for epinephrine pens was provided to medication technicians. A medication audit was conducted where it was observed that R1 was administered their levothyroxine medication incorrectly. Per R1’s medication instructions, R1 is to receive their medication six times per week and skip Sundays. Per medication notes reviewed, it was stated that R1’s Levothyroxine was administered on Sunday, 09/29/2024, and therefore was not given the medication on Monday, 09/30/2024. It was also revealed that R1 did not receive their levothyroxine medication on 02/28/2025 as the medication was being refilled and was not available to be administered. It was also observed that there were multiple instances of R1’s citalopram and losartan being unavailable at the facility to Continued on LIC9099C Continued from LIC9099C administer to R1 in December 2024. Review of medication notes stated that the medication was not in the cart or was awaiting refill. Based on record review and observations made, this allegation is Substantiated. “Resident Care Plan not being followed” – Complaint alleged that facility staff were not providing incontinence care, were not providing showers, and were not doing skin checks for R1. Interviews conducted with facility staff stated that R1 receives their showers three times per week and is assisted with incontinence care at least every two hours. Interviews also revealed that R1 had been observed to try and do their own activities of daily living (ADLs) such as showers or toileting and would sometimes refuse care. Documentation to support this evidence was not found in facility progress notes. Interviews conducted with facility staff stated that caregivers would verbally report any issues found with R1’s skin to the medication technicians or to the nurses on-site. These interviews revealed that skin checks were typically done during R1’s scheduled shower days. Facility staff interviews also revealed that any updates to a resident’s care plan would be verbally reported or written down on the communication board in the medication room. Email correspondence dated August 5, 2024 revealed that the facility had a conference to discuss R1’s care. These emails stated that the facility was to implement weekly skin checks for R1 every Wednesday to ensure the integrity of their skin. Review of R1’s progress notes revealed that another care conference was conducted on 06/27/2025 where it was stated that the facility would implement skin checks for R1 on their shower days. There was no indication that R1’s weekly skin checks were to stop since their implementation in August 2024. File review showed that R1 received skin checks on the following days, 11/15/2024, 11/16/2024, 11/17/2024, 11/18/2024, 11/20/2024, 11/21/2024, 11/22/2024, and 12/06/2024. There was no additional paperwork found to document proof of skin checks being done for R1 in 2024 or 2025. Based on record review, interviews conducted, and observations made, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. 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. **Executive Director/Administrator and LPA discussed PIN 19-21-ASC: Epinephrine Auto-Injectors (EpiPen). Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights, discussed and provided to Executive Director. Signature on form confirms receipt of documents. Continued from LIC9099 Director stated that facility staff members try to respond to resident pendant calls between 7 to 10 minutes. Interviews conducted with facility staff corroborated this statement. Review of R1’s pendant response log from September 3 – September 30, 2025 showed that R1 pushed their pendant 25 times that month. Out of these 25 pendant calls, 19 pendant calls were cleared within 7-10 minutes. Based on record review and interviews conducted, this allegation is Unsubstantiated. “Resident sustained unexplained bruising while in care” – Complaint alleged that R1 sustained unexplained bruising to their back and shin. Report further stated that R1’s bruising was observed on September 26, 2025. Review of facility documents showed that on 09/18/2025, R1 was found on the floor by facility staff. Per document, R1 denied hitting their head and denied any complaints of pain. Facility staff notified R1’s responsible party and Primary Care Physician. Review of Physician Communication dated 09/18/2025 showed that facility informed R1’s primary care physician of the fall. Review of facility documents showed that on 09/25/2025, R1 was observed to have bruising on their back while having their clothes changed. Per document, R1 informed facility staff that they had fallen earlier in the day but did not report it to facility staff. Review of facility’s internal incident report dated 09/25/2025 and physician communication dated 09/25/2025 showed that R1’s responsible party and primary care physician were notified. Review of R1’s medication list dated 02/13/2025 indicated that R1 is not on any blood thinner medications. There is no additional documentation regarding R1’s skin or skin condition prior to the bruising being identified on 09/25/2025. Department is unable to determine how R1’s bruising occurred. Based on record review, this allegation is Unsubstantiated. A finding that a 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 Executive Director/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 24, 2026 · control 21-AS-20251002164141

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 25, 2026

87465 Incidental Medical and Dental Care:(a)A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: based on record review, Licensee did not comply with the section cited above and did not ensure that medication was administered to R1 as required. R1 was not administered multiple medications due to it being unavailable or awaiting refill. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 24, 2026

Plan of correction: Licensee to submit self-certification that in-service training will be conducted for all staff that administer medications by POC due date of 02/25/2026. Training to review Resident 6 rights, medication refills, and PIN 19-21-ASC. Licensee to ensure that epinephrine pens is completed. Training to include: Date, Topic, Name/Job, Role, and Signatures. Proof of completed training to be submitted by 03/31/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(7) · Plan of correction due date: Feb 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, Feb 24, 2026

Plan of correction: Licensee to submit self-certification that in-service training will be conducted for direct care staff and dining/kitchen staff by POC due date of 02/25/2026. Training to include: Date, Topic, Name/Job, Role, and Signatures. Proof of completed training to be submitted by 03/31/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Mar 9, 2026

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted...within seven days of the occurrence of any of the events specified...below. This requirement was not met as evidenced by: Licensee did not comply with section cited above. Per record review, Licensee did not submit incident reports timely. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 24, 2026

Plan of correction: Licensee to submit self-certification that training will be conducted for management and direct care staff reviewing regulation by POC due date of 03/09/2026. Training to include: Date, Topic, Name/Job Role, and Signatures. Proof of completed training to be submitted by POC due date of 03/31/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 9, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities:(a) In addition to the rights listed in Section 87468.1... residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency...this requirement was not met as evidenced by: based on record review and observations made, Licensee did not ensure that resident received weekly skin checks as agreed upon during a resident care conference.the state’s words, verbatim · CDSS document, Feb 24, 2026

Plan of correction: Licensee to submit self-certification that training will be conducted for the Care Department reviewing documentation by POC due date of 03/09/2026. Training to include the following: Date, Topic, Name/Job Role, and Signatures. Proof of completed training to be submitted by POC due date of 03/31/2026.

Allegation investigated: Staff retained a resident with a prohibited health condition Staff did not seek timely medical care for resident in care

At approximately 12:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a complaint investigation regarding the above allegations and met with Executive Director, Tracy Freudendahl, and Health and Wellness Director, Stephanie Judd. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Staff retained a resident with a prohibited health condition, and Staff did not seek timely medical care for resident in care.” Complaint alleged that Resident 1 (R1) was observed to have a wound that looked to be a Stage 3 pressure injury which was not allowed in licensed Residential Care Facilities for the Elderly (RCFEs). Per complaint, facility management became aware of the wound on 12/18/2025 and R1 was observed to still be at the facility on 12/21/2025. Complaint stated that R1’s wound had an odor, that caregivers were wearing masks because the smell was overwhelming, and that facility staff provided showers for R1, but there was no documentation Continued on LIC9099C Substantiated Continued from LIC9099 of the wound. Complainant further stated that they didn't know how or when R1's injury occurred and didn't know if R1's home health agency or primary care physician had been notified. Review of R1’s progress notes showed that on 12/17/2025, facility caregivers observed that R1 had a big wound on their bottom. These notes further stated that the wound was observed to be an open hole, that it looked very bad, and was leaking a white liquid. R1’s nursing progress notes stated the following entries: · On 12/17/2025, a late entry was inputted to note that R1’s home health agency provided wound care with no additional details. · On 12/18/2025, facility notes stated that R1’s responsible party was contacted and that R1’s home health agency was providing wound care three times per week. Per notes, facility would communicate with R1’s primary care physician regarding intervention or in-house treatment. · On 12/20/2025, a late entry was inputted to note that R1’s home health agency provided wound care with no additional details. · On 12/21/2025, the resident care director and health care coordinator contacted R1's Primary Care Physician via a fax communication. Per fax communication, facility asked for further advice as it was believed that R1 had a stage 3 pressure wound and they wanted an update on R1’s hospice referral. Review of R1’s physician fax communication for 12/21/2025 stated that R1 had a wound that appeared to be a Stage 3 and that it was getting worse even though R1 had been receiving home health services. Fax further requested for a status update on R1’s hospice referral as being a licensed facility meant that R1 would need to be receiving hospice services if the facility were to retain a resident with a Stage 3 wound. Interview conducted with Resident Care Director (RCD) revealed that on 12/22/2025, emergency personnel (EMS) arrived at the facility to send R1 to the hospital. Per RCD, no one at the facility contacted EMS on 12/22/2025 and emergency personnel informed them that they received an anonymous phone call for R1. The Department observed that the facility did not request or submit any documentation for an exception for R1 to stay at the facility once it was believed that R1 could have had a stage 3 pressure injury on 12/21/2025. Review of R1's medical records showed that R1 was diagnosed with a Stage 4 pressure injury on 12/22/2025. Continued on LIC9099C Continued from LIC9099 Based on interviews conducted, record review, and observations made, these allegations are Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. 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. **An immediate Civil Penalty in the total amount of $500 has been issued for not seeking timely medical care (See LIC-421IM). An additional civil penalty may be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).** Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights, discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 3, 2026 · control 21-AS-20251222134309

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Feb 4, 2026

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes...and that appropriate assistance is provided...This requirement was not met as evidenced by: based on records, interviews and observations, Licensee did not ensure that Resident 1 (R1) received timely medical care. R1's pressure injury was observed to be a big hole, very bad looking, and was leaking a white liquid on 12/17/25. R1 did not receive medical care until 12/22/25. This poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Licensee to submit self-certification that in-service training will be conducted reviewing the regulation, 87466 Observation of the Resident. Self-Certification to be submitted by POC due date of 02/04/2026. Training to include the following: Date, Topic, Job Role, Staff Names, and Signatures. Training and supporting documents to be submitted to CCL for review and approval by POC due date of 03/03/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87616(a) · Plan of correction due date: Feb 16, 2026

87616 Exceptions for Health Conditions (a) ...the licensee may submit a written exception request if he/she agrees that the resident has a prohibited... health condition but believes that the intent of the law can be met through alternative means. This requirement was not met as evidenced by: based on record review, interviews, and observations, Licensee did not submit the proper paperwork to Community Care Licensing once it was believed that R1 had a Stage 3 wound. R1 was then diagnosed with a Stage 4 wound. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Licensee to provide a written plan to CCL outlining their intended training schedule. Plan to be submitted by POC due date of 02/16/2026. In-service training for all direct staff on the following regulations: 87616 Exceptions for Health Conditions and 87615 Prohibited Health Conditions. Training to Training to include the following: Date, Topic, Job Role, Staff Names, and Signatures. Training and supporting documents to be submitted toCCL for review and approval by POC due date of 03/03/2026.

Allegation investigated: Staff did not follow reporting requirements

At approximately 8:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a complaint investigation regarding the above allegation and met with Executive Director, Tracy Freudendahl. During the course of the investigation, the Department requested and reviewed documents and made observations. The following allegation was investigated, "Staff did not follow reporting requirements." Complaint alleged that Resident 1's (R1's) responsible party was not notified of a fall that resulted in R1 going to the hospital. Report stated that R1 had a fall on 10/31/2025 and that the responsible party was not notified until 11/03/2025 when they visited the facility and was handed a written report by facility staff. Report further states that the responsible party's phone number was called but a voicemail was not left and therefore does not consitute as a notification. Continued on LIC9099C Unsubstantiated Continued from LIC9099 Per Title 22 Regulations, Reporting Requirements, 87211(a)(1), "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days..." Review of R1's facility documents showed that an incident report submitted to the Santa Rosa Regional Office (SRRO) on 11/05/2025 which stated that on 10/31/2025, R1 was found on the floor with a cut on their cheek. Emergency personnel was contacted and R1 was transported to the hospital for further evaluation. Report also states that R1's emergency contact was notified. Facility documentation also showed that R1's responsible party was contacted on 10/31/2025 at 5:44AM via telephone. Text message correspondence provided to the Department also showed that on 11/03/2025, R1's responsible party was informed that R1 did have a fall and that facility staff called. Review showed that facility notified R1's responsible party within the regulation's time frame of seven days, as a written report was also provided on 11/03/2025 which was three days after the incident occurred. Based on record review and observations made, this allegation is Unsubstantiated. A finding that a 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 Executive Director/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 23, 2026 · control 21-AS-20251104150332

Allegation investigated: Resident sustained an unexplained injury while in care. Staff did not report an incident involving resident as necessary.

At approximately 3:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with met with Executive Director/Administrator, Angie Boucher-Turin. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation that “Resident sustained an unexplained injury while in care, and “Staff did not report an incident involving resident as necessary.” Complainant alleged that Resident 1 (R1) was subjected to physical abuse by facility staff while residing at the facility and that R1’s responsible party was not notified of an incident that occurred in April 2023. Additional information from Complainant stated that R1 had been isolating in their room due to testing positive for COVID-19 and was found to have a broken femur after they went to the emergency room. Complainant also stated that emergency room physician suspected abuse based on their observations of R1’s injury at the hospital. Continued on LIC9099 Unsubstantiated Continued from LIC9099 Community Care Licensing (CCL) received an incident report on 04/14/2023. Report stated that on 04/13/2023, R1 was observed by facility staff to have swollen feet and skin discoloration on their right leg. Per report received, facility staff notified R1’s responsible party via phone call and contacted Emergency Services for further evaluation. Facility progress note stated that on 04/13/2023, facility staff observed R1’s knee to be swollen and bruised, and when touched, R1 exhibited pain. Progress note also stated that facility staff notified R1’s responsible party and sent a text message of their observations to the responsible party and contacted emergency services. Review of documentation showed that R1 did not have an SOC-341 or abuse report filed in April 2023 by the hospital or other entities. Interview conducted with Witness 1 (W1) revealed that facility protocol is to contact the resident’s primary responsible party. If the primary responsible party is unavailable, then the facility is to contact the secondary responsible party. W1 was unable to recall any additional details of R1’s incident. Interview conducted with Witness 2 (W2) did not reveal any additional information as they were unable to recall details of R1’s incident. Facility documentation indicated that facility maintenance Director reviewed the video camera system and did not observe R1 to have a fall. LPA was unable to review the video footage as the facility camera system only archives up to 90 days and the incident occurred on April 13, 2023. Due to lack of evidence, the Department is unable to determine if there was a violation of Title 22 Regulation, therefore, 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. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 21-AS-20250224112540

Type of visit: Case Management - Other

At approximately 3:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other Visit and met with Executive Director, Angie Boucher-Turin. The purpose of the visit is to deliver an "Order to Licensee/Facility of Immediate Exclusion From Facility" notice for Staff Member 1 (S1). On 06/05/2025, the Department delivered an "immediate exclusion" notice to facility. Per notice, S1 cannot be allowed to work, be present and/or live in a CCL licensed facility, or have contact with clients in any residential facility or child day care licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Administrator stated they understood the notice. No Deficiencies Cited during visit. Exit interview conducted. Copy of report and Confidential Names (LIC811) discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 5, 2025

Type of visit: Required - 1 Year

At approximately 9:10AM, Licensing Program Analysts (LPAs) Deniz and Felias arrived unannounced to conduct a 1-Year Required Visit and met with Administrator/Executive Director, Angie Boucher-Turin. Facility serves older adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has a total capacity for 160 residents and an approved fire clearance for 130 non-ambulatory residents, of which 40 residents can be bedridden. Facility has an approved hospice waiver for 20 individuals. Upon arrival, LPA was informed that there were 112 Residents in care and 29 staff members on-site. At approximately 9:50AM, LPAs reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 10:00AM, LPAs conducted a walk-though of the facility with Maintenance Assistant Eddie. LPAs observed the following: Facility is a 3-story building for Assisted Living and Memory Care. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for a sample size of 13 sinks were found to be within Title 22 Regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected November 2024. Facility's fire and sprinkler system was last inspected March 2024. The next annual inspection is scheduled for next week, March 10, 2025. Facility's last emergency/disaster drill was conducted March 2025. Continued on LIC809 C… Continued from LIC 809… At approximately 12:00PM, LPAs reviewed 8 staff files. Files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. LPAs reviewed a sample size of 8 resident files and 6 resident medications. Resident files were found to be well organized, thorough and contained the required documentation. Medication was centrally stored and secure. During medication log review, LPAs observed that some medication date entries made by pharmacy were incorrectly logged. Per discussion with Administrator, facility is in the process of changing their pharmacy. Administrator's Certificate for Angela Boucher-Turin (7001386740) is current with an expiration date of 11/11/2025. No Deficiencies Cited during visit. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC610E- Disaster Plan Evidence of Liability Insurance 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, Mar 4, 2025

Type of visit: Case Management - Incident

At approximately 1:40PM, Licensing Program Analysts (LPAs) Felias and Deniz arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director/Administrator, Angie Boucher-Turin. The purpose of the visit was to follow up on documentation for a case management visit that was conducted on 11/22/2024. On 11/22/2024, LPA conducted a case management visit regarding self-submitted incident reports. During visit, LPA followed up on a report regarding missing medications. It was identified that the missing medications were narcotics and the facility was in the process of conducting an internal investigation and working alongside San Rafael Police. Per discussion with Executive Director the facility conducted the following: an internal investigation, a medication audit and a narcotic count which was conducted alongside a Nurse Consultant. San Rafael Police were also contacted to conduct their own investigation. LPAs obtained additional documentation related to the incident. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 29, 2025

Type of visit: Case Management - Incident

At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director/Administrator, Angie Boucher-Turin. The purpose of the visit was to follow up self-reported incidents that were submitted to Community Care Licensing (CCL). The Santa Rosa Regional Office (SRRO) received 9 late incident reports from the facility. Review of reports showed that incidents occurred on the following dates: 10/28/2024, 10/29/2024, 10/31/2024, 11/01/2024, and 11/03/2024. Reports were received by the SRRO on 11/12/2024. During LPA's visit, LPA discovered that Staff Member 1 (S1) did not submit the reports timely and that the Executive Director submitted the incident reports. Per Title 22 Regulations, incident reports must be submitted to CCL within seven (7) days of the incident occurring (deficiency cited, LIC809D, Regulation 87211(a)(1)). LPA followed up on the following incidents: Incident Report 1/SOC341: CCL received an incident report and SOC341 on 10/17/2024. Reports state that on 10/17/2024, Resident 1's (R1) family notified facility management of interactions between a facility staff member and Resident 1. Per R1's family, R1 stated to them that Staff Member 2 (S2) kissed them on two separate occasions. Facility made all appropriate notifications per regulation. Incident Report 2/SOC341: CCL received an incident report and SOC341 on 11/13/2024. Reports state that on 11/12/2024, facility management was informed by Staff Member 3 (S3) that they observed Staff Member 4 (S4) pinch Resident 2's (R2) nose and raise a hand towards them. Per report, the incident occurred 2 months prior. Facility made all appropriate notifications per regulation. Incident Report 3: CCL received an incident report on 11/20/2024. Reports state that on 11/18/2024, facility staff notified Executive Director that a former resident's medication was missing. Per report, the missing medications were discovered on 11/18/2024. Facility made all appropriate notifications per regulation. Continued on LIC809C Continued from LIC809 Per discussion with ED, internal investigations are ongoing and they have been in contact with the San Rafael Police Department regarding the incidents. LPA requested and reviewed documents, and conducted interviews. 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, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 22, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Dec 2, 2024

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted...within seven days of the occurrence of any of the events specified...below. This requirement was not met as evidenced by: Licensee did not comply with section cited above. Per record review, Licensee did not submit incident reports timely. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 22, 2024

Plan of correction: Licensee to submit Inservice Training for management and direct care staff. Training to include the following: Date, Topic, Name/Job Role, and Signatures. Training to be submitted tp CCL by POC due date of 12/02/2024.

Type of visit: Case Management - Incident

At approximately 1:40PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director/Administrator, Angie Boucher-Turin. The purpose of the visit was to follow up a self-reported incident that were submitted to Community Care Licensing (CCL). Incident Report 1: CCL received an incident report report on 09/13/2024. Reports state that on 09/11/2024, Resident 1 (R1) choked on a piece of food and turned pale. Facility staff administered Heimlich Maneuver and contacted emergency personnel for evaluation. Facility made all appropriate notifications per regulation. Per Executive Director, R1 has been observed to be at baseline and has no changes to their dietary needs. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 7, 2024

Allegation investigated: Staff was unaware of resident’s change of condition Staff are mismanaging resident’s medications

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Executive Director/Administrator, Angie Boucher-Turin. During the course of the Investigation, LPA requested and reviewed documents, conducted interviews, and made observations. There is an allegation that Staff were not aware of resident’s change in condition. Per Complainant, Resident 1 (R1) asked to be left outside so they could die. Complainant stated that they notified the facility of the conversation and the facility contacted emergency personnel. Complainant stated that R1 left with emergency personnel to be evaluated and had concerns since R1 no longer had a primary care physician or psychiatrist. Complainant also stated that R1 complained of stomach pain that would not go away and had trouble sleeping. Complainant was unable to state if R1 notified the facility of their stomach pain and of their trouble sleeping. Further discussion with the Complainant stated that they did not have Continued on LIC9099C Unfounded Continued from LIC9099 concerns with the facility and instead had concerns with other medical entities. Review of facility documents showed that R1 is their own responsible party, is independent of their care needs, and can communicate their needs. Review of Incident Report dated 06/17/2024, stated that R1 notified facility staff that they were having symptoms of shortness of breath, a burning sensation in their stomach, and increased anxiety. Review of Incident Report dated 06/18/2024 stated that facility staff was notified that R1 was having a mental health crisis. Reports showed that for both incidents, facility staff contacted emergency personnel to evaluate R1, and notified all appropriate parties per Title 22 Regulations. There is an allegation that staff are mismanaging resident’s medications. Complainant alleges that R1 is in distress and does not have access to their medication. Review of R1’s Physician’s Report dated 01/25/2019, and Resident Care Plan dated 01/07/2024, stated that R1 is able to manage and store their own medications. Based on review of documents, interviews conducted, and observations made, these allegations are Unfounded. A finding that the complaint is UNFOUNDED means that the allegation is false, could not have happened, and/or is without a reasonable basis. No Deficiencies Cited during visit. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 19, 2024 · control 21-AS-20240612092722

Type of visit: Case Management - Annual Continuation

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a 1-Year Required Visit and met with Administrator/Executive Director, Angie Boucher-Turin. Facility serves older adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has a total capacity for 160 residents and an approved fire clearance for 130 non-ambulatory residents, of which 40 residents can be bedridden. Facility has an approved hospice waiver for 20 individuals. Upon arrival, LPA was informed that there were 119 Residents in care. LPA reviewed a sample size of 10 resident files and 6 resident medications. Resident files were found to be well organized, thorough and contained the required documentation. Medication was centrally stored and secure. No Deficiencies Cited during visit. 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, Jun 20, 2024

Type of visit: Required - 1 Year

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Administrator/Executive Director, Angie Boucher-Turin. Facility serves older adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has a total capacity for 160 residents and an approved fire clearance for 130 non-ambulatory residents, of which 40 residents can be bedridden. Facility has an approved hospice waiver for 20 individuals. Upon arrival, LPA was informed that there were 117 Residents in care and 29 staff members on-site. At approximately 9:20AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 9:50AM, LPA conducted a walk-though of the facility with Maintenance Director. LPA observed the following: Facility is a 3 story building for Assisted Living and Memory Care. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. 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 November 2023. Facility's fire and sprinkler system was last inspected December 2023. Facility's last emergency/disaster drill was conducted March 2024. At approximately 12:00PM, LPA reviewed staff files. Files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Administrator's Certificate for Angela Boucher-Turin (7001386740) is current with an expiration date of 11/11/2025. 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 Administrator/Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 26, 2024