Cottages at Palm Springs

Allegation investigated: Staff do not keep the facility free of insects Staff do not ensure residents rooms are kept free of malodorous odors

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to initiate the investigation into the allegations listed above. The LPA met with Tammy Eddy, Executive Director, and informed them of the purpose of the LPA’s visit. On July 8, 2026, Community Care Licensing (The Department) received a complaint report with the following allegation. It was alleged that staff do not keep the facility free of insects. Information received indicated that Resident #1 (R1) moved into the facility in the first week of July 2026, and R1's room had insects crawling on the walls and ceiling. R1 had to be moved to a different room immediately. LPA's records review revealed that R1's room had insects crawling on the edges of celing on the first day of move-in. Staff moved R1 into a different room in the same builing on the same day that insects were observed. The facility maintenance staff treated the room on the same day. Continued on LIC9099-C.... Unsubstantiated LPA conducted interviews with four (4) residents, all of whom stated that they have not experienced any insect infestation. LPA conducted interviews with two (2) staff members, both of whom stated that R1's room did have insects, was treated on the same day, and is now free of insects. LPA conducted an interview with R1 who stated that their current room did not have any insects. LPA conducted a tour of the interior of the facility and did not observe any health and safety concerns, including insect infestation. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated. It was alleged that staff do not ensure residents rooms are kept free of malodorous odors. Information received indicated that Resident #2's (R2) room was observed to have strong odor. LPA conducted interviews five (5) residents, all of whom stated that they did not notice any strong odor from any other residents' rooms. All residents interviewed stated that their rooms have been cleaned once a week by housekeepers and were satisfied with the cleaning services. LPA conducted interviews with two (2) staff members, both of whom stated that R2's room had certain odor due to their physical and cognitive condition. R2's room is cleaned once a week or more frequently after any incidents. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 18-AS-20260708082415

Allegation investigated: Staff do not respond to call alert system in a timely manner

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegation. LPA met with Tammy Eddy, Executive Director, and informed them of the purpose of the LPA’s visit. The Department’s investigation involved interviews with staff and residents and review of records. On May 19, 2025, Community Care Licensing (The Department) received a complaint report with the following allegation. It was alleged that staff do not respond to call alert system in a timely manner. Information received indicated that Resident #1 (R1) pressed their call button for staff assistance, but no staff came to help. R1 then proceeded to walk out of the room and found a staff member who called 911 for R1. LPA conducted interviews with five (5) residents, all of whom stated that they have not had any problems receiving assistance from staff members when call button was pressed. Continued on LIC9099-C..... Unsubstantiated LPA conducted an interview with R1 who stated that it took about 30 minutes for two (2) staff members to come in and assist R1 back on their bed. R1 stated it was about 2:00 AM on an unknown date in 2025. R1 stated it was the only time when staff response time was delayed. R1 thought that was due to the incident took place at such early time of the day and the job required two (2) staff members. R1 could not remember any other incidents when staff response time was delayed. LPA's attempted interviews with additional two (2) residents were unsuccessful due to their cognitive condition. LPA conducted interviews with five (5) staff members, all of whom stated that they have not heard any complaints from residents regarding call button response time. Staff members interviewed stated that all caregivers carry radios or phone and respond to residents immediately. The facility's office has a central monitor that can display which calls were not responded. Staff's response time can vary depending on what they are working on or time of the day. Based on interviews conducted, the Department's investigation did not provide enough information to corroborate the allegation that staff do not respond to call alert system in a timely manner. LPA determined that R1's experience of delayed staff response time was an isolated incident, not an on-going problem at the facility. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, May 21, 2026 · control 18-AS-20250519140735

Allegation investigated: Resident was issued an unlawful eviction

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegation. LPA met with Tammy Eddy, Executive Director, and informed them of the purpose of the LPA’s visit. The Department’s investigation involved interviews with staff and residents and review of records. On November 13, 2025, Community Care Licensing (The Department) received a complaint report with the following allegation. It was alleged that resident was issued an unlawful eviction. Information received indicated that Resident #1 (R1) received a 30-day eviction notice from the facility staff. LPA conducted an interview with R1's relevant party (RP) who stated that there was a misunderstanding about what 30-day eviction notice was about. RP also stated that R1 had financial issues to continue living at the facility. Continued on LIC9099-C.... Unsubstantiated LPA conducted an interview the Executive Director who stated that the 30-day eviction notice issued to R1 was per the admission agreement. The 30-day eviction notice was due to non-payment of monthly rent. LPA's records review confirmed the Executive Director's statement. Based on interviews conducted and records review, the Department's investigation did not provide enough information to corroborate the allegation that resident was issued an unlawful eviction. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, May 21, 2026 · control 18-AS-20251113141019

Allegation investigated: Facility staff refused to provide refunds

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to investigate the above allegation. LPA met with Tammy Eddy, Executive Director, and informed them of the purpose of the LPA’s visit. The Department’s investigation involved interviews with staff and review of records. On May 18, 2026, Community Care Licensing (The Department) received a complaint report with the following allegation. It was alleged that facility staff refused to provide refunds. Information received indicated that Resident #1 (R1) moved out, but staff refused to refund $3,000.00 community fee paid upfront. LPA conducted an interview with R1's relevant party (RP) who stated that the community fee should not have been collected before resident's assessment was completed. RP stated that the entire community fee must be refunded. LPA conducted records review and observed that R1 moved in on April 9, 2026 and moved out on May 08, 2026. Continued on LIC9099-C.... Unsubstantiated R1's admission agreement stated that community fee is to be refunded in certain proportion depending on the time of termination of the admission agreement. LPA also observed that R1's admission agreement showed the amount of the community fee and was signed by all relevant parties. LPA obtained documentation from the facility's accounting department which showed the refund processed date of May 11, 2026. The refund was processed consistent with the Department's regulation. Based on records review and interviews conducted, the Department's investigation did not provide enough information to corroborate the allegation that facility staff refused to provide refunds. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, May 20, 2026 · control 18-AS-20260518145900

Allegation investigated: Resident do not have a working television

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to investigate the above allegation. LPA met with Tammy Eddy, Executive Director, and informed them of the purpose of the LPA’s visit. The Department’s investigation involved interviews with staff and resident and review of records. On May 19, 2026, Community Care Licensing (The Department) received a complaint report with the following allegation. It was alleged that resident do not have a working television. Information received indicated that Resident #1 (R1) does not have a working television in their room. LPA conducted an interview with R1 who stated that R1's friends brought two (2) televisions and one of them worked fine. R1 stated that the television in their room worked without any problems. LPA conducted an interview with Staff #1 (S1) who stated that R1's friends brought wrong remote control, so R1 could not use the television. R1's friends brought a correct remote control later, and the televeion was working fine. Continued on LIC9099-C.... Unfounded S1 stated that the televisions were all supplied by the residents or their families, not the facility. LPA's records review revealed that R1 was admitted to the facility on March 25, 2026, and television was not offered in the admission agreement. LPA's interview with the Administrator confirmed the statement from S1. Based on observation, interviews and records review, the Department's investigation did not provide any information to corroborate the allegation that resident do not have a working television. This allegation is unfounded. A finding of Unfounded means the allegation could not have happened, is false, and/or is without a reasonable basis. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, May 20, 2026 · control 18-AS-20260519115653

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced annual required visit. Upon entry, LPA was greeted by Tammy Eddy, Executive Director, and informed them of the purpose of the visit. Currently, the facility has 79 residents in care. Facility Overview: The facility is consisted of 6 cottages and an office building. Each cottage's capacity is up to 16 residents. There are no pools or known firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility has infection control plan in file. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. The facility has laundry room in each cottage, and LPA observed them to be operational. Sharp and dangerous objects were securely locked and inaccessible to residents. LPA obtained and reviewed the annual fire inspection report dated 06-10-2025, and the facility passed the inspection. LPA reviewed the monthly water temperature logs and observed the water temperatures in each cottage were within regulatory limit. Fire extinguishers installed on the walls of each cottage, and the fire extinguishers had current inspection tags. Continued on LIC809-C.... Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate. Record Review and Resident/Staff Files: LPA reviewed files for five (5) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Five (5) resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for five (5) residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 03-25-2026, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided. ***LPA left the facility at 12:00 noon and returned at 1:00 PM.the state’s words, verbatim · CDSS document, May 11, 2026

Allegation investigated: Staff had a physical altercation with a resident in care

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to initiate the investigation into the allegation listed above. The LPA met with Tammy Eddy, Executive Director, and informed them of the purpose of the LPA’s visit. On 02-12-2026, Community Care Licensing (The Department) received a complaint report with the following allegation. It was alleged that staff had a physical altercation with a resident in care. Information received indicated that Resident #1 (R1) displayed aggressive behavior toward Staff #1 (S1) and Staff #2 (S2) and rammed into S2. The incident occurred on 02-04-2026. Continued on LIC9099-C.... Unsubstantiated LPA attempted to conduct an interview with R1, but the interview was unsuccessful as R1 declined to answer any of LPA’s questions. LPA conducted interviews with four (4) other residents, none of whom were aware of any physical altercation in the facility. LPA conducted an interview with S1 who confirmed the information that R1 had a behavior episode, and R1 rammed into S2 on 02-04-2026. LPA conducted interviews with five (5) additional staff members, all of whom stated that they have witnessed R1’s aggressive behavior toward staff members in the past. LPA’s review of R1’s records confirmed the statements from the staff members interviewed. Based on records review and interviews conducted, the Department’s investigation did not find enough information to corroborate the allegation that staff had a physical altercation with a resident in care. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided. **LPA left the facility at 11:30 AM and returned at 12:30 PM.the state’s words, verbatim · CDSS document, Feb 17, 2026 · control 18-AS-20260212164222

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Seo Jeon arrived unannounced to the facility to conduct a case management visit to check on the health, safety, and welfare of residents in care. A report was received by the Department from the facility on 08-25-2025 regarding Resident #1 (R1) and Staff #1 (S1). LPA met with Tammy Eddy, Administrator, who allowed LPA entry. The LPA conducted a tour of the interior/exterior areas of the facility, conducted a review of records, obtained, and requested copies of pertinent documentation. LPA's interview with the Administrator and records review revealed S1 was removed from the facility staff schedule as of 08-15-2025. LPA's review of staff schedule confirmed S1 was not scheduled to be at the facility at the time of LPA's visit. LPA did not observe any health and safety concerns. No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted where a copy of this report was discussed with and provided to Tammy Eddy, Administrator.the state’s words, verbatim · CDSS document, Aug 26, 2025

Allegation investigated: Staff neglect resulted in resident sustaining broken femur. Staff did not seek medical treatment for resident. Licensee did not notify POA of resident fall.

On 06/30/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegations noted above. LPA met with Tammy Eddy, Executive Director and explained the purpose of the visit and the elements of the allegations. The allegations were investigated, which consisted of interviews and records review. It was alleged staff neglect resulted in Resident 1 (R1) sustaining a broken femur. A review of R1’s Resident Assessment dated 09/30/2022 revealed R1 is a full assist with daily living, unable to walk, and uses a wheelchair. A review of R1’s Needs and Services Plan dated 06/28/2022, R1 is noted to be a fall risk, and a 2 person assist. Interviews revealed on 01/28/2023, R1 sustained an unwitnessed fall. R1 was observed on the floor in their room yelling in pain. Staff interviews further revealed, multiple staff responded to R1s room as they had heard someone from the room scream/yell in pain. Staff observed R1’s hospital bed to be in the high position with the bed rail in an upward position, used to keep R1 from falling out of bed, but was observed to be in the lowered position. Substantiated Staff interviews conducted, confirmed the bed rails should have been in the up position and the hospital bed was observed to be in the lowered position. Information obtained from staff interviews revealed, if R1s bed were not left in the down position, R1 would not have fallen from their bed. In addition, the bed rails being put in the “up” position would prevent R1 from falling out of the bed, being that R1 would have behaviors that being that included moving around in the bed. A review of medical records dated 02/02/2023 revealed that R1 was diagnosed with an acute left femoral sub capital fracture with superior lateral displacement and varus angulation. R1 was required to have surgery after being admitted to the hospital. Therefore, the allegation of staff neglect resulted in resident sustaining broken femur is substantiated. Staff did not seek medical treatment for resident. According to staff interviews information revealed on 1/28/2023 at around 2:30pm R1 sustained an unwitnessed fall, this was confirmed by staff who responded to R1s room as they had heard someone from the room scream/yell in pain, upon arrival R1 was the only person in the room. A record review was conducted of the End of Shift Reports, these are reports completed by facility staff at the end of their shifts. The reports revealed the following: a written entry note stating “at the beginning of shift med tech received a call from Resident Assistant in Elm unit, R1 was on floor near bed, the med-tech conducted an assessment and indicated there were no visible cuts or bruising, and R1 was not complaining of pain. Additional information from the End of Shift Reports revealed following: dated 01/29/2023, note R1 seemed agitated and was kicking and yelling; on 01/30/2023, R1 was in pain on their left leg when staff attempted to turn R1; on 01/31/2023, R1 was in a lot of pain when attempts were made to turn and change R1, and hospice was notified. A record review of hospice records was conducted and revealed the hospice agency was notified of R’s fall on 02/01/2023 by a non-staff individual. A review of an Unusual Incident Report dated 01/28/2023 revealed during safety checks R1 was found in their room on the floor near the bed and R1 denied any pain at the time. The Unusual Incident Report also indicated there was no apparent injury. A visit from R1s hospice agency was conducted and a request was made to the hospice agency to get x-rays completed. X-ray results revealed a left hip fracture, resulting in R1 being sent out for further medical evaluation on 02/02/23, five (5) days after the injury/incident occurred. Therefore, the allegation of staff did not seek medical treatment for resident is substantiated. Licensee did not notify POA of resident fall. On 1/28/23 during safety checks R1 was found on the floor. It was determined that R1 had an unwitnessed fall. Per a records review conducted an unusual Incident/Injury report dated 1/28/23 sustained documenting that R1 suffered a fall on 1/28/2023, noting that R1s Primary Care Physician (PCP) and Power of Attorney (POA) were notified. Per a further records review revealed that there was an addition Unusual Incident/Injury report dated 2/2/23 stating that CCL, was informed of the incident on 2/8/23, Primary Care Physician 2/2/23, Placement agency (hospice) on 2/2/23 and R1s responsible party on 2/2/23. Per an interview with previous Residential Services Director Melissa Polendo who allegedly informed R1s POA and PCP of the incident, however Melissa stated that she was not the one that directly notified R1s POA and PCP, but the Medication Technician/Staff #1 (S1) was the one that did. Per an interview with S1 whom stated they informed their supervisors via text message. A further records review revealed that S1 was written up for not following up to ensure the supervisors were properly notified of the incident. Per an interview with R1s POA denied being contacted by facility staff regarding R1s fall on 1/28/23. The department is noted to have been notified of the incident on 2/8/23 however, there was no confirmation of the report being submitted/received. The Unusual Incident/Injury report dated 1/28/23 and 2/8/23 were not signed by the Executive Director nor was there a fax confirmation accompanying the reports. Based on interviews and records review the allegation of licensee did not notify POA of resident fall is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalty of $500 is being assessed. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department. An exit interview was conducted and a copy of this report, 9099C, 9099D, appeal rights, LIC421IM, and LIC811-Confidential names list was reviewed and provided to Tammy Eddy, Executive Director.the state’s words, verbatim · CDSS document, Jun 30, 2025 · control 18-AS-20230222155535

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(1)(c) · Plan of correction due date: Jul 1, 2025

Basic Services (1)Care and supervision defined in 87101(c)... (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident' s physical health, mental health safety, or welfare would be endangered. Assistance medications, money mgmt, or personal care. This requirement is not met as evidenced by: Facility staff did not ensure bed rails were in the upright position which caused an immediate health safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 30, 2025

Plan of correction: The Licensee agrees to conduct an in-service on the importance of following resident care plan. Proof of POC is to be submitted to the department by 5pm on the due date indicated.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1 · Plan of correction due date: Jul 1, 2025

87468.1- Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services. This requirement has not been met as evidenced by: the Licensee did not seek timely medical attention for R1. This is a immediate health safety and personal risk to person's in care.the state’s words, verbatim · CDSS document, Jun 30, 2025

Plan of correction: The Licensee agrees to conduct a review of resident fall risk procedures. Proof of POC is to be submitted to the department by 5pm on the due date indicated.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jul 7, 2025

Reporting requirements : (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident 7 days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidenced by: the licensee did not notify R1s responsible party of the incident, which posed a potential health, safety and personal rights risk to person's in care.the state’s words, verbatim · CDSS document, Jun 30, 2025

Plan of correction: The Licensee agrees to conduct an in-service on the importance of incident reporting and follow with RSD to ensure timely reporting to all applicable parties. Proof of POC is to be submitted to the department by 5pm on the due date indicated.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced annual required visit. Upon entry, LPA was greeted by Tammy Eddy, Executive Director, and informed them of the purpose of the visit. At the time of the visit, there were fifteen (15) staff members and sixty eight (68) residents present. Facility Overview: The facility is consisted of six (6) cottages for residents and one (1) main office building. There is no swimming pool on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. There is laundry room in each resident building. LPA observed inspection report from fire marshal dated 10-1-2024 which showed passing inspection of all fire extinguishers, smoke detectors, and carbon monoxide detectors. The facility has total of 14 fire extinguishers. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Continued on LIC809-C..... Care & Supervision/Administration: LPA reviewed staff schedules and observed there were sufficient staff coverages to provide care for the residents. Record Review and Resident/Staff Files: LPA reviewed files for five (5) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Six (6) resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked in med cart in med room. LPA reviewed medications for eight (8) residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 3-21-2025, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided.the state’s words, verbatim · CDSS document, May 30, 2025

Allegation investigated: Staff neglect resulted in a resident sustaining multiple pressure injuries.

On 05/07/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation noted above. LPA met with Patricia Russell, Resident Services Director and explained the purpose of the visit and the elements of the allegation. The allegation was investigated, the investigation consisted of observations, interviews and records review. On 12/24/24 Community Care Licensing received a complaint alleging staff neglect resulted in a resident sustaining multiple pressure injuries. It was alleged that Resident #1 (R1) was observed to have multiple wounds and skin tears. Per a records review R1 received the following supports: Home Health, Hospice and services from a wound care specialist agency. The home health discharge assessment note completed on 12/23/24 notes for R1 to have seven (7) wounds. The wounds are noted as traumatic wounds located on their left forearm, right inner calf, upper right left exterior (LE), left ankle and left upper arm. R1s previously noted to have a Stage 3 pressure injury left lateral lower leg on 11/19/24, and 9/25/24 Unsubstantiated traumatic wound to left lower dorsal leg. In the same discharge assessment date 12/23/24 R1 is noted to have new skin tears, and it is unknown as to how R1 sustained “so many new skin tears”. Per a file review conducted of Unusual/Incident/Injury report review there were no reports of any falls. Per the home health progress note revealed that R1 requires max assist when transferring from their bed to wheelchair. Home health services commenced on August 8, 2024. Home health is noted to come out to the facility every seven days (7). The third party wound care agency commenced services on 11/8/24 -12/17/24 and was coming out every six (6) days. On 11/8/24 R1 was observed to have a wound to their lower left anterior leg that was not healing despite measures taken such as topical antibiotics, Santyl, Medi honey, and Collagen. The wound is described as being a result of venous insufficiency, resulting a procedure was performed to remove slough and necrotic tissue. Per records reviewed of home health agency progress notes, “R1s left leg wound was noted to make no improvement and had worsened with drainage without significant improvement”. R1 is noted to have sustained additional wounds and the recommendation was to have skin grafting procedures completed”. Further notes reviewed revealed R1 is noted to have sufficient nutrition as well as normal oxygen level, the recommendation as noted in the home health progress notes was to reposition R1 every two (2) hours. Per R1s narrative charting the third party wound care specialist agency states in the notes for R1s dressing to be changed every 2-3 days as needed. Per an interview with Executive Director Tammy Eddy “facility staff were provided wound care training as well as the status of R1s condition was reviewed in regard to any applicable changes”. “Further due to the facility being non-medical, any wounds are reported to the primary care provider, and they refer out to Home Health for wound care”. Tammy further stated that the staff did not see the wounds as they were covered. Per additional staff interview conducted training was conducted which consisted of reporting observations of any wounds observed, and to apply basic first aid if applicable. Basic first aid consists of cleaning the wound with a wound solution spray and applying a bandage or gauze. Staff denied that the dressings were to be changed by facility staff, as home health or any other agency is involved, the responsibility is to report to the Primary Care Physician and keep following up until the resident has been seen by the necessary party. Despite efforts taken little to no improvement was made and a Hospice recertification was completed, and R1 received hospice services from 12/23/24 -1/31/24. Per a record review on R1s narrative charting, R1 is 12/23/24 R1 was admitted to a local hospital with the diagnosis of chronic wounds. On 1/31/24 R1 passed away and was unable to be interviewed in regard to the complaint allegation. Based on interview and record review the allegation of Staff neglect resulted in a resident sustaining multiple pressure injuries is 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(s) occurred. An exit interview was conducted and a copy of this report, LIC811-Confidential names list was reviewed and provided to Patricia Russell, Resident Services Director.the state’s words, verbatim · CDSS document, May 7, 2025 · control 18-AS-20241224155906

Allegation investigated: Staff neglect resulted in a resident sustaining an unexplained injury while in care.

On 04/25/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation noted above. LPA met with Tammy Eddy and explained the purpose of the visit and the elements of the allegation. The allegation was investigated, which consisted of observations, interviews and records review. On 07/25/23 Community Care Licensing received a complaint alleging staff neglect resulted in a resident sustaining an unexplained injury while in care. It was alleged that Resident #1 (R1) was observed to have a possible left femur fracture, as there was a bump on their left leg with swelling as well as a deformity to R1s left leg (hip). Information obtained from an interview conducted with facility Corporate Director of Dementia Services Melissa Polendo, denied R1 sustained any falls while at the facility. Additional staff interviews revealed R1 did not have wandering behaviors and would always ask for assistance. A records review of R1s narrative charting, revealed on 07/24/23 while having their brief changed, R1 was observed to have a bump on their left hip and was sent out for a medical evaluation. Unfounded R1 was admitted to a local hospital with hip pain. After further assessment the diagnosis given was mechanical function also known as “painful ortho hardware failure” due to a previous procedure. The mechanical function is not associated with a fall as it was also believed that was how R1 sustained the injury. Based on observations, interviews and records review the allegation of staff neglect resulted in a resident sustaining an unexplained injury while in care is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted and a copy of this report, 9099C, LIC811-Confidential names list was reviewed and provided to Tammy Eddy, Executive Director.the state’s words, verbatim · CDSS document, Apr 25, 2025 · control 18-AS-20230725110331

Allegation investigated: Resident sustained an arm fracture due to neglect/lack of care & supervision Staff did not ensure toileting assistance was provided to resident in care Staff did not ensure medications were dispensed to residents as prescribed

On 02/28/25 Licensing Program Analyst, (LPA) Kathleen Banrasavong, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA met with Executive Director, Tammy Eddy and explained the purpose of the visit and the elements of the allegations. The investigation consisted of interviews with staff members and residents, records review, and medical record review. On 05/15/2024, Community Care Licensing received a complaint alleging Resident 1 (R1) sustained an arm fracture due to neglect/lack of care & supervision. It was alleged staff did not provide supervision to R1 while toileting, resulting in R1 falling and sustaining a fracture. R1 was first placed at Pacifica in November 2020. The facility’s Physician’s Report dated 11/08/20 indicates under Capacity for Self Care, R1 cannot care for their own toileting needs. The facility’s Needs and Services Plan dated 02/28/2024 states R1 is a fall risk and needs standby assist. It reads R1 requires partial assist with toileting and total assist with transfers. The Resident Assessment dated 05/16/2024 shows standby assistance is required. The resident is supposed to ask staff for assistance transferring to/from bed, chair, and toilet. Facility charting shows a history of falls and attempts by resident to transfer themselves without requesting assistance by activating their call pendant. According to facility records, the resident had 14 falls while at the facility from the time period of 02/23/2022 to 04/16/2024. The resident had 4 falls in 2022, 8 falls in 2023 and 2 falls in 2024. Unwitnessed falls totaled 11 of the 14. On the charting entry dated, 09/05/2023, R1 was transferring on R1’s own, from the wheelchair to the bed without pressing R1’s pendant for assistance. Substantiated At this facility, there are multiple buildings identified as cottages. Within R1’s cottage, there are multiple apartment-like bedrooms with their own bathroom. Each cottage also has common areas which include kitchens shared by all residents. During staff interviews, it was reported that on 04/17/2024, R1 was assisted by staff to toilet in their apartment. Staff assisting R1 left R1 on the toilet, exited R1’s apartment, and went to the cottage’s kitchen to get water for R1. It was further reported the staff told R1 to stay seated on the toilet. It was estimated the staff was gone approximately 1-2 minutes. As staff made their way back to R1’s apartment, they heard R1 yelling for help. R1 was found on the floor. Staff called for medical attention. Charting notes dated 04/17/2024 with a time entered as 8:51pm revealed the following note: R1 had unwitnessed fall in their bathroom. R1 reported they wiped themselves with no caregiver present and fell. R1 refused for 911 to be called. The Serious Incident Report (SIR) dated 04/17/2024 revealed the date of the incident was 04/17/2024 and the time of incident was 6:55pm. It reads R1 got up to wipe themselves with no caregiver present and fell. R1 had red mark on their forehead. R1 refused for 911 services to be called. In the interview with R1, R1 reported experiencing a medical event and was administered their prescribed medication (M1). Charting note dated 04/17/2024 with a time entered of 3:55pm revealed the following note: R1 experienced the medical event and was given M1. R1 reported being especially concerned about being left alone in the bathroom that day. R1 said the medication “puts me out like a light.” R1 added the sedating effects M1 can last 5-7 hours, depending on how well R1 slept the night before. Because of the sedation, R1 was unable to estimate how much time had passed between the medical event and when R1 escorted to the bathroom by staff. Once R1 was positioned on the toilet, R1 reports they told S1 to stay with them. R1 added they had to remind all caregivers about staying with R1 after M1 is provided. R1 reported staff assisting them, left the room completely and did not say anything to R1 about why staff was leaving, how long they would be gone, nor did staff ask R1 to wait on the toilet until staff returned. When staff did not return after a period of time, R1 decided to try to wipe on their own. R1 can generally wipe on their own but tends to need help from the staff to get their pants and briefs pulled up. While attempting to wipe, R1 fell forward into the shower directly in front of the toilet. R1 landed on their left arm on the slightly raised lip/edge of the shower entrance. R1 estimated they were down on the bathroom floor for about 20 minutes until a staff member came to assist. Interviews revealed R1 was complaining of pain on 04/18/2024 and R1’s POA arrived and transported R1 to the hospital. Medical records were reviewed. Discharge paperwork dated 04/18/2024, revealed an x-ray of R1’s left arm was taken on 04/18/2024. X-ray revealed a distal humerus shaft fracture. In regards to the allegation that Staff did not ensure medications were dispensed to residents as prescribed. It was alleged that a medication was discontinued without a formal physician’s order. R1 was scheduled for a biopsy on August 15, 2022. Instructions were given for R1 to terminate the medication five days prior to the surgery. During the interview with Administrator, the facility provided R1’s Medication Administration Records (MAR) for the period May-August 2022. The August MAR shows the medication Clopidogrel (Plavix) was discontinued from August 11th to August 15th, 2022. An entry states the medication was suspended due to a procedure. . Staff could not find any formal physician’s order for this discontinuation. The Administrator confirmed that such a stoppage or discontinuation of a medication should not be done without a formal order. Resident Service Director, Patricia Russell indicated that she could not find a copy of the note from the neurologist to stop the medication. Information obtained from staff members stated that a request for a stop order was never requested from the neurologist. It was revealed that the physician did not send an order to the facility because the physician was not informed to terminate the order. Facility staff made a note in R1’s chart that the medication was terminated on August 10, 2024 and was suspended until the August 15th, 2024. Information obtained from interviews with Administrator stated that on 08/13/22, S1 gave R1 their nasal spray and it appeared to be working. She stated that family R1’s POA would visit and observed R1 resting for the first hour or so post- seizure. R1’s POA was concerned that R1 was not snapping back from the medication effects and the RP had the evening shift med tech send out R1. R1 was admitted for testing and observation. The Administrator stated that S1 did not observe any unusual behavior different from R1’s typical seizure activity, which is why she did not call 911 promptly. The previous Resident Services Director, Melissa Polendo confirmed that the RP did request permission to put up signs to educate staff about stroke signs to watch for. Polendo was not certain if staff had additional training on stroke recognition after this incident. In regards to the allegation that the Staff did not seek medical treatment for resident in care. The incident that occured on 04/17/2024. The resident was on M1 and had a history of strokes. The staff should have taken into account the R1's medical history and possibility of closed head trauma should have been the deciding factor and the facility should have taken the initiative and called 911 to have R1 sent out. It was reported that staff did not seek medical treatment for resident in care. Charting dated 8/13/22 shows R1 was seen by the med-tech after showing signs of weakness and slurring words. R1 was treated at 1443 hours for a seizure and monitored the rest of the day. R1 reported feeling better around 9 PM. R1’s POA came to the facility at 10:03 PM because the POA felt R1 did not sound good when the POA spoke to her by phone. The POA observed slurring, dizziness and poor balance, leading the POA to send R1 out by ambulance. On 8/14/22, facility records reported that tests were ongoing for a suspect stroke/TIA and a UTI. R1 was going to be transferred to an in-patient rehab facility for 1-2 weeks. Though R1 was displaying signs consistent with a stroke, staff failed to consider this possibility and did not send R1 for timely medical evaluation. R1 was eventually diagnosed with a stroke. Interview with the Administrator stated R1 was being actively monitored after the seizure. Staff indicted that they went into check on MJ every 30 minutes, even if R1 did not activate her pendant. The Administrator added that R1’s high cognitive functioning level and answering “no” to hitting R1’s head and being in pain was the deciding factor in not sending R1 out. The Administrator indicted that if the resident is competent, then the resident’s wish to go to the hospital or not go, is honored. Interviews with staff members which are corroborated by the facility’s charting dated 8/13/22 shows R1 was seen by the med-tech after showing signs of weakness and slurring words. R1 was treated at 1443 hours for a seizure and monitored the rest of the day. R1 reported feeling better around 9 PM. R1’s POA came to the facility at 10:03 PM because the POA felt R1 did not sound good when the POA spoke to R1. R1’s POA observed slurring, dizziness and poor balance, leading the POA to send R1 out by ambulance. Interview with other pertinent parties indicted that S2 correctly recognized that R1 was suffering symptoms consistent with a stroke. Staff 2 (S2) informed Staff (3). S3 then incorrectly determined R1 was suffering a seizure and treated R1 with Valium nasal spray medication. Next, S3 failed to contact the POA for five hours, even though the POA was supposed to be notified right away if there is a seizure. By the time the POA got to the facility, R1 was silently sleeping though a stroke due to the M1 that had been given inappropriately. R1’s POA immediately called 911 to get R1 to the hospital. Due to the delay by S3, it was too late for the physicians at the hospital to administer tPA, a clot-dissolving drug. R1 was ultimately diagnosed with a stroke in the same area as a previous ischemic stroke and spent about four weeks at Desert Regional’s in-house rehab center. R1’s POA said this second stroke undid all the progress R1 made recovering from R1’s first stroke. The hospital discharge paperwork dated 08/23/2022 on stated Chief Complaint: stroke, patient diagnosis: 1- Seizure, Page 17 out of 83. Page 31 of 83 stated that the patient was discharged in stable condition and to follow up with the PCP neurology and cardiology. Based on interviews and records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Based on records review and interviews, there was no information found to show that the facility made changes or attempts to change their care and supervision for the resident, based on her fall history. An exit interview was conducted where a copy of this report was discussed and provided along with copies of the LIC811, LIC9099D and appeal rights. In addition, an immediate civil penalty of $500 is being assessed. The LIC 421 was also reviewed, provided along with appeal rights. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department.the state’s words, verbatim · CDSS document, Feb 28, 2025 · control 18-AS-20240515085438

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.49(e) · Plan of correction due date: Mar 7, 2025

1569.49 Civil penalties; regulations setting forth appeal procedures for deficiencies. (e) For a violation that the department determines resulted in the death of a resident, the civil penalty shall be fifteen thousand dollars ($15,000). This requirement was not being met as evidenced by: staff neglect, staff caused serious injuries to resident while in care. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 28, 2025

Plan of correction: The Executive Director stated staff will be trained on the following procedures on how to follow each resident's care plan. This is to include training on how to follow up and arrange for medical care and follow ups with PCP. This training requirement is due to the LPA by email on COB on the POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to cite for a case management deficiencies, on a visit regarding the health, safety, and welfare of residents in care. During the Department's investigation for complaint control number #18-AS-20240515085438. The Department discovered that the facility failed to submit a serious incident report to the department. The Facility failed to show proof that there was any attempts made to notify the department of the incident where R1 had a fall on 08/13/22 and went to the hospital. Executive Director, Tammy Eddy stated to LPA Banrasavong the facility had no record of the incident via email correspondence, of any proof of any Serious Incident Reports (SIRS) submitted to Licensing. This is a violation of Title 22 Regulations Reporting Requirements. LPA toured the facility and observed all facility utilities to be on and operating without issues. Food supply is sufficient. There is no immediate concern for residents in care at this time. There is one (1) deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted, a copy of this report, the 809-D, an 811, and appeal rights were provided to the Executive Director, Tammy Eddy.the state’s words, verbatim · CDSS document, Feb 28, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Mar 7, 2025

REPORTING REQUIREMENTS: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to...: (1) A written report shall be submitted to the licensing agency... within 7 days of the occurrence of any of the events specified in (A) through (D)... This requirement was not met, as evidenced by: Based on record review the licensee did not ensure a written report was submitted within 7 days regarding R1's elopment from the facility. This poses a potential threat to the health, safety and personal rights of the resident in care.the state’s words, verbatim · CDSS document, Feb 28, 2025

Plan of correction: The Execcutive Director, Tammy Eddy reported staff training regarding reporting requirements will be conducted and proof submitted to the Department by COB on the POC due date.

Allegation investigated: Staff are not abiding to the admission agreement Staff do not provide adequate transportation for the residents scheduled appointments Staff did not timely repair the facility vehicle Staff do not ensure the resident laundry needs are being met

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced subsequent visit for additional investigation and met with Tammy Eddy, Executive Director. LPA informed them of the purpose of the visit. Throughout the investigation, LPA conducted resident and staff interviews, reviewed files, and records, and obtained supporting documentation to aid in determining the findings of the noted allegations. On December 24, 2024, Community Care Licensing (CCLD) received a complaint report with the following allegations. Allegation #1 - Staff are not abiding to the admission agreement. During the LPA’s initial 10-day visit on December 26, 2024, LPA’s review of admission agreement revealed that staff did not follow some of the basic services outlined in the admission agreement, such as the following. Staff did not provide transportation or make necessary arrangements for residents’ medical and dental needs. Staff did not ensure residents’ laundry needs were met in absence of laundry staff. LPA confirmed this while conducting resident interviews. Continued on LIC809-C.... Substantiated Allegation #2 – Staff do not provide adequate transportation for the residents scheduled appointments. Interviews with residents revealed that the facility bus has been out of service since mid-October 2024. Facility staff offered to reimburse any ride share or taxi invoices if submitted to the office, however information obtained through interviews revealed the residents did not know how. Residents who were not able to use ride share program or taxi service relied on their friends and family for transportation. 4 out 5 residents interviewed stated that they had to seek help from friends or family for transportation needs. Allegation #3 – Staff do not timely repair the facility vehicle. An interview with the executive director revealed that the facility bus had been out of service for 2 months. LPA obtained a repair estimate for the facility bus from the executive director. Executive director was waiting for corporate headquarter to approve the bus repair. Allegation #4 - Staff do not ensure the resident laundry needs are being met. LPA conducted review of admission agreement and confirmed the laundry service was included in the basic services provided. LPA’s interviews with residents revealed 2 out of 5 residents interviewed stated that their laundry service was skipped for one week when the laundry staff was on vacation in December 2024. Interviews with 4 staff members confirmed the laundry staff was on vacation in during that time period. Staff also stated any housekeeper would have taken care of the laundry upon request. LPA verified the laundry schedule which staff did not follow for all residents. LPA confirmed the facility did not implement an alternative laundry schedule to ensure residents laundry was done. Based on records review, client interviews, and staff interviews, above allegations are Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where a copy of this report was provided, along with a copy of LIC9099C, LIC9099D, and Appeal Rights were provided. Allegation #2 – Staff do not provide adequate care and supervision. LPA conducted review of the facility staff schedule and learned there are 6 cottages, each cottage has 2 care staff members assigned for every shift. 4 staff members interviewed expressed that there is adequate staff coverage. 4 out of 5 residents interviewed expressed that they are satisfied with the services provided and staff’s response time when call buttons were pressed. Allegation #3 – Facility does not have sufficient staff. LPA conducted review of the facility staff schedule and learned there are 6 cottages, each cottage has 2 care staff members assigned for every shift. 4 staff members interviewed expressed that there is adequate staff coverage. 4 out of 5 residents interviewed expressed that they are satisfied with the services provided and staff’s response time when call buttons were pressed. Based on records review, resident interviews, and staff interviews, this allegation is Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 21, 2025 · control 18-AS-20241224100529

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Feb 28, 2025

Section 87208 Plan of Operation (a) The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49 Based on record reviews and and interviews, the licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 21, 2025

Plan of correction: New transportation vehicle is scheduled to be purchase in April 2025. All residents have been informed to contact front desk for transportation needs. Staff will set up the appointment and pay for the service.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: Feb 28, 2025

87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility (2)The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which... Based on record reviews and and interviews, the licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 21, 2025

Plan of correction: New transportation vehicle is scheduled to be purchase in April 2025. All residents have been informed to contact front desk for transportation needs. Staff will set up the appointment and pay for the service.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: Feb 28, 2025

87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility (2)The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which... Based on record reviews and and interviews, the licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 21, 2025

Plan of correction: New transportation vehicle is scheduled to be purchase in April 2025. All residents have been informed to contact front desk for transportation needs. Staff will set up the appointment and pay for the service.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(F) · Plan of correction due date: Feb 28, 2025

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be... (3) Equipment and supplies necessary for personal care... (F) Basic laundry service Based on record reviews and and interviews, the licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 21, 2025

Plan of correction: Laundry schedule is made for staff to cover laundry services when the assigned attendant is absent.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that seventy-two (72) clients live at this facility. There was twenty (20) staff members present. The Executive Director, Tammy Eddy came to conduct and completed the facility tour. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Ten (10) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration: LPA reviewed employee records. Ten (10) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a location for sharps in the kitchen. Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 75 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 107.0 degrees F. Laundry is done in the designated laundry room in each cottage. There is a locked closet for storing laundry soap, cleaning supplies and chemicals in the closet located in the housekeeper’s closet. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA dialed the facility’s landline number, which rang and was operable. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There are seven (7) secured fireplaces at this facility, located in each cottage and the main office. There is not a pool at the facility. There is one (1) main secured gate that leads into the facility, that has a self-latching lock. LPA observed emergency supplies and seven (7) first aid kits, additionally one is found to be located in each cottage. The last emergency drill was done on 01/18/2024. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training. Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed that they were dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed smoke detectors and carbon monoxide detectors throughout the facility. There were twenty-eight (28) fire extinguishers on site, date serviced was 08/15/2023. The last fire inspection was 08/28/2023 done by the State Fire Marshal. The facility is monitored 24 hours by Desert Fire Extinguisher Co INC. Pursuant to Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to Executive Director, Tammy Eddy.the state’s words, verbatim · CDSS document, May 16, 2024

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff do not ensure a safe and healthful environment by not assisting a resident with incontinence needs.

Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an unannounced visit to deliver finings for a complaint investigation pertaining to the listed allegation. LPA met with Executive Director, Tammy Eddy, where LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of observation, interviews with staff members and residents, and records review. On 09/08/2023, Community Care Licensing received a complaint alleging that Staff do not ensure a safe and healthful environment by not assisting a resident with incontinence needs. It was reported that Resident #1 (R1)’s were not attended to for over 20 hours on September 8th, 2023. Information obtained from additional witness stated that on September 8th, in the late afternoon, additional witness, came to visit R1 and their bedding and chucks were soaked. Additional witness stated it was unknown liquid, which may have consisted of urine or seepage from the water blister wound that R1 had. LPA received photographs of the bedding being soaked. Substantiated Resident Care Manager, Patrica Russell addressed the additional witness’ concerns and in conjunction with additional witness, revised R1’s care plan. The care plan ensured that R1 would be checked on every hour and changed if needed. LPA reviewed records from the facility, in which additional witness requested facility staff implement every shift. LPA also reviewed documentation from the revised care plan and requested information regarding the communication between the facility and the hospice nurse. The information stated that there was a request in changing chucks due to excessive weeping from the wounds. LPA interviewed residents who stated that there were no issues with asking for assistance with an assistance in daily livings, which include incontinence matters. LPA interview staff, who indicated that they followed the new directive plan given to do rounds every two hours and after the revision of the care plan, increased checks on R1 every hour. Resident Care Director, Patrica Russell stated that the facility has been implementing the new procedures after the concerns were addressed to Resident Care Director. Based on LPAs observations and interviews which were conducted and record review(s), in regards to the allegation of staff do not ensure a safe and healthful environment by not assisting a resident with incontinence needs, the preponderance of evidence standard has been met. Therefore, the above allegation(s) is found to be SUBSTANTIATED. This poses a health and safety and or personal rights risks to residents in care. California Code of Regulations, (Title 22, Division 6 Chapter 8 Article 11. Health-Related Services and Conditions, 87625 (b)(3) ), are being cited on the attached LIC 9099D. An exit interview was conducted. A copy of this report, LIC 9099-D, and appeal rights were discussed with and provided to the Executive Director, Tammy Eddy.the state’s words, verbatim · CDSS document, Dec 27, 2023 · control 18-AS-20230908121201

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87625(b)(3) · Plan of correction due date: Dec 27, 2023

87625 (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 met as evidenced by: Based on LPA's record review, interviews, R1 was not accorded their right to be kept clean and dry, R1’s room was not free from odors from the Purewick machine.the state’s words, verbatim · CDSS document, Dec 27, 2023

Plan of correction: The Executive Director, Tammy Eddy stated that she will provide training and acknowledgement of staff training of the regulation and signature to the LPA by 01/10/2023.