Vista Montana Senior Living

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Deficiencies

On 9/1/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unnanounced visit to the facility and met with Administrator Maria Forkrud. LPA Flores introduced herself and explained the purpose of the visit. During the visit, LPA Flores requested a copy of Resident #1's admission agreement. According to the Administrator, the facility did not create an admission agreement for R1 as they made a contractual agreement with a third party. Therefore, a deficiency was issued during the time of visit. An exit interview was conducted an a copy of this report, LIC809G, LIC809D, and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 1, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(a) · Plan of correction due date: Sep 15, 2026

(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement was not met with evidence by: Administrator reports they did not complete an admission agreement for R1... as they had a contractual agreement with a third party.the state’s words, verbatim · CDSS document, Sep 1, 2026

Plan of correction: Administrator agreed to read Title 22 section 87506 Resident Records. Administrator agreed to provided LPA an overview of what was learned along with a signature confirming completion. Plan of correction will be provided to LPA by Close of Business (COB) on 9/15/2026.

Allegation investigated: Staff does not provide adequate food service.

Licensing Program Analyst (LPA) Ivashia Wright conducted an unannoced visit to the facility in order to initiate a complaint investigation. LPA met with Maria Forkrud, Administrator, and advised of the listed allegations. LPA conducted a tour of the interior/exterior areas of the facility, conducted interviews, and requested copies of pertinent documentation. Regarding the allegation that Staff does not provide adequate food service, it was reported that staff are serving uncooked food. LPA Wright toured the dining hall, food supply and observed the kitchen was clean and well kept. The food quality appeared adequate, free of contaminants, and stored appropriately. Interview with the Administrator, Maria Forkrud stated residents have the option of having the food on the menu prepared to their preference. It was advised that residents sitting in the dining hall could make changes to their meal options on the spot and request alternatives. Cont LIC 9099C Unsubstantiated Information obtained from interviews with additional staff corroborated the information obtained from Administration. Additional interviews with staff revealed that the kitchen only prepares meat well done. Interviews with residents revealed that the kitchen has never served any meat items raw and alternatives are offered when requested. Based on staff interviews, resident interviews and facility records the allegation that Staff does not provide adequate food service is deemed unsubstantiated. This means that although the allegations may have happened or are valid, the preponderance of evidence requirement has not been met to prove that the alleged violations did or did not occur. An exit interview was conducted and a copy of this report, LIC 9099C, were reviewed and provided to Maria Forkrud.the state’s words, verbatim · CDSS document, Aug 5, 2026 · control 18-AS-20260802235258

Allegation investigated: Facility staff are not meeting resident's dietary needs. Facility staff member is mishandling resident's funds.

On July 02, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced complaint visit. LPA met with the Administrator (A1), Maria Forkrud, and explained the purpose of the visit. The complaint investigation consisted of the following. On July 2, 2026, the Department obtained various documents, including the Personnel Report LIC 500 (dated 07/01/26) and the Resident Roster (dated 06/19/26). The Department reviewed and collected documents for Resident 1 (R1), including the Admission Agreement dated 06/20/2024, the physician's Report dated 06/14/2024, and the facility history Ledger payment dated 12/13/2024. The Department interviewed the Administrator (A1), five staff members (S1-S5), and nine residents (R2-R10). On July 2, 2026, the Department was unable to interview Resident 1 (R1) because the resident moved out of the facility on 12/13/2024. The Department later confirmed through the Assisted Living Worker (ALW) that Resident 1 moved out of the facility on December 13, 2024. Unsubstantiated Allegation #1: Facility staff are not meeting resident’s dietary needs. The complaint alleged that the facility failed to provide residents with food. On July 2, 2026, the department interviewed the Administrator (A1), who denied the allegation. A1 stated that the facility has a weekly menu, an alternating menu, and a diabetic menu. Meals are served at the following times: breakfast at 7:00 a.m., lunch at 11:00 a.m., dinner at 4:00 p.m., and snacks are available between lunch and dinner. A snack cart is also accessible in the medication room at 6:00 p.m. upon request. On the same date, the department interviewed five staff members (S1-S5), all of whom denied the allegation. They confirmed that for all residents with doctor’s orders, as well as those with diabetes or allergies, the medication technician ensures that the kitchen is informed and that relevant information is posted on the whiteboard for kitchen staff and caregivers. Additionally, the department interviewed nine residents (R2-R10), all of whom denied the allegation, stating that they enjoy the food served at the facility and that the portion sizes are adequate. On November 15, 2024, the department also interviewed resident R1, who denied that the facility fails to provide meals, stating that R1 has three meals a day and does not require a modified diet. The department later confirmed through the Assisted Living Worker (ALW) that resident R1 moved out of the facility on December 13, 2024. Report Continued on LIC9099C During the facility tour on July 2, 2026, the department observed a food menu available to residents that included well-balanced, nutritious meal options. They also noted that the facility maintained an adequate supply of food, including fruits and vegetables. A review of resident R1's physician's report showed no dietary restrictions or special orders. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. Allegation #2: Facility staff member is mishandling resident's funds. The complaint alleged that the facility is not providing resident R1 with their finances. On July 2, 2026, the department interviewed the Administrator (A1), who denied the allegation, stating that the facility does not manage R1's finances. The Assisted Living Waiver (ALW) deposits a portion of the rent into the facility's account, and R1 pays the remaining portion directly to the facility. A1 also mentioned that since R1 moved to the facility on June 20, 2024, the facility has never managed R1's personal and incidental (P&I) funds. On the same day, the department interviewed five staff members (S1-S5), all of whom stated they did not know about the resident's finances. Additionally, the department spoke to nine residents (R2-R10); three of them claimed that the facility manages their finances and that they have never experienced any issues with their money. The other six residents reported that they manage their own finances. Report continued on LIC9099C On November 15, 2024, the department interviewed R1, who denied the allegation, explaining that they handle their own finances. R1 receives income from Social Security and Disability, which covers their rent, and they also manage their own cash. The department further interviewed the ALW on July 2, 2026, who confirmed that they deposit only their portion of the rent into the facility and that R1 pays the remaining balance. Finally, on July 2, 2026, the department reviewed R1's Tenant Ledger records, which indicated that R1 paid the remaining portion of the rent to the facility by check and in cash until R1 moved out on December 13, 2024. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator, Maria Forkrud.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 18-AS-20241107143439

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Tremayne Barra made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with Executive Director Maria Forkrud. The LPA informed the Administrator of the purpose for the visit. The inspection included the following: LPA toured the assisted living section of the facility. LPA observed the facility to be clean and in good repair. The building is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured within regulation throughout the facility. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats present. Laundry room is present at the facility. Laundry room is locked with cabinets present for storing laundry soap and other chemicals on the first floor. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility and no bodies of water observed. LPA began review of client records. Seven (7) 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. LPA observed client records to be available and complete. (LIC809 continued.....) LPA reviewed employee records- Seven (7) 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 administrator certification; expiration date 11/04/2027. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. 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. Medications are centrally stored. There is a locked room in the first floor allocated for medication storage. Centrally stored medication and destruction logs are maintained electronically. Medications reviewed appear to have been dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Several fire extinguishers were observed throughout the facility, last serviced on 09/08/2025. Fire drills are conducted monthly at the facility with the last drill conducted on 04/17/2026 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, Maria Forkrud.the state’s words, verbatim · CDSS document, May 5, 2026

Allegation investigated: Staff did not prevent resident from being assaulted by other resident while in care

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegation. LPA met with Maria Forkrud, Administrator and informed them of the purpose of the visit. The Department's investigation involved interviews with staff and resident and review of records. On September 6, 2024, Community Care Licensing Division (The Department) received a complaint report with the following allegation. It was alleged that staff did not prevent resident from being assaulted by other resident while in care. Information received indicated that staff did not prevent Resident #1 (R1) from being assaulted by another resident. The Department's records review revealed the following: On September 5, 2024, R1 was observed and examined at Riverside University Health System Medical Center following the alleged incident. Continued on LIC9099-C.... Unsubstantiated During the evaluation, R1 provided limited history and did not answer questions asked by the examiner, often discussing unrelated topics. R1 frequently fell asleep and was not easily awakened. R1 fell asleep multiple times during the interview and exam. R1 was allowed to sleep, and the examining nurse returned to R1 multiple times to complete the interview and exam. The forensic exam concluded when R1 declined to proceed with any additional medical exam. The evaluation did not reveal any conclusive findings. The Department conducted an interview with R1 who stated that R1 was never assaulted by Suspected Abuser (SA), adding that SA was R1's friend and admitted the allegation was false. R1 stated that R1 submitted a signed handwritten statement to the Administrator, recanting R1’s previous claims and allegations. Maria Forkrud, the Administrator, stated an internal facility investigation was conducted, and staff attempted to interview R1’s roommate, Resident #2 (R2). Due to R2’s health condition, R2 was unable to provide any detailed information about the alleged incident. On September 12, 2024, the Administrator stated that R1 gave a statement recanting R1's allegations against SA and contacted Hemet Police Department and retracted R1's statement previously made to the police. R1 wrote a written statement to the police that the alleged incident never occurred. The Administrator stated that R1 and SA are currently seeing each other as friends. Based on interviews conducted and records review, the Department's investigation did not provide enough information to corroborate the allegation that staff did not prevent resident from being assaulted by other resident while 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.the state’s words, verbatim · CDSS document, Apr 6, 2026 · control 18-AS-20240906104031

Allegation investigated: Staff did not ensure that resident took medication as prescribed. Staff did not address a change in resident's condition

Licensing Program Analyst's (LPAs), Armando Perez, Ahliah Sharp and Tremayne Barra conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with Executive Director Maria Forkrud, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and witnesses, and file reviews. On January 13, 2026, Community Care Licensing Division (CCLD), received a complaint alleging that facility staff did not ensure that resident took medication as prescribed and staff did not address a change in resident's condition. Interview with Executive Director, Maria Forkrud, revealed that the name provided did not match any current or former residents. Interview with Staff 1 (S1) reviewed records and corroborated ED statements. LPA attempted to interview Additional Witness 1 (AW1), in order to obtain additional information; however, LPA was unable to obtain contact. Interview with Witness 2 provided the correct address, further revealing that the additional information does not align with the current facility. Continued on LIC 9099-C. Unfounded A review of facility records, including resident rosters, revealed no documented names matching the name reported. Based on interviews, research, and record review, the allegation that facility staff did not ensure that resident took medication as prescribed and staff did not address a change in resident's condition is unfounded due to the listed resident not residing at the facility. A finding that the allegation is unfounded meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. Therefore, this complaint is dismissed. An exit interview was conducted. A copy of this report was provided to Executive Director Maria Forkrud.the state’s words, verbatim · CDSS document, Jan 26, 2026 · control 18-AS-20260113222258

Allegation investigated: Facility failed to notify resident's family about their death in a timely manner.

On December 16, 2025, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent visit to deliver findings regarding the above allegation. LPA Richard met with the Administrator Maria Forkrud (A1), and the purpose of the complaint was explained. LPA and the Administrator toured the facility. The investigation consisted of the following: On April 22, 2025, Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with the administrator, Maria Forkrud, and informed her of the purpose of the visit. On December 11, 2025, Licensing Program Analyst (LPA) Antonine Richard reviewed and received the following documents: the Resident Roster (dated12/10/21), the Staff Roster (dated12/02/25), the Admission Agreements (dated 04/23/24) for Residents #1 (R1), and R1's face sheet. Physician Report (dated 04/22/24), for R1. Physician Orders for Life-Sustaining Treatment (POLST dated 11/16/2023). Unusual Incident Report missing R1, and R1 Death Report (dated September 24, 2024). LPA also conducted interviews with five Residents (R2-R6), five Staff members (S1-S5), one Med Tech (MT), and the Administrator (A1). Unsubstantiated Allegation: Facility failed to notify the resident’s facility about their death in a timely manner. The complaint alleged that the resident left the facility on September 22, 2024, and was struck by a car while crossing the street. Resident #1 (R1) passed away on September 23, 2024, at approximately 7:30 PM. However, the facility did not notify the family until September 24, 2024. On December 11, 2025, LPA Richard interviewed the administrator (A1), who stated that Med Tech had informed the Resident Care Director (RCD) about a call from the coroner confirming R1's passing. The administrator also mentioned that the facility had filed a missing person report with the Hemet Police Department and was actively searching for the residents. At approximately 10:00 PM on September 23, 2024, the coroner's office contacted the facility to inform them of R1's passing. The coroner instructed them not to notify the family at that time, as they would handle the notification themselves. On December 16, 2025, LPA Richard interviewed one Med Tech (MT) by phone, who corroborated receiving a call from the coroner. The coroner's instruction not to inform the family was the reason they were not notified of R1's passing sooner. Report Continued on LIC9099C. On December 11, LPA Richard reviewed the facility's Unusual Incident Report dated September 24, 2024, and the Death Report dated the same day. These reports indicated that the facility submitted an unusual incident report to the Community Care Licensing Department regarding R1's status as missing and their subsequent passing. LPA Richard was unable to interview R1 due to their passing on September 23, 2024. Although the allegation may have happened or is 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 cited. An exit interview was conducted. A copy of the report was provided to the administrator Maria Forkrud.the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 18-AS-20240924112333

Allegation investigated: Staff do not ensure that a resident's needs are being met. Staff did not assist resident with arranging medical care.

On December 16, 2025, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent visit to deliver findings regarding the above allegations. LPA Richard met with the Administrator Maria Forkrud (A1), and the purpose of the complaint was explained. LPA and the Administrator toured the facility. The Investigation consisted of the following: On 6/7/2024, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to investigate the allegations listed above. LPA met with General Manager (GM) Raquel Montes, who was informed of the purpose of the visit. On December 11, 2025, Licensing Program Analyst (LPA) Antonine Richard reviewed and received the following documents: the Resident Roster (dated12/10/21), the Staff Roster (dated12/02/25), the Admission Agreements (dated 09/18/20) for Residents #1 (R1), R1 face sheet (dated 08/10/2021). Physician Report (dated 03/29/24), for R1. LPA Richard also conducted interviews with five residents (R2-R6), five staff members (S1-S5), and the administrator (A1). Unsubstantiated Allegation #1: Staff do not ensure that the resident’s needs are met. The allegation alleged that the resident, who arrived at the hospital, appeared to be malnourished, unkempt, malodorous, and having fecal matter stuck to him on a soiled diaper and frail. On December 11, 2025, the Licensing Program Analyst (LPA) interviewed the Administrator (A1), who denied the allegation of malnutrition and stated that the facility provides three meals a day along with snacks between meals. A1 emphasized that no residents could be malnourished. The resident in question, Resident #1 (R1), has expressed a desire not to be touched. On the same day, the LPA interviewed five staff members (S1-S5), all of whom also denied the allegation. They confirmed that the facility offers adequate portions of food to all residents and provides an optional menu for those who do not want what is currently being served. It was noted that R1 prefers not to be touched by caregivers, except for one specific staff member, who is making efforts to assist R1 with showering and changing clothes whenever R1 is willing. The LPA further interviewed five additional residents (R2-R6), all of whom stated that their needs are being met. They indicated that staff cannot force them to participate in activities they do not want to engage in because they have rights. Each resident expressed that they had a scheduled shower unless they chose to refuse it. The LPA was unable to interview R1, as R1 no longer resides at the facility and moved out on September 30, 2024. On December 11, the LPA also reviewed R1’s physician report (LIC602A), which showed that R1 was capable of dressing, grooming, and feeding themselves. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur; therefore, the allegation is Unsubstantiated. Allegation #2: Staff did not assist a resident with arranging medical care. The complaint alleged that the resident presented with a left eye mass, causing pain and vision loss. R1 reported experiencing pain for a week, but the facility only sent R1 to the hospital. On December 11, 2025, the LPA interviewed the Administrator (A1), who denied the allegation and stated that the facility had made several appointments for R1 to see R1's primary doctor, but R1's responsible party kept cancelling the doctor appointments. On the same day, the LPA interviewed five staff members, #1-5 (S1-S5), who also denied the allegation. S1 also stated that S1 made several appointments for R1, but R1, the responsible party, cancelled the appointments. Finally, S1 decided to call 911 and sent R1 to the hospital. S1 also stated that the facility tried to have the facility doctor see R1, but R1 refused. The LPA also interviewed five residents #2-6 (R2-R6), all of whom denied the allegation and stated that they had seen the facility doctor twice a month. If they need more urgent care, the facility will call 911. LPA was unable to interview R1 because R1 no longer resides at the facility and moved out on September 30, 2024. Although the allegation may have happened or is 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 cited. An exit interview was conducted. A copy of the report was provided to the Administrator Maria Forkrud.the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 18-AS-20240530120048

Type of visit: Case Management - Deficiencies

On December 16, 2025, Licensing Program Analyst (LPA) Antonine Richard conducted a case management deficiency visit regarding Complaint Control Number 18-AS-20240924112333. During the investigation, LPA Richard identified a deficiency and submitted a report to Vista Montana Senior Living. While reviewing records of a resident reported missing on September 22, 2024, and deceased on September 23, 2024, LPA observed that the Physician Report LIC602A indicated the resident was able to leave the facility unassisted but needed assistance from one person. The deficiency is being cited based on observations, interviews, and record review, in accordance with the California Code of Regulations, Title 22, see LIC809D—a violation concerning Personal Rights and Procedures for responding to incidents and complaints. An exit interview was conducted, and the Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator, Maria Forkrud.the state’s words, verbatim · CDSS document, Dec 16, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jan 5, 2026

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. based on observations, interviews, and record review, in accordance with the California Code of Regulations, Title 22, see LIC809D—a violation concerning Personal Rights and Procedures for responding to incidents and complaints.the state’s words, verbatim · CDSS document, Dec 16, 2025

Plan of correction: The POC will be: Facility is to provide all residents with the required care, supervision and services to meet their individual needs at all times. Additionally, the facility administrator is to review resident records, including physician reports, for all residents in placement and provide training to care staff to ensure they are aware of such needs for each individual by 01/05/2026. Certification that this has been completed must be sent to Antonine.Richard@dss.ca.gov

Allegation investigated: Staff financiallly abused resident in care.

On December 11, 2025, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent visit to deliver findings regarding the above allegation. LPA Richard met with the Administrator Maria Forkrud (A1), and the purpose of the complaint was explained. LPA and the Administrator toured the facility. The investigation consisted of the following: On July 15, 2024, Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to initiate an investigation into the allegation listed above. On December 11, 2025, Licensing Program Analyst (LPA) Antonine Richard reviewed and obtained the following documents: the Resident Roster (dated12/10/25), the Staff Roster (dated12/02/25), the Admission Agreements (dated 08/25/20) for Residents #1 (R1), and the Personal & Incidental (P&I) funds records (dated 06/16/25, 12/01/25) for Residents #1. Physician Report (dated 03/18/25), for (R1). Facility ledger for R1 (dated 10/31/23, 03/01/24 and 6/04/24). LPA Richard also conducted interviews with six residents (R1-R6), five staff members (S1-S5), and the administrator (A1). Unsubstantiated Allegation: Staff financially abused resident in care. The complaint alleged that a resident closed the bank account on 07/11/24 due to unauthorized charges and concerns about account activity, which resulted in a low balance. On December 11, 2025, the LPA interviewed the Administrator (A1), who stated that this happened under a former Administrator (A1) when the incident was brought to the facility's attention, and the facility took action. A1 is no longer employed here. On December 11, 2025, the LPA also interviewed five staff members (S1-S5), who stated that they were informed about the incident and had never accessed any of the residents' bank accounts. Additionally, on December 11, 2025, the LPA interviewed Resident #1 (R1), who stated that R1 believed the case was closed because no one had access to R1's bank account and R1 didn’t want to discuss it. R1 stated that the bank account was closed, and R1 is the only one with access to R1's money. The matter is now closed. LPA interviewed five residents (R2-R6). 3 out of 5 stated they have no problems with their P&I money. On December 11, 2025, during the review of the facility ledger records and bank statements, the LPA observed that some unauthorized charges bore R1's signature. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur; therefore, the allegation is unsubstantiated. Exit interview conducted with Administrator Maria Forkrud, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 12, 2025 · control 18-AS-20240711152741

Allegation investigated: Staff did not ensure that resident was adequately fed. Staff does not treat resident with dignity or respect. Staff does not ensure residen's needs are met.

On December 11, 2025, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent visit to deliver findings regarding the above allegations. LPA Richard met with the Administrator Maria Forkrud (A1), and the purpose of the complaint was explained. LPA and the Administrator toured the facility. The investigation consisted of the following: On April 09, 2024, Licensing Program Analyst (LPA) Yolanda Delgado conducted an unannounced visit to the facility to initiate an investigation into the allegations listed above. LPA met with Administrator Mary Ann Nevarez and explained the purpose of the visit. LPA Delgado interviewed two (2) staff members and one (1) resident and requested and obtained copies of pertinent documentation. On December 11, 2025, Licensing Program Analyst (LPA) Richard reviewed and received the following documents. Resident roster (dated 12/10/25), the Staff Roster (dated 12/02/25), and the admission agreements (dated 08/25/20). Physician report (dated 03/18/24) for (R1). Facility menu dated June 2023. LPA, Richard, also conducted interviews with six residents (R1-R6) and five staff members (S1-S5), and the administrator (A1). Unsubstantiated Allegation #1: Staff did not ensure that the resident was adequately fed. The complaint alleged that when bringing food to resident R1, R1 ate so quickly that R1 claimed not to have been eating. On December 11, 2025, the LPA interviewed the Administrator (A1), who denied the allegation and stated the facility offers three meals a day along with snacks between meals. On the same day, the LPA interviewed five staff members #1-5 (S1-S5), who also denied the allegation and affirmed that the facility provides all residents with adequate portions of food and offers an optional menu if they do not want what is served. They also provide snacks three times daily. Additionally, on December 11, 2025, the LPA interviewed six residents #1-6 (R1-R6), five of whom denied being inadequately fed by the facility. Three out of five residents mentioned that the facility gave them a second plate when asked. The same day, the LPA reviewed the facility’s menu, which showed a variety of foods and an optional menu. The LPA observed residents eating lunch and noted that the portions served were substantial. On December 11, 2025, the LPA attempted to interview R1; however, R1 was unable to answer the questions due to cognitive impairment. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur; therefore, the allegation is Unsubstantiated. Report continued on LIC9099C. Allegation #2: Staff do not treat the residents with dignity and respect. The complaint alleged that the facility staff are mean to R1, who felt scared. On December 11, 2025, the LPA interviewed the Administrator (A1), who denied the allegation and stated that R1 never mentioned that the staff is mean to R1. On the same day, the LPA interviewed five staff members #1-5 (S1-S5), who also denied the allegation and confirmed that no residents ever complained to them about other staff being mean to them. Additionally, on December 11, 2025, the LPA interviewed six residents, #1-6 (R1-R6), five of whom denied that staff were mean to them. On December 11, 2025, the LPA attempted to interview R1; however, R1 was unable to answer the questions due to cognitive impairment. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur; therefore, the allegation is Unsubstantiated. Allegation #3: Staff do not ensure residents’ needs are met. The complaint concerned resident 1 (R1)'s overall well-being and whether R1's needs are being met. On December 11, 2025, LPA Richard interviewed the Administrator (A1), who denied that the residents' well-being was being neglected. Report continued on LIC9099C. On the same day, LPA interviewed five staff members, #1-5 (S1-S5), all of whom denied the allegation and stated that the residents are well cared for daily. The caregiver checked on the residents every 2 hours. If a resident pressed the pendant for help, a staff member would go to assist them. Additionally, on December 11, 2025, LPA interviewed six residents, #1-6 (R1-R6). Five of the six denied the allegation, stating that staff helped them and that their needs are being met. LPA attempted to interview R1; however, R1 was unable to answer the questions due to cognitive impairment. On December 11, 2025, LPA observed staff interact with residents with care and respect. Residents were showing pictures on the wall and smiling. Although the allegation may have happened or is 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 cited. An Exit interview was conducted. A copy of this report was provided to the Administrator Maria Forkrud.the state’s words, verbatim · CDSS document, Dec 12, 2025 · control 18-AS-20240405113514

Allegation investigated: Staff are charging resident additional fees for food Staff do not ensure that resident's personal information is kept confidential Staff do not ensure that resident rooms are free of bugs

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Maria Forkrud, Administrator, and informed them of purpose of the LPA's visit. The Department investigation involved interviews with staff, client, and a review of records. On October 21, 2024, Community Care Licensing (The Department) received a complaint report with the following allegations. It was alleged that staff are charging resident #1 (R1) additional fee for food. It was alleged that staff do not ensure that resident’s personal information is kept confidential. It was alleged that staff do not ensure resident rooms are free of bugs. Continued on LIC9099-C..... Unfounded LPA Seo Jeon obtained resident and staff rosters and staff schedule from the administrator. LPA’s review of resident rosters revealed R1 lives in the independent part of this facility. It is an apartment building next to the assisted living facility. Independent living apartment is not within the Department's jurisdiction. LPA visited and conducted an interview with R1 and verified that R1 resides at independent part of the facility. Based on records review and interviews, the above mentioned allegations were 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, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 18-AS-20241021122200

Allegation investigated: Residents are not accorded privacy while in care.

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver amended findings of the above allegation. LPA met with Maria Forkrud, Administrator. The Department investigation involved interviews with staff and review of records. On April 4, 2022, Community Care Licensing Division (CCLD) received a complaint report alleging that residents are not accorded privacy while in care. Information received indicated two (2) different staff members entered a resident’s room without knocking or receiving permission to enter. Additionally, during interviews conducted by LPA, three (3) out of eight (8) residents stated some staff members had entered their rooms without knocking beforehand. All eight (8) residents stated all staff members now knock on the doors before entering their rooms. Continuned on LIC9099-C.... Substantiated Based on the interviews and information received, the allegation that residents are not accorded privacy while in care 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 exit interview was conducted and copy of this report was provided to the Administrator along with LIC9099-D and Appeal Rights.the state’s words, verbatim · CDSS document, Aug 29, 2025 · control 18-AS-20220404101121

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Aug 29, 2025

Additional Personal Rights of Residents in Privately Operated Facilities (a)In addition to the rights listed in Section 87468.1....(1)To have a reasonable level of personal privacy in accommodations.... This requirement was not being met as evidenced by: Based on observations and interviews, LPA found that residents were not accorded privacy while in care.the state’s words, verbatim · CDSS document, Aug 29, 2025

Plan of correction: This deficiency has already been corrected as all staff now knock on the residents' doors and ask for permission to enter.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Seo Jeon, conducted an unannounced visit to the facility to deliver amended findings of complaint report number 18-AS-20220404101121. The LPA was allowed entrance into the facility and met with Maria Forkrud, Administrator. The LPA informed the Administrator of the purpose for the visit. LPA toured the interior and exterior of the facility. LPA did not find any concern for health and safety of the residents in care. Amended findings were delivered and an exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Aug 29, 2025

Allegation investigated: Resident sustained multiple bruises while in care.

Licensing Program Analyst (LPA) Debbie Palacios conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Debbie Palacios met with Administrator Maria Forkrud and explained the reason for the visit. On 10/24/2022, the Riverside Adult and Senior Care Regional Office (RO) received a complaint regarding a Neglect/Lack of Supervision Allegation. Resident #1 (R1) was brought to the hospital on 10/16/2022 with multiple bruises to legs and face that were inconsistent with a fall. According to the facility file documents reviewed, R1 was admitted to the facility on 09/01/2021. Per the review of R1’s Physician’s Report, the primary diagnosis includes Muscle Weakness, History of Falls, and Alzheimer’s. R1’s Secondary diagnosis includes Abnormal and Unsteady Gait, Fracture of Right Patella, and Unsteady on feet. R1 is listed as ambulatory. R1’s Needs and Services Plan was completed on 09/02/2021. Unsubstantiated The Needs and Services Plan documents, “R1 ambulates independently, is alert and able to make needs known. R1 is able to transfer to and from bed and chair, needs help toileting, dressing and bathing.”R1’s Individual Service Plan was updated on 07/14/2022. The plan documents R1’s diagnosis as Mild Cognitive Impairment and requires reminders from staff. R1 requires assistance with mobility/ambulation, and the plan states “RCFE staff will continue to reinforce fall precautions and will assist R1 in mobility or ambulation as needed, per patient’s request.” A review of the Special Incident Reports (SIRs) submitted by the facility revealed the following: On 09/29/2022, at approximately 11:55pm, while doing rounds, care staff found R1 on the floor in their room with a big bump on forehead. 911 was called and R1 was transported to the hospital. On 10/02/2022, the facility shift report notes R1 had a fall but was not hurt. On 10/16/2022, the SIR documents R1 had a fall in the hallway and sustained an injury to their forehead, and it was bleeding. 911 was called and R1 was transported to the hospital. On October 16, 2022, at 5:33am, R1 was transported by ambulance to the hospital emergency department (ED) with a head injury from a fall. Per the EMS report, R1 had an unwitnessed fall at the facility and was found in the hallway by staff. R1 was noted to have a hematoma to the forehead. Per EMS, R1 stated R1 thought R1 was in R1’s room and was trying to get up when R1 fell. R1 denied loss of consciousness, neck pain or back pain. No other complaints were reported at this time. R1’s initial diagnosis included traumatic head injury with multiple lacerations, traumatic injury of head with hematoma of scalp, and facial hematoma. At 7:17am, the ED notes documented, R1 has a large hematoma to forehead with bleeding controlled and bruising around left orbital (eye) and left cheek. R1 reports that R1 had been falling more often. R1 reports slight soreness to area but recently got an IV. R1 has a wound on the right shin in the late stages of healing. R1 with bruising in multiple stages of healing, history of recent frequent falls. R1’s assessment also documented a urinary tract infection (UTI). On 10/21/2022, R1 was discharged back to the facility with an order of outpatient physical therapy for continued rehabilitation of functional mobility. Upon returning from the hospital on 10/21/2022, staff ordered Home Health Services, a hospital bed, and reassured R1’s resident representative that the staff would increase the frequency of checks and encourage R1 to utilize the walker when ambulating. Staff assessed R1 after each incident and notified 911 in a timely manner. The information obtained during the Department’s investigation did not sufficiently support the allegation. While R1 did sustain falls which resulted in multiple bruises, the investigation did not provide sufficient evidence to substantiate neglect/lack of supervision. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Aug 20, 2025 · control 18-AS-20221024110115

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility for a case management in regards to complaint control #18-AS-20220404101121. LPA met with Maria Forkrud, Administrator, and informed them of the purpose of the LPA’s visit. The LPA conducted a tour of the interior/exterior areas of the facility. LPA interviewed residents and staffs. 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, and a copy of this report was provided to Maria Forkrud.the state’s words, verbatim · CDSS document, Jun 27, 2025

Allegation investigated: Staff does not ensure that residents are provided a safe environment.

Licensing Program Analyst, (LPA) Yolanda Delgado arrived unannounced to the facility to conclude an investigation pertaining to the allegation listed above. LPA met with Maria Forkrud and explained the purpose of the visit. On December 5, 2024, Community Care Licensing received a complaint alleging Staff does not ensure that residents are provided a safe environment. LPA conducted interviews with Administrator, staff, residents, and additional witnesses. LPA also conducted a review of pertinent documentation. Regarding the allegation staff does not ensure that residents are provided a safe environment, it was reported that residents being kept in rooms during construction to walls with exposure to extreme mold and debris. Information obtained from the interview with Administrator denied that any construction has taken place at the facility were construction to walls with exposure to extreme mold and debris. (Continued on Page 2) Unfounded (Continued from Page 1) Information obtained from interviews with Residents could not corroborate the allegation that they were kept in rooms during construction to walls with exposure to extreme mold and debris. Information obtained from an interview with a witness stated that there was a plumbing issue at 175 N Girard Ave, Independent Living Building, not at 155 N Girard Ave, Assisted Living. Based on staff interviews, resident interviews, witnesses’ interviews, facility records. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Maria Forkrud and a copy of this report along with LIC811- Confidential Names list was provided.the state’s words, verbatim · CDSS document, May 19, 2025 · control 18-AS-20241205161237

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with Executive Director Maria Forkrud. The LPA informed the Administrator of the purpose for the visit. The inspection included the following: LPA toured Building C, which is designated as the assisted living section, inside and outside. LPA observed the facility to be clean and in good repair. The building is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured within regulation in 8 randomly selected rooms. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats present. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals on the first floor. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility and no bodies of water observed. LPA began review of 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. LPA observed client records to be available and complete. 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 administrator certification; expiration date 11/04/2025. LPA observed four out ten records did not have the health screening/ TB test results completed and four out of ten did not have the First Aid/CPR certification completed. A deficiency will be issued for each violation. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. 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. Medications are centrally stored. There is a locked room in the first floor allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers was last serviced on 11/26/2024, Fire drills are conducted monthly at the facility with the last drill on 04/01/2025 . Based on the information received during this visit today in the areas reviewed, there are deficiencies that are being cited per Title 22, Division 6 of The California Code of Regulations. This LIC 809, LIC 809-C, 809-D and Appeal Rights report was reviewed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, May 16, 2025

Allegation investigated: Staff is unlawfully evicting the residents while in care

Licensing Program Analyst (LPA) Javina George made an unannounced visit to deliver findings for the allegation listed above. LPA met with General Manager Raquel Montes where LPA explained the purpose of the visit and the elements of the allegation. The allegation was investigated, the investigation consisted of observations, interviews, records review. On 12/31/21 Community Care Licensing received a complaint alleging staff is unlawfully evicting the residents while in care. Regarding the allegation of staff is unlawfully evicting the residents while in care. Resident #1 (R1) and Resident #2 (R2) were issued an eviction notice on 12/2/21 due to failure to pay rent and services. Per records review conducted LPA observed for R1 and R2 to still have an outstanding balance that ended up being written off. LPA reviewed an email dated 07/28/21 referencing R1 and R2 monthly rate and how they had not paid the full amount of rent after having moved into the facility on 7/21/21-R2 and 7/15/21-R1. Per General Manager Raquel Montes, this continued to be a reoccurring theme throughout R1 and R2s tenancy. Additionally Raquel stated that the monthly invoices are hand Unfounded which detailed the November 2024 delivered to residents four (4) days before the first of each month. LPA was unable to interview R1 and R2. R1 moved out on 12/14/21 and R2 moved out 12/10/21. Based on observations, interviews and records review the allegation of staff is unlawfully evicting the residents 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 was provided to Raquel Montes, General Manager. payments and would pay in cash. LPA was unable to interview R1 and R2. R1 moved out on 12/14/21 and R2 moved out 12/10/21. LPA reviewed the - Record Of Client's/Resident's Safeguarded Cash Resources for the current residents check being deposited and, rent being deducted and P& I being issued. Per interviews conducted with residents there were no concerns with their finances, and that the money is given when expected. Based on interviews and records review the allegation of Residents are being financially abused while in care is unsubstantiated. Regarding the allegation of Residents are being mishandled while in care. It was alleged the residents are being mishandled with in care. LPA conducted interviews with residents which revealed that there are not any concerns with being mistreated or mishandled by staff. Staff are speaking to residents with dignity and respect and using appropriate voice tones and language. Based on interviews the allegation 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 was provided to Raquel Montes, General Manager.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 18-AS-20211223160102

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced case management visit in response to an incident report received by the department. LPA met with the administrator, Maria Forkrud, and she was informed of the purpose of the visit. On 8/16/2024 the department received an incident report for Resident #1 (R1), incident had occurred on 8/14/2024. LPA conducted a walk through, interview and records review at the time of the visit. No deficiencies were cited at the time of the visit. An exit interview was conducted with the administrator where this report was reviewed and provided to her.the state’s words, verbatim · CDSS document, Sep 6, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility for a case management visit to follow up on the elopement of a resident in care. The LPA was allowed entrance into the facility and met with Interim-Administrator, Raquel Montes. The LPA informed Montes of the purpose for the visit. A report was received by the Department from the facility on 06/19/2024 regarding Resident One (R1) not being able to be located at the facility on 06/11/2024. Staff One (S1) attempted to locate R1 during their scheduled round; however, the resident was not found. According to the Unusual Incident/Injury Report (UIR) and a staff interview, R1 was last seen at 10:00 AM on 06/11/2024. The report states staff searched for the resident; however, their attempts were unsuccessful. Per Interim-Administrator Montes, R1 has not been found as of this date. R1's medical assessment (Physician's Report for Residential Care Facilities for the Elderly) was reviewed. The report, dated 12/14/2023, revealed the resident is diagnosed with a condition which does affect their cognition; however, the report also states the resident is able to leave the facility unassisted. According to staff interviews, R1 frequently leaves the facility without supervision and has returned on their own or with an escort from law enforcement. Montes reported that when R1 returns to the facility they have never returned injured. The UIR (written report), regarding the elopement of R1 was not submitted within seven (7) days. Based on a fax transmittal the incident, which occurred on 06/11/24, was reported on 06/19/2024. A citation will be issued. An exit interview was conducted; this report was reviewed with Interim-Administrator and a copy was provided, along with the LIC 811, LIC 9098, and instructions on appeal rights.the state’s words, verbatim · CDSS document, Jul 31, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Aug 7, 2024

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, Jul 31, 2024

Plan of correction: The Interim-Administrator reported staff training regarding reporting requirements will be conducted and proof submitted to the Department.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility for a continuation of a required annual inspection. The LPA was allowed entrance into the facility and met with Interim-Administrator, Raquel Montes. The LPA informed the Montes of the purpose for the visit. The inspection was started on 05/30/2024; however, due to technical concerns and insufficient time, deficiencies observed during the inspection could not be cited until this visit. The below violations are being cited: - Two staff members, S3 and S5, did not have proof of Dementia Care training. S2, S3, and S4 did not have Restricted Healthcare training. S2, S3, S4, and S5 did not have postural support training or the complete hours for hospice care training. This violation poses a potential threat to the health, safety and personal rights of the residents in care. - Initial medication training was not observed on file for S5. This violation poses a potential threat to the health, safety and personal rights of the residents in care. - The Appraisal/Needs and Services Plan for R2, R3 and R5 were not updated within a 12 month period. This violation poses a potential threat to the health, safety and personal rights of the residents in care. - No written agreement was observed on file for residents receiving services from home health agencies; including for R6, R7 and R8. This violation poses a potential threat to the health, safety and personal rights of the residents in care. An exit interview was conducted, where this report was reviewed with Interim-Administrator Montes and a copy was provided, along with the LIC 811 and instructions on appeal rights.the state’s words, verbatim · CDSS document, Jul 31, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced case management visit in response to an incident report received by the department. LPA met with Administrator, Maria Nevares who was informed of the purpose of the visit. On 6/20/2024 the department received an incident report for Resident #1 (R1), incident had occurred on 6/11/2024. LPA conducted a walk through, interviews, and records review at the time of the visit. No deficiencies were cited at the time of the visit. An exit interview was conducted with the administrator where this report was reviewed and provided to them. *LPA was off site from 12:30pm to 1:35pmthe state’s words, verbatim · CDSS document, Jun 24, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility for a required annual inspection. The LPA was allowed entrance into the facility and met with Administrator, Maryann Kanekoa Nevarez. The LPA informed the Administrator of the purpose for the visit. The inspection included the following: Physical Plant: The facility has an approved fire clearance for 120 non-ambulatory residents, of which 10 may be bedridden. The LPA inspected the facility; there are no bodies of water located on the property. According to Administrator Nevarez, no weapons are stored in the facility. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats or strips present. The alarm panel for the smoke and carbon monoxide detectors was observed to be in a normal status. The facility was kept clean. Food Service: There is a minimum of two (2) days supply of perishable foods and one (1) week's supply of non-perishable foods available. Sufficient supplies were available for resident's dinning use. Record Review: The facility currently has an approved Hospice Waiver for twenty (20) residents; of which eleven (11) are currently receiving services. Staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Complete training on Dementia Care, Postural Supports, Restricted Health Conditions, and Hospice Care was not observed to be on file for staff. Two staff members, S3 and S5, did not have proof of Dementia Care training. S2, S3, and S4 did not have Restricted Healthcare training. S2, S3, S4, and S5 did not have postural support training or the complete hours for hospice care training. A citation will be issued. Initial medication training was not observed on file for S5. A citation will be issued. Training was observed on file relating resident's rights. There is a disaster and mass casualty plan in place. Emergency Drills are being completed. Services requiring specialized skill are being performed by appropriately skilled professional. The Appraisal/Needs and Services Plan for R2, R3 and R5 were not updated within a 12 month period. Physician's Report for Residential Care Facilities for the Elderly (RCFE) (LIC 602A) and Admission Agreements were observed on file. No written agreement was observed on file for residents receiving services from home health agencies; including for R6, R7 and R8. A citation will be issued. The LPA was informed there were residents in care with Restricted Health Conditions who are not receiving services from a hospice or home health agency. According to Administrator Nevarez, there were no exception requests submitted to the department to retain the residents. A citation will be issued. Medication Review: The LPA inspected the medication room and carts. The medications were observed to be well organized and inaccessible to unauthorized individuals. Centrally Stored Medication and Destruction records were observed to be maintained at the facility. An exit interview was conducted with Administrator Nevarez, in which this report was reviewed and a copy was provided, in addition to the LIC 811. Due to technical concerns a return visit will need to be completed to issue citations.the state’s words, verbatim · CDSS document, May 30, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to deliver an amended copy of a previously issued report. LPA met with Executive Director Maria Nevarez, and explained the purpose of the visit. LPA conducted an exit interview and reviewed and provided copies of the amended report to Maria Nevarez. Nothing further is needed at this time.the state’s words, verbatim · CDSS document, Dec 15, 2023

Allegation investigated: Staff did not provide adequate supervision, resulting in a resident wandering away from the facility.

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Administrator, Maryann Kanekoa Navarez, and informed her of the purpose for the visit. A report was received by the Department alleging Resident One (R1) was found outside of the facility and did not know what their current location was. The investigation included staff/resident interviews, records review, and records collection. R1 was interviewed though could not provide a statement regarding the incident. Administrator Navarez was interviewed and reported she was notified on 11/05/2023 of R1 being out in the community on 11/04/2023. She stated the resident was picked up by staff and returned to the facility the same day without injuries. Facility staff were interviewed and reported the resident does not usually leave the facility on their own. It was reported no similar incidences have happened prior to 11/04/2023. R1's Physician's Report for Residential Care Facilities for the Elderly (RCFE) revealed R1 is able to leave the facility unassisted; Unsubstantiated however, an Assessment Tool completed on 03/01/2023, by a third-party agency, revealed R1 was observed to usually not be able to make decision, judgement frequently impaired/requires cues and supervision. In addition, the report stated R1 did not have symptoms of wandering at the time of the assessment. Administrator Navarez reported she has reached out to R1's case worker to have the individual re-evaluated. Therefore, based on records, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted; this report was reviewed with Administrator Navarez and a copy was provided.the state’s words, verbatim · CDSS document, Nov 13, 2023 · control 18-AS-20231106130652

Allegation investigated: Staff member sexually assaulted resident.

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to conclude and deliver findings to an investigation regarding the above allegation. LPA was granted entry and met with Executive Director Maria Nevarez who was informed of the purpose of the visit. Regarding the allegation “Staff member sexually assaulted resident”, LPA conducted interviews and record review in relation to Resident One (R1). R1 stated Staff One (S1) had sexually assaulted R1 by performing inappropriate actions during a bathing and diaper change routine. Based on interviews conducted with staff and R1, during the bathing and diaper change, S1 had inappropriately flicked R1 on their breast and had made R1 uncomfortable during a diaper change. During the diaper change, S1 had their head uncomfortably close to R1’s lower body area while changing them. R1 had informed other staff members regarding the incident and Staff Two (S2) had reported it to management. LPA’s interview with Resident Care Director, Nikki Carter (NC), revealed that S1 stated they were picking at a pimple that was on R1’s breast. NC informed S1 to “not go near R1 after this incident”. (CONTINUED LIC 9099-C) Unsubstantiated LPA asked if S1 had been assigned to bathe R1 prior to this incident and NC stated yes S1 was assigned to bathe and conduct diaper changes for R1 with no prior incidents. Based on LPA’s interviews and record review there were no previous incidents regarding S1 and other residents. S1 was sent home on 08/28/2023 due to pending test results for a drug test. S1 does not have a valid phone number on file and the facility has not been able to reach S1. LPA contacted S1’s previous employer at a different facility requesting S1’s contact information. S1’s contact information from the previous employer was not in service and S1 is currently homeless. LPA asked if S1 was currently working at the facility and Executive Director Nevarez stated S1 had quit and is no longer working at the facility. Due to the lack of contact information for S1, LPA was not able to conduct an interview with S1. Staff and resident interviews provided no information that could corroborate or refute the validity of the allegation. Therefore based on interviews and record review this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was reviewed with and provided to Executive Director Maria Nevarez.the state’s words, verbatim · CDSS document, Nov 13, 2023 · control 18-AS-20230927151818