Aegis Living Corte Madera

Type of visit: Required - 1 Year

At approximately 9:05AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1 year required visit and met with Administrator, Eugene Pascual, and Executive Director, Terry Bechtold. 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 150 residents and an approved fire clearance for 150 non-ambulatory residents, of which 35 residents can be bedridden. Facility has an approved hospice waiver for 25 individuals. Upon arrival, LPA was informed that there were 118 Residents in care and 47 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 Administrator and Executive Director and observed the following: Facility is a 2-story building for Assisted Living and Memory Care. Facility's Memory Care consists of two areas - Lee's Lane and Hogan's Court. 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 7 of 10 sinks were found to be out of compliance with Title 22 Regulations, measuring at 125.6F, 125.2F, 122.5F, 123.0F, 121.8F, 120.3F, 120.2F. Facility's fire extinguishers and smoke and carbon monoxide detectors were last inspected January 2026. Facility's fire and sprinkler system was last inspected June 2025. Continued on LIC809C Continued LIC809C Facility's emergency disaster plan was last reviewed and updated on 10/15/2025. Facility's infection control plan was last reviewed and updated 01/05/2026. Facility was observed to have enough water available in the event facility had to shelter in place for 72 hours. Facility's last emergency disaster drill was conducted April 2026. LPA observed that facility only conducted emergency disaster drill for the morning shift. Facility was unable to provide proof that drill was conducted for evening and overnight shifts. LPA discussed the importance of ensuring that all shifts receive the emergency disaster drill training every quarter. During walkthrough, LPA observed a carton of expired yogurt located in the dining room fridge of Lee's Lane Memory Care. Executive Director disposed of the item. LPA, Administrator, and Executive Director also observed medications in two resident rooms. LPA and Administrator confirmed with Facility's Wellness Director that these two residents are receiving assistance with medications and therefore their medications should be centrally stored. Administrator's Certificate Terry Bechtold (6079066740) was current with an expiration of 10/02/2027, Administrator's Certificate for Eugene Pascual (7037022740) was shown to be pending, with an application received date of 04/08/2026. LPA began staff file review. LPA discussed the following with Administrator and Executive 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 Administrator and Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 5, 2026

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

At approximately 11:10 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management visit and met with Administrator, Eugene Pascual and Health Services Director, Tosha Chowdory. Today's visit was in regards to two (2) Incident Reports (IRs) for Resident 1 (R1) and for Resident 2 (R2) submitted to Community Care Licensing (CCL) by the facility. The IR for resident R1 states that on 2/25/2026, while being transferred by one (1) staff member (S1) resident R1 fell. Facility Progress Notes for resident R1 indicate that they did not directly fall, but instead was lowered to the ground by staff member S1. Paramedics were called and resident R1 was taken to a local hospital. Resident R1 did not suffer any fractures as a result of this incident. Resident R1's Individualized Service Plan states that two (2) staff members are needed to assist transferring resident R1. As the facility did not follow residents R1's Individualized Service Plan, the facility will be cited for this deficiency. During today's visit, LPA was informed that staff members carry phones that show in the individual care needs of each resident to whom they are assigned. On 2/26/2026 the facility conducted Care Plan training to reiterate to staff members that they need to review residents care needs and to follow the Individualized Service Plans of residents. As a result of this incident, staff member S1's employment with the facility was terminated. As the facility has already conducted Care Plan training, the deficiency will be cleared during today's visit. The IR for Resident R2 states that on 2/17/2026, resident R2 was mistakenly given the wrong medications. At 7:00 AM, staff member S2 was preparing medications for the morning medication pass. They put medications for a third (3) resident (R3) in a cup for dispensing. Staff member S2 then realized that resident R3 had left the facility for a doctors appointment. Staff member S2 contacted the family member escorting resident R3 to their doctors appointment. The family member asked that the medications be held until resident R3 returned to the facility. Continued on 809-C... ...Continued from 809 At approximately 2:00 PM, resident R2 requested their normal afternoon medications. Staff member S2 then proceeded to add resident R2's medications to cup that contained resident R3's missed morning medications. As a result of this error, resident R2 mistakenly took medications intended for resident R3. The facility immediately had resident R2 assessed by a Registered Nurse and placed resident R2 on alert charting with hourly checks of vital signs. R2's emergency contacts were notified. Additionally, the facility's Medical Director (a licensed Medical Doctor) was on site and they also monitored R2's condition. Resident R2 was kept on alert charting for 72 hours. Resident R2 suffered no adverse effects of the medication error. The facility will be cited for this medication error. The facility took disciplinary action against staff member S2. Staff member S2 also underwent four (4) days of retraining and shadowing the lead Medical Technician (Med Tech). Additionally, all the facility's Med Techs underwent Medication Policy training. As this disciplinary step and retraining was already completed, the deficiency will be cleared during today's visit. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809Ds, Plan of Corrections, 811 Confidential Names, Appeal Rights and Letters of Deficiency Citations Cleared discussed and provided to Administrator Pascual. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 10, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 11, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights...: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are...to meet their needs. This requirement is not met as evidenced by: Based on interview & record review, the licensee did not comply with the section cited above in that R1's Individualized Service Plan was not followed when R1 was transferred by only one (1) staff member which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 10, 2026

Plan of correction: Licensee or Administrator to conduct Care Plan training for staff members to reiterate that residents' Individualized Service Plans be followed and to submit proof of training to Community Care Licensing by POC due date of 3/11/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 11, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical... shall be developed...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interview & record review, the licensee did not comply with the section cited above in that medications for resident R3 were given to resident R2, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 10, 2026

Plan of correction: Licensee or Administrator to conduct Medication Policy training for the facility's Medical Technicians and submit proof of training to Community Care Licensing by POC due dater of 3/11/2026.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management - Incident Visit and met with Terry Bechtold, Executive Director (ED) & (HSD) Health Services Director, Tosha Chowdory. The purpose of the visit was to follow up on two self-report incidents submitted to Community Care Licensing (CCL). On 12/26/25 the department received the first incident report notifying about resident (R1) who on 12/20/25 was admitted to the hospital after their responsible party transported them to the hospital for further evaluation due to pain. On 1/27/26 a second incident report was received at CCL reporting that on 1/22/26 R1 was found on the toilet of their bathroom shaking, vomiting and screaming in pain. Staff called 911 and paramedics arrived, R1 was given pain medication through IV and they transported R1 to the emergency room for further evaluation. Responsible parties were notified. Per incident report, R1 had some imaging and testing done, which indicated a diagnosis of uncontrolled pain secondary to fractured hip, then R1 had surgery on 1/23/26 to repair their hip. Upon discharge from the hospital, R1 will have to go to a skilled nursing for rehabilitation. During today's visit, LPA learned through a conversation with HSD and ED that R1 had a fall outside of the community back in December while walking with their private companion. At that time, there were no complaints of pain until days later, R1 complained of pain in their hip, and their physician was waiting on an opening to schedule a surgery. Continued on LIC809C... Continued from LIC809... Based on records review, the facility provided internal incident report dated 12/1/25 at 1:15pm, there was an incident documented for R1 who had a witnessed fall off the community property while walking with their companion. According to the description of the incident, companion stated that R1 fell onto the ground more on right wrist and caught themselves from hitting ground, but did graze their upper lip. After the fall they spent few hours at R1's house. The assessment was performed by the facility indicating skin tear of R1's right wrist, which did not require any emergency services. R1 was added to the alert chart and incident was documented in the resident's progress notes. LPA reviewed R1's progress notes that confirmed there were no complaints of pain at the time of assessment. However, on 12/15/25 R1 complained of right hip pain, the facility notified their physician who prescribed Lidocaine patch, but pain increased through the days affecting their mobility. R1's responsible party requested the facility that they prefer not to send R1 to the emergency room because they were under the impression that they could mange their pain with medication and they did not want to cause any distress to R1 due to their progressed dementia. Although, R1's physician instructed the facility to send R1 to the hospital for pain management. On 1/2/26, R1 returned to the community requiring a higher level of care until they undergo surgery. Their diagnoses confirmed a status of post advanced degenerative arthritis of the right hip with pain, fracture of the right femur, fracture of the left wrist, Alzheimer disease and depression. The facility updated R1's care plan accordingly, care managers were updated of R1's higher care needs including behavioral expressions like impulsiveness and consistency of forgetfulness by not asking for assistance. On 1/27/26, R1's physician notified the facility that R1 had an insufficiency fracture as a reason why they did not perform surgery right away. On 1/28/26, R1 had a total hip replacement and they might have to go to skilled nursing for at least a couple weeks until returning to the community. Based on records review and interviews with facility staff, it was determined that the facility followed up their protocol. No deficiencies were cited during today's case management visit. Exit interview was conducted and a copy of this report was given to the Executive Director.the state’s words, verbatim · CDSS document, Jan 29, 2026

Type of visit: Case Management - Deficiencies

At approximately 12:50 PM, Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator/BOM Eugene Pascual, Executive Director, Terry Bechtold, & (HSD) Health Services Director, Tosha Chowdory. The purpose of the visit was to follow up on 3 self-reported incidents submitted to Community Care Licensing (CCL). On 8/29/2025 CCL received 3 unusual incident reports regarding 3 different residents (R1)(R2)(R3) who missed some of their medications : (R1) 8/21- 24/2025, (R2) 8/21-25/2025, & (R3) 8/22-25/2025 due to not arriving in pharmacy routine cycle. Per conversation with HSD on 8/19/25 facility received monthly medications for residents finding 25 residents missing medications, contacted pharmacy requesting missing medications. Cycle starts on 8/21/25 and most of the missing medications had arrived. Staff did not notice the 3 residents still missing medications or notify doctor, hospice, or family until 8/24 & 8/25. Residents were put on 72 hour monitoring, none were observed to have any adverse side effects. Retraining on cycle fills and reordering process to ensure timely and accurate medication management was conducted. Nursing to now follow up on all pharmacy communication along with a medication refill binder has been implemented for review at each shift change. LPA obtained new plan, disciplinary action, & training at visit. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights providedthe state’s words, verbatim · CDSS document, Sep 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(5) · Plan of correction due date: Sep 19, 2025

87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by: Based on record review and interview with HSD, the facility did not ensure R1, R2, & R3’s medications were given as prescribed by doctor as pharmacy did not send monthly refills on time which is also a pharmacy error which poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Sep 18, 2025

Plan of correction: LPA obtained investigation along with disciplinary action. LPA also obtained medical staff retraining on the cycle fill and reordering process of medications. Deficiency cleared at visit.

Type of visit: Case Management - Deficiencies

At approximately 9:00 AM, Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management - Incident Visit and met with General Manager, William Phelps. The purpose of the visit was to follow up on self-reported incident that was submitted to Community Care Licensing (CCL). CCL received an incident report on 04/28/2025. The report stated that on 04/25/2025, Resident (R1), who has a diagnosis of dementia and is unable to leave facility unassisted, eloped from community at approximately 7:20 PM, by exiting through side/delayed egress gate out of memory care courtyard as it had been unlocked by maintenance department, staff (S1) for landscaping and did not re-lock and the alarm never went off to alert care managers. At approximately 7:30 PM, R1 was observed by staff on their way to work, laying on the ground as emergency medical was arriving and transported R1 to hospital returning same night with minor injuries; PCP and family were notified. LPA was provided; staff signed training for elopements, plan to keep residents safe from future risk, and investigation documents. Per R1’s Physician’s Report (LIC602) R1 is diagnosed with dementia and is unable to leave the facility unassisted. (Deficiency cited) This is the 3rd incident a resident has eloped from the memory care unity from facility: 1/30/2024 & from the memory care courtyard gate on 9/19/2024. Civil Penalty for $500.00 was issued during today's visit for Zero Tolerance, Absence of Supervision. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, May 20, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 21, 2025

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by: Based on incident report and interview, facility did not provide supervision to R1 resulting in an elopement. The absence/lack of supervision is an immediate risk to the Health, Safety and Rights of resident in carethe state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: On 4/28/2025 GM submitted in-service training for staff (signed & dated) of elopement procedures. Lock box for access key installed in facility; access to exit memory courtyard gates now only to Med care mgrs.... & Maintenance staff. Sign above lock “Whoever unlocks the gates must stay and re-arm device”, failure to do so will result in termination. ****A civil penalty is being assessed for $500.00 POC cleared at time of visit

Type of visit: Required - 1 Year

License Program Analyst (LPA) Shannan Hansen arrived at facility to conduct an unannounced annual inspection and was greeted by Bill Phelps, Interim Administrator. Facility is 2 stories with 84 AL apartments & 2 memory care units totaling 34 apartments. Fire clearance has been approved for 150 non-ambulatory residents, of which 35 may be bedridden, by the County Fire Department. There is currently a total of 121 residents, of which 33 are living in memory care, and 13 residents under Hospice care. Facility tour/inspection began at 9:00 AM: LPA toured the community with Interim Administrator. The tour of the facility included 15 resident apartments, activity rooms, Library, Salon, dining rooms, kitchen and outdoor patios. All interior parts of the facility were found to be a comfortable temperature measuring between 75 to 78 degrees F. Exits and pathways were free from obstructions. The assisted living residents also have an outdoor patio courtyard. Delayed egress doors from the memory care units (Lee’s Lane & Hogan’s Court) have audible alarms when doors are opened without access codes. Hot water temperature in 15 total rooms of AL & MC measured between 112.8 degrees F to 132 degrees F. with 14 rooms not within regulation of 105 to 120 degrees F. Temperature immediately turned down and per Administrator, plumber was contacted to assess issue following day (see LIC 809D) Resident bathrooms had required slip resistant mats and grab bars. While touring facility at approximately 9:36 AM to 11:00 AM LPA and Interim Administrator observed 4 storage closets ( in MC & AL) unlocked containing multiple gallons of paint, toxic chemicals, cement, cleaning products (see pic & LIC 809-D), staff locked doors. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for residents in care. Food was found to be handled and stored in a safe manner. Dining rooms and kitchen were inspected and maintained per regulation. Menus with snack and beverages are available to residents. Activity schedules are posted. Facility has a theater and multiple indoor and outdoor sitting areas and a private dining area. Continued on LIC809C Continued from LIC809: Fire extinguishers were last serviced 1/8/2025. Fire safety system including smoke detectors and carbon monoxide detectors and sprinklers were last tested by Central Marin Fire Dept. on 11/13/2023 having a 5 year check next due 2026. Fire department conducted Kitchen inspection 2/2/2025 which fully passed along with the elevator. Disaster drills are conducted quarterly with the last being 3/7/2025. Facility has a permanently installed generator to power entire facility should there be a power outage. At approximately 12:30 AM, LPA reviewed 10 resident records and found 10 of 10 residents have current physician's reports and updated care plans. 10 of 10 records contained current and signed admission agreements and medication records are thorough and contained physician's orders for each resident. LPA reviewed centrally stored medication record and found to be in compliance. At approximately 1:45 PM, LPA reviewed 10 staff records. All records contained documentation of completed training as required. Evidence of current first aid and CPR training were present for required staff. All staff had required criminal record clearance and were associated. Rabah Sbaitan Administrator Certificate 6071494740 expires 7/24/2026. LPA observed Interim Administrator William Phelps Administrator Certificate pending. All fees are current. CCL had not received any incident reports since 3/3/2025 & inquired. LPA was presented with 6 Incident Reports, one a Death Report that occurred from 3/9/2025 to 4/18/2025 that are to be submitted within seven (7) days. Interim Administrator advised staff to send by fax manually as there must be a problem with the machine (see LIC809-D). Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.. LPA Hansen is requesting Licensee to update and submit the following documents by 5/9/2025 to SRRO: LIC 308 Designation of Facility Responsibility LIC 610 Emergency Disaster Plan (if changes) Copy of current Lease Copy of Administrator Certificate Proof of Liability Insurancethe state’s words, verbatim · CDSS document, Apr 24, 2025

Type of visit: Case Management - Incident

On November 6, 2024, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Case Management visit in response to a self-reported incident report and met with Rabah Abusbaitan, Administrator. On October 30, 2024 the Santa Rosa Regional Office received a self-reported incident report reporting resident (R1) in memory care made statements that R1 was raped. LPA requested documentation. LPA verified that local police department, responsible party and Ombudsman were notified. Administrator stated that an exam by doctor was declined by responsible party. No citations issued.the state’s words, verbatim · CDSS document, Nov 6, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hansen arrived unannounced at facility to conduct a case management and met with Tosha Chowdory, Health Services Director & Rabah Abusbaitan, Administrator. The purpose of this case management inspection is to follow up on a self-reported incident report submitted to Community Care Licensing (CCL). On 9/24/2024 CCL received an incident report form reporting on 9/19/2024 at approximately 7:30pm resident in the assisted living observed resident (R1) had eloped from community. At approximately 8:00 PM facility received a call R1 was located next door at grocery store, approximately 30 minutes later. Investigation revealed R1 left through side gate of facility memory care unit after landscaping company left gate open. R1 assessed at return to facility no injuries and vitals noted. LPA obtained records indicating R1 has diagnosis of dementia and is not to leave facility unassisted and exit seeks. Appeal Rights Given The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Sep 26, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Sep 27, 2024

87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. Not met as evidence by** Based on record review it was found that resident (R1) had been reported by facility to be missing from facility care. R1 is diagnosed with dementia and based upon Physicians Report, requires special supervision for confusion and wander risk. This is an immediate health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Facility provided Elopement in-service training conducted, for regulation 87705 Care of Persons with Dementia with staff. In addition, a plan of how residents in Memory Care will be kept safe from wandering when landscaping company cuts grass. LPA Obtained copy of trainings w signatures and dates. Including, new plan for days when gardeners come. Citation cleared at visit....

Allegation investigated: Staff did not ensure medication was dispensed as prescribed

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegation and met with Rabah Sbaitan, General Manager. Staff did not ensure medication was dispensed as prescribed – Complainant alleges resident (R1)’s nebulizer was broken making staff unable to provide liquid albuterol treatment and when the resident was questioned, they stated they didn’t remember because it had been so long. Per review of Medication Administration Records (MAR) and interviews conducted indicated, resident was given nebulizer treatment as prescribed. Per interview with staff (S1) they experienced functional issues with the nebulizer but determined this nebulizer functioned differently than others they had used. S1 was able to figure out how nebulizer worked and provided treatment per doctors’ orders. No further issues noted. Continue on LIC9099-C Unsubstantiated R1 was admitted on 4/17/2024, responsible party provided nebulizer to facility on 4/18/2024, which was reported to be functioning. On 4/19/2024 LPA was informed issues with device and doctor contacted and provided order for new machine. Per interview with staff at another licensed facility where resident now resides, S2 initially believed the device was not functioning properly until a medication technician was able to get it to operate. Based on LPAs interviews with staff, complainant, and documents obtained, LPA was unable to either prove or disprove staff did not ensure medication was dispensed as prescribed. Therefore, the allegation is Unsubstantiated. Although the allegation above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.the state’s words, verbatim · CDSS document, May 9, 2024 · control 21-AS-20240422101726

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Shannan Hansen was at facility opening a complaint and conducted a Case Management for the purpose of following up on a self reported incident report submitted to Community Care Licensing (CCL). LPA met with Rabah Sbaitan, General Manager & Divinder Singh, Health Services Director. On 4/22/2024 CCL received a self reported incident report indicating on 4/18/2024 facility conducted a medication review and it was revealed that on 4/9/2024 resident (R1) received 1 tablet of Clonazepam (1mg) instead of the prescribed 2 tablets. No adverse effects observed, all required parties notified. LPA obtained, investigation and disciplinary actions for staff. On 6/15/2023 LPA conducted a case management and cited facility for medication errors following regulation 87465(a)(5) and on 4/3/2024 LPA conducted a case management of facility and cited for two self-reported medication errors and assessed civil penalties to facility for repeat violations in less than 12 months for same regulation. LPA is issuing a citation today for medication errors and Civil Penalties for a 3rd repeat violation in less than 12 months. Citation issued during visit. ****Civil Penalties are being assessed in the amount of $1000 due to a third repeat citation issued for the same section 87465(a)(5) Incidental Medical and Dental Care Services. in less than 12 months. Deficiency last cited on 6/15/2023 & 4/3/2024. *******Total Civil Penalties being given today $1,000.00 The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights providedthe state’s words, verbatim · CDSS document, Apr 25, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Apr 26, 2024

87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by: Based on record review and interview with GM & HSD, the facility did not ensure R1 medications were given as prescribed by doctor which poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: LPA obtained investigation along with disciplinary action. LPA is requesting facility to provide name of training company by POC due date of 4/26/2024 & for LPA facility to conduct Internal medication training from person outside of organization to all staff providing ...... medication on all shifts and submit log in sheet with written staff names & signatures w/ date and signed by trainer by POC due date 5/9/2024 to clear POC. Civil Penalties for $1000 for 3rd repeat violation of same deficiency in less than 12 months.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Shannan Hansen conducted an unannounced Case Management inspection of the facility for the purpose of following up on an Order of Immediate Exclusion letter issued on February 8, 2024. Also to follow up on three self reported incident reports submitted to Community Care Licensing (CCL). LPA met with Rabah Sbaitan, General Manager. During the Case Management inspection, General Manager Rabah Sbaitan confirmed Excluded Staff Member is no longer working in the facility or residing in the facility. LPA obtained a copy of the Resident Roster, LIC 500 and the staff schedule. In addition, LPA and General Manager toured the facility. Excluded Staff Member was not seen on the premises. Based on evidence obtained during today’s Case Management Inspection, the LPA has verified Excluded Staff Member is not present, employed, or residing at the facility. Verification of removal is complete. LPA also followed up on 2 medication errors that were self-reported to community care licensing on 3/6/2024 & 3/11/2024. On 3/1/2024 it was noted by staff (S1) Resident (R1) had been given a double dosage of medication on 2/27/2024 new bubble pack opened 2/28/2024 given out of a second bubble pack. No adverse effected noted and all required parties notified. Conversation with Health Services Director (HSD) indicated facility has made changes to medication entering policies to prevent future medication errors. LPA obtained additional information regarding a medication error that occurred on 3/1/2024 when staff observing R2 holding medications in mouth noticed previous days 6 medications in medicine cup, to have been taken later on the previous day. No adverse effects observed, all required parties notified. LPA obtained in service training's, disciplinary actions for staff & investigations. Continue on LIC809-C On 6/15/2023 LPA conducted a case management and cited facility for medication errors following regulation 87465(a)(5) and again on 2/12/2024 LPA conducted a case management of facility and cited for multiple self-reported medication errors and assessed civil penalties to facility for repeat violations in less then 12 months for same regulation. LPA is issuing a citation today for medication errors and Civil Penalties for a 3rd repeat violation in less then 12 months. Citation issued during visit. ****Civil Penalties are being assessed in the amount of $250 due to a second repeat citation issued for the same section 87465(a)(5) Incidental Medical and Dental Care Services. in less than 12 months. Deficiency last cited on 2/12/2024 & 6/15/2023. *******Total Civil Penalties being given today $250.00 Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights providedthe state’s words, verbatim · CDSS document, Apr 3, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Apr 4, 2024

87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by Based on record review and interview with GM & HSD, the facility did not ensure R1-R2 medications were given as prescribed by doctor on 2 different incidents which poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Apr 3, 2024

Plan of correction: LPA obtained log of in-service trainings with signatures regarding medication handling & investigations. POC has been cleared at today's visit. Civil Penalties for $250 for repeat violation of same deficiency in less then 12 months.

Type of visit: Required - 1 Year

License Program Analyst's (LPA’s) Shannan Hansen arrived at 8:15 AM to conduct an unannounced annual inspection and was greeted by Rabah Abusbaitan, General Manager. There is a total of 102 residents, of which 23 dementia residents, and 13 residents under Hospice care. Facility tour/inspection began at 8:45 AM: LPA toured the community with General Manager and Maintenance Director Jose Herrera. The tour of the facility included nine resident apartments, activity rooms, Library, Salon, dining rooms, kitchen and outdoor patios. All interior parts of the facility were found to be a comfortable temperature measuring between 75 to 78 degrees F. Exits and pathways were free from obstructions. The assisted living residents also have an outdoor patio courtyard. Delayed egress doors from the memory care units (Lee’s Lane & Hogan’s Court) have audible alarms when doors are opened without access codes. Memory care courtyard was observed to have broken glass on ground (see pic & LIC809-D) glass was immediately removed by maintenance director. Hot water temperature measured within regulation of 105 to 120 degrees F in eight of nine rooms tested; although one memory care room did not have hot water only reaching 67 degrees F observed by LPA & General Manager at approximately 9:30 AM (see LIC 809-D), as well bathroom window was open and did not contain required screen (see pic LIC 809-D). Bathrooms contained necessary grab bars and showers contained non-slip floor/mats. While touring memory care kitchenette at approximately 9:36 AM LPA and General Manager observed a bottle of Clorox toilet bowl cleaner in unlocked cabinet (see pic & LIC 809-D), staff removed. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for residents in care. Food was found to be handled and stored in a safe manner. Dining rooms and kitchen were inspected and maintained per regulation. Menus with snack and beverages are available to residents. Activity schedules are posted. Facility has a theater and multiple indoor and outdoor sitting areas and a private dining area. Continued on LIC809C Continued from LIC809 Fire extinguishers were last serviced 1/9/2024. Fire safety system including smoke detectors and carbon monoxide detectors and sprinklers were last tested by Central Marin Fire Dept. on 11/13/2023. LPA observed multiple smoke detectors and carbon monoxide detectors functioning. Disaster drills are conducted quarterly with the last being 3/26/2024. Facility has a permanently installed generator to power entire facility should there be a power outage. At approximately 10:45 AM, LPA reviewed 5 resident records and found 5 of 5 residents have current physician's reports and care plans. 5 of 5 records contained current and signed admission agreements and medication records are thorough and contained physician's orders for each resident. LPA reviewed centrally stored medication record and found to be in compliance. At approximately 12:30 PM, LPA reviewed 5 staff records. All records contained documentation of completed training as required. Evidence of current first aid and CPR training were present for required staff. All staff had required criminal record clearance and were associated. Staff (S1)’s records did not contain required health screening or TB results (see LIC 809-D). LPA Hansen is requesting Licensee to update and submit the following documents by 4/22/2024 to SRRO: LIC 308 Designation of Facility Responsibility LIC 500 Personnel Record LIC 610 Emergency Disaster Plan (if changes) Copy of Administrator Certificate Proof of Liability Insurance Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..the state’s words, verbatim · CDSS document, Apr 3, 2024

Allegation investigated: Facility did not report incident to responsible party timely

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegation and met with Rabah Sbaitan, General Manager. Facility did not report incident to responsible party timely – Complainant alleges resident (R1) fell the morning of 12/6/2023 and the facility did not contact R1’s family for over 24 hrs regarding the incident. LPA’s interview with staff (S1) revealed once they were informed by staff, S1 called R1’s responsible party. (LPA observed personal cell phone of wellness nurse showing 1 call made to responsible party on 12/6/23). S1 also indicated they could not leave a message as the phone stated, "voice mail was full and could not accept message". Emergency Medical Services (EMS) report obtained revealed 911 was called at 11:14am on 12/6/2023 and paramedics arrived shorty after. Continue on LIC9099C Unsubstantiated Paramedics found R1 sitting in a chair with care staff. R1 denied falling or hip pain. EMS assessment revealed hips and pelvis feel intact and firm, no obvious signs of broken bones or dislocation and R1 able to bare weight with walker. R1 denied any other pain. R1 advised an ambulance was on scene and transport could be conducted to ER. R1 understood this but did not want ambulance transport but wanted to take pain meds and rest at facility. Attempts to contact R1’s daughter via phone were unsuccessful. Facility care notes revealed on the following day (12/7/2023) at approximately 11:10am private 1:1 reported to nurse R1 was experiencing pain in left hip, nurse assessed and agreed at which point, 1:1 contacted family with nurse present and decided to call 911 again, sending R1 to hospital. Self reported incident submitted to community care licensing on 12/13/2023 revealed R1 diagnosed with closed dislocation of left hip and returned to facility same day. Former Administrator indicated, the facility Plan of Operations (POO's) does not state any specific time frame at which staff needs to contact the family etc. of an incident other than as soon as possible and within Regulations. Based on LPAs interviews with staff, complainant, and documents obtained, LPA was unable to either prove or disprove facility did not report incident to responsible party timely. Therefore, the allegation is Unsubstantiated. Although the allegation above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.the state’s words, verbatim · CDSS document, Feb 12, 2024 · control 21-AS-20231208162004

Allegation investigated: Facility staff did not safeguard resident’s personal belongings

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegation and met with Rabah Sbaitan, General Manager. Facility staff did not safeguard resident’s personal belongings – Complainant alleges resident (R1)’s gold necklace with pendant went missing after hospital visit 6/2022 and reported to general manager, then in 9/2023 R1’s watch went missing. R1s’ Personal Property Inventory documents obtained from move in singed and dated by POA 6/13/2014 indicates “Items to be inventoried will be listed on form LIC 621, signed, and dated by all parties. A copy of the inventories will be provided to all parties. If no inventory is desired, the resident or responsible party will write “waived” on the LIC 621 form, and sign & date it. Waived has been written on form. Continue 9099C Unsubstantiated Staff informed If items go missing or are brought to the facilities attention our procedure is, we have a missing register log and we report it to the general manager, who reports it to the family, and if the item is more than $100.00 we do a police report. Facilities theft & loss log obtained 11/22/2023 from 1/2020 through 11/11/2023 lists 28 missing items 18 found. No items for R1 on list. Interview with former Administrator indicated one gold necklace was reported via email from reporting party but was not aware of any other items missing. Interviews with 5 out of 7 staff revealed no information of missing items or that they were reported to them. Police report regarding missing items was obtained and indicates case closed. Based on LPAs record review of facility as well as outside documents, and interviews with staff, LPA was unable to either prove or disprove facility staff did not safeguard resident’s personal belongings. Therefore, the allegation is Unsubstantiated. Although the allegation above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.the state’s words, verbatim · CDSS document, Feb 12, 2024 · control 21-AS-20231114084622

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hansen conducted an unannounced case management inspection, while delivering complaint findings, and met with General Manager Rabah Sbaitan. The purpose of this case management is to follow up on five self reported incident reports submitted to Community Care Licensing (CCL). Two on 12/22/2023 and one on 12/28/2023, 1/29/2024, 2/1/2024, & 2/8/2024. CCL received a self reported incident report reporting on 12/14/2023 night medication technician (Med-tech) notified nurse resident (R1) had frequent urination. Review of R1’s medication records revealed R1 had not received Tamsulosin medication since 11/26/2023 due to pharmacy unable to renew prescription as incorrect doctor was listed. Primary Care Physician’s (PCP) office notified, and emergency supplies of medication were delivered and given to R1 on 12/15/2023. LPA obtained additional information regarding a medication error that occurred on 12/14/2023 involving R2. On 12/13/23 delivery of Midodrine was assigned to Med Tech instead of nurse, which was given at 8 am, then another dose was given at 9:40am by nurse without checking Emar. R2 assessed with no adverse effects noted. All required parties notified. In-service training provided & LPA obtained copy. LPA followed up on an incident submitted to CCL on 1/16/2024 for a medication error that occurred on 12/28/2023. On 12/29/2023 AM Medication manager found cup with R3’s PM medications. Nurse assessed R3 with no adverse effects. LPA obtained internal investigation, disciplinary action, & In-service training. LPA is providing LIC 9102 TA for reporting incident to CCL later then Title 22 regulations of 7 days. CCL received a self reported incident report on 1/29/2024 of a medication error that occurred on 1/17/2024. R3 had received two 5mg tablets of their amlodipine instead of one as staff opened a new bubble pack of mediation prior to finishing the current supply. There were no adverse effects shown and all required parties notified. Continue on LIC809-C LPA obtained internal investigation, disciplinary action, & in-service training. On 2/8/2024 CCL received a self reported incident report regarding R4. On 1/29/2024 staff provided R4 2 doses of Levetiracetam 250mg at 9am instead of 1. R4’s Mediation records indicate 1 dose in AM & double the dose at 5pm, daily. It was revealed a new bubble pack was opened when the old one was not empty. R4 did not show any adverse effects. All required parties notified. LPA obtained staff records & in-service training. LPA is issuing a citation today for multiple medication errors and Civil Penalties for repeat violation in less then 12 months. CCL received a self reported incident report reporting on 1/30/2024 at approximately 5:40 pm R5 eloped from community. Staff and law enforcement conducted search. At approximately 6:15 pm R5 was escorted back to community by neighbors of area. Full assessment conducted of R5 with no signs of injury or pain noted. LPA obtained records indicating R5 has diagnosis of dementia and is not to leave community unassisted. LPA is issuing a citation today for R5 eloping from facility without staff knowledge on 1/30/2024. General Manager has informed R5 just moved into facility end of January 2024. Wonder guard alarm had been placed on R5 and 1:1 had been implemented but after care meeting on 2/6/2024 R5 was moved to memory care unit. Citation issued during visit. ****Civil Penalties are being assessed in the amount of $250 due to a second repeat citation issued for the same section 87705(b)(2) Care of Persons with Dementia, in less than 12 months. Deficiency last cited on 4/11/2023. Citation issued during visit. ****Civil Penalties are being assessed in the amount of $250 due to a second repeat citation issued for the same section 87465(a)(5) Incidental Medical and Dental Care Services. in less than 12 months. Deficiency last cited on 6/15/2023. *******Total Civil Penalties being given today $500 Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights providedthe state’s words, verbatim · CDSS document, Feb 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Feb 12, 2024

87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by: Based on record review and interview with GM & HSD, the facility did not ensure R1-R4 medications were given as prescribed by doctor on 4 different incidents which poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Feb 12, 2024

Plan of correction: LPA obtained log of in-service trainings with signatures regarding medication handling & investigations. HSD has informed Med Techs on duty have been provided numbers to contact if unable to complete med pass. POC has been cleared at today's visit. Civil Penalties for $250 for repeat violation of same deficiency in less then 12 months.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(b)(2) · Plan of correction due date: Feb 13, 2024

87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. Not met as evidence by Based on a record review & interview with GM it was found that resident (R5) had been reported by facility to be missing from facility care. Medical documents indicate diagnosis of dementia.the state’s words, verbatim · CDSS document, Feb 12, 2024

Plan of correction: Facility conducted care confrence with family and moved R5 to memory care unity within the week of incident. POC has been cleared at today's visit. Civil Penalties for $250 for repeat violation of same deficiency in less then 12 months.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Hansen was at facility continuing investigation into a complaint and conducted a case management for a medication error department received. LPA met with Administrator Nithi Narasappa. On 11/27/2023 Community Care Licensing (CCL) received a self-reported incident report from facility of a medication error that occurred on 11/20/2023. Resident (R1) has an as needed (PRN) prescription for Acetaminophen 500 mg. At approximately 12:45 pm R1 was inadvertently given another resident’s PRN pain medication by staff (S1). Shortly after, S1 realized error and reported to General Manager and Administrator, who notified primary care (PCP) of PRN medication not being given to R1 as prescribed by physician. Responsible party notified. R1 was monitored and had no adverse side effects from other resident’s PRN medication and remains at baseline. Report also indicates policy and procedure review was conducted with staff and an in service training on Medication Policy. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..the state’s words, verbatim · CDSS document, Nov 30, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Dec 1, 2023

87465 (c )(2) Incidental Medical & Dental Care 87465(c)(2) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on self-report submitted by facility, a staff, provided another resident’s PRN pain medication to a resident, not administering PRN medication to R1 as prescribed by their Physician which is an immediate Health and Safety risk to the resident(s) in care.the state’s words, verbatim · CDSS document, Nov 30, 2023

Plan of correction: LPA was provided Signed documentation of Policy and procedure review with Staff (S1) as well as In-Service training of Medication error protocol, Documentation Standards for Medication Policy, & Controlled Substance Medication protocol. POC cleared at time of visit. POC cleared at time of visit.

Type of visit: Case Management - Other

Licensing Program Analyst Leibert arrives unannounced for the purpose of amending a report from 11/14/2023 which did not final print the signature of the facility representative. In addition, the report indicated a $1,000.00 civil penalty for a repeat violation within 12 months. While the violation was repeated within 12 months, the penalty amount was in error and should have been issued in the amount of $250.00. This visit amends the report and issues a correct civil penalty in the amount of $250.00.the state’s words, verbatim · CDSS document, Nov 28, 2023

Allegation investigated: Staff neglect resulted in resident developing sepsis ***** This is an amended version of the original report******

Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. It has been alleged that staff neglect resulted in R1's sepsis condition. This investigation indicates that resident ( R1) was hospitalized on 9/12/23 for symptoms of rhinovirus infection; R1 was discharged on 9/16/23 with diagnosis that included Sepsis; R1 reported upon admission to be feeling in R1's "general state of health until earlier the same day;" Staff physician observed R1 mid-day 9/12/23 and reports" ( R1) did not have any respiratory distress evident;" Private caregiver for R1 who provides care twice a week has stated that caregiver has no knowledge of any neglect of R1 by staff; Facility caregivers who showered and assisted R1 the morning of 9/12/23 report not observing R1 exhibiting any unusual symptoms that would require intervention. This investigation included review of documents, including medical records for R1, as well as interviews with staff; relatives, and witnesses. Although the allegation may be true, based upon the documents and statements, there is not a preponderance of evidence to prove the allegation true or false. Therefore, the allegation is UNSUBSTANTIATED. Report left. Unsubstantiated Exit interview conducted and appeal of rights provided. $250.00 Civil Penalty issued for repeat violation with 12 months. Report left. ****This is an amended version of the original report*****the state’s words, verbatim · CDSS document, Nov 14, 2023 · control 21-AS-20230914082504

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Nov 21, 2023

87465(a)(4) Incidental Medical and Dental Care… The plan shall… provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self administered medications as needed. *** Based on statements and documents, this requirement not met as evidenced by: PRN medication ordered by physician for R1 was not administered on 9/12/23. This posed an immediate risk to R1’s health. $250.00 Civil Penalty issued for repeat violation within 12 months.the state’s words, verbatim · CDSS document, Nov 14, 2023

Plan of correction: Administration will provide refresher training in medication administration for all staff who administer medications. Training to include addressing issues identified by this complaint. Proof of training to be submitted to CCL by POC date in order to clear the deficiency. ***This is an amended version of the original report******

Allegation investigated: Staff are locking residents in their rooms Resident care needs are not met resulting in pressure injuries

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations and met with Administrator, Nithi Narasappa. During complaint investigation LPA conducted interviews with 4 staff and outside individual, made observations at facility on 8/15/2023 & 10/26/2023 and reviewed records. Staff are locking residents in their rooms- Complainant alleges another individual informed, residents in the memory care are locked in their rooms any time they are in their rooms and when inquired, response was, locking memory care residents is legal as this keeps residents from wandering out. LPA observations of facilities memory care unit on 10/26/2023 revealed five of ten apartment doors checked were locked, with residents in the five rooms. Continue on LIC9099-C Unsubstantiated LPA’s interview with Administrator Nithi Narasappa and staff (S1) revealed, in the memory care units, residents who are able to go in and out of their rooms on their own do not have their doors locked when they are in them. Residents who are in wheelchairs and unable to get up on their own have their doors locked when they are in their rooms so other residents who have challenging behaviors do not go into these residents’ rooms or interrupt them and only have to push the door handle down to open if resident is inside. LPA observed locking system on door to ensure any resident that has the capability of leaving, through door, which can be freely opened by any resident residing in the room. Interview on 11/6/2023 with senior general manager revealed facility policy in memory care is to conduct continuous 2-hour room checks on the residents who are in/use wheelchairs and are behind locked doors. Based on LPAs observations, record review, and confidential interviews (8/15/2023, 10/26/2023 & 11/6/2023) with staff, outside individuals, and information received from administrator, LPA was unable to either prove or disprove staff were locking residents in their rooms with the intent of resident not to be able to exit on their own will. Therefore, this allegation is Unsubstantiated. Resident care needs are not met resulting in pressure injuries- Complainant alleges another individual informed there are unknown pressure sores on a resident. LPA conducted record review and interviews with outside parties, staff, and medical professionals that revealed R1 was seen by an outside medical professional (Hospice Nurse) since December 2022 and informed in July 2023 R1 had pressure injuries to both heals. LPA’s interviews with staff confirmed knowledge of R1’s care plan and it appears care plan is being followed. In August 2023 a pressure injury to the buttocks was noted on R1 and with staff following doctors’ orders is almost healed. Interviews with Medical professional did not reveal concerns regarding R1’s care needs are not being met. Progress notes for R1 indicates same findings as interviews. Based on LPAs observations, record review, and confidential interviews with staff, outside individuals, and medical professionals, LPA was unable to either prove or disprove resident care needs were not met resulting in pressure injuries. Therefore, this allegation is Unsubstantiated. Although the allegations above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.the state’s words, verbatim · CDSS document, Nov 13, 2023 · control 21-AS-20230814125522