Sierra Ridge Senior Living

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.

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: Facility is understaffed staff did not prevent resident on resident altercation

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Executive Director Alyssa Sellers to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 12, 2026 · control 59-AS-20260106124506

Allegation investigated: Lack of staffing/supervision

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Executive Director Alyssa Sellers to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 12, 2026 · control 59-AS-20251209112349

Allegation investigated: Inadequate staffing to provide care Emergency pull cords not functioning

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Executive Director Alyssa Sellers to deliver findings for the above complaint allegations. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 12, 2026 · control 59-AS-20251203135514

Allegation investigated: Facility did not allow resident to go their doctor appointment.

Licensing Program Analyst Kerry Hiratsuka conducted this unannounced complaint visit to deliver the results of the allegation above. LPA interviewed Administrator and staff. LPA reviewed records. One day, R1’s power of attorney (POA) arrived at the facility to take R1 to an appointment. Interviews indicate staff were instructed to call the R1’s POA for instructions before the resident was allowed to leave the facility. After the doctor's visit R1’s POA changed and the documentation was provided to the facility. Facility staff contacted the incorrect POA resulting in R1 missing their appointment. R1’s POA left the facility because they were too late to make the appointment. Although the facility did not restrict the resident from attending their appointment, the facility caused an unnecessary delay resulting in the resident missing their appointment. Substantiatedthe state’s words, verbatim · CDSS document, Oct 22, 2025 · control 59-AS-20250717092158

Allegation investigated: Staff did not provide responsible party resident's records.

Licensed Program Analyst (LPAs) Cassandra Mikkelson and Kerry Hiratsuka arrived at the facility unannounced and met with Tony Sellers to deliver findings for the above complaint allegations. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 15, 2025 · control 59-AS-20251006095132

Allegation investigated: Staff did not provide medication assistance to resident in care Staff did not provide proper meals to residents in care Staff did not prevent resident from engaging in inappropriate behavior in residents' rooms Staff did not provide shower assistance to resident in care Staff did not properly report resident's incident Hygiene supplies are not readily available to residents in care Staff left resident in care in soiled clothes for an extended period of time

Licensed Program Analyst (LPAs) Cassandra Mikkelson and Kerry Hiratsuka arrived at the facility unannounced and met with Tony Sellers to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unfoundedthe state’s words, verbatim · CDSS document, Oct 15, 2025 · control 59-AS-20250825141240

Allegation investigated: Staff are not following resident's care plan. Staff did not notify resident's responsible party of resident leaving the facility.

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Alexis Thacker to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unfoundedthe state’s words, verbatim · CDSS document, Oct 8, 2025 · control 59-AS-20250902172728

Allegation investigated: Resident sustained multiple injuries while in care due to staff neglect Staff does not provide drinking cups for residents Staff not maintaining residents hygiene

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Administrator Tony Sellers to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unfoundedthe state’s words, verbatim · CDSS document, Aug 27, 2025 · control 59-AS-20250807102552

Allegation investigated: Staff are not permitting resident to leave the facility Staff are not permitting resident to have visitors

On August 19, 2025 LPA Tryon visited the facility to complete the complaint. LPA met with Interim Executive Director Tony Sellers and spoke by phone with covering ED Alyssa Sellers. LPA has interviewed witnesses, resident, Directors and staff. In speaking with witnesses, LPA learned that on at least one occassion, family members came to visit resident R1 at the facility. They were told by the ED at the time that R1 could not go into the community with them; and that they needed to leave. Therefore, the allegations that staff are not permitting resident to leave the facility; and staff are not permitting resident to have visitors is Substantiated. A finding of substantiated means that the allegation is valid because a preponderance of the evidence standard has been met. Deficiency cited as per Title 22 Regulations and the Health and Safety Code. Appeal rights provided, exit interview conducted. Substantiatedthe state’s words, verbatim · CDSS document, Aug 19, 2025 · control 59-AS-20250520151357

Allegation investigated: Staff did not dispense medication to residents as prescribed. Staff did not refill residents’ medication prescriptions in a timely manner.

On 8/6/2025 LPA Tryon and LPM Ordonez visited the facility to complete the complaint. LPAs met by phone with Alyssa Sellers covering Executive Director. LPA has interviewed staff, reviewed facility documents and records. Regarding the allegation that staff did not dispense medication to residents as prescribed, LPA has interviewed 4 involved staff and reviewed records. LPA learned that a new medication administration computer system was initiated in about January 2025. In the process of switching from the old to the new system, there were some "glitches" and issues; apparently not all the information transferred correctly, some dropped, etc. From interviews it appears that staff did the best they could with trying to keep up with the medications, used a combination of systems until it got straightened out, etc. Opionions seemed to differ somewhat between staff interviewed as to whether medicatons were given correctly, there were issues between various staff, etc. At this time, LPA is nthe state’s words, verbatim · CDSS document, Aug 6, 2025 · control 59-AS-20250414122356

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: Licensee overcharged resident for services Staff did not provide resident’s DNR directives to medical personnel

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Cheya Lovelace, Resident Care Coordinator to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unfoundedthe state’s words, verbatim · CDSS document, Jul 10, 2025 · control 59-AS-20250626150100

Allegation investigated: Staff not providing care and supervision to resident

On 5/1/2025 LPA Tryon visited the facility to complete the complaint. LPA met with Executive Director Alexis Thacker. Over the course of the investigation LPA has interviewed 6 staff, reviewed documentation. LPA found that resident R1 had fallen several times while living at the facility. Through interview and review, LPA learned that R1 spent a lot of time walking around the facility; and walked head-down. R1 had a frequently recurring medical condition. When the condition popped up, R1 would suddenly start running down the hall, head-down. Staff would get medical attention ASAP for R1, but since the condition recurred fairly often, it would happen before anyone was aware, and R1 would run. When R1 ran, R1 would run into objects like tables/chairs, the wall; and then fall. Staff tried diligently to redirect R1 to activities; tried putting R1 to bed after meals to rest; tried having R1 sit, but R1 would frequently "bounce back up" and attempt to run. Hospice services were started, andthe state’s words, verbatim · CDSS document, May 1, 2025 · control 59-AS-20240805134831

Allegation investigated: Resident developed Stage 4 pressure injuries while in care.

Licensing Program Analyst Todd Tryon visited the facility unannounced on 04/9/25 to deliver the findings of the investigation completed by the Department. LPA met with Executive Director Alexis Thacker. During the course of the investigation, CCL staff has interviewed witnesses, staff, residents, outside agencies, reviewed documentation, reviewed medical records. Neglect: Lack of care/ supervision resulted in resident R1 developing stage four pressure injury. Based on interviews, medical documentation, and facility records, it was determined that the facility failed to provide adequate care and supervision to Resident 1 (R1), resulting in the progression of a pressure injury from stage two to stage four within a span of seven days. The facility did not ensure proper wound care, consistent repositioning, or timely medical attention, which contributed to R1's decline and subsequent admission to hospice care. Based on review of the medical documentation, on 6/19/2024 R1's medical recordsthe state’s words, verbatim · CDSS document, Apr 9, 2025 · control 59-AS-20240926141557

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: Licensee does not ensure sufficient number of staff on site to assist residents with toileting needs. Staff are not providing adequate laundry services for resident

On 9/25/2024 LPA Tryon and LPA Gunby visited the facility to complete the complaint. LPAs met with Executive Director Jennifer Fuston. During the course of the investigation, LPA has toured the facility, checked resident rooms and closets, inspected the laundry area, visited residents in common and dining areas, and interviewed 6 staff and ED. Regarding the allegation that Licensee does not ensure sufficient number of staff on site to assist residents with toileting needs, LPA learned that there has been an issue with hiring and retaining qualified staff. However, during the past months staff who were present worked hard to meet resident needs. Even though residents may have had to wait a little longer, residents appear to have had basic needs met by staff who were present. At this time the facility has been working hard to maintain a staff consisting of 4 caregivers and 2 med techs on day and evening shifts; and 2 caregivers and 1 med tech on night (NOC) shift. The facility does use athe state’s words, verbatim · CDSS document, Sep 25, 2024 · control 59-AS-20240708155450

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.

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.

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.