Bruceville Point

Type of visit: Case Management - Annual Continuation

On June 2, 2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct a case management visit to continue to annual inspection that was initiated on May 27, 2026. LPA met with Business Office Director, Breah Taylor (OD), and Event/Activity Director, Jaime Cervantes (EA), and stated the purpose of the visit. The Executive Director/Administrator, Marianne Richardson (AD), was unable to be present during this visit. Overview: Facility is a three-story building located in a residential neighborhood. Facility is licensed to serve up to 200 elderly residents, 150 of which may be non-ambulatory and 10 may be bedridden. Any unit on the first floor can be for bedridden use; any unit on the first and second floor may be for non-ambulatory use; and any unit on all three floors may be for ambulatory use. Delayed egress is cleared in the Memory Care area only. Facility has a current hospice waiver for 10 residents. Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident units, resident bathrooms, dining room and outdoor areas. LPA and AD inspected all three floors. Four resident units were inspected, three in Assisted Living and two in the Memory Care area. Each resident unit has its own bathroom. Per observation, bathrooms are equipped with non-skid flooring and grab bars. Faucet, toilet and shower are in working condition. Hot water temperatures were taken in resident bathrooms and were between 114 and 116 degrees Fahrenheit. Each unit has its own air and heater and can be controlled by residents. Hallway temperature was maintained at 72 degrees Fahrenheit throughout this visit. {1 of 2} In the kitchen/dining area, LPA observed at least 7-day nonperishable and 2-day perishable food items. Knives/sharps and cleaning chemicals were locked and not accessible. Fire extinguishers were observed throughout the hallways, on each floor, and in the kitchen. Smoke detectors and carbon monoxide detectors were observed throughout. Menu was observed to be posted. Residents with food allergies were written on a board. Refrigerator and Freezer temperatures were within regulatory standards. There are three dining rooms in the Assisted Living (AL) area and one dining room in the Memory Care (MC) area. Medication Room for the AL is located on the second floor and the MC has its own medication room. Outdoor area was inspected. Walkways were observed to be unobstructed. Fence and gate were in good repair at this time. There is a shaded area for outdoor activities. LPA observed outdoor furniture. Record Reviews: During this visit, LPA reviewed seven staff files, including review of background clearance, first aid/CPR certification, and training. Per review, Fire/Emergency Drill is being conducted at least quarterly and last drill was conducted on 5/12/26. Fire sprinkler system and fire alarms were tested on 3/10/26. Medication review will be conducted at a later visit. Interviews: Two resident interviewed and two staff interviewed. Documents Requested: LPA requested a copy of updated Liability Insurance LIC500, and LIC308. Per the California Code of Regulations, Title 22, Division 6, no deficiencies were cited. Exit interview was conducted with AD. A copy of the report was provided upon exit. {2 of 2}the state’s words, verbatim · CDSS document, Jun 2, 2026

Type of visit: Required - 1 Year

On May 27, 2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct the annual inspection visit. LPA met with Executive Director/Administrator, Marianne Richardson (AD) and stated the purpose of the visit. Overview: Facility is a three-story building located in a residential neighborhood. Facility is licensed to serve up to 200 elderly residents, 150 of which may be non-ambulatory and 10 may be bedridden. Any unit on the first floor can be for bedridden use; any unit on the first and second floor may be for non-ambulatory use; and any unit on all three floors may be for ambulatory use. Delayed egress is cleared in the Memory Care area only. Facility has a current hospice waiver for 10 residents. Record Review: Review of nine (9) resident files was conducted, including but not limited to, review of Admission Agreement, Physician Reports, Care Plans and Ambulatory Status. Facility does not have physical files. Their resident files have been digitized. The review was conducted via laptop. Based on today's visit, this annual inspection will require a continuation visit. The Department will return at a later date to continue the inspection. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 27, 2026

Allegation investigated: Facility staff did not dispense medications as prescribed

Licensing Program Analyst (LPA) Sommer Hayes and Licensing Program Manager (LPM) Stephen Richardson arrived at the facility to complete a complaint investigation regarding the allegation noted above. LPA and LPM met with Marianne Richardson, Executive Director and stated the purpose of this visit. LPA and LPM arrived to complete a complaint investigation for an allegation that facility staff failed to dispense medications as prescribed to former resident, Resident 1 (R1). The Reporting Party 1 (RP1) alleged that after the facility assumed responsibility for not administering R1’s medication Levothyroxine for one week, there were ongoing issues with medication availability, timeliness, and staff competency. RP1 reported difficulty obtaining PRN medications, concerns about staff responsiveness, and stated that R1’s laboratory values related to the missed medication, Levothyroxine became significantly elevated during the period of facility medication management. Continued on 9099C Substantiated LPA Hayes reviewed the facility’s Medication Administration Records (MAR) for March 2025 for R1. R1 was prescribed Levothyroxine SOD 0.175 MG, 1 tablet (175 MG) to be given daily at 5:00 AM. In a phone interview on 1/8/2026, with Executive Director (ED), Marianne Richardson, ED confirmed this medication was not given to the R1 on 3/11/2025, due to a medication delivery issue with Omnicare. On 1/9/2026, LPM Richardson reviewed a proof of medication delivery statement from Omnicare which indicates that Levothyroxine was shipped out on 3/10/2025 but was not delivered to the facility until 3/11/2025 at 1:47 PM. Due to the delay in delivering the medication timely to the facility, it caused R1 to not receive their dose of Levothyroxine on 3/11/2025 on time. LPA Hayes also reviewed the Medication Administration Records (MAR) for R1, dated 3/2025, and confirmed that the medication was marked as a missed medication. LPA Hayes interviewed multiple residents residing at the facility regarding their experiences with medication administration. Three of three residents who participated in the medication management program reported receiving their medications as scheduled and did not report missed, delayed, or incorrect medication administration. Community Director (DW1) reported that the facility uses an electronic medication administration system. They stated that medications are administered according to physician orders, that medication orders must be entered into the electronic system prior to administration, and that any gaps in medication are reported to the residents’ physician and family. Based on the review of records, interviews, and facility statements, the investigation determined that R1 did not receive Levothyroxine medication as prescribed on March 11, 2025. The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. This facility is being cited per Title 22 CCR Section 87465 (a)(4) being cited on the attached LIC 9099D. An exit interview, appeal rights and a copy of this report were left with Marianne Richardson, Executive Director.the state’s words, verbatim · CDSS document, Jan 9, 2026 · control 27-AS-20250724114324

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 10, 2026

87465 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 was not met as evidenced by: Based on interviews and resident records facility staff did not dispense medications as prescribed which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Jan 9, 2026

Plan of correction: Executive Director Marianne Richardson agrees to We will review our medication delivery process to ensure timely delivery. Retraining with Medication Techs with the fillings of prescriptions. Email sent to sommer.hayes@dss.ca.gov and stephen.richardson@dss.ca.gov

Type of visit: Case Management - Incident

On 7/31/25, Licensing Program Analysts Sommer Hayes and Arvin Villanueva (LPAs) arrived unannounced at this facility to conduct a case management visit. LPAs met with Executive Director/Administrator Eric Hostetter (S1) and stated the purpose of the visit. Overview: The purpose of this visit is to follow up on an incident that was reported on 5/1/2025. A resident (R1) reported to facility staff that a staff member (S2) pushed R1; and R1 also mentioned having a bruise on their left forearm. Facility staff reported the incident to local law enforcement and the Ombudsman about the incident. Facility Action: S1 and the Memory Care Director (S3) conducted an internal investigation, which included reviewing the Fall Detection System in R1's room. The review showed that R1 went up to S2 and then fell onto the bed, and then onto the floor. The system also showed that S2 helped R1 get back up. It was noted that S2 was taken off the schedule after this incident. When S1 and S3 were interviewed during the visit, they stated that the police had reviewed the Fall Detection footage and had no concerns. They also mentioned that S2 had not returned to work since the incident. Based on today’s visit, no deficiencies were cited. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 31, 2025

Type of visit: Required - 1 Year

On 5/22/2025, Licensing Program Analysts Arvin Villanueva and Sommer Hayes (LPAs) arrived at this facility unannounced to conduct their required annual inspection visit. LPAs met with Executive Director/Administrator Eric Hostetter (AD) and stated the purpose of the visit. This facility is currently approved to retain/accept 10 hospice residents and fire cleared to retain/accept 10 bedridden residents in the first floor only. The LPAs and ADM toured the facility to verify compliance with Title 22 regulations. The facility is a three-story building, with memory care located on the first floor. It has a capacity of 200 residents, serving independent living, assisted living and memory care. The LPAs inspected all three floors, activity rooms, dining rooms, theater room, salon, laundry room, elevator, stairwells and resident apartments/units. Second floor is where medication room is located, and medications were found to be securely stored, locked, and inaccessible to residents. 1 of 2 elevators was tested and found to be in good repair at this time. 1 of 4 stairwells were inspected and found to have evacuation chair. Per administrator, each stairwell is equipped with evacuation chair located in the third floor. LPAs observed 10 resident apartments/units (5 in Assisted Living and 5 in Memory Care) and were spacious enough to accommodate personal furnishings, and all observed units were clean, sanitary, and in good repair. Each resident unit had a smoke and carbon monoxide detector. In the Independent/Assisted Living area, each unit is equipped with their own washer and dryer. Each memory care units is equipped with electronic monitoring systems installed on the ceiling to detect falls and notify staff. Memory care also has delayed egress doors. One of the delayed egress doors was tested and found to be operable at this time. {1 of 2} The LPAs observed the kitchen area to be clean, sanitary and free of pests. The refrigerator, freezer, and pantry areas were observed to have an adequate food supply. Refrigerator and freezer were maintained within the regulatory temperature. The facility maintains a minimum of two days’ worth of perishable food and seven days’ worth of non-perishable food. All appliances were observed to be in working condition. The LPA reviewed the menu and activity calendar, and the Administrator confirmed that each resident is provided with a copy of both. During the visit, kitchen staff were preparing lunch. The LPAs observed a shaded area in the courtyard with tables and chairs, and the outdoor activity area is secure for residents. The outdoor passageways, walkways, driveways, and steps were free from obstructions and hazards. The facility does have a water fountain but it is not in use at this time. The facility has a generator to utilize during power outage. Water temperature in 2 resident units were measure between 114 and 115 degrees Fahrenheit. Room temperature in the hallways were measured between 72 and 73 degrees Fahrenheit. Review of 10 resident files (R1 - R9) which include review of Admission Agreement, Medical Assessment, Needs and Services Plan, and Ambulatory Status. No issues were noted at this time. LPAs did not conduct medication review during this visit. Facility does not manage resident cash resources at this time. Review of 10 staff files (S1 - S9) which include review of background clearance, First Aid and/or CPR, Health Screen, Initial and Ongoing Training. Per interview and record review, med tech staff are required to have current CPR certificate. No issues were noted at this time. Facility conducts quarterly disaster drill. Last drill was conducted on 5/21/25. Last fire inspection report was conducted on 3/7/24 to include tests on all manual pull stations and smoke detectors. Per report, test results passed. Facility has a dementia and infection control plan. Administrator provided the following documents during this visit: current Liability Insurance Certificate, LIC500 and LIC308 to the Department. No deficiencies are being cited at this time. Exit interview was conducted and a copy of this report were provided. {2 of 2}the state’s words, verbatim · CDSS document, May 22, 2025

Allegation investigated: Resident missed medications. Staff do not give resident medication timely. Resident being charged for services not rendered.

Licensing Program Analyst (LPA) Kimberly Viarella arrived unannounced to deliver complaint findings. LPA Viarella met with Eric Hostetter and explained the purpose of the visit. The investigation consisted of interviews with Staff 1 (S1), Staff 2 (S2), Resident 1 (R1), and a review of facility records. The following has been determined as it relates to the aforementioned allegations. On 01/23/25, LPA Christina Valerio interviewed facility staff. S1 informed LPA that residents are billed for extra charges if they purchase items outside of dinning hours from the bistro or bar and if they chose the option to get their meals to go. The facility charges $1 if a resident chose to have their meal for to-go rather than eat in the dining halls. The facility implemented this policy to create an incentive for residents to dine with others. Residents will also be charged for any alcohol that is purchased with their meal. S1 stated residents are charged a base rate for their room and can be charged service level fees and premium level fees. Those fees are dependent on a resident's assessment for care needs. Unfounded According to an interview with Staff 2, S2 reported if a resident did not get a medication, their Medication Administration System would have it documented in red and have a note explaining the reason for the missed medication. The reason for not receiving a medication could be refusal, a physician hold order, or the resident was not in the community. S2 recalls times where R1 requested medications from staff; however, could not receive the medication because R1 took the maximum dosage for the day or the time frame was outside the medication order window. S2 stated R1 is vocal and would tell the community if R1 was unhappy with services. On 01/23/2025, LPA Valerio interviewed Resident 1 (R1). R1 reported wanting to manage their own medications rather than having to have staff bring the medications. R1 stated R1 is working closely with S2, their primary care provider, and case manager regarding the timing of medications. R1 does not like not having control over the time to take medications. R1 did not disclose medications were not given to R1 or R1 missed any dosages. When asked about dinning charges, R1 confirmed understanding of the $1 charge. R1 mentioned that R1 felt odd telling staff R1 was sick over the phone and needed food delivered. R1 stated R1 will call the order in and pick it up to eat in the room. R1 stated R1 used to go to the hall before COVID, but without the same people, the dining hall is not the same. LPA Valerio reviewed facility records. Based on record review, R1 is considered independent and responsible for oneself. According to R1's invoice for December 2025, R1 was charged $1.00 forty-one times for utilizing the option to take meals back to the room rather than dinning. The invoice also displayed charges for Alcohol purchases, one-bedroom base rate, Care Plan Fees. According to R1's invoice for January 2025, charges were the same except there were no charges for to-go dinning. LPA Valerio compared the charges on the invoices with R1's Semi-Annual Assessment, and Admission Agreement. LPA Valerio also observed signed agreements between the resident and the facility regarding Fee increases, Meal Pricing, Increase for Base Rate Fees, New To-Go Surcharge, and New Transportation Guidelines. According to Medication Administration Records for December 2024 - January 2025, R1 was observed to receive all schedule medications within the prescribed order and observed to receive all PRNs requested by R1. Based on this information, the allegation is unfounded. A finding of unfounded means the allegation is false, could not have happened, or is without a reasonable basis. Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 27-AS-20250114162347

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management - incident visit. LPA Valerio met with front desk staff, and explained the purpose of the visit. LPA then met with Administrator Eric Hostetter. LPA Valerio and Administrator Eric discussed five (5) incident reports that were sent by the facility. Incidents included a few falls and an incident between two residents. Administrator Eric discussed the follow up care that has been provided to the residents and an update for each incident. LPA Valerio reviewed Unusual Incident Reports and supportive facility documentation. There were no health, safety, or personal rights violations noted. An exit interview was held, and a copy of this report was provided to Administrator E. Hostetter.the state’s words, verbatim · CDSS document, Apr 23, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA Valerio met with Administrator Eric, and explained the purpose of the visit. LPA Valerio and Administrator Eric toured the facility to ensure compliance with Title 22 regulations. Upon entry, visitors enter the main lobby and sign in with front desk staff. Residents utilize the desk to sign in and out for any outings. Hand sanitizer was available for use at the front and throughout the facility. LPA observed the common areas on the first floor, including the formal dinning area, cafe, bar/lounge area, library, and lobby seating areas, to be clean, free from debris, free from odors, and fully furnished. The memory care section of the facility has an entry key pad entry door. The facility delayed egress system was observed to be in working condition. Hot water was measured in a resident bathroom. The thermometer read 114.4 degrees Fahrenheit, which is within the regulatory range of 105.0 - 120.0 F. LPA observed three (3) staff and thirteen (13) residents. Residents were observed eating lunch or in their room during the time of the tour. Bedroom apartments were observed to be clean and free from odors. Sharps, cleaning supplies, and chemicals were observed to locked and inaccessible to residents in care. A first aid kit was observed in the medication room. The facility has a large commercial kitchen that prepares made-to-order meals and snacks for residents. Areas of the kitchen were observed to be clean, organized, and free from pests. Servers and kitchen staff were observed to be utilizing safe food handling procedures. The refrigerator, freezer, and pantry areas were observed to have an adequate food supply. All appliances were observed to be in working condition. LPA Valerio and Administrator Eric toured the Assisted Living/Independent areas of the facility. LPA observed resident apartments, which ranged from a studio, one bedroom, and one bedroom with a den. All bedrooms were observed to be clean and fully furnished. Continues on LIC 809 - C... Continued from LIC 809 LPA Valerio and Administrator Eric observed the theater room, physical therapy room, activity/craft room, physical activity/gym room, salon area, staff break room, and medication rooms. All rooms were observed to have sharps or any other harmful devices to be locked away and inaccessible to residents. Hand sanitizer, water stations, and unisex restrooms were observed to be available for the residents throughout the facility. Medication room was observed to be locked when staff were not present. LPA Valerio observed medication technician staff pass medications, which was observed to be in compliance. LPA observed staff to resident interactions. Interactions were observed to be engaging, positive, helpful, supportive, and friendly. Staff were observed assisting residents with meal service, greeting residents, assisting residents with multiple activities, cleaning the facility common areas, checking on the resident bedrooms, conducting medication pass, completing resident charting notes, assisting outside contractors with outdoor or indoor maintenance, and assisting with family or friend visits. The facility has completed emergency drills. The last fire drill was conducted with AM, PM, and NOC staff on 03/18/24 and 04/12/24. A facility wide evacuation training was conducted on 04/12/24. Fire extinguishers located around the facility were observed to be fully charged with an annual maintenance date of 11/29/2023. Fire extinguishers, fire alarms, and carbon monoxide detectors are regularly monitored by maintenance staff. The facility has an emergency supplies readily available, if necessary. LPA Valerio observed thirteen (13) resident files. Resident files were observed to be complete with updated assessments and resident information. Four (4) staff files were observed in addition to all staff in-service training. Staff files were observed to have up to date first aid certificates, training, fingerprint clearance, and necessary documentation. Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, no deficiencies were observed during today's visit. An exit interview was held, and a copy of this report was provided to Administrator Eric.the state’s words, verbatim · CDSS document, Apr 23, 2024

Allegation investigated: Resident was left unattended without staff supervision resulting in hospital visit

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA met with designated staff person Misty Veloz, and explained the purpose of the visit. The Department has determined the following as it relates the allegation of: Resident was left unattended without staff supervision resulting in hospital visit. The investigation consisted of interview with responsible parties, interview with facility staff, video recording review, and facility records review. On 11/06/23, LPA Valerio conducted a 10-Day Visit after being informed that Resident 1 (R1) had fallen on a Friday night and was not found by staff until Sunday morning. R1 did not have the call pendent on one's self to call for help. On Sunday morning, R1 was found to be dehydrated and had not eating or taken medications. R1 was taken to the hospital right away. Continues on LIC 9099 - C... Unsubstantiated Continued from LIC 9099 According to an interview with a responsible party (RP), the responsible party stated the facility informed the RP of the incident and immediately assisted the resident. The RP stated the facility corrected the issue and made adjustments to the care plan to ensure the incident with R1 does not happen again. LPA reviewed facility records. According to an incident report submitted by the facility on 09/27/23, R1 had an incident on 09/24/23. Housekeeping staff went to resident's apartment at 10:30 AM and R1 was found on the couch. R1 stated R1 did not feel well and housekeeping called for staff assistance. Resident told staff 3 (3) and staff 4 (S4) that R1 was having back pain and leg pain and had been on the couch since the night before (Saturday night). When Emergency Medical Support staff arrived R1 informed EMS staff that R1 has been on the couch since Friday Night. R1 was treated in the hospital for dehydration and impacted bowel. According to the incident report, Administrator Eric learned from R1's RP that R1 missed Saturday's AM/PM dose of medication. LPA reviewed facility records for R1. According to R1's LIC 602 Physician Report, R1 is considered an independent adult. R1 does not require continued bed care, is able to bathe, dress/groom, feed, and care for own toileting needs, able to administer own prescription medications, and able to store own medications. According R1's Needs and Service Plan, night-time checks utilizing the manual "flipper" door monitoring system is adequate for resident's current needs. Both the LIC 602 and Needs and Service Plan are signed by the RP and Facility Administrator. LPA interviewed staff. According to S1 and S2, R1 reported conflicting information as to when R1 had fallen. One moment R1 stated Saturday evening and the next moment it was reported Friday evening. S2 states that staff are good about checking on the resident's daily. S2 stated that the facility has implemented an extra step to the monitoring system by having staff initial stating they checked on each resident, even those who are considered independent. According to S3, S3 did not see R1 on Friday; however, did see R1's flipper down. S2 stated that the flipper down means that the resident opened their door that day. LPA Valerio reviewed video footage recordings provided by the facility. The facility has security cameras located in common areas of the facility. Continues on Page 3, LIC 9099 - C... Continued from Page 2, LIC 9099 - C Video footage revealed that on 09/22/23 22:45:03 - NOC staff, Staff 4(S4), is seen walking down the hallway. S4 flips up the flipper, which indicates that the flipper was down. On 09/23/23 11:11 AM - AM staff, S3, is seen walking down the hallway. S3 is seen walking up and down the hallway. On 09/23/23 22:29:00 NOC staff, S4, is seen walking down the hallway. S4 is seen going to the door of the resident; however, the camera does not catch whether or not the staff member opened the door or the flip was switched. The staff was in front of the door for less than 10 seconds. Due to the above noted information, 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, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held, and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, Dec 26, 2023 · control 27-AS-20231105181914

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management visit to follow up on an incident report submitted to the Department. LPA met with designated staff person Misty Veloz, and explained the purpose of the visit. On 12/12/23, The Department received an Unusual Incident/Injury Report submitted by Resident Services Director Misty Veloz. On 12/12/23, Resident 1 (R1) was found laying on the floor of the bathroom after R1's spouse altered staff via pull cord. R1 was sent to the hospital and received a diagnosis of a fractured hip. LPA requested additional information regarding R1 (LIC 602, Needs and Service Plan, Death Report, and any supportive documents) be sent to LPA Valerio. According to an interview with staff, R1 had previous health conditions and was on hospice prior to passing away. No deficiencies are being cited on today's visit. An exit interview was held, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 26, 2023