The Oars at Greenback Lane

Type of visit: Case Management - Incident

On 09/10/2026 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a case management visit. LPA met with Executive Director (ED), Christal Anderson, and explained the purpose of the visit. The purpose of the visit is to gather additional information regarding an unusual incident/injury report that was sent to Community Care Licensing (CCL) on 08/13/2026 regarding Resident #1 (R1). During today's visit LPA conducted interviews regarding the incident. No deficiencies cited at this time. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Sep 10, 2026

Allegation investigated: Staff mishandling resident’s medication

Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived on 07/28/2026 unannounced to conclude a complaint visit regarding the above allegation. LPA met with Memory Care Director Rae Ortiz and Paige Perkins Health Care Director and explained the purpose of the visit. LPA conducted staff interviews regarding the allegations. Please continue to LIC9099C.... Substantiated LPA interviewed staff regarding the allegations. LPA learned the following: R1 is prescribed two medications for pain: Acetaminophen 325 mg and Norco 5-325 mg. The directions for acetaminophen state “take 2 tabs (650 mg) by mouth every 4 hours as needed for breakthrough pain” while the directions for Norco state “take 1 tablet by mouth every 4 to 6 hours as needed for pain”. According to staff interviews, R1 will routinely as for a pain pill. Staff interviewed could not state the reasoning to give the acetaminophen rather than a Norco when R1 asked for a pain pill. According to R1’s MAR, there was no discernible pattern associated with the administration of each medication. Additionally, the prescribing physician was not contacted for clarification regarding which medication to give first for pain. Based on the information detailed above, LPA finds the allegation to be substantiated. A finding that the allegation is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiency cited on 9099-D. Exit interview conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 59-AS-20260612100622

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 29, 2026

87465(a)(4) Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews and file reviews the Licensee did not comply with the section cited above in facility did not contact the prescribing physician for clarification.the state’s words, verbatim · CDSS document, Jul 28, 2026

Plan of correction: Facility to submit and come up with a plan to follow regarding when facility will contact primary physician for clarification.

Allegation investigated: reporting requirements false claims

Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived on 07/28/2026 unannounced to conclude a complaint visit regarding the above allegation. LPA met with Memory Care Director Rae Ortiz and Paige Perkins Health Care Director and explained the purpose of the visit. LPA conducted staff interviews regarding the allegations. Please continue to LIC9099C.... Unsubstantiated LPA conducted staff interviews regarding the allegations. LPA learned the following: On May 15, 2026, R1 told their daughter that they fell earlier in the day but were able to get themselves back in bed. Staff working that day were interviewed and stated that R1 never fell nor found on the floor. LPA reviewed R1’s file which did not show any documentation of a fall. R1 is diagnosed with Dementia. According to R1’s care plan, they experience occasional episodes of hallucination/delusion. Additionally, R1 needs moderate assistance from staff for mobility, escorts, transferring and extensive assistance for bathing, grooming, dressing, and toileting. Based on information obtained during the investigation, LPA finds the allegations to be 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 evidence to prove that the alleged violation occurred. Exit interview. A copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 59-AS-20260612173203

Allegation investigated: Untrained staff are dispensing medications to residents in care Staff do not ensure medications are kept secure in a centrally stored area

Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday May 20, 2026, unannounced to conclude a complaint which was received by the Department on 4/22/2026. LPA met with Administrator Christal and explained the purpose of the visit. LPA interviewed the management, med techs, and caregivers regarding the allegations. LPA learned the following: 4 staff interviews revealed that med techs have asked caregivers to hand out medication. According to interviews, this has occurred on AM and PM shifts. Additionally, two interviews revealed that medications have been kept unsecured and accessible to residents. According to one interview, a med tech will place medication cups on the kitchen counter, tucked in a corner, until they are ready to give the medication to residents. Additionally, one staff acknowledged that a med tech will keep medication in an unlocked kitchen drawer, accessible to residents. LPA obtained a picture of unsecured medication in a kitchen drawer. Substantiated Based on the information detailed above, LPA finds the allegation to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, May 20, 2026 · control 59-AS-20260422104107

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 21, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees . . .This requirement was not met as evidenced by staff interviews and photo documentation. This posese a direct threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, May 20, 2026

Plan of correction: Facility agrees to: submit a meeting date/time within the 24 hours. Meeting will include the following topics: medication policy and procedures, disciplinary action for failture to follow, grevience procedure.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(4) · Plan of correction due date: May 21, 2026

87411 Personnel Requirements - (d) All personnel shall be given on the job training or have related experience in the job assigned to them. . . (4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement was not met as evidenced by staff acknowledging that med techs give caregivers medications to dispense. This poses a direct threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, May 20, 2026

Plan of correction: Facility agrees to: submit a meeting date/time within the 24 hours. Meeting will include the following topics: medication policy and procedures, disciplinary action for failture to follow, grevience procedure.

Type of visit: Required - 1 Year

On 01/06/2026 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced at the facility to conduct a required 1-year annual inspection utilizing the CARE tool. LPA met with Executive Director (ED), Christal Anderson, and explained the purpose of the visit. The facility has a hospice waiver for sixteen (16) residents. Currently, there are eleven (11) residents under hospice care. LPA and ED conducted a tour of the interior of the facility. Areas toured included but not limited to: resident rooms, kitchen, dining rooms, medication room and common areas. LPA observed residents in common areas with staff participating in activities. The residence was found to be clean, safe, sanitary and in good repair. LPA observed the facility to have the mandated posters posted. Fire extinguishers are maintained and ready for emergency use. Facility has required food supplies. There are appropriate staff present to meet the needs of residents. In areas toured, LPA did not observed any violation of health, safety and personal rights. LPA conducted a file review of ten (10) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. LPA reviewed ten (10) staff files. A review of staff files indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current training completed. As a result of todays inspection no deficiencies observed. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 6, 2026

Allegation investigated: Facility failed to notify responsible party

On 10/30/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to deliver final findings to a complaint Community Care Licensing (CCL) received on 06/03/2025. LPA met with Executive Director (ED) Christal Anderson and explained the purpose of the visit. During the course of the investigation, the Department conducted interviews and record review. Interviews revealed that facility was late in telling R1s responsible party of the incident. The incident occurred on 05/26/2025 and facility did not notify residents responsible party in writing within seven (7) days of occurrence. Interviews revealed the family recieved the incident report on 07/22/2025 when R1s file was picked up by their responsible party. Based on file review and interviews, the facility did not ensure incident report was sent to R1s responsible person as required. Therefore the preponderance of evidenced standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. Exit interview conducted. A copy of the report and appeal rights left at the facility. Substantiated Allegation: Staff did not ensure care and supervision was provided resulting in resident sustaining a hip fracture On 5/26/2025 Staff #1 (S1) was conducting the last rounds of their shift, when entering Resident #1 (R1s) bedroom. R1 informed staff they needed to go to the restroom. S1 assisted R1 out of bed and R1 had complaints of pain. S1 advised R1 to wait so they could get R1 checked out, but R1 refused, demanding they use the restroom. S1 walked R1 to the toilet, when R1 sat down on the toilet, they “screamed” in pain. S1 called a Med-Tech who had just come on shift for assistance. S1 and Med-Tech escorted R1 to a sofa in their room, sat them down and evaluated them. At this point R1 could not stand up. Several other staff members were interviewed, and they all recalled the same story. S1 escorted R1 to the toilet, R1 called out in pain, and S1 called for help, R1 was evaluated and sent out. No fall during the night was reported. R1 was diagnosed with a “right femoral head, neck fracture.” Several residents were interviewed. All residents interviewed had no complaints about the facility and enjoyed the care they received. R1 was interviewed but due to mild cognitive impairment, they were unable to provide a comment on what occurred. Based on the information obtained during this investigation, it is unknown how R1 sustained their injury. R1 does not require any special checks during the night and was checked on throughout the night, staff reported they were sleeping. Based on R1’s care needs the facility staff acted appropriately per policy. Based on this information, this allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated.the state’s words, verbatim · CDSS document, Oct 30, 2025 · control 59-AS-20250603141930

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Nov 13, 2025

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not met as evidenced by: Based on interviews the Licensee did not comply with the section cited above in facility did not notify responsible party in writing within seven (7) days of the incident.the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: Licensee is to come up with a procedure on how the facility will ensure families are notified in wiriting within seven (7) days of an incident.

Allegation investigated: Staff does not ensure facility is up to code with the Fire Department.

On 03/27/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to deliver final findings for a complaint Community Care Licensing (CCL) received on 01/30/2025. LPA met with Executive Director (ED) Christal Anderson and explained the purpose of the visit. During the course of the investigation, the Department conducted a file review, interviews and obtained pertient documents relevant to the complaint investigation. Please continue to LIC9099C Substantiated LPA conducted a file review of facility file. During file review it revealed that the facility did not have an approved fire clearance for the facility to use a delayed egress system. Facility is currently working with fire to become in compliance with fire safety. Based on file review and interviews, the facility did not ensure that they had an approved fire clearance to use a delayed egress system. Therefore the preponderance of evidenced standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. As a result of facility not being in compliance with fire safety, civil penalties are assessed in the amount of $500. Exit interview conducted and a copy of the report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Mar 27, 2025 · control 59-AS-20250130152939

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Mar 28, 2025

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on file review the facility did not comply with the section cited above in not having an approved fire clearance to use delayed egress system.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Licensee is to continue working with fire to become in compliance. After which facility will request a new fire clearance with their LPA.

Type of visit: Required - 1 Year

On 02/05/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced at the facility to conduct a required 1-year annual inspection utilizing the CARE tool. LPA met with Executive Director (ED), Christal Anderson, (Administrator Certificate #7010318740 Exp. 02/02/2026) and explained the purpose of the visit. LPA and ED conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: ten(10) resident rooms, laundry room, kitchen, dining rooms, medication room and common areas. LPA observed residents in common areas with staff participating in activities. The residence was found to be clean, safe, sanitary and in good condition. LPA observed the facility to have the mandated posters posted. Fire extinguishers are maintained and ready for emergency use. Facility has required food supplies. There are appropriate staff present to meet the needs of residents. In areas toured, LPA did not observed any violation of health, safety and personal rights. LPA conducted a file review of ten (10) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. LPA reviewed ten (10) staff files. A review of staff files indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current training completed. As a result of todays inspection no deficiencies observed. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 5, 2025

Type of visit: Case Management - Incident

On 12/11/24 Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived at the facility unannounced to conduct a case management visit regarding a Death report that the department received on 12/05/24. LPAs met with Executive Director (ED) Christal Anderson and explained the purpose of the visit. The purpose of the visit is to gather more information regarding a death report Community Care Licensing (CCL) received on 12/05/24. LPAs spoke with the ED regarding the events leading up to R1s death. Death report states that the immediate cause of death is still pending. ED is awaiting Coroners report and will send LPAs a copy once received. LPAs obtained a copy of R1's LIC602, ID page, and hospice notes. At this time, no deficiencies are cited. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Dec 11, 2024

Type of visit: Case Management - Incident

On 09/04/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a case management visit regarding an absent without incident report the department received via fax on 08/26/24. LPA met with Executive Director (ED) Christal Anderson and explained the purpose of the visit. The incident occurred on 08/23/24 at approximately 11:35 AM facility staff observed R1 to be missing. Staff conducted a search throughout the community. Staff was unable to locate R1. Facility called 911, police conducted a search and found that R1 still owns a home in the area. R1 was located at their home and returned back to the community around 3:30 with no injuries. Facility was unaware that R1 has a home in the area. Based on R1's LIC602 Physician's Report, signed on 01/29/24, indicated that R1 was deemed unable to leave the facility unassisted. LPA and ED discussed how R1 has only been living at the facility for two months and staff are still learning about R1. R1 does have an appointment with their PCP tomorrow for a revaluation. R1 now has a wanderguard in place and has the project life saver tracker with the local police department. When R1 was brought back into the community they had apologized to staff and stated they did not know they could not leave the facility unassisted. Staff have been coming into work earlier to observe R1 to find any possible triggers. Additionally, facility is taking R1 on more outings in the community with other residents and staff. At this time, no deficiencies were cited during today's visit. Exit interview conducted and copy of the report left at the facility.the state’s words, verbatim · CDSS document, Sep 4, 2024

Allegation investigated: Facility staff are not changing residents in a timely manner Facility staff handle residents in a rough manner Facility staff do not provide adequate food service to residents Facility staff do not treat residents with dignity or respect

On 05/23/24, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to deliver final findings to a complaint the Department received on 04/10/24. LPA met with Dining Services Director, Mikah Montoya and explained the purpose of the visit. During the course of this investigation, the Department conducted interviews and obtained pertinent documents relevant to the investigation. Please continue to LIC 9099-C... Unfounded Facility staff are not changing residents in a timely manner. - Unfounded LPA conducted interviews with facility staff. Staff interviews indicated that residents’ incontinence needs are being met every two hours. On an average shift staff are assisting residents three (3) times per their shift and then as needed. For AM shift staff are assisting residents with their incontinent needs, staff generally assist residents after meals and snack times and as needed. For PM shift staff assist residents with their incontinent needs, staff check on residents in their rooms and assist them with incontinent needs after meals and snack time, before bed and as needed. Facility staff handle residents in a rough manner. - Unfounded LPA conducted interviews with facility staff and a facility observation was done to investigate this allegation. Interviews indicated there has been no witnessed issues with staff members handling residents in a rough manner. During LPA visit on 04/15/24 LPA conducted a tour of the facility. LPA observed staff to be engaging with residents and when assisting them it was in an appropriate manner. During the investigation process there was no information given indicating that facility staff handled residents in a rough manner. Facility staff do not provide adequate food service to residents. -Unfounded During the course of the investigation, LPA conducted interviews and obtained the facility menu. The facility is on a five (5) week menu cycle. Items within the menu changes depending on the time of year. If a resident has certain dietary needs, all kitchen staff are aware. Mealtimes are at 8AM, 12PM and 5PM. Snack times are at 10AM, 2PM and 8 PM. If residents are hungry during anytime between mealtimes or snack time, additional snacks are made available to residents. Additionally, interviews indicated there are some residents who need assistance with feeding. Staff will either fully assist those residents or do hand over hand. Interviews further revealed that sometimes residents will ask for something not on the menu. Kitchen staff will attempt to accommodate food requests. Facility staff do not treat residents with dignity or respect. -Unfounded LPA conducted interviews with facility staff. Interviews indicated there has been no witnessed issues with staff members treating residents without dignity and respect. During LPA visit on 04/15/24 LPA conducted a tour of the facility. While on the tour LPA observed facility staff to be attentive to residents needs and treating them with dignity and respect. LPA also observed some residents on the first floor to be engaged in a game at a table with a staff member. Based on information obtained through interviews, the Department finds the allegation to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, May 23, 2024 · control 59-AS-20240410144827

Type of visit: Required - 1 Year

On 01/25/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced at the facility to conduct a required 1-year annual inspection. LPA met with Executive Director (ED), Christal Anderson, (Administrator Certificate #6035240740 Exp. 02/02/24) and explained the purpose of the visit. Facility is licensed for 57 non-ambulatory residents, hospice waiver of 11. Facility currently has 47 residents, 11 on hospice services. LPA and ED conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: twelve (12) resident rooms, laundry room, kitchen, three dining rooms, Beauty Salon, Spa Room, medication room and common areas. LPA observed residents in common area with staff participating in activities. The residence was found to be clean, safe, sanitary and in good condition. LPA observed the facility to have the mandated posters posted. Fire extinguishers are maintained and ready for emergency use. Facility has required food supplies. There are appropriate staff present to meet the needs of residents. LPA conducted a file review of five (5) resident files and five (5) staff files. All files had the required documents. LPA also conducted four (4) staff interviews. In areas toured, LPA did not observed any violation of health, safety and personal rights. LPA completed the CARE tool and found the facility to be in compliance at this time. No deficiencies observed. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 25, 2024

Type of visit: Case Management - Incident

On 01/04/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a case management visit to follow up on the incident report the department received on 12/14/23. LPA met with Administrator, Christal Anderson, and explained the purpose of the visit. On 12/21/2023, LPA Ratajczak and LPA Yang conducted a visit regarding the reported incident of R1 allegedly being "kinda" slapped by caregiver. During the course of the department’s investigation on this matter, LPA interviewed five (5) staff, Executive Director and attempted contact with the reporting party of this incident. At this time, the Department has no concerns regarding this incident as there is insufficient evidence of the incident taking place. Today’s visit, no health and safety and personal rights violation observed. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Jan 4, 2024

Type of visit: Case Management - Incident

On 12/21/23 Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Cassie Yang arrived at the facility unannounced to conduct a case management visit regarding an incident report the department received on 12/14/23. LPAs met with Administrator, Christal Anderson, and explained the purpose of the visit. LPAs discussed the incident report which occurred on 12/12/23 regarding R1 being "kinda" slapped by S1. The incident was reported by S2 on 12/13/23 to Supervisor, Rae Ortiz. LPAs were informed that S1 is currently on administrative leave and S2 quit immediately. Based on interview with Administrator, facility followed the proper protocol with reporting the incident to Community Care Licensing (CCLD), Long Term Care Ombudsman (LTCO), and local law enforcement (LE). Administrator stated internal investigation conducted and determined no findings. Administrator stated as a safety precaution, S1 will not be returning to the facility until cleared by CCLD, LTCO, LE. At this time, this incident remains under review by the Department. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Dec 21, 2023