Buena Vista Assisted Living

Allegation investigated: Facility staff did not ensure to provide a safe environment for residents in care. Facility staff denied resident(s) to be able to attend their medical appointment. Facility staff did not treat residents with dignity and respect. Facility staff do not maintain a comfortable temperature for residents.

On 09/16/2026 Licensing Program Analyst (LPA), Ahliah Sharp, conducted an unannounced visit to the facility to deliver findings regarding the allegations above. During the investigation, LPA Sharp conducted an inspection of the facility, interviewed staff and residents, reviewed facility records and made necessary observations pertaining to the allegations listed above. On 04/07/2026, Community Care Licensing (CCL) received a complaint alleging staff did not ensure to provide a safe environment for residents in care, staff denied resident(s) to be able to attend their medical appointments, staff did not treat residents with dignity and respect and staff did not maintain a comfortable temperature for residents. Regarding the allegation of staff failing to ensure a safe environment for residents, information obtained from interviews with staff denied the information. Continued on LIC 9099C... Unsubstantiated Continued from LIC9099... Three (3) of the six (6) staff interviewed mentioned an increase in memory care residents being admitted, and a change overall in the residents that are being allowed to be admitted, noting that although this has happened, they do not feel the staff are failing to keep the residents safe. Executive Director Robyn Icamen noted that one of the main priorities is, and has always been, the safety of the residents in care. The remaining three (3) were completely unaware of any concerns surrounding the safety of residents. Information obtained from interviews with residents denied the information and confirmed the information obtained from staff. Nine (9) residents were interviewed, out of the nine (9) interviews, five (5) residents mentioned the increase of memory care patients, two (2) of those five (5) noted the memory care resident’s inability to remember their correct room from time to time. Two (2) residents did indicate a ‘fear’ that they attributed specifically to the residents but neither of the two noted staff as the problem in failing to keep them safe. The remaining two (2) interviewed denied any concerns at all. Out of the initial five (5) residents, although they expressed concern for the residents, they did not specifically state this caused them to believe they were not safe or that staff has somehow failed to keep them safe. It was noted more of a frustration than an actual concern for their safety. Based on the information obtained from interviews with staff and residents, the allegation that staff failed to provide a safe environment for residents has been deemed UNSUBSTANTIATED. Unsubstantiated means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation of staff denying residents to be able to attend their medical appointments, information obtained from interviews with staff denied the information. Out of the six (6) staff interviewed, six (6) out of six (6) denied the information. They denied having any knowledge of any residents ever being denied access to medical appointments. They denied any knowledge of any residents notifying them of being denied access to medical appointments. Information obtained from interviews with residents denied the information. Out of nine (9) interviews conducted, all nine denied any issues with staff denying residents the ability to attend their medical appointments. Continued on LIC9099C...(2) Continued from LIC9099C...(2) Three (3) of the nine stated they have appointments and a family member makes all their arrangements and coordinates their transportation. One (1) said they do not really have any appointments, one (1) said the appointments they have are generally done in house and the doctor comes to the facility, one (1) said they had one problem with insurance failing to coordinate with their transportation services to bring them to their appointment but acknowledged this was an insurance issue and not an error of the facility itself. The remaining three (3) denied any issues or problems with appointments. There were no documented issues noted in any files reviewed. Based on the information obtained from interviews with staff and residents, and record review, the allegation that staff denied residents to be able to attend their medical appointments, has been deemed UNSUBSTANTIATED. Unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation that staff did not treat residents with dignity and respect, the information obtained from staff denied the information. According to the staff interviews, none of them reported any information to support the allegation. They were asked if any resident had reported any information about being mistreated by staff, and they denied having any knowledge to support the allegation. Information obtained from the interviews with residents denied the information and corroborated the information from the staff. Out of the nine (9) interviews conducted, seven (7) residents denied feeling like they were not being treated with dignity and respect. One (1) resident stated they have never felt any form of disrespect and shared that they came from a place that did not treat them so well, and they were so grateful that their experience is so much better here than it was at the old facility. The remaining one (1) resident stated that although they feel like they have not been treated poorly, they reported, “Some of the staff do not act like they really want to be here, they act like it is just a job.” They still did not mention feelings of disrespect. Based on the information obtained from interviews with staff and residents, the allegation that staff did not treat residents with dignity and respect has been deemed UNSUBSTANTIATED. Unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Continued on LIC9099C...(3) Continued from LIC9099...(3) Regarding the allegation that staff do not maintain a comfortable temperature for residents, the information obtained from staff denied the information. According to staff interviews, out of the six (6) interviews, two (2) acknowledged the difficulties with keeping the temperature satisfactorily for so many residents having different needs and wants as it relates to body temperature. They reported being mindful of this and still doing their best to be accommodating to residents if they say it is too hot or too cold. The controls are maintained in the main office. Information obtained from Executive Director Robyn Icamen, if or when residents state they are hot, they will lower the temperature, the same attention is given if they say they are too cold. According to residents’ interviews, one (1) resident mentioned knowing that they are cold often, so they take it upon themselves to make sure to dress in layers, they noted that it is not fair to have the facility to keep it warm just for them. Seven (7) residents denied any issues with the temperature and the remaining one (1) acknowledge that Robyn is good at keeping up with the different temperature requests. Based on observation of LPA Sharp when at the facility conducting the investigation. LPA made several visits throughout the course of this investigation (4/6;4/9/; 5/12; 6/3; 6/15), LPA observed the thermostats and all of them were well within the Department regulation at those times. Based on the information obtained from interviews with staff and residents, and observation, the allegation that staff do not maintain a comfortable temperature for residents has been deemed UNSUBSTANTIATED. Unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were issued and no immediate health and safety concerns were observed at time of visit. A copy of the reports LIC9099, and all LIC9099C's were reviewed and provided to Executive Director Icamen.the state’s words, verbatim · CDSS document, Sep 16, 2026 · control 18-AS-20260407151225

Allegation investigated: Staff do not serve residents with food of good quality Staff did not meet resident’s showering needs. Staff do not safeguard resident's personal belongings

LPA contacted Reporting Party (RP) and they stated the Alleged Victim (AV) no longer wishes to follow through with the complaint. On July 21, 2026, Licensing Program Analyst (LPA), Ahliah Sharp, conducted an unannounced visit to the facility to deliver the findings regarding the allegations above. During the investigation, LPA conducted an inspection of the facility, interviewed Staff and Residents, reviewed facility records and meal logs from the weeks of January 19th-25th; January 26th-February 1st; February 23rd -29th and March 2nd -8th. On March 12, 2026, Community Care Licensing (CCL) received a complaint alleging that Staff do not safeguard Resident's personal belongings, Staff do not serve Residents with food of good quality, and Staff did not meet Resident’s showering needs. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... Regarding the allegation pertaining to the quality of food, information obtained from interviews with Residents indicated there are no concerns regarding the quality of the food. LPA observed menus which identified a typical breakfast consisting of Oatmeal, cereal, and milk that are offered daily in addition to itemized scheduled breakfast items (e.g., omelets, toast, pancakes, fruit, yogurt etc.). Lunch menu provides flexible options (sandwiches nachos, soup, etc.) and an afternoon snack at 2:30pm. Dinner also has a flexible schedule with pork chops, meat loaf, ravioli and salads etc., and an evening snack at 7:00pm. Regarding the allegation pertaining to Staff not meeting Resident’s showering needs, information obtained from an interview with Executive Director (ED) Robyn Icamen, the facility abides by and maintains a shower schedule for Residents. It was explained there is an application on their work phone that provides them with the schedule of who is supposed to shower that day and if a Resident opts out, it is logged in this system. Information obtained from interviews with Staff confirmed the information. Information obtained from interviews with Residents had no complaints about their showering needs being met. It was further reported that some Residents refuse showers, but the facility works with Residents to prevent this from being problematic or habitual. Residents were able to articulate which day(s) of the week they were scheduled and reported never missing their designated day. LPA observed the shower schedule log; it indicated that Residents receive their regularly scheduled showers. Regarding the Resident’s belongings being safeguarded, information from ED indicated that this has not been an issue or area of concern. Apart from occasional laundry mishaps; which is typically rectified quite quickly, due to Staff’s familiarity with Resident’s belongings, this has not been an issue that she has been made aware of. Information obtained from interviews with Staff stated the same thing as what was shared above; an occasional mishap with laundry. Information obtained from interviews with Residents, two Residents mentioned issues with their belongings. It was stated that laundry is often misplaced but typically provided later. The remaining Residents interviewed reported no issues with their belongings. Continued on LIC9099C... Continue from LIC9099C... Based on information obtained from interviews with Staff and Residents, record review, and observation, the allegation that Staff do not safeguard Resident's personal belongings, Staff do not serve Residents with food of good quality, and Staff did not meet Resident’s showering needs, have all been deemed UNSUBSTANTIATED. Unsubstantiated means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was provided to ED Robyn Icamenthe state’s words, verbatim · CDSS document, Jul 21, 2026 · control 18-AS-20260312145021

Allegation investigated: Staff do not ensure Resident’s room is cleaned appropriately Staff do not ensure Resident’s room is free of pests Staff do not ensure Resident’s hygiene needs are met

On July 21, 2026, Licensing Program Analyst (LPA), Ahliah Sharp, conducted an unannounced visit to the facility to deliver the findings regarding the allegations above. During the investigation, LPA interviewed staff and residents, reviewed facility records, and conducted observations. Regarding the cleanliness of Resident’s rooms, it was reported that while visiting Resident at the facility, reporting party (RP) became outraged due to the appearance of Resident and their room. RP reported seeing dirty clothes in the corner of the room, and that it ‘smelled like urine’ alleging Resident was not being cared for properly. RP reported seeing ants all over, including some on Resident while in bed and on ceiling. RP stated they had video/pictures to corroborate their allegations. Information obtained from interview with Executive Director (ED), stated that the responsibility for cleaning not only falls on the housekeeping staff, but also on the caregivers in the absence of housekeeping. Continued on LIC9099C... Unsubstantiated Continued from LIC9099 LPA also interviewed additional staff, including housekeeping and it was reported that they all work together to ensure the cleanliness of the facility. One staff did not think it was ‘clean’ but admitted that everyone views cleanliness differently. Information obtained from interviews with Residents stated they do not have any issues with the cleanliness of their rooms. Some Residents do not want it done by Staff and are ‘particular’ about how they want certain things, but otherwise, when Housekeeping is off, all other Staff are responsible. On April 6th, April 9, and May 12, 2026, LPA conducted visits to the facility. During each visit, LPA observed the facility to be free of debris and clutter. LPA did not observe any issues regarding cleanliness of the facility that would pose any immediate health or safety concerns or personal rights issues. Regarding the allegation that staff do not ensure Resident’s rooms are free of pests, ED reported that pest control comes two (2) times each month to service the outside, and in the event a Resident mentions a need inside, that is provided on a case-by-case basis as well. Information obtained from staff stated that they see an occasional pincher bug [Earwig] from time to time but stated that being in a ‘desert’ area, it is not uncommon. Information obtained from interviews with residents stated they had no concerns about pests. LPA conducted an interview with Additional Witness and it was stated that photographs and video of their concerns were taken. LPA requested the evidence on two (2) separate occasions, but the Additional Witness failed to provide any evidence supporting the allegation. Regarding the allegations pertaining to staff not ensuring Resident’s hygiene needs are being met, information obtained from interviews with ED stated that showering schedules are implemented and tracked through a new digital system. On occasion, Resident might want to refuse showers, but it is logged and Staff will work hard to encourage Resident to shower at a later time or date. Information obtained from interviews with Staff corroborated the reports from ED. Information obtained from residents and reviewing records, also corroborated the reports from ED. Continued on LIC9099C... Continued from LIC9099C... Based on the information obtained regarding the allegations and the inability to obtain pertinent evidence, this complaint has been deemed UNSUBSTANTIATED. Unsubstantiated means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of the report was provided to ED Robyn Icammen.the state’s words, verbatim · CDSS document, Jul 21, 2026 · control 18-AS-20260402112716

Allegation investigated: Staff did not safeguard resident’s personal belongings Staff stole resident’s personal belongings

On July 21,2026, Licensing Program Analyst (LPA), Ahliah Sharp, conducted an unannounced visit to the facility to deliver the findings regarding the allegations above. During the investigation, LPA conducted an inspection of the facility, interviewed five staff and 11 residents, and conducted a review of records. On April 2, 2026, Community Care Licensing (CCL) received a complaint alleging that staff did not safeguard resident’s personal belongings and that staff stole resident’s personal belongings. Information obtained from interview with Administrator indicated that the facility does not have an issue with belongings other than the occasional laundry mishap. Information obtained from interviews with staff stated the same as listed above. Continued on LIC9099C... Unfounded Continued from LIC9099... S1 mentioned a Resident falsely accusing S1 and another Staff of taking an item in the past but that Resident was memory care and tends to get confused. S1 mentioned they have a security system and said that it would be easy to check the cameras to prove S1 had not taken Resident’s item. Interview with Residents stated that from time to time, as mentioned above, laundry ends up in the wrong room, but it is quickly rectified. Interview with Additional Witness stated that the missing items noted in the allegations were not missing from the facility, but from a previous facility that Resident was placed at. It was stated that there were no concerns or issues regarding Resident’s personal property at this facility. LPA conducted a review of Resident belongings form and that revealed that the forms were left blank. They are provided for family members to fill out during intake, but according to ED, most simply opt out of filling it out since many residents come with very little. It is noted that they did not fill out the form,the responsible party signs as verification and ED also signs and forms are placed in the respective files. Based on the information obtained from interviews and record reviews, the allegation that staff did not safeguard Resident’s personal belongings and staff stole Resident’s belongings are deemed to be UNFOUNDED. Unfounded means the allegation is false, could not have happened, or is without a reasonable basis. The Department has dismissed the complaint. An exit interview was conducted and a copy of the report was provided to ED Robyn Icamenthe state’s words, verbatim · CDSS document, Jul 21, 2026 · control 18-AS-20260402112716

Type of visit: Required - 1 Year

On 5/12/2026, Licensing Program Analyst (LPA) Ahliah Sharp conducted an unannounced required annual visit. LPA met with Executive Director Robyn Icamen who was informed of the purpose of the visit. The facility’s current census is 49, with approval for fifty-eight (58) ambulatory, fifteen (15) non-ambulatory, one (1) bedridden resident; and a hospice waiver approved for eight (8) residents. LPA conducted a tour of the interior and exterior of the facility, reviewed facility documents and conducted five interviews; two (2) staff and three (3)residents. LPA observed the following: LPA observed the physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good working conditions. The outdoor area was observed to be free of any hazards. LPA observed a courtyard with outdoor furniture and shaded area for residents. Facility kitchen had the ability to prepare food in a clean environment and possessed equipment in good working conditions. The sharp and dangerous objects were observed to be inaccessible to residents in the kitchen. Facility kitchen receives one shipment of food every week, ordered on Monday and arrives on Tuesday. LPA observed the facility sketch, exit routes, personal rights, complaint information and emergency phone numbers posted around the facility. The smoke detectors and carbon monoxide detectors were operational. LPA observed the facility exceeded the required two (2) day supply of perishable and seven (7) day supply of non-perishable foods. LPA conducted medication review with staff, and observed the medical sharps stored in locked boxes inaccessible to residents in care. Continued on LIC809C Continued from LIC809... Staff files review included, but are not limited to, personnel records, criminal record clearance, required training, and valid first aid/CPR certification. The employee health screenings had been removed when the new company took over. They were advised that they would need to be made available in the employee files. Resident files included but are not limited to signed admission agreements, pre-placement, personal rights, needs and service plans, and updated physician reports. LPA reviewed the facility's emergency and disaster plan. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. Facility contained multiple charged fire extinguishers last serviced in March 2026, and Fire and Earthquake drills were last conducted on April 15, 2026. LPA observed all six (6) of the thermostat temperatures ranging from 75-78 degrees F. LPA advised ED about the water temperature needing to be a little warmer even though the resident was comfortable with the current temperature of 99.9F and the access to the health screenings of the staff need to be placed back in the staff files. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to ED Robyn.the state’s words, verbatim · CDSS document, May 12, 2026

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 9/17/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced case management visit to the facility due to the capacity increase request submitted by the Licensee. LPA Flores met with Administrator, Robyn Icamen, and explained the purpose of the visit. At the time of the visit there was (40) forty residents. The facility is currently licensed for (15) fifteen non-ambulatory, (33) thirty-three ambulatory residents, of to which (1) one may be bedridden. The facility is wishing to add additional bedding to selected units to create a shared bedroom. LPA observed units to a large enough space to allow for easy passage between and comfortable usage of beds and other required items of furniture specified below, and any resident assistant devices such as wheelchairs or walkers. Units observed did not have more than two residents shall sleep in a bedroom. LPA reviewed a Fire Safety Inspection Request (STD. 850) dated 7/21/2025, granted a fire clearance for (58) fifty-eight ambulatory, (15) fifteen non-ambulatory residents, to which (1) one may be bedridden. LPA toured the facility with Administrator Robyn. The physical plant is ready for the capacity increase as the facility sketches show sufficient livable space to accommodate the requested capacity. No health or safety issues were observed during the visit. A new license will be mailed to the facility to reflect the approved capacity increase. An exit interview was conducted where this report was reviewed and provided to Administrator, Robyn Icamen.the state’s words, verbatim · CDSS document, Sep 17, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Debbie Palacios conducted an unannounced annual required visit . LPA met with Clinical Care Director Vanessa Navarro who was informed of the purpose of the visit. Facility was approved for thirty three (33) Ambulatory, fifteen (15) Non-ambulatory, and one (1) bedridden resident; Hospice waiver approved for eight (8) residents. LPA conducted a tour of the interior and exterior of the faciity, reviewed facility documents and conducted interviews. LPA observed the following: LPA observed the physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed a courtyard with outdoor furniture and shaded area for residents. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies and detergents were stored and inaccessible to residents in care. The sharp and dangerous objects were observed to be locked and inaccessible to residents in the kitchen. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector and carbon monoxide was operational. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Facility receives one shipment of food every week scheduled for Wednesday. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Staff files reviewed include but not limited to have personnel records, health screenings, criminal record clearance, required training, and valid first aid/CPR certification. Resident files included but are not limited to signed admission agreements, pre-placement, personal rights, needs and service plans, and updated physician reports. LPA reviewed the facility's emergency and disaster plan. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. Facility contained multiple charged fire extinguishers last serviced on 03/31/2025.Fire and Earthquake drills were conducted on 04/03/2025. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Clinical Care Director Vanessa Navarro.the state’s words, verbatim · CDSS document, May 23, 2025

Type of visit: Case Management - Deficiencies

This Case management– Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Abdoulaye Zerbo on 1-9-25 for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 18-AS-20250109153636. LPA met with Robyn Rebollar and explained purpose of the visit. During the visit, LPA interviewed management and observed that the facility did not report the power outage to the department. Based on observations, record review and interviews , deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809-D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative, Robyn Rebollar.the state’s words, verbatim · CDSS document, Jan 9, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80061(b)(1)(E) · Plan of correction due date: Jan 23, 2025

80061 Reporting Requirements (b) ...during the operation of the facility... a report shall be made to the licensing agency...(1) Events reported shall include the following(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. Requirement was not being met as evidenced by: Licensee did not report SIRs to the Department for the power outage that occured on 1-8-25 at 12:30 PMthe state’s words, verbatim · CDSS document, Jan 9, 2025

Plan of correction: Licensee will conduct staff training on the reporting requirements and provide proof of training and training material to LPA by the plan of correction date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with MedTech Gabriella Delharo, who was informed of the purpose of the visit. Clinical Care Director Vanessa Navarro arrived shortly after LPA's arrival to assist LPA with tour of the facility. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed a courtyard with outdoor furniture and shaded area for residents. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies and detergents were stored and inaccessible to residents in care. The sharp and dangerous objects were observed to be locked and inaccessible to residents in the kitchen. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector and carbon monoxide was operational, and the hot water temperature in multiple resident bathrooms met department requirements. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Facility receives one shipment of food every week scheduled for Wednesday. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA reviewed eight (8) staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Aid Certification. Five (5) resident files were reviewed, and possessed all required paperwork which included Admissions Agreement, Needs and Service Plan, and Physician's Report. The listed administrator possesses a current administrator's certificate. Resident medication was centrally stored and locked in the medtech room. LPA reviewed medications prescribed to the residents and found all medication listed on electronic Medication Administer Record (eMAR) and all required labeling was found to be in place. LPA reviewed the facility's emergency and disaster plan. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. Facility contained multiple charged fire extinguishers. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Clinical Care Director Vanessa Navarro.the state’s words, verbatim · CDSS document, May 9, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.