Menifee Senior Living

On 4/29/2025, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to the facility to deliver findings of an investigation into the allegations listed above. LPA met with Administrator, Rance Leth who was informed of the purpose of the visit. The investigation consisted of interviews conducted and records reviewed. A review of R1’s admission agreement indicates R1 was admitted to the facility on 12/22/2022. A review of R1’s Physician’s Report dated 12/20/2022 indicates the categories, ‘able to communicate needs’, ‘able to bathe, dress/groom, and feed self’, ‘able to care for own toileting needs’, marked as 'yes', and ‘requires continuous bed care’ marked as 'no'. The Physician’s Report also indicates R1 is non-ambulatory and able to independently transfer themselves to and from the bed. A review of R1’s Preplacement Appraisal Information dated 12/22/2022 notes R1 exhibited short term memory loss, does not use any ambulation devices, is able to communicate their needs andRead the full finding— CDSS inspection report, April 29, 2025 · control 18-AS-20230428143402

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit related to the allegations listed above. LPA initially met with facility staff and explained the reason for today’s visit. LPA met with Executive Director Rance Leth at 09:56AM. Entrance interview conducted. During today's visit, LPA interviewed 6 (six) residents and 6 (six) staff between 09:25AM – 09:40AM and 10:17AM to 02:45PM, interviewed R1’s private caregiver, interviewed R1’s family member telephonically and obtained and reviewed copies of relevant documents. During an initial complaint visit conducted by LPA Cheryl Goodrich on 12/06/2023, LPA Goodrich toured the facility, interviewed residents and staff, and collected pertinent documents. During a subsequent complaint visit conducted by LPA Kathleen Banrasavong on 03/27/2024, LPA conducted a tour, reviewed and obtained documents, and interviewed residents and staff. Throughout the course of the investigation, LPA Dulek reviewed all doRead the full finding— CDSS inspection report, April 22, 2025 · control 18-AS-20231129162111

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit related to the allegations listed above. LPA initially met with facility staff and explained the reason for today’s visit. LPA met with Executive Director Rance Leth at 09:56AM. Entrance interview conducted. During today's visit, LPA interviewed 6 (six) residents and 6 (six) staff between 09:25AM – 09:40AM and 10:17AM to 02:45PM and obtained and reviewed copies of relevant documents. During an initial complaint visit conducted by LPA Venus Mixson on 05/09/2024, LPA Mixson toured the facility, made observations pertaining to the allegations and received copies of pertinent documents. On 12/11/2024, LPA Yolanda Delgado conducted a subsequent complaint visit. LPA Delgado interviewed Administrator and 6 (six) staff and obtained copies of pertinent documents. Throughout the course of the investigation, LPA Dulek reviewed all documents gathered. The following was then determined: Report ContinuedRead the full finding— CDSS inspection report, April 22, 2025 · control 18-AS-20240502133223

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit related to the allegations listed above. LPA initially met with facility staff and explained the reason for today’s visit. LPA met with Executive Director Rance Leth at 09:56AM. Entrance interview conducted. During today's visit, LPA interviewed residents and staff between 09:25AM – 09:40AM and 10:17AM to 02:45PM and obtained and reviewed copies of relevant documents. During an initial complaint visit conducted by LPA Yolanda Delgado on 11/22/2024, LPA Delgado interviewed Business Office Manager, two (2) staff, one resident (1) requested and obtained copies of pertinent documentation. Throughout the course of the investigation, LPA Dulek reviewed all documents gathered and conducted additional staff interviews telephonically. The following was then determined: Report Continued on LIC 9099-C UnsubstantiatedRead the full finding— CDSS inspection report, April 22, 2025 · control 18-AS-20241118143654

On 4/22/25 at 8:50 a.m. Licensing Program Analyst (LPA) Melisa Rankin arrived to conduct an unannounced visit to the facility to investigate and deliver the findings regarding the above allegations. The LPA met with Executive Director (ED), Rance Leth, and informed him the purpose of the visit. An initial visit on 9/14/22 by LPA Stephanie Torres was conducted. LPA Torres conducted staff interviews, reviewed records, and took copies of pertinent documentation. On the allegations Resident is not provided a sanitized foley bag and Resident was left soiled for an extended period of time. UnsubstantiatedRead the full finding— CDSS inspection report, April 22, 2025 · control 18-AS-20220907084531

On 4/22/25 at 8:50 a.m. Licensing Program Analyst (LPA) Melisa Rankin arrived to conduct an unannounced visit to the facility to complete the investigation and deliver the findings into the above allegation. The LPA met with Executive Director (ED), Rance Leth, and informed him of the purpose of the visit. An initial visit on 8/21/24 by LPA Javina George was conducted. LPA George reviewed records and took copies of pertinent documentation. On the allegation Staff do not meet a resident's hygiene needs. Complaint alleges Resident 1’s (R1) hygiene was not good and toenails were long and unkept. UnsubstantiatedRead the full finding— CDSS inspection report, April 22, 2025 · control 18-AS-20240818221750

On 4/22/25 at 8:50 a.m. Licensing Program Analyst (LPA) Melisa Rankin and Kelly Dulek arrived to conduct an unannounced visit to the facility to deliver the findings of the investigation into the above allegations. The LPA met with Executive Director (ED), Rance Leth, and informed him of the purpose of the visit. An initial visit on 01/27/25 by LPA Yolanda Delgado was conducted. LPA Delgado, conducted interviews, reviewed records and took copies of pertinent documentation. Continued on 9099-C Unsubstantiated— CDSS inspection report, April 22, 2025 · control 18-AS-20250121133146

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegation. LPA met with Executive Director, Rance Leith, who was informed of the purpose of the visit. The investigation consisted of interviews and records review. It was alleged that “Staff do not ensure medications are dispensed as prescribed” It was alleged Resident#1 (R1) did not receive their PRN medication as prescribed June of 2024. Interview with R1 was unable to be conducted as R1 has since passed away. Interview with R1’s responsible party revealed they were unaware of any medication errors or PRN medication not being given as prescribed. SubstantiatedRead the full finding— CDSS inspection report, February 25, 2025 · control 18-AS-20240626140848

Licensing Program Analyst (LPA Javina George made an unannounced visit to the facility to commence a complaint investigation in regard to the allegations noted above. LPA met with Executive Director Rance Leth and explained the purpose of the visit and the elements of the allegations. The allegations were investigated, which consisted of observations, interviews and records review. On January 25, 2024, Community Care Licensing received a complaint alleging that the facility has mold and that the facility roof is in disrepair. Regarding the allegation of the facility has mold specifically in Resident #1 (R1)s and Resident #2 (R2)s bedroom. On 01/31/24 LPA conducted a tour of the interior and exterior areas of the property. LPA did not observe the presence of mold, or a mold like odor. In addition LPA conducted interviews with facility staff whom denied there being any reports from other staff, visitors or residents reporting that they have physically seen or smelled mold at the facilityRead the full finding— CDSS inspection report, February 21, 2025 · control 18-AS-20240125113223

Licensing Program Analyst (LPA Javina George made an unannounced visit to the facility to commence a complaint investigation in regard to the allegation noted above. LPA met with Executive Director Rance Leth 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 August 15, 2024, Community Care Licensing received a complaint alleging that a staff member caused an injury (bruising) to resident. It was further alleged that a staff member had grabbed Resident #1 (R1) by the wrist and pinched them. Prior to going out to the facility a file/records review was conducted which revealed the facility submitted an unusual incident/injury report on 08/13/24 reporting R1 to have unexplained bruising. LPA conducted interviews with R1 whom stated and re-enacted how they were grabbed by an unknown staff member and pinched, however did not think that the staff had intent to harm themRead the full finding— CDSS inspection report, February 21, 2025 · control 18-AS-20240815095433

Licensing Program Analyst, (LPA) Yolanda Delgado arrived unannounced to the facility to conclude an investigation pertaining to the allegations listed above. LPA met with Executive Director Rance Leth and explained the purpose of the visit. On April 22, 2022, Community Care Licensing received a complaint alleging facility staff not feeding resident in a timely manner and staff financially abused resident. LPA conducted interviews with Administrator, staff, residents, and additional witnesses. LPA also conducted a review of pertinent documentation. In regards to the allegation that facility is not feeding resident in a timely manner, it was reported that Resident had to wait 2 hours to eat. Information obtained from an interview with Administrator stated food trays can be ordered and would be delivered at the designated times. (Continued on Page 2) UnsubstantiatedRead the full finding— CDSS inspection report, February 19, 2025 · control 18-AS-20220422163744

Licensing Program Analyst, (LPA) Yolanda Delgado arrived unannounced to the facility to conclude an investigation pertaining to the allegations listed above. LPA met with Executive Director Rance Leth and explained the purpose of the visit. On April 22, 2022, Community Care Licensing received a complaint alleging staff stole resident’s bank statements, resident does not have access to a phone, and facility overcharged resident for services. LPA conducted interviews with Administrator, staff, residents, and additional witnesses. LPA also conducted a review of pertinent documentation. Regarding the allegation staff stole resident’s bank statements, it was reported that Administrator went into client’s room and stole bank statements. It was also reported that Administrator is taking money from Resident. Information obtained from the interview with Administrator denied that they retrieved any resident’s (Continued on Page 2) UnfoundedRead the full finding— CDSS inspection report, February 19, 2025 · control 18-AS-20220422163744

Licensing Program Analyst (LPA), Kathleen Banrasavong, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA met with Administrator, Rance Leth, and explained the purpose of the visit and the elements of the allegation. The investigation included observations, interviews with staff members and residents, and a review of records. On November 2, 2023, Community Care Licensing (CCL) received a complaint alleging that residents had become ill after eating food served at the facility and that a resident found hair inside their food and on the plates. It was alleged that three residents became ill after eating food at the facility. An interview with Administrator advised that kitchen staff follow proper protocols to ensure staff’s hair is covered during preparation. UnsubstantiatedRead the full finding— CDSS inspection report, February 18, 2025 · control 18-AS-20231102114046

Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility to deliver findings on a complaint investigation regarding the allegations listed above. LPA met with Christina Mulligan, Resident Care Coordinator, and explained the purpose of the visit. During the investigation interviews and record reviews were conducted. On 7/26/2023, Community Care Licensing received an allegation that the facility is not in good repair. It was alleged that the elevator located near the dining area keeps breaking down and is always out of service. Records review demonstrated that the facility has a contract with an elevator servicing company. LPA viewed documents which show service request dates and the date of service each time the elevator was not working. Documents viewed show that the elevator was repaired within 24 hours. Interviews with staff also demonstrated that the elevator was fixed in a timely manner and the facility made reasonable accommodations for resideRead the full finding— CDSS inspection report, December 29, 2023 · control 18-AS-20230726162249

Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Executive Director (ED), Rance Leth, and informed him of the purpose of the visit. A report was received alleging facility staff administered one discontinued medication to Resident One (R1) from February 21, 2023 through March 21, 2023. The LPA conducted staff/resident interviews, reviewed records and took copies of relevant documentation. Medication Aministration Records (MAR) from February and March 2023 were reviewed. The reports revealed the facility did administer to R1, from February 21, 2023 to March 23, 2023, the medication allegedly discontinued. Physican Orders were reviewed and it was found the medication administered to R1 was discontinued on February 21, 2023; however, the document was not signed and dated. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.Read the full finding— CDSS inspection report, April 5, 2023 · control 18-AS-20230330111640

Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegation. The LPA met with Executive Director (ED), Rance Leth, and informed him of the purpose of the visit. A report was received alleging Resident One (R1) fell in their bedroom on or around November 13, 2022, and was not found by facility staff until November 15, 2022. The LPA conducted staff/resident interviews, reviewed records, and took copies of relevant documentation. An Unusual Incident Report (UIR) was obtained and revealed R1 was found on the floor of their bedroom on November 15, 2022. Staff interviews revealed there are residents, R1 included, who request less frequent checkups by staff. One interview revealed staff checked on R1 once or twice on November 13, 2022, and once on November 15, 2022. A second interview revealed staff did not check on R1 on November 14, 2022. A third-party interview revealed R1 missed aRead the full finding— CDSS inspection report, April 5, 2023 · control 18-AS-20221121162823

Licensing Program Analyst (LPA) Javina George arrived at the facility unannounced to deliver findings for the allegation listed above. LPA met with Rachelle Wheaton, Resident Care Director and explained the purpose of the visit and elements of the allegation. The department investigated the allegation of Facility did not safeguard resident's personal items. The investigation consisted of observation, interviews and a review of documentation. The missing items are a pendant, 4 rings, and a bracelet that was given to Resident #1 (R1) by their spouse. R1 is in a private room that includes an in room safe to lock to store items of value. Per Executive Director Rance, Residents are the only ones with access to the in room safe, if a resident was to lose a key or move out, the lock smith would have to come out to remove and replace with a new lock. Additional interviews conducted revealed that there was not any supporting documentation such as a receipt, or even photographs of the items in qRead the full finding— CDSS inspection report, May 17, 2022 · control 18-AS-20220321152507

Licensing Program Analyst (LPA) Javina George arrived at the facility unannounced to deliver findings for the allegation(s) listed above. LPA met with Executive Director Rance Leth and explained the purpose of the visit and elements of the allegation(s). The department investigated the allegation of resident is being overcharged. The investigation consisted of observation, interviews and a review of documentation. LPA reviewed documents such as Resident #1 (R1) admission agreement, rate increase notification and monthly ledger since being admitted to the community on 4/1/2021. R1 is responsible for their finances which includes paying their own rent. Per R1s ledger there is no indication of any discrepancy with being over or under charged. Per the ledger, the facility did issue a one time credit in September 2021 for the laundry fee as R1 did not feel that the facility was not doing R1s laundry and did not agree to be charged. LPA reviewed the facility charge room which indicates thatRead the full finding— CDSS inspection report, February 23, 2022 · control 18-AS-20220218085144