Senior Living Community for the Eastern Star in CA

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Staff does not ensure pre-admission procedures are being followed. Staff do not ensure residents are placed in correct level of care.

On July 20, 2026, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Administrator Kat Farris and explained the purpose of the visit. The investigation consisted of the following. LPA Kim toured the facility. LPA requested and obtained copies of the resident and staff rosters. LPA Kim reviewed and obtained copies of resident roster, staff roster, and three resident’s records, which include: Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans/Reappraisal, and other pertinent records. LPA Kim conducted interviews with seven staff and five residents. The investigation revealed the following: Continued on LIC9099C Unsubstantiated Allegation: Staff does not ensure pre-admission procedures are being followed. It is alleged Staff #2 (S2) is not following pre-admissions procedures. It is alleged S2 is admitting residents to assisted living when they should be placed in memory care. It is alleged resident #1 (R1) should have been placed in memory care from date of entry. Based on record review, R1, R2, and R3, all had preplacement appraisals, admission agreement, facesheets, and medical assessments completed prior to moving into the facility. R1 moved into the facility on June 30, 2025, with a Preplacement Appraisal completed, Functional Capability Assessment dated June 25, 2025, and medical assessment completed on June 26, 2025. R2 moved into he facility one August 13, 2025, with a completed admission agreement on August 11, 2025, Preplacement Appraisal completed on August 11, 2025, Medical Assessment completed on August 12, 2025, and a Functional Capability Assessment completed on August 8, 2025. R3 moved into the facility on July 25, 2023 with a completed admissions agreement, completed medical assessment on May 1, 2023, preplacement appraisal completed on May 1, 2023, and completed Functional Capability Assessment. Based on interviews conducted, three out seven of staff confirmed the allegation. Four out of seven staff denied the allegation. S1 stated that S2 has always completed the pre-admission’s procedures and made sure all Department of Social Services Title 22 regulations are being followed prior any resident being admitted to the facility. S1 stated that all residents are placed based on the help of admissions, care director staff, and others reviewing all documentation such as preplacement assessments, functional capability assessment, and medical assessment. Applicants and applicants responsible parties also play a vital role in determining if the resident fits in with the facility and providing the right level of care. Through talking with staff and applicants with examining all necessary documentation, the facility can make sure the applicant is a fit for the facility. Based on the information gathered, the above allegation could not be corroborated. The records for R1, R2, and R3, show the facility has records of providing all necessary records prior to being admitted to the facility. Allegation: Staff do not ensure residents are placed in correct level of care. It is alleged residents who require memory care services are admitted to assisted living. It is alleged that the Administrator will not acknowledge Resident #2 (R2) and Resident #3 (R3) should be moved from assisted living to memory care. Continued on LIC9099C Based on interviews conducted, four out of seven staff confirmed the allegation. Three out of five residents and three out of seven staff denied the allegation. Two out of five residents could not confirm or deny the allegation. S1 stated that residents are placed according to their level of care. The Level of Care is determined from the preadmissions procedure and a review of all their documentation. For R1, R2, and R3, they were placed to assisted living because of what the medical assessments, preplacement appraisals, functional capability assessment, and on interviews. There was nothing on the documentation or from the interviews that determined the residents required a care other then what they were admitted to. Based on record review, R1’s move-in date is on June 30, 2025, from their admission agreement and their facesheet. Functional Capability Assessment dated June 25, 2025, stated R1 is an independent resident who can transfer themselves from in and out of bed, wears hearing aids, can reposition themself, can communicate, and uses a walker to ambulate. Preplacement Appraisal stated R1 uses their walker for safety and has a history of falls. It is noted that R1 is able to walk without any physical assistance, which includes not using a walker. The functional capabilities stated they use a walker. It is stated that the resident does not need help transferring in and out of bed and dressing and moving around the facility. The medical assessment dated June 26, 2025, states the resident has motor impairment and has a walker as an assistive device. R1 had seven falls from July 7, 2025, to August 31, 2025. Facility conducted an appraisal on August 18, 2025, and the resident had a new medical assessment on August 15, 2025. Through an assessment by facility it was determined that R1 would be a fit for Memory Care. S1 stated R1 did not agree with the assessment and moved out of the facility on September 25, 2025. R2's move-in date on August 13, 2025, based on their admission agreement and facesheet. R2’s medical assessment dated August 12, 2025, diagnoses R2 with Atrial Fibrillation, hypertension, and mild cognitive impairment. It is also stated R2 does not have bowel incontinence, bladder incontinence, and has hallucinations. R2’s Preplacement Appraisal dated August 11, 2025, states resident needs physical assistance to walk with a walker. The Preplacement Appraisal states R2 does not need assistance transferring in and out of bed, moving around the facility, and special medical attention. R2’s resident appraisal dated September 9, 2025, stated R1 has a hearing loss and demonstrates confusion throughout the day. They have become lost in the facility. R2 needs a walker with assistance to get in and out of it. Functional Capability Assessment dated September 18, 2025, stated resident has a severe hearing loss and is very confused at times. R2 moved into memory care due to increased confusion and severe hearing loss. Continued on LIC9099C R3 moved into the facility on July 25, 2023 based on their admission agreement and facesheet. R3’s medical assessment dated May 1, 2023, diagnoses R3 with Mild Cognitive Impairment and is able to bathe themselves, dress themselves, and take care of their own toileting needs. R3 was being taken care by their spouse from July 25, 2023, until July, 3, 2026. R3 was diagnosed with dementia from their medical assessment dated February 12, 2026. It is noted that the spouse would be helping R3 with all their daily needs. With the care and supervision from the spouse, R3 remained in Assisted Living as needed. As of July 3, 2026, R3 was placed in memory care because it was determined R3 needed assistance beyond the capabilities R3’s spouse could provide. Based on information gathered, the above allegation could not be corroborated. The records for R1, R2, and R3, show the facility placed residents on the level of care they needed from admission. As the needs changed of the residents, the facility responded to provide the level of care needed for each of the resident. Based on observations, interviews, and records review, LPA did not find sufficient evidence to support the above allegations Staff does not ensure pre-admission procedures are being followed and Staff do not ensure residents are placed in correct level of care. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview was conducted and a copy of the report was provided to Administrator Kat Farristhe state’s words, verbatim · CDSS document, Jul 20, 2026 · control 22-AS-20250923132258

Type of visit: Case Management - Other

On 06/11/2026 at approximately 8:45am, Financial Analyst (FA) Arne Bracchi arrived at the community for the scheduled 9:00 site visit and was met by Controller John Lee. The purpose of the visit was to conduct a triennial site visit with Controller and the Executive Director (ED) Kat Farris During today's visit, we discussed SLC’s organizational structure which includes The Grand Chapter of California, Order of the Eastern Star. ED reports to the board of trustees; Controller reports to the board’s finance committee. FA requested copy of Resident Satisfaction Survey; notice of Monthly Care Fee Increase; proof of 2025 Annual Report posted on SLC website; copies of current resident roster, resident handbook, and resident contracts. FA also re-asked site visit questions and documented ED’s responses. FA then requested a tour of SLC to ensure all postings and required documents were accessible to residents and visitors. This included ascertaining if the COA is listed and/or displayed in the Hallway Lobby. The tour of the community included the resident dining room, common areas, ice cream parlor, and an unoccupied assisted living unit. As a result of today's visit, no compliance issues pursuant to the Continuing Care Contract Statutes were cited. FA told Controller and ED he would document today’s visit via a completed LIC 809 upon return to HQ and would e-mail the 809 to ED for signature.the state’s words, verbatim · CDSS document, Jun 11, 2026

Allegation investigated: Staff overmedicated a resident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and resident as well as reviewed and obtained pertinent documentation such as medication administration record (MAR). Regarding the allegation that staff overmedicated a resident, the investigation revealed the following: Interview with Resident 1 (R1) showed the resident had a lack of awareness of which medications are prescribed. Medication orders show R1 is prescribed Hydrocodone (Norco) 10/325mg twice daily and Trazadone HCL 50mg at bedtime. Review of MAR indicates resident has been receiving the medications as prescribed. Per physician report dated 12/16/2025, R1 is diagnosed with Mild Cognitive Impairment with disorientation. Based on interviews conducted and record review, the allegation is deemed UNFOUNDED, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to facility representative. Unfoundedthe state’s words, verbatim · CDSS document, Mar 2, 2026 · control 22-AS-20260225105026

Type of visit: Required - 1 Year

On December 18, 2025, at 8:30 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by staff. LPA Kim met with Executive Director (ED) Kat Farris and explained the purpose of the visit. The facility is licensed to operate for seventy-six (76) nonambulatory residents and have a hospice waiver for seven (7) residents. The facility is a single-story structure. It consists of the following: fifty-eight (58) resident bedrooms, sixty-nine (69) bathrooms, eight (8) offices, lounge area, main dining area, auxiliary dining area, private dining room, kitchen, an outdoor covered seating areas, beauty salon, meeting room, chapel, craft room, ice cream parlor, library, storage rooms, laundry room, ceramic room, waiting room, and a tower room. LPA Kim toured inside and outside of the physical plant with ED Farris. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 15, Resident Room 21, Resident Room 29, Resident Room 34, Resident Room 41, Resident Room 45, and Resident Room 58. Bathrooms were found to be clean and operational. The water temperature measured at 110.7 degrees F to 115.7 degrees F. A comfortable temperature of 71 degrees F was maintained in the facility. Evaluation Report Continues on LIC 809-C LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency safety drills were last conducted on November 25, 2025, and are conducted quarterly. During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. Alarm systems are tested annually by Five Star Fire Protection and last conducted their annual inspection on August 12, 2025. A working telephone (714-577-9281) remains available, and the facility has computers available in the library that can be used for video teleconference purposes. Emergency food and supplies are stored in 2 storage rooms next to the kitchen, and emergency water is stored in a storage room next to the utility room. The facility has twenty-nine (29) fire extinguishers that were charged, mounted throughout the facility, and last serviced on October 25, 2025. First aid kit is maintained and contains all the necessary elements. Evidence of Liability Insurance was effective October 1, 2025, to October 1, 2026. LPA Kim conducted an audit of eight (8) resident files (R1-R8), seven (7) staff files (S1-S7), and medication and medication administration record that were all in order and complete. LPA Kim conducted five (5) staff interview and seven (7) resident interviews. No Deficiencies were cited during the time of the visit. An exit interview was conducted, and a copy of this report was provided to Executive Director Kat Farris.the state’s words, verbatim · CDSS document, Dec 18, 2025

Type of visit: Required - 1 Year

On December 6, 2024, at 8:30am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by staff. LPA Kim met with Executive Director (ED) Kat Farris and explained the purpose of the visit. The facility is licensed to operate for seventy-six (76) nonambulatory residents and have a hospice waiver for seven (7) residents. The facility is a single-story structure. It consists of the following: fifty-eight (58) resident bedrooms, sixty-nine (69) bathrooms, eight (8) offices, lounge area, main dining area, small dining area, private dining room, kitchen, an outdoor covered seating areas, beauty salon, meeting room, chapel, craft room, ice cream parlor, library, storage rooms, laundry room, ceramic room, waiting room, and a tower room. LPA Kim toured inside and outside of the physical plant with ED Farris. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 8, Resident Room 16, Resident Room 18, Resident Room 19, Resident Room 33, Resident Room 38, Resident Room 39, Resident Room 46, Resident Room 49, and Resident Room 50. Bathrooms were found to be clean and operational. The water temperature measured at 116.2 degrees F to 119.3 degrees F. A comfortable temperature of 72 degrees F was maintained in the facility. LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency safety drills were last conducted on November 21, 2024, and conducted quarterly. Evaluation Report Continues on LIC 809-C Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. Alarm systems are tested annually by Cosco Fire Protection and last conducted their annual inspection on November 21, 2024. A working telephone (714-577-9281) remains available, and the facility have computers available in the library that can be used for video teleconference purposes. Emergency food and supplies are stored in 2 storage rooms next to the kitchen, and emergency water is stored in a storage room next to the utility room. The facility has twenty-nine (29) fire extinguishers that were charged, mounted throughout the facility, and serviced on October 9, 2024. First aid kit is maintained and contains all the necessary elements. LPA Kim conducted an audit of ten (10) resident files (R1-R10), ten (10) staff files (S1-S10), and medication and medication administration review that were all in order and complete. LPA Kim conducted one (1) staff interview and seven (7) resident interviews. No Deficiencies were cited during the time of the visit. An exit interview was conducted, and a copy of this report was provided to Executive Director Kat Farris.the state’s words, verbatim · CDSS document, Dec 6, 2024

Type of visit: Case Management - Incident

On September 27, 2024, at 8:00am Licensing Program Analyst (LPA) Edward Kim conducted an unannounced Case Management Visit to follow-up on a Report of Suspected Dependent Adult/Elder Abuse (SOC341) received on September 20, 2024 pertaining Resident #1 (R1) regarding an incident where staff were rough handling R1 during transfers. LPA Kim was greeted and granted entry by staff. LPA Kim explained the purpose of the visit to Executive Director Kat Farris. During today’s visit, LPA toured the interior and exterior of the facility. Residents in care appeared to be safe; no imminent health/safety concerns were observed. LPA Kim inspected the indoor and outdoor of physical plant with ED Farris. No health/safety hazards were observed. Facility was maintained at a comfortable temperature for the residents in care. Thirty-two residents are currently living and present at the facility. Twenty-one staff members are also present at the facility. Residents at facility were observed to be clean and well groomed. LPA inspected facility food supplies. Food supplies were observed to be sufficient at the time of the inspection. LPA Kim obtained R1's records which includes the Physician's Report, Emergency Information, and Appraisal and Needs Services plan. LPA Kim conducted four (4) resident interviews and five (5) staff interviews. Based on LPA's observations there were no signs of injury on R1. Interviews conducted with four out of four residents and five out of five staff did not corroborate the alleged incident. Therefore, no deficiencies are cited during this visit. An Exit interview was conducted, and a copy of this report was provided to the Executive director Kat Farris.the state’s words, verbatim · CDSS document, Sep 27, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report/ SOC 341 received by the department. LPA was greeted and granted entry into the facility and explained the reason for the visit. Incident report/ SOC 341 dated 04/02/2024 indicated that on 04/01/2024, Resident 1 (R1) told staff that a registry caregiver had been rough and unprofessional with the resident the night before. Staff assessed resident and observed discoloration on the resident's right upper arm. Facility alerted resident's family, physician and licensing. Resident's physician assistant ordered an x-ray for 04/04/2024. X-ray was performed with no fracture or dislocation detected. Facility notified registry of alleged incident and requested caregiver not return to facility. OC Sheriff was notified and interviewed resident. Resident denied abuse or harm from caregiver. During the investigation, LPA interviewed Resident 1 who denied any abuse or harm as well from caregiver. Resident verbalized feeling safe at the facility. LPA observed bruising on resident's arm which resident indicated came from the resident falling in the shower and the caregiver attempting to break the fall. Per physician order dated 03/12/2024, Resident is diagnosed with Mild Cognitive Impairment and is taking Eliquis twice daily. No further action required. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 8, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit to follow up on an incident report received by Community Care Licensing on 2/27/2024. LPA met with Executive Director (ED) Kat Farris and explained the reason for the visit. Incident report indicated that on 2/24/2024 Resident 1 (R1) missed a dose of medication. Medication had originally been ordered on 2/20/2023. During interviews, Director of Wellness (DW) Lida Spicer stated medication dose was missed due to medication not being delivered by the pharmacy. DW and ED denied having any additional related incidents. During today’s visit, LPA obtained copies and reviewed pertinent documentation including R1's centrally stored medication record, R1's Medication Administration Record (MAR) for February 2024, medication request dated 2/17/24, and emergency request sent by facility Licensing Vocational Nurse (LVN) on 2/24/24. Per R1's centrally stored medication record, medication dose which was missed is of one capsule to be taken routinely by mouth before breakfast. Per medication request record, medication was requested on 2/17/24 to be approved on 2/20/24. Per R1's MAR, medication was missed on 2/24/24 and 2/25/24. LPA was provided with proof of emergency request submitted by LVN on 2/24/24. Medication was refilled the evening of 2/25/24 and R1 resumed medication on 2/26/24. R1's MAR indicated medication has been taken routinely since 2/26/24 and no further action is required. Based on observations made during today's inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 29, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of a Plan of Correction (POC) visit based on deficiencies cited on 12/05/2023. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87412(c) pertaining to Personnel Records has been cleared. Licensee provided proof of annual training. Licensee has complied with the terms of the POC. Licensee has been advised to maintain all items in compliance with Title 22 regulations. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 8, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report received by the department on 02/02/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit. Incident report dated 01/28/2024 indicated that Staff 1 (S1) had inserted a diabetic sensor/ glucose monitor into Resident 1's (R1) arm. Facility investigation revealed that R1's new sensor had not arrived at the facility timely and the resident would need to utilize a finger stick instead of the sensor in the interim. Resident spoke with S1 regarding the situation and the staff inserted a spare sensor in the resident's arm. Facility observed the staff inserting the sensor on video surveillance. S1 is employed at the facility as an Activities Assistant and is not a skilled professional. S1 is receiving a write-up which was provided to LPA and further action from facility is pending. Based on the observations made from today's visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided to Administrator as well as Appeal Rights.the state’s words, verbatim · CDSS document, Feb 8, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: Feb 9, 2024

The licensee shall be permitted to accept a resident who has diabetes if the resident is able to perform his/her own glucose testing.., and is able to administer his/her own medication including medication.., or has it administered by an appropriately skilled professional. This req is not being met as evidenced by: Based on interviews conducted, the Licensee failed to ensure glucose testing is performed by an appropriately skilled professional. The activities assistant inserted a diabetic sensor/ glucose monitor into R1's arm. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 8, 2024

Plan of correction: Licensee to provide an in-service on glucose testing/ injections and forward proof to LPA by POC due date.

Allegation investigated: Resident sustained unexplained injuries while in care Facility did not seek timely medical attention for resident Resident sustained pressure injury while in care

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegation listed above. LPA was greeted and granted entry by front desk staff after explaining the purpose of the visit. The initial complaint investigation was conducted by LPA Kathrina Chin on February 25, 2022. LPA spoke to the facility's Director of Wellness as well as with the facility's Executive Director via telephone. Resident records for R1 including hospital discharge and email records of interactions with the resident's responsible party were obtained in addition to a resident interview with R1. LPA Saborit-Guasch conducted a follow-up investigation visit on October 17, 2023. LPA interviewed the facility's Wellness Director as well as requested, obtained and reviewed the staff shift notes from the period of January 1, 2022 until February 8, 2022. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM LIC9099 - Multiple signed testimonies by staff members were additionally provided by facility during the visit in addition to Medication Administration Records for resident R1. Physician follow-up notes for visits from R1's primary care providers dated February 8, 15, 18 and 22nd, 2022 also provided. On February 17, 2022, R1 was transferred to Placentia Linda Hospital via after paramedics were activated due with complaints of a low grade fever, low oxygen saturation and emesis. R1 was evaluated at the hospital and received lab and imagery testing before being discharged to the community on the same day. Upon arrival at the hospital, R1 was observed to have some bruising present in the hip region that prompted hospital staff to conduct x-ray in order to rule out further injury. No fractures were assessed to be present per R1's discharge notes. Regarding the allegation that Resident sustained unexplained injuries while in care, the following has been concluded: Based on a review of hospital records as well as staff interviews and seven separate written and signed statements provided during the investigation, no bruising had been observed by facility staff during toileting care provided prior to the activation of paramedics, suggesting that the bruising may have occurred during the ambulance transport. Furthermore, no additional injuries were assessed at Placentia Linda Hospital where the ultimate diagnosis documented was of a Urinary Tract Infection. Regarding the allegation that Facility did not seek timely medical attention for resident, the following has been concluded: Based on resident records, facility charting and hospital records, there is little to no evidence of a delay in providing necessary medical attention to R1. Routine appointments with the resident's primary care provider had taken place weekly prior to the hospitalization and the resident was additionally followed upon twice after their discharge. Regarding the allegation that Resident sustained pressure injury while in care, the following has been concluded: Resident had a physician order for Calmoseptine dated February 2, 2022 for the treatment of a rash in the resident's diaper area for a period of 10 days. The physical examination performed at Placentia Linda Hospital on February 17, 2023 indicates the skin condition to be "Normal color, no rash". Facility charting additionally does not evidence the presence of pressure injuries at that time. The three allegations above are therefore found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM LIC9099-A Multiple signed testimonies by staff members were additionally provided by facility during the visit in addition to Medication Administration Records for resident R1. Physician follow-up notes for visits from R1's primary care providers dated February 8, February 15, February 18 and February 22, 2022 were also provided and copied. Regarding the allegation that Staff did not notify responsible party of incident, the following has been concluded: Copies of electronic messages sent to the resident's responsible party and attorney-in-fact on February 17, 2022 were provided during the investigation, confirming that they were promptly notified of the change in condition and of the decision to make a call the paramedics for evaluation resulting in the transfer to Placentia Linda Hospital on the same day. As a result, the allegation is found to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jan 24, 2024 · control 22-AS-20220217113100

Allegation investigated: Residents medication is being mishandled

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegation listed above. LPA was greeted and granted entry by front desk staff after explaining the purpose of the visit. The initial complaint investigation visit was led by LPA Kathrina Chin on January 25, 2022. LPA met with the Director of Resident Services and gathered pertinent documents for resident R1. A follow-up visit was conducted by LPA Saborit-Guasch on October 17, 2023. LPA interviewed the facility's Wellness Director as well as requested, obtained and reviewed the complete Medication Administration Records for resident R1 covering the admission period from December 2020 until March 2022. Records obtained include physician orders for medication and topical treatments as well as copies of the paper and electronic records documenting the administration process. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 Additional evidence was gathered during the investigation process and witness interviews conducted. Regarding the allegation that Residents medication is being mishandled, the following has been concluded: Based on interviews conducted and a review of the Medication Administration Records (MAR) provided by the facility, it was determined that all medications dispensed had a corresponding prescription/physician order as required by Title 22 Regulations. Title 22 regulations do not require pre-approval from or notification to the attorney-in-fact prior to dispensation as long as physician orders are on file. However, it was also determined during the investigation that a request to discontinue the administration of Depakote was made by the resident's attorney-in-fact and implemented effective January 25, 2022 per the MAR and physician order reviewed. Later blood tests performed on March 9, 2022 after R1 was hospitalized at Saddleback Hospital show blood levels for Valproic Acid (Depakote) to be below 3ug/ML which was determined to be consistent with the medication being discontinued per the request expressed to the facility. Pharmacy invoices provided also confirm that no additional billing for that specific medication is present after the discontinuation. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jan 24, 2024 · control 22-AS-20220119151449

Allegation investigated: Facility does not provide a safe environment for the residents Facility is retaining a resident requiring a higher level of care Facility does not have adequate night staff to meet the needs of the residents Facility does not adequately communicate with the residents

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility, interviewed staff and residents as well as reviewed and obtained pertinent documentation such as physician reports. Regarding the allegations that facility does not provide a safe environment for the residents, facility is retaining a resident requiring a higher level of care, facility does not have adequate night staff to meet the needs of the residents, and facility does not adequately communicate with the residents, the investigation revealed the following: LPA toured Resident 's (R1) apartment during the investigation. LPA observed a two bedroom apartment with one room being used as storage. Resident indicated items in the storage room belonged to the resident's deceased spouse and is still processing the death. The main room and additional bedroom are cluttered but LPA observed ample walking space and an uncluttered exit path. R2 is diagnosed with Parkinson's Disease and per resident and staff, the disease is progressing. CONTINUED ON LIC 9099C DATED 12/05/2023 Unsubstantiated R3 denies not be afforded that opportunity to bring representation. R3 indicated that nothing came of the warning on the letter and provided a copy of the letter to LPA. Facility administrator meets the qualifications for Administrator and has a current administrator certificate expiring on 12/15/2024. Therefore the allegations are deemed UNFOUNDED, meaning the allegations were false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to facility representative. Six out of six staff as well as resident confirm care being provided is meeting the resident's needs. Facility staffing schedule is as follows: Two caregivers, two LVN's and two Wellness support staff for 1st shft, one LVN, one caregiver and overlapping Wellness support for 2nd shift and two caregivers/ med techs for NOC shift. Facility is filling in with agency as needed and provided documentation as such. Facility confirms no staffing requirements are mandated by the Assisted Living Waiver program and the program conducts visits at the facility to observe residents. Six staff and three residents confirm communication in the facility is sufficient between management and residents. Facility conducts resident council meetings monthly for the residents. Management do not attend the meetings per department guidelines. Residents confirm knowing about the meetings and attending as they wish. Based on interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 5, 2023 · control 22-AS-20231108153030

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c) · Plan of correction due date: Dec 19, 2023

Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not being met as evidenced by: Based on record review, Licensee failed to ensure staff records include documentation of required training. Eight out of eight staff do not have proof of required training. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2023

Plan of correction: Licensee to ensure all staff have required training and forward proof to LPA by POC due date.