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to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following— CDSS inspection report, August 15, 2023

On 8/15/23, Licensing Program Analyst (LPA) Kevin Mknelly spoke with Caregiver to deliver complaint findings for the above allegation. Administrator, Anita Heydon, arrived for the report review. LPA reviewed resident records, facility records and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. Records review found that S1, S3, S4, S5 and S6 are not associated to the facility. Administrator stated that they are experiencing difficulties accessing the Guardian system. S1 is considered by the Administrator to be a volunteer who does not do resident care. However, statements provided found that S1 does assist with care at times and is unsupervised with residents at times. Regardless, Volunteers are required to obtain a criminal record clearance before presence in the facility. S1 was associated to this home on 8/8/23. S3 has no record of fingerprint clearance. S3 worked at this home for approximately seven months. S4 had no known prior clearancRead the full finding— CDSS inspection report, August 15, 2023 · control 59-AS-20230728115741

On 8/15/23, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Anita Haydon, Administrator, to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. LPA found that by having 6 residents and the Administrators family member residing at the home and receiving care from caregivers also, the facility was over their fire clearance capacity of 6 residents. On 8/4/23, R1 was in process of moving from the facility. Licensee will continue to include family member, R4, as a resident as long as R4 resides at the facility and receives care from caregivers. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 RegulationRead the full finding— CDSS inspection report, August 15, 2023 · control 59-AS-20230727143011

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 3/22/22 to provide complaint findings. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Upon arrival LPA completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility. LPAs reviewed resident records, facility records and conducted interviews. The department finds that facility met Tittle 22 requirements. Resident returned to the facility when licensee set up Covid care staffing for the resident. This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have hapRead the full finding— CDSS inspection report, March 22, 2022 · control 25-AS-20220106080402

On 12/16/21, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Licensee of facility. The reason for the visit was to deliver findings for the allegation sited above. Upon entering the facility, analyst spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening, wore a surgical mask and maintained distance during the visit. LPA reviewed staff and resident records and conducted extensive interviews. LPA finds that the allegation cited above are Unsubstantiated. Neither residents nor staff coroborated that Licensee was disrespectful to or threw water at a resident. Licensee stated that she always notified families of resident hospitalizations. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of theRead the full finding— CDSS inspection report, March 22, 2022 · control 25-AS-20211228145848

On 9/9/21 at 2:00 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with caregiver. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; and completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by caregiver. LPA conducted records review and interviews. LPA is unable to find and or meet the preponderance, per policy. Licensee acknowledged that they and a family member occasionally have animated conversations yet stated that they are sure to have those conversations away from other residents. Others who were interviewed did not report witnessing or being distRead the full finding— CDSS inspection report, September 9, 2021 · control 25-AS-20210714120704