Kirkwood Orange

Type of visit: Required - 1 Year

On August 21, 2026, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced required one-year annual inspection. LPA Haddadin introduced himself, explained the purpose of the visit, and was granted entry into the facility by ED Erin Palposi The facility is licensed to serve 66 non-ambulatory residents, of whom eight may be bedridden, and has an approved hospice waiver for 15 residents. At the time of the inspection, three residents receiving hospice services were in care. The facility is a two-story building consisting of 58 private and shared resident rooms. Assisted Living and Memory Care units are located on both floors. Common areas include activity rooms, a bistro, an ice cream parlor, a salon, dining rooms on both levels, and enclosed outdoor patios equipped with delayed-egress gates. LPA Haddadin conducted a tour of the interior and exterior areas of the. No bodies of water or safety hazards were observed on the premises. Resident rooms were inspected and found to be appropriately furnished. Beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage space was available for residents’ personal belongings. The hot water temperatures measured in resident bathrooms and kitchen sinks ranged from 112.8 to 117.3 degrees Fahrenheit. The facility was observed to be clean, sanitary, and appropriately furnished. Toxic substances, cleaning supplies, and sharp objects were securely stored and inaccessible to residents. The kitchen was inspected and contained an adequate food supply consisting of at least two days of perishables and seven days of nonperishables. Emergency food and water supplies were also available. LPA Haddadin observed eight fully charged and properly mounted fire extinguishers. Three evacuation chairs were available near the second-floor stairwells. The facility’s smoke and carbon monoxide detectors were tested on August 21, 2026, and were operational. The facility’s most recent fire drill was conducted on June 22, 2026. The first-aid kit was complete and maintained, and a working landline telephone was available. LPA Haddadin reviewed six Medication Administration Records (MARs), and all six records were complete and in compliance. LPA Haddadin also reviewed four resident records and four staff records. All records reviewed were complete and up to date. Based on observations made during today’s inspection, no deficiencies are being cited pursuant to Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted with Executive Director Dan Kashani, and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 20, 2026

Allegation investigated: Staff did not properly inform resident's responsible party of the resident's change of condition. Staff did not properly report incident to resident's responsible party. Staff does not treat residents in care with respect.

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit. The Department received a complaint on Feburary 22 2026 and the initial 10 day visit was conducted on Feburary 27,2026. LPA Mendivil obtained copies of records including assessments, physician's reports, admission agreements, emails regarding rate change and email correspondence. LPA Mendivil interviewed staff and residents. Regarding the allegations staff did not properly inform resident's responsible party of the resident's change of condition, staff did not properly report incident to resident's responsible party, and staff does not treat residents in care with respect the investigation revealed the following: It was alleged that staff did not properly inform resident's responsible party of the resident's change of condition. Per interviews with former nurse Putri Tarigan staff will report changes of condition to her and she will inform families. Unsubstantiated Interviews with 3 out of 5 residents stated that their responsible parties have been informed of change of condition when something happens to them. The remaining two residents did not have issues with change of condition. It was alleged that Staff did not properly report incident to resident's responsible party. Interviews with 6 out of 6 staff stated all incidents are reported to responsible parties. Interviews with 3 out of 5 residents stated if there is an incident their responsible parties are informed either via calls or emails. The remaining 2 residents did not have incidents occur. It was alleged Staff does not treat residents in care with respect. Interviews with 6 out of 6 staff stated they treat all residents with respect. Interviews with 5 out of 5 residents stated they are treated with respect by all staff. Therefore based on the preponderance of evidence through interviews and observations the allegations Staff did not properly inform resident's responsible party of the resident's change of condition, Staff did not properly report incident to resident's responsible party, and Staff does not treat residents in care with respect are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiencies cited. An exit interview was conducted and a copy of this report this report was left at the facility.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 22-AS-20260222214303

Allegation investigated: Staff do not do proper reassessments before a level change

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit. The Department received a complaint on Feburary 25, 2026 and the initial 10 day visit was conducted on Feburary 27,2026. LPA Mendivil obtained copies of records including assessments, physician's reports, admission agreements, emails regarding rate change and email correspondence. LPA Mendivil interviewed staff and residents. Regarding the allegation Staff do not do proper reassessments before a level change the investigation revealed the following: It was alleged that the staff do not do a proper assessments before a level change. It was alleged that Resident 1 (R1) had a change of condition due to behaviors such as rearranging their furniture and wandering which resulted in a higher level of care needed. Unsubstantiated Per interviews with Current Executive Director Erin Palposi, Erin stated that there was a new care assessment tool, August, which went into effect on January 1st, 2026. Erin provided an email sent to families on October 2, 2025 regarding the rate structure change which would take effect on Jan 1, 2026. Per the email it was notated that care levels have changed and provided a new rate and level structure. Per review of R1's Resident Assessment dated on September 08, 2025 R1 was at a total of 52 points which placed R1 at Level 1 of care. On September 29, 2025 R1 was reassessed to be at a Level 2 with 96 points. Both assessments were conducted with AL Advantage which resulted in lower levels of care reflected. Per review of August assessment dated September 29th, 2025, R1 was assessed at a Level 4 with 133 points due moderate help needed for cognitive/orientation, stating "Resident constantly rearranges personal belongings and furniture... requiring constant re-arranging and redirection" Per review of email sent on September 29. 2025 to R1's responsible party the new assessments and points were provided to R1's responsible party. Based on interviews with staff, residents were not charged for the new level of care based on August assessments until Jan 1st 2026. Per review of billing for R1 there were credits added to R1's account to reduce care rate to reflect the lower level of care payment until January 1, 2026. Per ED R1 had an episode of wandering outside of the facility in early February 2026, ED stated that R1 was in the front of the building with the front desk staff and did not leave from staff's side. ED stated that she went to assist with the resident and redirect R1 back into the facility. Per ED it had been reported that R1 had previously tried to exit the facility. ED stated they called R1's responsible party and informed them of R1's attempt to exit. Per review of email from ED to R1's responsible party it was explained that due to R1's exit seeking behavior R1 would remain at a level 4 care needs in February of 2026. Per ED the facility is required to provide all care needs if that is what the resident is care assessment requires. Per interviews with 5 out of 5 residents stated rate structures and care assessments were explained and it was explained as care needs increase the care rate will increase. Therefore based on the preponderance of evidence through records reviewed and interviews the allegation Staff do not do proper reassessments before a level change is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiencies cited. An exit interview was conducted and a copy of this report this report was left at the facility.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 22-AS-20260225091435

Allegation investigated: Facility staff do not arrange or assist in arranging, for medical care appropriate to the conditions and needs of resident. Facility staff do not accord dignity and respect to resident in their personal relationships.

On June 12, 2026, Licensing Program Analyst (LPA) Hiratsuka, contacted the facility via phone and email to deliver final findings regarding a complaint that was received on 11/18/2022. The time frame of the allegations is prior to the complaint received by the department Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegations listed above. Therefore, the allegations above are unsubstantiated. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 12, 2026 · control 22-AS-20221118112503

Allegation investigated: Staff are not meeting resident's toileting needs Staff are not feeding resident's in a timely manner

On June 12, 2026, Licensing Program Analyst (LPA) Hiratsuka, contacted the facility via phone and email to deliver final findings regarding a complaint that was received on 02/01/2022. The time frame of the allegations is prior to the complaint received by the department Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegations listed above. Therefore, the allegations above are unsubstantiated. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 12, 2026 · control 22-AS-20220201143127

Allegation investigated: Resident sustained injuries from a fall while in care

On June 12, 2026, Licensing Program Analyst (LPA) Hiratsuka, contacted the facility via phone and email to deliver final findings regarding a complaint that was received on 09/08/2021. The time frame of the allegations is prior to the complaint received by the department Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegations listed above. Therefore, the allegations above are unsubstantiated. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 12, 2026 · control 22-AS-20210908141134

Allegation investigated: Staff are not providing adequate billing services to resident Staff did not ensure resident's sink was not in disrepair Staff inappropriately installed a sensor on resident's door

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on May 9, 2024. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Erin Palposi. LPA explained the reason for the visit. This Department has investigated the complaint alleging that staff are not providing adequate billing services to resident. Regarding the allegation the following was revealed: During the course of the interviews six of eight individuals interviewed denied the allegation. During the course of the investigation LPA reviewed documents including the Kirkwood Orange Admission Agreement dated February 16, 2024, for Resident 1 (R1). Per Admission Agreement, under Monthly Fee it states Resident will receive monthly a statement itemizing all separate charges incurred by Resident. Per Admission Agreement, under Modification-Rate Increases it states if there is a change in condition, you will begin being charged for the new level of care services immediately. LPA reviewed documents including the Kirkwood Orange monthly statements dated March 2024 through May 2024. CONTINUED ON LIC9099-C... Unsubstantiated Per monthly statements, it includes the date, description and charged amount. During the interviews with residents, R2-R4 reported that they have not had issues with their billing and/or stated that they are being provided with adequate billing services. During the course of the interviews with staff, Staff 1 (S1) reported that the resident was billed properly for the services she was provided. Regarding the allegation that staff did not ensure resident’s sink was not in disrepair, the following was revealed: During the initial visit on May 16, 2024, and subsequent visit on November 21, 2025, LPA tour R1’s bedroom and observed that the sink was in good repair. During the interviews with residents, R2 reported that she has no issues with her sink and stated that maintenance will help quickly if needed. Per R3, the water goes down her sink properly. R4 stated that he has not had issues with his sink and reported that maintenance will assist the residents the same day. During the interviews with staff, S1 reported that they have a system where staff can open a ticket for repair/work orders. Per S1, staff always ensure that the residents’ sinks are working properly. S3 reported that R1 never complained about her sink being broken or clogged. Regarding the allegation that staff inappropriately installed a sensor on resident’s door, the following was revealed: During the initial and subsequent visits LPA tour R1’s bedroom and did not observe a sensor on the resident’s door. During the interviews with residents, R2-R4 reported that they have never seen a sensor on the residents' doors. During the interviews with staff, S1 reported that the facility never installs sensors on the residents’ doors. Per S2, she has never seen a sensor on the residents' doors. S3 stated that during the morning rounds that staff notice an aerial alarm/ sensor on the resident's door and reported that the next day the sensor was gone. Per S3, the facility staff did not place the sensor on the resident’s door. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with ED Palposi, and a copy of this report was provided to the facility. Regarding the allegation that staff are not keeping track of resident's documents, the following was revealed: During the investigation LPA review the Resident file for R1. LPA observed that the file for R1 included the following documentation: Admission Agreement, Medical Assessment, Consent Forms, Identification and Emergency Information, Preplacement Appraisal Information, MAR, Resident Assessment, maintenance work orders, Resident Personal Rights, Safeguards for Property/Valuables and Cash Resources, and monthly billing statements. During the interviews with residents, R2-R4 reported that they have not had issues with their documents and/or reported that their Responsible Party (RP) received a copy of their records. During the interviews with staff, S2 reported that staff keep accurate track of the resident documents. Per S3, staff provided R1's RP with all documentation requested. Therefore, the allegations are deemed UNFOUNDED, meaning the allegations are false, could not have happened and/or are without a reasonable basis. LPA Ramirez conducted an exit interview with ED Palposi and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 22-AS-20240509142005

Type of visit: Required - 1 Year

On September 22, 2025, Licensing Program Analysts (LPA’s) Jenifer Tirre and Eboni Bentley conducted an unannounced required visit using the CARE Inspection Tool. LPA’s were greeted by staff and granted entry after stating the purpose of the visit. Director of Health Services Putri Tarigan helped assisted with today’s visit. Executive Director Dan Kashani arrived shortly after and assisted with the facility inspection. The facility is licensed for Sixty six (66) non-ambulatory residents of which eight (8) may be bed ridden with approved hospice waiver for fifteen (15) residents. Currently, there are three (3) Hospice residents present during today’s visit. Facility is a two story building with 58 resident rooms (combined private and shared). Facility has Assisted Living and Memory Care located on both floors. Facility has activities room, Bistro, ice cream parlor, salon parlor, dining rooms located on both levels as well as enclosed outside patios with delayed egress gates. At around 8:50AM, LPA’s conducted a tour of the physical plant accompanied by Director of Health Services Putri Tarigan, and the following was observed: There were no bodies of water on the premises. Resident rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. During visit water temperature inside resident bathrooms and kitchen sinks were tested operational with water temperatures measured between 112.8 to 117.3 degrees F. A comfortable temperature of 74 degrees F. was maintained in the facility. LPA’s observed the facility to be furnished at the time of the visit. Storage areas for toxins, cleaning supplies and sharps objects were stored and not accessible to residents. CONTINUED 809C The kitchen was inspected, facility has sufficient two day perishables and seven day non-perishable foods. Facility had supply of emergency food and water. LPA’s observed facility had emergency food kits with servings varying from 12 to 93 per kit. LPA’s observed eight fire extinguishers which were fully charged and mounted. LPA’s reviewed facility has three Evacuation chairs posted on second floor stairwells. A review of the Medication Records Administration (MAR) was conducted, and LPA observed six of six records are in compliance. During the visit, LPA observed the facility's infection control practices. LPA’s observed sanitizing stations in common areas and restrooms. LPA’s observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Facility mandated inspection control posters were posted. LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on September 18, 2025. Based on in house documentation from Direct Supply Tels and Champion Fire Solutions Inc facility had operational smoke and carbon monoxide detectors tested and passed on July 10, 2025. The facility has current liability insurance on file effective 7/1/2025 – 7/1/2026. A review of six residents (R1-R6) service files and six staff (S1-S6) personnel files revealed to be complete. The facility has the current administrator's certification on file for Faraz Kashani # 7030587740 - Expiration 5/1/2027. No deficiencies during this inspection visit. An exit interview was conducted with Executive Director Dan Kashani, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 22, 2025

Type of visit: Required - 1 Year

On this day, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and William Vanegas made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPAs were greeted and granted entry by facility front desk staff after introducing themselves and stating the reason of the visit. Executive Director Megan Blacher was present and assisted during the visit. During the inspection, LPAs and facility staff conducted a tour of the physical plant and observed the following: The facility is a two story residential building with a basement. There are assisted living and memory care units on each of the levels. There are currently a total of sixteen (16) residents in assisted living and twenty-nine (29) residents. There are six residents currently receiving hospice care. Assisted living units are either studios or one-bedroom apartments while memory care units are a combination of shared and individual studio units. All units are equipped with an en-suite bathroom equipped with anti-slip flooring and grab bars. All currently occupied resident bedrooms have the required furnishings. Vacant units are in the process of being renovated with new paint and new flooring. LPAs observed all beds have linens and blankets. Water temperature was verified to be within acceptable range in unit bathrooms located on both the ground level and second floor. LPAs observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Fire and emergency drills have been conducted regularly as confirmed by a review of the facility's training records. LPAs accompanied by Executive Director additionally toured the basement level of the facility which includes storage observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food. Smoke and carbon monoxide detectors tested operational. Fire extinguishers present are observed to be fully charged throughout the premises. Smoke detectors with sprinkler systems are centrally wired throughout the facility and have been checked by the fire department. A follow-up inspection is documented to be scheduled on August 28, 2024. CONTINUED ON FORM LIC809-C CONTINUED FROM FORM LIC809 There are two patios in the facility's courtyard, including a secure one adjoined to the facility's memory care unit. Both patios have shaded areas and outdoor furniture. The routes of egress are free of obstructions and accessed through delayed egress gates. Entry and exit into the memory care and outside the assisted living courtyard are also delayed egress devices. There is one locked medication room on the second floor for residents under medication management. There were several locked janitorial closets for storage of toxins and cleaning equipment. An emergency call system is in place in each apartment and residents can be provided with a pendant and/or WanderGuard device depending on their needs and wishes. An activity room, outdoor patios, library and beauty salon were available for resident use. Activities are observed to be conducted through the duration of the visit. Medication, sharp items and cleaning supplies were confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure in three medication carts equipped with locks and stationed in the medication room. The facility uses electronic Medication Administration Records which was demonstrated by Med Tech staff during the visit. LPAs reviewed six resident files and eight staff files. Resident records include all necessary components, however two out of six physician reports were found to have been established over a year ago for two residents with an indication of dementia. Two staff members were observed to have been separated by mistake and were associated again during the visit. Based on the observations made during today’s inspection, one type B deficiency is being issued per Title 22 Division 6 of the California Code of Regulations. Two Technical Assistance advisory note are issued regarding staff association and the operation of hand-washing facilities. An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Aug 21, 2024

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not safeguard resident's personal items Staff did not keep the facility free from odor (marijuana) Staff conduct poses a risk to residents in care Staff do not provide daily activities for residents in care Staff did not keep the facility free from pest

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility for the complaint and to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted by Executive Director (ED) Megan Blacher. During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that staff did not safeguard resident's personal items. LPA De Perio conducted 5 resident interviews, of which 5 out of 5 resident interviews did not corroborate with the allegation by stating that staff do safeguard resident’s personal items. 2 out of 2 staff interviews conducted, also did not corroborate with the allegation by stating that personal items are kept in locked areas, if the family requests it, however, per documentation review, LPA De Perio observed that all residents and responsible parties, opted out in signing the facility document regarding in the resident’s personal inventory list. Unsubstantiated It was alleged that staff did not keep the facility free from odor (marijuana). LPA De Perio conducted 5 resident interviews, of which 5 out of 5 resident interviews did not corroborate with the allegation and denied any concerns and instances related to this allegation. 2 out of 2 staff interviews conducted, also did not corroborate with the allegation by stating that there have been no issues amongst staff or residents smelling like or using marijuana. LPA De Perio conducted a tour of the physical plant of the facility and selected random resident rooms and did not observe or smell any areas of the facility having an odor from marijuana. LPA De Perio conducted documentation review and observed that staff are required to acknowledge and sign the facility handbook upon hire, acknowledging that staff are prohibited to be under the influence while on the job or company property, and that it is subject to termination. Per documentation review, there were no history of documents It was alleged that staff conduct poses a risk to residents in care. LPA De Perio conducted 5 resident interviews, of which 5 out of 5 resident interviews did not corroborate with the allegation by stating that there were no health and safety concerns present and provided positive feedback regarding staff. 2 out of 2 staff interviews conducted, also did not corroborate with the allegation by stating that all staff undergo training regarding resident care and are not allowed to start working until completed. LPA De Perio conducted documentation review and observed that current facility management will hold meetings with staff if there were any risk concerns while providing care, and that there are ongoing trainings that are held. It was alleged that staff do not provide daily activities for residents in care. LPA De Perio conducted 5 resident interviews, of which 5 out of 5 resident interviews did not corroborate with the allegation by stating that the facility offers activities but is voluntary for residents to attend. 2 out of 2 staff interviews conducted, also did not corroborate with the allegation by stating that activities are offered to both the assisted living and memory care areas of the facility. Upon LPA De Perio entering the facility, LPA De Perio observed that residents were actively participating in an activity led by staff, in the lobby. LPA De Perio conducted a tour of the physical plant of the facility and observed that the facility has an activity schedule posted for both the assisted living and memory care area. Per documentation review, LPA De Perio observed that the facility activities scheduled daily for residents. It was alleged that staff did not keep the facility free from pest. LPA De Perio conducted 5 resident interviews, of which 2 out of 5 resident interviews corroborated with the allegation by stating that they have observed one or two cockroaches in the facility, but stated that the facility attends to the situation by hiring pest control. 3 out of the 5 resident interviews did not corroborate with the allegation by denying of ever observing any pests at the facility. 2 out of the 2 staff interviews stated that pest control is scheduled to come to the facility monthly for maintenance. LPA De Perio conducted a tour of the facility, and of random resident rooms, and did not observe any pests. Per documentation review, facility has hired EcoLab and Optum Pest Management, and both companies have conducted work at the facility since January 2024. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with ED Blacher. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, May 8, 2024 · control 22-AS-20240503120613

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced case management visit to the facility for an incident report received on April 24, 2024, that occurred on April 22, 2024. LPA De Perio explained the purpose of today's visit, was greeted by Executive Director (ED) Megan Blacher. During this visit, LPA De Perio conducted interviews, and record review. Per incident report, resident 1 (R1) had received a medication error, and that ED, Health and Wellness Director, R1's physician, and R1's responsible party were immediately notified. R1 was placed on a 48-hour observation and was assessed by the physician. An interview was conducted with R1 who expressed no health and safety concerns at the facility. For this visit, citations were issued per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with ED Blacher. A copy of this report and Appeal Rights were provided and explained.the state’s words, verbatim · CDSS document, May 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: May 17, 2024

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by: Based on LPA's interviews, review of documents obtained and observations, resident 1 (R1) had a medication error due to being given double the dose of the prescribed medication. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: As a plan of correction (POC), facility will provide proof of understanding of the regulation cited to the assigned LPA on or by 5/17/2024.

Allegation investigated: Facility did not provide medications to residents as prescribed. Facility did not follow reporting requirements of missed medications to the department.

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted by business office manager (BOM) Alexis Islas. It was alleged that facility did not provide medications to residents as prescribed. 9 out of 9 resident interviews corroborated with the allegation by confirming that medications were missed. 2 out of 2 staff interviews provided direct admission that medications were missed for a total of 9 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9). Per documentation review of incident reports and the medication administration record, on 12/16/23, R1 missed carbidopa-levo 25-100mg, R2 missed acetaminophen 325mg, R3 missed losartan potassium 100mg and multivitamin tabs, R4 missed acetaminophen 325mg, R5 missed amiodipine besylate 5mg, R6 missed carbidopa-levo 25-100mg, R7 missed sotalol 120mg, R8 missed acetaminophen 325mg, and R9 missed amiodipine besylate 5mg. Substantiated It was alleged that facility did not follow reporting requirements of missed medications to the department. 9 out of 9 resident interviews were unable to provide additional information regarding this allegation. 2 out of the 2 staff interviews corroborated with the allegation by stating that the executive director present during December 2023, did not report the missed medications to the department due to the facility undergoing changes in management and staffing, which led to the failure of reporting to the department. Per documentation review, a total of 9 residents missed their medications on 12/16/23, and reported it to the department thirteen days later on 12/29/23. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, the preponderance of evidence standard has been met, therefore the allegations are SUBSTANTIATED. For this visit, citations were issued. An exit interview was conducted with BOM Islas. A copy of this report was explained, and appeal rights were provided during the visit.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 22-AS-20231228123933

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Mar 21, 2024

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by: Based on LPA's interviews, review of documents obtained and observations, facility admitted to not giving a total of 9 residents their medications per psychian's directions, and was observed via medication log and incident report that medications were missed in December 2023. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: As a plan of correction (POC), licensee will provide proof of understanding of the regulation cited to the assigned LPA on or by 3/21/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Mar 27, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency...within seven days of the occurrence. This requirement is not met as evidence by: Based on LPA's interviews, review of documents obtained and observations, facility failed to report incidents to the licensing department within seven days. Per documentation review, the 9 residents who missed their medications occurred on 12/16/23, but was reported to the department on 12/29/23. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: As a plan of correction (POC), licensee will provide proof of understanding of the regulation cited to the assigned LPA on or by 3/27/24.