Avella of Roseville

Type of visit: Case Management - Other

On 8/26/26, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while also investigating an unrelated complaint and met with Executive Director (ED) . On 8/5/26, the department received a resident death report regarding R1. The death report referenced R1 having sustained a fall with injury on 5/6/26. LPA is collecting records and conducting interviews regarding the circumstances around the May fall and care being provided at that time. LPA plans additional interviews. As a result of today’s inspection, no deficiencies were noted at this time. Report reviewed. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 26, 2026

Type of visit: Case Management - Other

On 8/13/26, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Administrator . In the meeting Resident care managers were also present. The department had received a death report for resident R1 who was receiving hospice services. During today's visit, LPA and Avella of Roseville team members discussed R1's fall history prior to initiation of hospice services. LPA has received some requested records and is requesting the following additional records regarding R1: Falls history for 2026, written record of fall prevention strategies initiated, records of discussions with R1's representative regarding care needs and safety concerns, communications with health care providers regarding falls, staff names and contact information for staff who were working in assisted living on 5/5/26 when R1 experienced a fall with injury. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report emailed to Admin.the state’s words, verbatim · CDSS document, Aug 13, 2026

Allegation investigated: Staff do not ensure that facility is free of pests.

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with administrator Michael Clymo during today’s inspections. LPA investigated allegation, “Staff do not ensure that facility is free of pests.” Relevant Party indicated that the facility residents have found rodents in their rooms. LPA interviewed administrator in which he stated the incident did not occur at Sonrisa Assisted living but it did occur at the independent living facility and was taken care of. LPA reviewed documentation and found the incident did occur at the independent living community. LPA did review the recent pest control invoices and found pest control company is coming out to the facility consistently. Due to the information gathered, LPA finds allegations to be UNFOUNDED. Exit interview conducted and report provided to administrator. Unfoundedthe state’s words, verbatim · CDSS document, Aug 5, 2026 · control 59-AS-20260726211332

Allegation investigated: Resident food not prepared in a safe manner.

On 7/16/26, Licensing Program Analyst (LPA) Kevin Mknelly spoke with Exec. Dir. (ED), Michael Clymo, to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records, food inspection and conducted interviews. LPA finds that the allegations cited above are substantiated. It was reported that on 6/7/26, R1 received pureed fruit, prepared by S1, that when served by R1's private caregiver, was found to contain small pieces of plastic. LPA reviewed photos of the food and physically examined the food. Plastic of variable sizes were found to be present in the food. In interview with S1 on 7/16/26, S1 described what they could recall as the preparation of R1's pureed fruit on 6/7/26. S1 recalled being in a hurry and that the supply of normally used Thick-it was not available. As a Thick-it substitute, S1 used a piece of bread. The bread loaves have small white tab closures similar to the color and thickness of the plastic found in the food served to R1. S1 did not specifically recall though stated that the loaf of bread used may or may not have been in close proximity to the food prepared. Substantiated On 6/17/26, LPA conducted a kitchen inspection. LPA found no other items or utensils in the kitchen other that the bread closure tabs that matched the color and thickness that matched the plastic found in the food delivered to R1. The contaminated food was discovered by care providers before food was eaten by R1. No harm resulted to R1 as a result. 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 . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 59-AS-20260610084730

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(9) · Plan of correction due date: Jul 30, 2026

General Food Service Requirements (b)(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met based on observations and statements. R1 was served food which was improperly prepared resulting in a foreign substance being in R1's food. This posed a potential risk to the resident.the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: Executive Director will conduct a training of kitchen staff regarding safequards for ensuring foreign substances do not come into contact with food served to residents. Proof of training to be submitted by the POC date of 7/30/26.

Allegation investigated: Facility staff did not provide resident's special diet. Facility staff did not provide resident with assistance with activities of daily living.

On 7/16/26, Licensing Program Analyst (LPA) Kevin Mknelly spoke with Exec. Dir. (ED), Michael Clymo, to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records, first responder records, room inspection and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. The investigation found that on 5/14/26, R1 experienced an unwitnessed choking incident during breakfast in their apartment between approximately 8:45 AM and 8:57 AM. S1 reported that they were assigned to R1 on 5/14/26 AM. S1 reported that they had assisted R1 with morning activities of daily living (ADLS). S1 had delivered breakfast which contained an omelet, turned the TV on for R1, cut breakfast to “small bites” and presented the food to R1, who was seated in a recliner. Report continued... Substantiated S1 then left R1 with their food while S1 was called away to assist another resident. S1 stated in interview that they were aware that there was an agreement between R1’s family and the care team that R1 was to be supervised when eating. S1 stated that they planned to only be gone for “a few minutes” and that R1’s 1:1 aids were due to arrive. S1 stated that they heard a call for assist to R1’s room moments after they left but S1 could not return to assist R1 due to the care needs of another resident. At 8:57 there was a pendant call for assistance. Interview with private caregiver (PC) for R1 stated they arrived at R1’s room, the door to R1's room was open, R1 was slouched in their reclined, R1's lips were blue and R1 had food on them from possible vomit or fell out of their mouth. PC stated that some of the food on R1 appeared to have been larger than bite sized pieces. PC began Heimlich from behind R1 with R1 still in a large recliner. PC pressed R1's pendant and knowing that could take some time, they also called to the Resident Care Coordinator (RCC) and the med tech as they knew their numbers as a past employee. RCC, Christina Aldana (Carderas), and med tech (S6) arrived and R1 was moved to the floor with first aid continuing. PC scooped more egg, of variable sizes, from R1's mouth. R1's airway cleared enough for R1's breathing to continue. First responders arrived at the community at 8:56 AM on 5/14/26 and took over aid to R1 upon entry to R1’s apartment. Report continued... Emergency responder notes stated: …(R1 was) lying supine on the ground unresponsive with shallow respirations. Upon arrival, staff stated that prior to calling 9-1-1 the patient was eating eggs when (they) started choking and went unresponsive…Staff stated that they performed chest compressions for approximately 4 minutes before the patient spit up some of the eggs. E7 assessed the patient and found egg still in their airway… airway cleared via suction and due to inadequate respiration an Igel was placed… Emergency notes from the treatment hospital noted: Visit diagnosis- Cardiac Arrest due to unspecified cause and Aspiration of food into trachea. Additionally, the hospital report stated: (R1) is a 91 female with dementia and Parkinson's disease who presents with unresponsiveness after choking. At (their) senior living facility this morning (5/14/26) (they) choked while eating eggs and became unresponsive. Staff initiated CPR for less than 2 minutes and removed food material from (R1’s) mouth. By EMS arrival (R1) was breathing spontaneously but remained unresponsive with abnormal respirations. EMS found a large amount of egg material in the airway above the vocal cords, which they suctioned with improvement in respiratory rate to about 10/min. (R1) was bradycardic to the 30s, improving to the 60s, and blood pressure stayed above 90 mmHg with a last value near 120/84. Blood glucose was 226. EMS reports that at baseline (R1) is ambulatory, verbal, and mildly confused. R1’s Service Plan Report notes, under Eating/Meals/Hydration, updated on 8/21/25: Care associates will report any changes in ability to eat independently. Care associates will provide occasional prompting or cueing, encouraging words, and monitor resident to Report continued... ensure proper eating and dining experience. Associate will provide assistance with opening containers, cutting food or using utensils/ adaptive equipment as needed. R1’s Service Plan also designates bathing support by private caregivers. R1’s family had established private caregivers to be with R1, 12 hours per day, 7 days per week. According to caregivers and med techs interviewed, the meal plan is for facility staff to deliver R1’s meals and to not present to meal to R1 unless/ until the private caregiver is present to monitor and assist R1 with eating as needed. Care givers and med techs stated that they received that instruction with the agreement of the facility’s RCC, and that it was communicated to all staff who provide care to R1. Interview with RCC found that R1 had a change of condition weeks prior to choking on 5/14/26. R1 was observed to have significantly increased difficulty chewing, pacing and swallowing before putting more food or drink on their mouth. RCC stated that family of R1 was encouraged to seek a swallowing assessment. In response to the food management deficit by R1, staff were to cut foods to small diced and to have care staff or PCs monitor/ assist R1 while eating or drinking. While supervision of R1’s meals was not explicitly stated in the Service Plan Report, family of R1 had received agreement to this plan from the facility’s care coordinator “and other”. In April 2026, R1’s family representative met with the facility’s Resident Liaison and RCC to create a care checklist to be posted in R1’s room. The checklist states “Ensure eggs/ potatoes are DICED bit sized”. Diced food is defined as .5 inches or smaller. Report continued... Therefore, on 5/14/26, R1 was served food that exceeded the “Diced size” agreed to and S1 provided food to R1 without the agreed to supervision for R1 while eating. 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. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on health and safety code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted. Report reviewed with Admin. Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 59-AS-20260518103141

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 17, 2026

Additional Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met based on records and interviews. On 5/14/26, caregiver S1 did not provide R1 with properly prepared food or supervision required for R1's safety while eating. This posed an immediate risk to R1.the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: Executive Director agreed to submit a plan for inservice regarding the failures in this case to review proper proccedures for: observed need/ risk, reappraisal, plan updated and staff communication with management regarding care needs by the POC date of 7/17/26.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(10) · Plan of correction due date: Jul 30, 2026

General Food Service Requirements (b) (10) Where indicated, food shall be cut, chopped or ground to meet individual needs. This requirement was not met based on interviews. Witnesses at the time of R1's choking on 5/14/26, said in statements that food that R1 choked on was not cut to diced size. This posed an immediate risk to R1.the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: Executive Director agreed to submit a plan which identifies procedures to be followed when there is an identified need or preference , that kitchen staff prepare the food vs caregiver discretion and preparation by the POC date of 7/17/26.

Allegation investigated: Staff are not providing adequate care and supervision to residents in care.

On 6/17/26, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Michael Clymo, Executive Director, 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. The review of time card records for staff working in the facility’s memory care community, for Nov.2025- Feb. 2026 found that the majority of shifts had 1 med tech and 3 caregivers for the AM/PM shifts and 1 med tech and one caregiver for the overnight shift. While several shifts had more staff scheduled, there were several shifts that had fewer staff for part of the shift. Specific instances where too few staff were present to meet the needs of residents were: Report continued... Substantiated On 1/8/26, evening staff signed out by 10:40 PM leaving a lone overnight staff until the med tech for the shift arrived at 10:53 PM. During the time between 10:40-10-53 PM, R1 fell in their room and tore out their catheter. R1 had a diagnosis of dementia, was noted as a fall risk and lacked hazard awareness and impulse control. Additionally, R1 had an incident of getting out of bed unnoticed the prior night before found by staff in the common area. Records showed that staffing was not increased following R1 being found wandering on the overnight. Family of R1 was interviewed and reported many lapses in care during the short time of R1’s residence.They reported slow response times when R1’s call button was used, delays in prompts for meals and longs periods of times without staff interaction though family had been assured of intensive monitoring during R1’s first week in the community. R2’s records review found that R2 has limited mobility, incontinence, is a 2 person lift assist and was to be assisted with repositioning due to bed sores while in hospice care. Staff and family statements found that as R2 required 2-person assist, there were many times when R2’s incontinence care was delayed when insufficient staff were present to meet R2’s and other residents’ needs. R2 moved from this community to another care home. LPA conducted a visit to observe R2 and check on their status. R2 was gaining weight, pressure injuries were resolving and they were increasing their communication with others. 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. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Administrator . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 59-AS-20260224132358

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jun 18, 2026

Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not net based on records reviews, incident reports and statements.This posed an immediate reisk to residents.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Licensee will submit a plan to review resident assessments and individual care needs to be utilized to determine staffing needs and how to rapidly respond to unplanned time off. By POC date of 6/18/26 licensee will submit who will be involved in the planning and a target date (no later than 7/2/26) for the planning to be completed.

Type of visit: Case Management - Deficiencies

On 6/17/26, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Executive Director . While conducting a complaint investigation for complaint number 59-AS-20260224132358, LPA Mknelly noted the following additional violation. Facility staff failed to report the following as required: R1’s fall/ injury on 1/8/26 and hospital death on 1/15/26 were not reported until requested on 4/20/26; R8 had a fall with rib fractures on 12/25/25 that was not reported; On 4/2/26 a resident made an allegation of staff sexual misconduct, yet the department learned about the allegation on 5/19/26. This final incident posed an immediate risk to the resident as it is a mandated reporter violation. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Jun 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 18, 2026

Reporting Requirements (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met based on records and statements. This posed an immediate risk to residents.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Licensee will submit a detailed plan for the procedures for reporting incidents of resident injury or abuse allegations (to include from the moment to observed, to who is to write reports, to ensuring reports are submitted to CCLD). POC is due 6/18/26

Type of visit: Case Management - Incident

On 4/9/26, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Executive Director (ED), Michael Clymo. Resident Care Director and Memory Care Director (interim) also joined the discussion. The department received incident reports of residents (R1, R2, R3 and R4) falls that resulted in injuries. Each fall was discussed to review causes (if known) and staff care at the time. LPA found no staff action or inaction as contributing to the falls reviewed. LPA and Sonrisa staff discussed, in detail, staff observations of falls for possible causes, staff training (the department's TSP webinar and web page as a resource), collaboration with residents, family and medical providers to ensure all reasonable measures are in place to reduce the likelihood of future falls. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report to be provided by emailthe state’s words, verbatim · CDSS document, Apr 9, 2026

Type of visit: Case Management - Other

On 10/30/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with the Executive Director (ED)/ Administrator . The department received incident reports regarding R1's behavioral episodes on 10/16/25 and 10/18/25, both of which required medical assessment. LPA and ED discussed the current behavioral expressions plan and factors to consider in developing ongoing strategies for this resident. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Oct 30, 2025

Type of visit: Required - 1 Year

On 9/10/25,L icensing Program Analyst (LPA) Kevin Mknelly arrived unannounced at the facility to conduct a required annual inspection utilizing the full CARE tool. LPA met with Executive Director, Michael Clymo, and explained the purpose of the visit. During today's inspection, LPAs and Executive Director conducted a tour the interior and exterior of the facility. Areas toured included but not limited to: courtyard, memory care unit bedrooms, assisted living unit bedrooms, main dining, kitchen, gym, and the common areas. LPAs observed care staff assisting residents with walking and other activities. LPAs observed the facility to be clean, safe and in good repair. File review was conducted for 6 residents and 2 personnel files. LPAs observed the files to be mostly complete with the required documents. Inspection tool completed and found staff training documentation to not contain required training for some staff. 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 Michael Clymo . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 10, 2025

Allegation investigated: Facility staff do not respond to call bell in a timely manner. Facility staff do not meet a resident's incontinence needs.

On May 6, 2025 , Licensing Program Analyst (LPA) Kevin Mknelly spoke to Carol Pickard 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. Records reviewed regarding R1 found that R1 has a major cognitive disorder, incontinence and diabetes. Interviews were conducted and call button records reviewed and found that there were call responses of 61 minutes for 2 calls made on 1/9/25 and 42 minutes on 1/13/25. These response times exceed the facility policy, as stated by staff, of response between 5 and 15 minutes. Facility staff acknowledged in statements that there were some call button operation issues shortly after R1’s admission. As regulation requires immediate response the period where the signal system did not properly function and the long response times noted above did not identify the reason for the slow response time, the licensee did not ensure safe operations and response to resident calls. Function of R1’s call system have since been corrected and are regularly monitored at this time. Report continued... Substantiated In interviews with staff, it was found that R1 is regularly incontinent yet does not notify staff for assistance and attempts to clean up on their own and R1 is, at times resistant to assistance. In November 2024, as was acknowledged by staff interviews, R1’s behavior of not disclosing their incontinence and poor communication/ coordination of emptying R1’s trash and laundry lead to R1’s room to be malodorous. Communication and documentation procedures have since been put in place to remediate the issue. 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 and appeal rights provided. 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 6, 2025 · control 59-AS-20250204081226

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(A) · Plan of correction due date: May 7, 2025

Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1)(A) Operate from each resident's living unit. This requirement was not met based on records and statements. This posed a potential risk to a resident.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Equipement is operational and monitored as well as R1's care plan being updated. Citation POC cleared by visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: May 7, 2025

Managed Incontinence(b) (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not based on statements. This posed a potential risk to the resident.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Resident's care plan has been updated and is effectively addressing R1's needs. Citation POC cleared by visit.

Allegation investigated: Staff did not ensure reporting requirements were followed

On April 9, 2025, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Executive Director/ Administrator, Michael Clymo, 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. Interviews of facility staff found that when a infectious illness was discoverd at the facility and email was sent out to families. Due to a administrative error, family of R1 was left off the email list and not notified. This lead to exposure of family. 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 executive director . Copy of this report and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Apr 9, 2025 · control 59-AS-20250109141346

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Apr 10, 2025

Observation of resident- The licensee shall ensure that residents are regularly observed for changes... When changes such as ... physical health condition ... and brought to the attention of the resident's physician and the resident's responsible person... This requirement was not met based on statements that found responsible party was not notified timely of an infectious illness. This posed a potential risk to others.the state’s words, verbatim · CDSS document, Apr 9, 2025

Plan of correction: During the investigation, the error was identified a and corrected. This citation is cleared at the time of this visit.

Allegation investigated: Staff do not ensure infectious disease protocols are being followed to prevent the spread of scabies. Licensee does not ensure there are sufficient staff to meet the needs of the residents

On 2/11/25, Licensing Program Analyst (LPA) Kevin Mknelly spoke with ED/ 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. Records and interviews found that the facility had the first case of a resident (R1) treated prophylactically for scabies on 11/26/24. The second (R2) began prophylactic treatment on 12/3/24. The third (R3) was the first confirmed case, by skin biopsy, on 12/7/24. Since the initial treatments began, there have been 12 residents and 7 staff treated, mostly prophylactically as a precaution as recommended by resident’s physicians, public health or by person choice due to possible exposure. Public health states that a reportable outbreak is when there are 2 or more known or suspected cases in the community. Substantiated The facilities infection control plan states that contact precautions are to instituted, staff training will be conducted and visitors will be notified. During the course of this investigation, records and statements, by staff and families, found that facility’s infection control measures were not implemented comprehensively at the unset of the outbreak (though improved during the course of this investigation). Additionally, during the time of the onset of the outbreak, a number of factors lead to occasional staffing shortages. Records and statements found that there were insufficient staff to meet the needs at times of residents. R4 is a 4 person assist for incontinence care when the use of hoyer lift was not yet utilized. AM staff were. At times, only an AM med tech and 2 staff, between 7-9 AM, leading to R4 having a delay in care while other residents were attended to and for other staff to arrive. 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. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Administrator . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 11, 2025 · control 59-AS-20241211084922

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(a) · Plan of correction due date: Feb 25, 2025

Infection Control Requirements (a) A licensee shall ensure that infection control practices are maintained... This requirement was not met based on interviews and records review witch founfd that the infection crol for this outbreak was not consistently and effectively implemented. Thisposed a risk to residents.the state’s words, verbatim · CDSS document, Feb 11, 2025

Plan of correction: The facility has a comprehensive scabies mitigation plan at this time. The licensee agrees to submit the action plan for who is responsible for the implementation of all aspects of the plan by the POC date of 2/25/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 25, 2025

Additional Personal Rights of Residents in Privately Operated Facilities (a) ... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, ...to meet their needs. This requirement was not met based on records and interviews which found that that for a period of time, there were insufficient staff to meet residents needs. This posed a potential risk to residents.the state’s words, verbatim · CDSS document, Feb 11, 2025

Plan of correction: At this time, staffing has been corrected to resident needs. Licensee agrees to submit a plan for addressing acute or chronic staffing needs when staff shortages are experienced by the POC date of 2/25/25.

Allegation investigated: Staff is mismanaging resident's medication

On 12/19/24, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Exec. Dir., Carol Pickard, 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. It was reported that on 12/13/24, it was witnessed that R1 was wheezing. A family memembr requested to see if R1 had received their morning respiratory medication treatment. The inhaler shown to family member for use for R1 showed there to be "0" doses remaining in the inhaler and had a start date noted of 10/8/24. An internal audit conducted by the Program Director found there to be 2 open inhalers- one was empty and one had doses remaining. It was indetemined how many doses were missed by R1 as the fill and start dates on the centrally storred medication record showed medications documented out of order from when received and started. Substantiated 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. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Administrator . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 59-AS-20241217152717

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 20, 2024

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self- administered medications as needed. This requirement was not met based on statements and records that showed that the plan for medication administration compliance was not followed resulting in an immediate risk to R1the state’s words, verbatim · CDSS document, Dec 19, 2024

Plan of correction: Licesnee agrees to conduct retraining for med techs on the proper use of treatment dispensers as well as institute a procedure for orderly use of medications in the order received. Training dates to be submitted by the POC date of 12/20/24 along with medication storage/ use procedure. This is a repeat violation. Civil penalties are applied

Allegation investigated: Staff did not adequately monitor resident’s oxygen administration.

On 11/19/24, Licensing Program Analyst (LPA) Kevin Mknelly spoke with Executive Director, Carol Pickard 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. Staff did not adequately monitor resident’s oxygen administration- Records review R1 is diagnosed with chronic respiratory failure, requires oxygen, edema, fluid restrictions and mild cognitive impairment. R1 can follow instructions and is able to communicate needs. R1 is ambulatory and has escort services identified due to fall risk. Interviews found R1’s Services Plan identifies that R1 has a low salt diet and recommended fluid restriction, R1 is to be escorted to and from meals and events and that staff will observe/ maintain/ report safe environment for oxygen and will evaluate needs of oxygen management. Substantiated Documentation by the facility that escorts were provided to or refused by R1 were not available. Interviews found that R1 would at times call for and accept escorts and at other times R1 would not. Interviews of visitors for R1 found that R1 was found at times to not be using oxygen as recommended. Interviews also found that there were not clear procedures in place to ensure that, even when R1 left an area not having asked for escort, R1 was then located and oxygen assistance was offered. Therefore, there were times where R1 was not monitored as agreed to in the care plan which resulted in R1 not using oxygen as prescribed. The incidents observed did not result in R1 needing medical assistance for oxygen. 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 Carol Pickard . Copy of this report and appeal rights provided. Staff did not seek timely medical attention for resident- Statements made found that R1 received medical care at times when visitors insisted but R1 did not feel it was necessary. Staff were following written physician instruction for when medical care should be sought. During the course of this investigation, R1's PCP has provided further guidance. LPA advised that when R1 returns from hospitalization that clear guidance and communication is in place for the monitoring and responses to R1's medical conditions. During this investigation, R1 sustained a fall with injury. R1 had not requested assistance in getting out of bed, slipped and fell, and staff called for emergency services. LPA inspected the site of the fall after carpet cleaning had been done and did not find anything to have contributed to R1's fall. 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, Nov 19, 2024 · control 59-AS-20240924145842

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87618(b)(1) · Plan of correction due date: Dec 10, 2024

Oxygen Administration -(b) In addition to Section 87611(b), the licensee shall be responsible for the following: (1) Monitoring of the resident's ongoing ability to operate the equipment in accordance with the physician's orders. This requirement was not met based on records and interviews resulting n potential risk to the resident.the state’s words, verbatim · CDSS document, Nov 19, 2024

Plan of correction: Licensee will submit a plan for insuring that residents with oxygen are monitored in their movements within the facility and that oxygen operations are available as prescribed by the POC date of 12/10/24.

Allegation investigated: Staff did not administer medication(s) to resident as prescribed. Staff are mismanaging residents' medications.

On 10/15/24, Licensing Program Analyst (LPA) Kevin Mknelly spoke to ED Carol Pickard, 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. Records and statements supported that on 9/9/24, R1 was given medications by med tech S1 that contained a half tab of a medication that did not belong to R1. S1's explanation of how the medication mix up happened were not credible. The error was caught by a family member present. R1 did not take the wrong medication that was dispensed to them. Additionally, R1 was to receive a medication that is to be administered before and seperate from other medications. Records and statements showed that upon admission R1 took a 7 AM medication. With an update to medication administration records (MAR) that same medication was then combined with others at 8 AM. Substantiated During this investigation, an additional medication issue was found. On 10/11/24, R2's family was notified of two medications that are due for refills. Due to the short notice weekend alert and some pharmacy related issues, R2 missed a dose of two medications. Furthermore, family provided and the staff accepted medications into the med room that were not in prescription bottles not logged into centrally stored medication. All medications for R2 have since been filled and R2 was unharmed. Centrally stored medication records for the two missed medications for R2 did not record the number of refills available for the medications. 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. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Carol Pickard . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 15, 2024 · control 59-AS-20240911170931

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 16, 2024

Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met based on statements and records which found an incident of a resident being handed another's medication and an incident of a missed meication. This posed an immediate risk to residents.the state’s words, verbatim · CDSS document, Oct 15, 2024

Plan of correction: Licensee will conduct and audit of all current medications and record the results of the audit to include refill numbers and next refill dates of all medications. Licensee will then submit a plan for periodic audits of medications. By 10/16/24, licensee will submit the plan and timeline in which the audit will be conducted and the plan to be submitted (with the plan date to be no later than 11/12/24).

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: Nov 29, 2024

Incidental Medical and Dental Care (h)(5) Each resident's medication shall be stored in its originally received container. This requirement was not met based on statements that found medication was accepted into central storage and that those medications were no longer in their original container. This posed a potential risk to resident.the state’s words, verbatim · CDSS document, Oct 15, 2024

Plan of correction: Licensee will submit proof of retraining for staff not accepting medications out of their original container and for correct recording of centrally stored medications by the POC date of 11/29/24.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Graham Gunby and Kevin Mknelly arrived unannounced at the facility to conduct a required annual inspection utilizing the full CARE tool. LPA met with Executive Director, Carol Pickard, and explained the purpose of the visit. Today's census is 114 residents, the facility is licensed for 199 residents with a hospice waiver for 15. During today's inspection, LPAs and Executive Director conducted a tour the interior and exterior of the facility. Areas toured included but not limited to: courtyard, memory care unit bedrooms, assisted living unit bedrooms, main dining, kitchen, gym, and the common areas. LPAs observed care staff assisting residents with walking and other activities. LPAs observed the facility to be clean, safe and in good repair. File review was conducted for 10 residents and 6 personnel files. LPAs observed the files to be mostly complete with the required documents. Inspection tool completed and found facility to be in substantial compliance. LPAs noted and discussed with the administrator the requirements for the hospice care plan content. During the personnel file reviews LPAs requested copies of 2 staff first aid training certificates. No deficiencies observed during today's inspection. Exit interview conducted and a copy of report was provided.the state’s words, verbatim · CDSS document, Sep 18, 2024

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 8/30/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit regarding an unexpected resident death and met with Senior Executive Director (ED), Carol Pickard and Program Director (PD), Liza Spencer, LVN. On 8/29/24, the department received a death notification regarding R1, who passed away on 8/27/24. LPA, at todays visit, received and reviewed R1's LIC 602, care plan, medication administration records and call pendant records. R1 was found to have multiple chronic illnesses. R1 had had a medical appointment the day prior with no noted new health concerns. R1 was last observed the evening before. R1 had not made any calls for assistance by pendant on the overnight of 8/26-8/27/24. When 8 AM staff assistance was provided, R1 was found to be unresponsive and 9-1-1 was called. At this time, R1 appears to have passed away due to natural causes and appeared to have received the necessary level of care and supervision for identified needs. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Aug 30, 2024

Type of visit: Case Management - Other

On 4/19/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with executive director, Eva Bowlin and memory care director Aaron Burgos . The purpose of the visit was to discuss incident reports received by the department. On 3/27/24, R1 exhibited a change in condition and upon hospital evaluation was found to have a UTI and dehydration. LPA and director discussed R1's care plan and efforts to assist R1 stay hydrated. Additionally, overall resident hydration measures were discussed as warmer weather has begun. The licensee appears to have proper measures in place. On 3/29/24, R2 and R3 were found to have left the memory care unit and be walking in the facility's parking lot. Staff who found the residents, redirected them to return to the unit to get ready for dinner. Resident's were unharmed. Residents were thought to be last seen approximately 10 minutes before found. The delayed egress system was reviewed to try to determine how residents left unnoticed. The system is found to be working properly, staff training has been done, residents' care plans have been updated. If additional measures will be added to the facility's plan of operations, the update will be submitted to the regional office. No violation is noted for this event. On 3/27/24, R4 had an unwitnessed fall and fracture. R1 pressed their pendant for assistance and received timely medical care. R1 is currently in rehabilitation, will be reassessed before return and their care plan will be updated as needed. In addition to this incident, LPA and director discussed the licensee's fall prevention and assessment program. No violation is noted for this event. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Apr 18, 2024

Type of visit: Collateral

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a collateral visit. LPA met with Administrator Jessica Galvez during today's visit. LPA arrived today to interview resident concerning an issue that was not related to this facility. In the areas that were evaluated, no deficiencies were observed at the time of the visit. Exit Interview conducted.the state’s words, verbatim · CDSS document, Dec 20, 2023

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 11/17/23 to conduct a Post Licensing Inspection utilizing the CARE inspection tool. LPA met with the Executive Director (ED)/ Administrator and explained the purpose of the visit. . LPA and ED 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, 1 resident bedroom, med rooms, kitchen and dining, and The Gardens (Memory Care section). In the areas toured no immediate health, safety, or personal rights violations were observed. LPA reviewed resident files. Files were complete. LPA and ED discussed ensuring physician reports in a non-standard LIC 602 format be double checked for completeness of required information. Staff files were reviewed. Files are complete. LPA and ED discussed consolidating/ organizing files to have required forms and training in one place to help the review be more efficient. LPA requested resident roster and LIC 500 be submitted. No deficiencies are being cited as a result of todays inspection. Exit interview conducted. Report provided copy provided.the state’s words, verbatim · CDSS document, Nov 17, 2023