Brookdale Nohl Ranch

Allegation investigated: Staff did not ensure resident took medication as prescribed Staff retaliated against resident for exercising their rights

On this day Licensing Program Analyst (LPA) Jenifer Tirre made a subsequent visit for complaint investigation. LPA Tirre stated purpose of visit and met with Executive Director Sarah Devore. The investigation consisted of staff and resident interviews and review of Resident 1’s (R1) facility records. The Investigation was completed by department and revealed the following: On November 20, 2025, the department received allegations that Staff did not ensure resident took medication as prescribed and Staff retaliated against resident for exercising their rights. Regarding the allegation staff did not ensure resident took medication as prescribed, interviews were conducted with staff and residents, the following information was provided: Eight of eight staff members interviewed stated that residents received assistance with their medications from Medication certified staff such as Medication Technicians, Clinical Nurse, Resident Care Coordinator and additional care staff that are certifiedthe state’s words, verbatim · CDSS document, Dec 9, 2025 · control 22-AS-20251120151058

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff verbally abuses residents Resident wandered away from the facility due to lack of supervision Resident sustained a fall while in care and staff did not assist resident in a timely manner Resident was left outside the facility for extended periods Facility is in disrepair Facility has mold Residents’ rooms are not being cleaned properly Facility has an outbreak of flu due to unsanitary conditions of the facility Staff did not prevent resident from being harmed by other residents

Licensing Program Analyst (LPA) Celine Rodriguez conducted a continuation visit to the facility for the complaint and to deliver the findings. LPA Rodriguez explained the purpose of today's visit and was greeted by Executive Director (ED) - Sarah Devore and Resident Care Coordinator (RCC) - Kim Bennett. It was alleged that staff verbally abuses residents. LPA Rodriguez conducted a total of 7 resident interviews of which all 7 interviews did not corroborate with the allegation by stating that staff are nice, helpful, and denied of being a victim of verbal abuse or witnessing it. LPA Rodriguez conducted a total of 3 staff interviews of which all 3 interviews did not corroborate with the allegation. Per staff interviews, staff are required to complete a training on abuse prior to taking care of residents and are not allowed to be on the floor until training is completed. Per record review, LPA Rodriguez observed that all staff have completed abuse training, resident rights, and how to carthe state’s words, verbatim · CDSS document, Jun 18, 2025 · control 22-AS-20240227140230

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not administer prescribed medication to a resident in care. Staff is smoking a vape pen inside of the facility. Staff did not properly bathe a resident in care.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on July 03, 2024. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Sarah DeVore. LPA explained the reason for the visit. This Department has investigated the complaint alleging that staff did not administer prescribed medication to a resident in care, staff is smoking a vape pen inside of the facility and staff did not properly bathe a resident in care. Resident 1 (R1) was admitted to the facility on February 28, 2024. Regarding the allegations, the following was revealed: During the course of the interviews six of seven individuals interviewed denied the allegations. During the course of the investigation LPA reviewed documents including the Physician Report (LIC602A) dated March 15, 2024 for R1. Per Physician Report R1 is able to administer own prescription medications. During the course of the interviews withthe state’s words, verbatim · CDSS document, Oct 30, 2024 · control 22-AS-20240703101647

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are not cleaning facility properly.

Licensing Program Analyst (LPA) Jessica Cho made a subsequent unannounced visit to deliver the findings into the above allegation. LPA met with Operations Specialist (OS) Tierny Wilburn and stated the purpose of the visit after reviewing the allegation. During the initial complaint inspection conducted on January 31, 2024, between 3:05pm to 5:00pm, the following were observed: LPA and OS Wilburn toured and inspected all common areas on levels 1-3. There are no common areas on levels 4-5. There is a strong odor lingering in the lobby past the living room and by the north elevator. The odor was still present on today's date as well. Food particles and dust have accumulated below the dining tables, and the floor was sticky. The floor of the north/south elevator were sticky and had a strong smell of urine inside the north elevator. The floor in the four bathrooms located on the first floor were sticky and had a smell of urine. LPA and OS Wilburn observed two full trash bags in front of unithe state’s words, verbatim · CDSS document, Feb 9, 2024 · control 22-AS-20240126094209

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.