Sapphire Senior Care

Allegation investigated: Staff did not abide to the admission agreement

On 2/18/26, Licensing Program Analyst (LPA) Kevin Mknelly spoke with care giver S1 who notified Natalia Tulenenova. Natatia arrived for LPA to investigate and to deliver complaint findings for the above allegation. LPA reviewed resident records and conducted interviews. LPA finds that the allegations cited above are substantiated. R1 was admitted to te facility while in hospice care on 11/22/25. R1 passed away on 11/25/25. R1's belongings were removed from the facility on 11/25/26 . To date, R1's representaives were not reimbursed for the balance for fees paid for Nov. 2024. Therefore R1's representative is owed a refund As a result of this investigation, LPA finds allegation to be (S) Substantiated - Report reviewed with Natalia . Copy of this report and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Feb 18, 2026 · control 59-AS-20260212093422

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(a) · Plan of correction due date: Mar 4, 2026

(a) A residential care facility for the elderly shall not require advance notice for terminating an admission agreement upon the death of a resident. No fees shall accrue once all personal property belonging to the deceased resident is removed from the living unit. This requirement was not met based on records and statement. This posed a potential riskthe state’s words, verbatim · CDSS document, Feb 18, 2026

Plan of correction: Licensee will submit proof of reimbursement by the POC date of 3/4/26

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 11/14/25 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. Administrator arrived to assist with the visit. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. Advised by LPA to repair a torn screen. LPA reviewed resident and staff files. Resident files complete. Staff files needed more organization and to have training hours more clearly documented, No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facilitythe state’s words, verbatim · CDSS document, Nov 14, 2025

Type of visit: Case Management - Other

On 10/7/25, LPA Kevin Mknelly conducted a case management visit and met with caregiver. Administrator was notified and arrived to assist. The purpose of the visit was for a health and safety check. LPA observed 6 residents and reviewed resident files. LPA spoke with administrator and reviewed records and services plans for residents. As a result of today's inspection no deficiencies were found. Report reviewed and copy provided.the state’s words, verbatim · CDSS document, Oct 7, 2025

Allegation investigated: Facility was not kept free of pests Staff did not treat residents with respect Facility was not kept free of mold Staff is not able to communicate with residents

On 7/8/25, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with xxx xxx. LPA conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. During inspections no pests were observed and Administrator denied that there has ever been a pest problem. Residents interviewed stated they had not recalled having been spoken to harshly. Mold was not observed by LPA to be present on surfaces. During past and recent inspections, LPA observed staff to have adequate language proficiency to communicate with residents. 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 the evidence to prove that the alleged violation occurred. Exit interview with administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 8, 2025 · control 59-AS-20250515100934

Allegation investigated: Facility failed to contact resident's conservator that resident was taken to the hospital.

On 7/8/25, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Natalia Tuleninova, Administrator, to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted interviews. LPA finds that the allegations cited above are substantiated. Documents and conservator's office statement showed that Admin failed to notify the conservator's office as required for R1's hospitalization. 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 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Admin . Copy of this report and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Jul 8, 2025 · control 59-AS-20250519143314

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jul 9, 2025

Observation of the Resident- The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning ...the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person. This requirment was not met based on statements that the conservator was not notified timely.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: Licensee has received and will follow Conservator emergency contact guidelines that have been provided. POC cleared by visit.

Type of visit: Case Management - Other

On 2/4/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Administrator . On 1/25/25, R1 experienced bleeding into their catheter. R1 was on Hospice and hospice responded to a call. Bleeding restarted after Hospice service. R1 was sent to an area hospital for care. R1 passed away in hospital on 1/26/25. LPA reviewed R1 records and interviewed Administrator. LPA received copies of requested records. LPA requested Administrator gather additional details and timelines for events of 1/25/25 for R1's incident and resubmit the death report with requested details. LPA to contact R1's representative and Hospice for additional information As a result of today’s inspection, no deficiencies were noted at this time . Report reviewed. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Feb 4, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 10/30/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. Administrator was present to assist with the visit. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. LPA advised on a few topics that are not violations. LPA and administrator discussed the exception process were they to consider care for a resident where a exception is needed. Licensee is in process of a room renovation. LPA will be notified when it is completed. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facilitythe state’s words, verbatim · CDSS document, Oct 30, 2024

Allegation investigated: Staff yells at resident in care.

On 5/9/24, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Administrator. LPA conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. It was alleged that staff were hear to yell and swear at R1 in two different occasions while R1 was outside on the facility property with staff. R1’s records indicate that R1 is wheelchair dependent and has memory loss due to cognitive decline. When interviewed by LPA, R1 stated on multiple occasions that R1 does not go outside and that staff treat R1 respectfully. R1 stated that R prefers to stay in bed and that staff meet R1’s care needs. Interviews with staff also found that R1 rarely wishes to leave R1’s room despite staff encouragement to do so. Staff interviewed stated that they had not witnessed R1 being mistreated. Interviews with other residents of the home found they had not observed R1 to go outside the house nor that staff were ever heard to yell at or insult R1. Unsubstantiated LPA attempted to interview the neighbor adjacent to the house and left a business card for a call back. Neighbor did not respond to LPA attempts. 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 the evidence to prove that the alleged violation occurred. Exit interview with administrator.the state’s words, verbatim · CDSS document, May 9, 2024 · control 59-AS-20240326134435

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 3/20/2024 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home was found to be clean, safe and sanitary. Licensee advised to review sample menu with residents and modify the menu as needed for resident preferences and health needs. LPA reviewed 3 resident files and 2 staff files. Staff and resident files are incomplete. Licensee advised on required forms an better organization. Licensee advised regarding use of Guardian for transfer requests. Licensee advised regarding valid signed medication orders. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Mar 20, 2024

The state marks this report as 7 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 12/5/23 to conduct a Prelicensing Inspection utilizing the CARE tool. LPA Met with Administrator. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. Component III completed No deficiencies are being cited as a result of todays inspection. Facility is in significant compliance. License is pending. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Dec 5, 2023