Carlton Senior Living Orangevale

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Allegation investigated: Staff do not prevent the spread of scabies.

On 7/21/26, Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to do complaint investigation for allegations listed above. LPA met with Administrator, Emanuel Dirar during today's visit and explained the purpose of the visit. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. Based on observation, record review, and statement reviewed, the facility was following universal precautions to address scabies cases at the facility. As a precaution, during the first sign of a rash of any resident, facility puts out PPE outside the resident room, notifies staff of the potential of scabies, and an in-service to staff is reviewed on proper hand washing and universal precautions. Facility encouraged residents to stay in their room during the episode. During the course of investigation, it was learnt that facility has two confirmed cases of scabies (one in April and one in June 2026) in memory care unit but no cases for staff due to this matter. Additionally, staff were reporting any unusual skin rash concerns for any resident with their doctors and following their recommendation for treatment. It was also noted that facility notified all scabies cases to Local Health Department and followed their guidelines to handle these cases. Local Health Department conducted facility visit due to this issue on 7/16/26 and there were no findings. Based on the information gathered, it was evaluated that facility took appropriate measures to address scabies cases for residents and there were no concerns, therefore, the allegation is Unsubstantiated. This agency has investigated this allegation, and it was concluded that it was Unsubstantiated.A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted. A copy of this report was left at the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 21, 2026 · control 59-AS-20260714110409

Allegation investigated: Staff do not prevent the spread of scabies.

On 7/8/26, Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to deliver complaint findings for allegations listed above. LPA met with Administrator,Emanuel Dirar during today's visit and explained the purpose of the visit. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. Based on observation, record review, and statement reviewed, the facility was following universal precautions to address scabies cases at the facility. As a precaution, during the first sign of a rash of any resident, facility puts out PPE outside the resident room, notifies staff of the potential of scabies, and an in-service to staff is reviewed on proper hand washing and universal precautions. Facility encouraged residents to stay in their room during the episode. During the course of investigation, it was learnt that facility has two confirmed cases of scabies (one in April and one in June 2026) in memory care unit but no cases for staff due to this matter. Additionally, staff were reporting any unusual skin rash concerns for any resident with their doctors and following their recommendation for treatment. It was also noted that facility notified all scabies cases to local health department and followed their guidelines to handle these cases. Based on the information gathered, it was evaluated that facility took appropriate measures to address scabies cases for residents and there were no concerns, therefore, the allegation is Unsubstantiated.This agency has investigated this allegation, and it was concluded that it was Unsubstantiated.A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted. A copy of this report was left at the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 8, 2026 · control 59-AS-20260617112643

Allegation investigated: Staff threatened resident.

On 7/8/26, Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to deliver complaint findings for allegations listed above. LPA met with Administrator,Emanuel Dirar during today's visit and explained the purpose of the visit. LPA Bains interviewed staff and residents during complaint investigation. Department investigated the stated allegation of this complaint. Department conducted a tour of the facility and conducted interviews with administrator, residents, and staff. Interviews did not indicate any residents, staff and/or witness observed that staff are threatening any residents in care. Department observed while doing facility tours that facility staff appeared to be attentive to resident’s needs and treating residents with dignity and respect. During residents’ interviews, residents stated that facility staff treat all residents with respect and dignity. Based on facility tours, interviews and observation, department found out that there is no evidence that resident (s) are being threatened by facility staff, therefore this allegation is found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted. A copy of this report has been provided to facility. Unfoundedthe state’s words, verbatim · CDSS document, Jul 8, 2026 · control 59-AS-20260608101821

Allegation investigated: Staff are not meeting residents needs.

On 7/8/26, Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to deliver complaint findings for allegations listed above. LPA met with Administrator,Emanuel Dirar during today's visit and explained the purpose of the visit. The department conducted record review, interviewed staff and residents to investigate this allegation. Some residents stated in interviews that when they need assistance, staff are available to assist them but sometimes there are delays in getting assistance as staff were assisting other residents with their care needs. Residents did not indicate there is an issue with staffing. Staff interviews indicated that the facility could use more staffing, but staff are still able to meet all the needs of the residents in care. Staff stated that sometimes staff call off, but management will try to bring in a substitute. Administrator stated that there was adequate staffing to meet residents’ needs and staff work overtime to meet the needs of the residents in care. This agency has investigated this allegation, and it was concluded that it was Unsubstantiated.A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted. A copy of this report was left at the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 8, 2026 · control 59-AS-20260529104210

Allegation investigated: Staff did not administer prescribed medication to a resident in care.

On 7/8/26, Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to deliver complaint findings for allegations listed above. LPA met with Administrator,Emanuel Dirar during today's visit and explained the purpose of the visit. The department conducted record review, interviewed staff and residents to investigate this allegation. Record review indicated that resident, R1 have scheduled colonoscopy for 5/14/26. Staff received instructions from R1s medical professionals regarding certain medications which need to be held due to the procedure. Staff failed to contact R1s ophthalmologist regarding R1s eye drops due to the procedure. Record review and staff interviews reflected that staff did not administer R1’s glaucoma medication (eye drops) on 5/14/26 without consulting R1’s ophthalmologist. Interview with resident, R1 indicated that staff held their glaucoma medication on 5/14/26 without permission from their Ophthalmologist.Based on the information gathered, the preponderance of evidence standards has been met, therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiency is being cited on the attached LIC 9099-D page. Exit interview conducted. Appeal rights and a copy of this report were provided. Substantiatedthe state’s words, verbatim · CDSS document, Jul 8, 2026 · control 59-AS-20260518125925

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80075(b)(5)(B) · Plan of correction due date: Jul 22, 2026

80075 -Health Related Services (b)(5)(B) - Once ordered by the physician the medication is given according to the physician's directions.... This requirement was not met as evidenced by: Based on incident report, staff interviews and medication record review from the facility, It was determined that staff did not administer eye drops to R1 which poses a potential health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2026

Plan of correction: Administrator agreed to submit a self certification for this regulation and will do training for all staff regarding medication administration and submit proof to LPA by POC date-7/22/26.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to conduct a case management visit. LPA met with Administrator Emanuel Dirar during today's inspection. Department followed up on Incident Report and SOC 341 sent by facility on 7/1/26 for date -6/27/26 regarding resident, R1 and two staff S1,S2. Facility notified law enforcement, long term care ombudsman (LTCO) and R1s responsible party regarding this incident. Department conducted interview with resident, R1 regarding this incident during today’s visit. LPA spoke with two staff S1,S2 regarding the incident. At this time, this case in under review and department will do follow up as needed. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, Jul 8, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with Administrator Emanuel Dirar during today's inspection. The department received an incident report concerning R1 sustaining an unwitnessed fall on June 17th. Resident was sent out to the hospital and returned back to the facility the same day. On June 18th resident continued to complain of pain and was sent out to the hospital again and was discharged to a skilled nursing facility with a hip fracture. PCP and family were notified. At the time of this visit no deficiencies were given. Exit interview and report provided.the state’s words, verbatim · CDSS document, Jul 1, 2026

Allegation investigated: Resident sustained injuries due to staff neglect/lack of supervision.

On 4/23/26, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced and met with Administrator, Emanuel Dirar to deliver complaint findings into allegations listed above. LPA explained the purpose of the visit upon arrival. Allegation- Resident sustained injuries due to staff neglect/lack of supervision. Unsubstantiated The department conducted records review, facility observations and interviews with residents and staff to investigate this allegation. Medical assessments and hospice notes reflected that resident, R1 was fall risk and exhibit agitated behaviors. Video footage showed that on 2/6/26 around 2:31AM, R1 opened the courtyard door and walked out and at 2:32 AM staff member followed R1 to redirect R1 back into the community. Shortly after the footage shows staff grabbing a wheelchair and escorting R1 back into the building. Also, facility reported this incident to all relevant parties and sought medical care for R1 as needed. Based on gathered information, it was evaluated that even R1 got injured from this incident, it was not due to lack of care and supervision from the staff, therefore, this allegation was Unsubstantiated. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted. A copy of this report was left at the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 23, 2026 · control 59-AS-20260211120241

Allegation investigated: Staff are mismanaging resident medication.

On 3/26/26, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced and met with Administrator, Emanuel Dirar to do complaint investigation into allegations listed above. LPA explained the purpose of the visit upon arrival. Throughout the course of the investigation, LPA interviewed staff and reviewed records. Additionally, LPA reviewed R1-R5 medications administration records (MARs), medications orders and staff notes. ALL MARs records were reviewed and found to be complete. MARs matched with current physician orders. Additionally, residents notes detailed communication with primary physicians regarding medications orders and administration. Facility was following Department’s guidelines regarding medications disposal and there were no issues identified. Based on LPA interviews and review of documentation, the preponderance of evidence standards was not met, therefore, the above allegation is found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted. A copy of this report was left at the facility. Unfoundedthe state’s words, verbatim · CDSS document, Mar 26, 2026 · control 59-AS-20260318165615

Allegation investigated: Staff do not ensure residents receive meal services. Staff do not ensure residents receive feeding assistance. Staff do not ensure residents incontinence care needs are being met. Staff do not ensure residents catheter care is being provided in a timely manner. Staff do not ensure residents receive adequate care with Hoyer transfers.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 3/26/26 to deliver complaint findings for above allegations. LPA met with Administrator, Emanuel Dirar and explained the purpose of the visit. The department conducted records review ,facility observations and interviews to investigate the complaint. **Report continued on LIC9099-C** Unfounded **Report continued from 9099..... Allegation- Staff do not ensure residents receive meal services. Staff do not ensure residents receive feeding assistance. UNFOUNDED An investigation has been conducted regarding the above allegations. LPA observed the facility food supply as well as interviewed four residents regarding the food service. Based on observation and interviews, the facility keeps the required amount of food supply in the facility. Additionally, four residents’ interviews indicated that residents are satisfied with the food service at the facility and there were no concerns. During the facility tour, LPA observed the food menu for residents in the common area. Three staff interviews reflected that residents were satisfied with meal services and residents can choose alternatives if they do not like the food items served in the regular menu. Furthermore, staff delivered food trays to those residents who were unable to go to the dining room and assist residents with feeding who require assistance without any problems. Based on this information, these allegations are UNFOUNDED. Allegation- Staff do not ensure residents incontinence care needs are being met. Staff do not ensure residents catheter care is being provided in a timely matter. UNFOUNDED Based on interviews conducted with three staff and four residents, as well as the review of facility records, including charting notes, staff schedules, and resident records, it has been determined that the facility is meeting the resident's ADL (Activities of Daily Living) needs as required. The interviews with both staff and residents indicated that care was being provided in a professional manner, and no concerns were expressed. Based on these investigations, it has been concluded that the facility has enough staff to meet the residents' needs. Staff and residents interviews did not reflect any concern regarding resident’s toileting and any other care needs including catheter care. Based on this information, these allegations are UNFOUNDED. Allegation- Staff do not ensure residents receive adequate care with Hoyer transfers. UNFOUNDED Department interviewed three staff and four residents during complaint investigation. Department has reviewed facility records, including charting notes, staff schedule and resident records. Interviews and record review indicated that facility was following resident's physician's orders while transferring them. Residents and staff interviews indicated that facility has all transferring equipment's such as hoyer lift, sit to stand lift to transfer residents and all equipment's were in good working condition without any issues. Furthermore, staff get proper training in timely manner regarding safe transfer techniques for residents and can ask any questions from management in case they have any questions or issues to address in this area; therefore, the above allegation is found to be UNFOUNDED. Based on the investigation, the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, Mar 26, 2026 · control 59-AS-20260204082328

Type of visit: Case Management - Incident

On 3/26/26, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 02/21/26 . LPA met with Administrator Emanuel Dirar and explained the reason for visit. Incident Report, IR (LIC 624) submitted by facility on 02/21/26 to CCL stated that resident, R1 was given wrong morning medications on 02/21/26. IR indicated that on 2/21/2026 at approximately 9:00 AM, staff made a medication error and administered medications intended for another resident to R1. The medications administered by error were Buspirone 5 mg tablet, Donepezil 10 mg tablet and Vitamin B12 1000 mcg tablet. Staff notified immediately of the facility’s management regarding the medication error. Facility notified R1’s physician, responsible party and other required agencies regarding this medication error. LPA was notified that R1 was doing fine at the facility as of today. Based on incident report, staff interviews and medication record review from the facility, It was determined that facility administered wrong medications to R1 which poses a immediate health and safety risks to residents in care. Deficiencies are cited on LIC809D, pursuant to California Code of Regulations, Title 22, Section 80075(b)(5)(B) and documented on the attached LIC809D. Civil penalties may be assessed if facility does not comply with POC requirements which were issued today. Immediate Civil penalty of $250.00 was assessed on LIC421FC today due to repeat violation of the same regulation within 12 months. The report was reviewed, appeal rights and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80075(b)(5)(B) · Plan of correction due date: Mar 27, 2026

80075 -Health Related Services (b)(5)(B) - Once ordered by the physician the medication is given according to the physician's directions.... This requirement was not met as evidenced by: Based on incident report, staff interviews and medication record review from the facility, It was determined that facility administered wrong medications to R1 which poses a immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2026

Plan of correction: Administrator agreed to submit a self certification for this regulation and will do training for all staff regarding medication administration and submit proof to LPA by POC date-3/27/26. Furthermore, facility shall conduct medications administration training monthly till June 2026 and will send proof to LPA. Immediate Civil penalty of $250.00 was assessed today.

Type of visit: Case Management - Incident

On 3/26/26, Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to conduct a case management visit. LPA met with Administrator,Emanuel Dirar and explained purpose of inspection. The Department conducted a case management visit to follow up on the death of R1. The department conducted an investigation which found that R1’s death was determined to be from natural causes. Based on the information obtained, R1’s death was not due to negligent from the facility therefore no citations will be issued due to this incident. Exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 26, 2026

Allegation investigated: Resident sexually assaulting residents in care.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 2/18/26 to deliver complaint findings for above allegations. LPA met with Administrator, Emanuel Dirar and explained the purpose of the visit. Allegation- Resident sexually assaulting residents in care. UNFOUNDED. The Department conducted records review, interviews with staff and residents to investigate this allegation. Staff and interviews reflected that they were not aware of any such incident. Record review did not indicate that resident, R1 was sexually assaulted any residents. Based on gathered information, this allegation was Based on the investigation, the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted. A copy of this report has been provided to facility.UNFOUNDED. Unfounded **Report continued from 9099-A...... Allegation - Resident inappropriately touching staff. Unsubstantiated The Department conducted records review, interviews with staff and residents to investigate this allegation. Residents and staff interviews reflected that resident, R1 has dementia with behaviors and R1 can be challenging sometimes with other individuals but staff are able to redirect them in safe and professional manner. Facility was continually working with R1s physicians and family to manage R1s behaviors with adjustments in their medications and other possible ways. Additionally, facility provided the required training's to staff regarding working with dementia residents on on-going basis and providing adequate staffing to take care of R1 and other residents. Based on this information, these allegations were found to be Unsubstantiated means Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation(s) occurred. Allegation - Facility is not meeting reporting requirements. Unsubstantiated. During complaint investigation, it was evaluated from record review and from staff interviews that facility was reporting all reportable incidents to department per Reporting Guidelines. It was learnt that there were incidents where resident, R1 was exhibiting challenging behaviors while staff were assisting them with their care needs, but staff were able to manage R1s care needs and able to redirect them when needed. There was insufficient information available regarding any incidents which were not reported to the department. Based on gathered information, this allegation was Unsubstantiated. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No citations were issued today per CCR, Title 22 Regulations. Exit meeting conducted with administrator. A copy of this report has been provided to the facility.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 59-AS-20251226092941

Allegation investigated: Staff mishandled a resident's medications. Staff did not follow the orders of a licensed physician.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 2/18/26 to deliver complaint findings for above allegations. LPA met with Administrator, Emanuel Dirar and explained the purpose of the visit. The department conducted records review ,facility observations and interviews to investigate the complaint. **Report continued on LIC9099-C** Unfounded **Report continued from 9099..... Allegation- Staff mishandled a resident's medications. Staff did not follow the orders of a licensed physician. Based on the information provided, the investigation conducted by the department involved facility observations, record review, and interviews with staff and residents to investigate the complaint allegation. During these interviews with three (3) staff and three (3) residents, it was revealed that the facility dispensed all residents' medications on time and administered them as scheduled. Residents’ interviews indicated that staff were assisting them with their medications without any issues. Furthermore, a review of the records for the month of October 2025, indicated that the facility maintained proper logs for all medications in the centrally stored medication log, following physician's orders, and documenting them in the Medication Administration Record (MAR) without any errors. Staff interviews reflected that residents were given medications on time per their physician’s orders and there were no problems to address. R1’s hospice agency staff’s interviews indicated that there were no concerns regarding facility staff’s care or medications management related to R1. Based on these findings, this allegation is considered UNFOUNDED. Based on the investigation, the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 59-AS-20251208112753

Allegation investigated: Facility did not safeguard resident's wedding ring.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 2/9/26 to deliver complaint findings for above allegations. LPA met with Administrator, Emanuel Dirar and explained the purpose of the visit. The department conducted record review, interviews with residents, staff and other relevant parties regarding this allegation. It was learnt that resident, R1 resides in the memory care unit at the facility, and it was noted that R1 was wearing their ring around 11/12/25 and noted to be missing ring between 11/13/25 till 11/20/25 by staff and R1s family. R1s record review and interviews with residents, staff and relevant did not provide information as to how the ring went missing. Department was notified by facility administrator that facility and R1s family came into agreement as facility will acknowledge original value of ring and will credit towards monthly charges towards R1’s facility account. Although the facility reimbursed R1 for the value of the missing ring, there is insufficient information that the facility failed to safeguard R1’s property therefore the allegation is UNSUBSTANIATED. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No citations were issued today per CCR, Title 22 Regulations. Exit meeting conducted with administrator. A copy of this report has been provided to the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 9, 2026 · control 59-AS-20251205112949

Type of visit: Required - 1 Year

On 10/09/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to conduct a required 1 year inspection utilizing the care tool. LPA met with Administrator Emanuel Dirar and explained the purpose of the visit. LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to residents bedrooms, kitchen, bathrooms, dining room, common areas, storage area, and laundry area. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Hot water temperature was measured at 116 degrees Fahrenheit , which is within the required range of 105 to 120 degrees. The temperature in the facility was 73-74 degrees. First aid kit was completed. LPA observed fire detectors and carbon monoxide detectors to be operable. LPA observed the fire extinguisher, located in common areas which were ready for emergency use. LPA reviewed fire and disaster drill logs, which are conducted quarterly. LPA observed required Licensing posters posted throughout the facility. LPA conducted a file review of five (5) staff and eight (8) residents records. Residents and staff records were found to be complete. Medications are centrally stored, locked, and were inaccessible to residents. No deficiencies were observed or cited from this inspection per Title 22 Regulations. Exit interview was conducted and copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Oct 9, 2025

Type of visit: Case Management - Incident

On 10/09/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding incidents related to resident, R1. LPA met with Administrator Emanuel Dirar and explained the reason for visit. Incident Report (LIC 624) submitted by facility on 09/27/25 to CCL stated that R1 had a fall on 9/11/25 was sent out to local hospital and diagnosed with fracture of 5th metacarpal. R1 returned to the facility presented with increased confusion and pain when standing. R1s primary care physician (PCP) advised for resident to be sent out for further evaluation on 9/19/25. Staff sent out R1 to hospital per PCP directions. It was learnt that R1 was sent to skilled nursing facility for rehab services per their PCP’s orders and R1 did not return to facility as of today. Based on incident report, staff interviews and record review from the facility, it was determined that facility did not report R1s fall and injury related incident from 09/11/25 in timely manner to CCL as required per Reporting Requirements. Based on gathered information, deficiencies are cited pursuant to California Code of Regulations, Title 22, Section 87211 and documented on the attached LIC809D. Civil penalties may be assessed if facility does not comply with POC requirements which were issued today. Exit interview was conducted, copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 9, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 23, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including... (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... (D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Based on record review and staff interviews, it was concluded that resident, R1 had a fall with injury on 09/11/25 but an incident report was not submitted within required time frame , which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Oct 9, 2025

Plan of correction: Licensee/ Administrator shall review CCR Regulation 87211and shall submit a statement of understanding of the regulation to LPA via email. Facility should train staff and implement a plan how facility shall meet reporting requirements . POC due date is 10/23/25.

Allegation investigated: Staff are not properly addressing pest infestation in the facility. Staff are not practicing proper hand washing procedures. Facility kitchen is not kept clean and orderly.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 08/28/25 to deliver complaint findings for above allegations. LPA met with Administrator, Emanuel Dirar and explained the purpose of the visit. The department conducted records review ,facility observations and interviews to investigate the complaint. **Report continued on LIC9099-C** Unfounded ***Report continued from 9099...... Allegation- Staff are not properly addressing pest infestation in the facility.-UNFOUNDED Based on documents obtained and statements reviewed, the department determined that there was insufficient evidence that the facility is not kept free of pests. The facility representative stated that the pest control company comes in monthly, and more often as needed. The department reviewed Pest Control dates for the monthly visits for 2025 which did not indicate any concerns. It was stated that the Pest Control company just visited the facility over a week ago and sprayed the exterior and interior of the building. The pest control company is continuing to monitor any pest activity. Five (5) staff and five (5) residents were interviewed and stated they have not seen any pests at the facility. During the department visits, the facility was toured and there were no concerns that were noted about this area. Therefore, the above allegation is UNFOUNDED. Allegation- Staff are not practicing proper hand washing procedures. -UNFOUNDED The Department conducted record review, interviewed five residents and five staff members to investigate this allegation. Staff interviews reflected that facility are following infection control guidelines including proper hand washing and there were no issues to report. Resident’s interviews indicated that the facility was complaint with infection control guidelines, and they were satisfied with staff’s care at the facility. Staff interviews also reflected that staff were getting the required training and in-services per department’s directions for infection control and other required topics and there were no concerns. Based on these findings, this allegation is considered UNFOUNDED. Allegation- Facility kitchen is not kept clean and orderly. -UNFOUNDED The department toured the facility during the investigation which included resident’s rooms , bathrooms, kitchen, dining area and other areas in the facility and did not observe any concern regarding cleanliness. LPA reviewed documents pertinent to the investigation which indicated that residents’ rooms are being cleaned and maintained by staff. LPA reviewed work orders placed at the facility for maintenance like carpet and floor cleanings which indicated staff and maintenance teams were cleaning on a regular basis to keep the facility and resident rooms and other areas clean and sanitized. Five staff and five resident’s interviews did not reflect any concerns that the facility was not kept clean and orderly. Based on the information gathered, this allegation was found to be UNFOUNDED. Based on the investigation, the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 59-AS-20250804120930

Allegation investigated: Staff failed to provide care to meet resident's care and toileting needs. Facility did not provide clean linens and clothing to resident. Facility did not provide adequate meal service to resident.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 08/28/25 to deliver complaint findings for above allegations. LPA met with Administrator, Emanuel Dirar and explained the purpose of the visit. The department conducted records review ,facility observations and interviews to investigate the complaint. **Report continued on LIC9099-C** Unfounded **Report continued from 9099.... Allegation- Staff failed to provide care to meet resident's care and toileting needs.-UNFOUNDED Based on interviews conducted with five staff and five residents, as well as the review of facility records, including charting notes, staff schedules, and resident records, it has been determined that the facility is meeting the resident's ADL (Activities of Daily Living) needs as required. The interviews with both staff and residents indicated that care was being provided in a professional manner, and no concerns were expressed. Based on these investigations, it has been concluded that the facility has enough staff to meet the residents' needs. During the department's visits, it was observed that the residents’ needs were being met. Based on the investigation, the allegation made against the facility is found to be UNFOUNDED. Allegation- Facility did not provide clean linens and clothing to resident.-UNFOUNDED The Department conducted record reviews, facility observations, five staff and five residents interviews to investigate complaint allegations. During the Department visit on 08/06/25, LPA Bains observed that the facility has adequate linen supplies and clothing for all residents. Staff interviews indicated that there was no linen shortage at the facility and things were fine with linen supplies and usage. Resident’s interviews did not indicate any concerns in this area and expressed their satisfaction with clean linen supplies. Based on this information, this allegation was found to be Unfounded. Allegation- Facility did not provide adequate meal service to resident.-UNFOUNDED An investigation has been conducted regarding the above allegations. LPA observed the facility food supply as well as interviewed four residents regarding the food service. Based on observation and interviews, the facility keeps the required amount of food supply in the facility. Additionally, five residents’ interviews indicated that residents are satisfied with the food service at the facility and feel that they have enough food to eat at every meal. During the facility tour, LPA observed the food menu for residents in the common area. Five staff interviews reflected that residents were satisfied with meal services and residents can choose alternatives if they do not like the food items served in the regular menu. Furthermore, staff delivered food trays to those residents who were unable to go to the dining room during mealtimes. Based on this information, this allegation is UNFOUNDED. Based on the investigation, the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 59-AS-20250805143935

Type of visit: Case Management - Incident

On 08/06/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 07/25/25. LPA met with Administrator, Emanuel Dirar and explained the reason for visit. Incident Report (LIC 624) submitted by facility on 08/04/25 to CCL stated that resident, R1 was sent to hospital on 07/25/25 , after R1 was given the wrong insulin dose by staff. The incident report indicated that R1 was given wrong insulin dose around 11AM on 07/25/25. Staff notified immediately of the facility’s management regarding the medication error and facility send out R1 to hospital to seek medical care. R1 came back to the facility on 07/25/25. Facility notified R1s physician and the responsible party regarding medication error. LPA was notified by administrator that the facility took appropriate action with staff regarding this incident according to the facility policy who was associated with this incident . Based on incident report, staff interviews and medication record review from the facility, It was determined that facility administered wrong medication to R1 which poses a immediate heath and safety risks to residents in care. Deficiencies are cited on LIC809D, pursuant to California Code of Regulations, Title 22, Section 80075(b)(5)(B) and documented on the attached LIC809D. Civil penalties may be assessed if facility does not comply with POC requirements which were issued today. The report was reviewed, appeal rights and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Aug 6, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80075(b)(5)(B) · Plan of correction due date: Aug 7, 2025

80075 -Health Related Services (b)(5)(B) - Once ordered by the physician the medication is given according to the physician's directions.... This requirement was not met as evidenced by: Based on record review from the facility, it was observed that on 07/25/25, resident, R1 was given wrong insulin dose by staff which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Administrator agreed to submit a self certification for this regulation and will do training for all staff regarding medication administration and submit proof to LPA by POC date- 08/07/25.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 04/03/25 to do case management visit . LPA met with Administrator, Emanuel Dirar and explained the purpose of the visit. Incident for Resident, R1- Department followed up on SOC 341 sent by facility on 04/02/25 stating resident (R1) reported to the management on 04/02/25 that staff, S1 were unprofessional and physically abusive to resident, R1 during morning shift on 03/21/25. Facility notified R1s physician, LTCO ,law enforcement and responsible party regarding this incident. Facility Nurse checked R1 for any injurers on 04/02/25 and none were present. SOC341 also indicating that during facility’s internal investigation, S1 denied any wrongdoings and provided their written statement. LPA learnt that S1 was on administrative leave at this time due to this incident. Department conducted interviews with four residents and three staff members during today's visit. LPA requested incident related documents and facility shall send all requested information via email by 04/07/25 (Monday) by 9AM. At this time, this incident is under review and department will do follow up if warranted. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, Apr 3, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 03/27/25 to do case management visit . LPA met with Executive Assistant, Ellaina Canady and explained the purpose of the visit. Incident for Resident, R1- Department followed up on SOC 341 sent by facility on 03/25/25 stating staff (S1) reported to the management on 03/20/25 around 6 pm that S1 witnessed that staff S2 and S3 were rough and verbally abusive to resident, R1 while S2 and S3 were providing care to R1 during morning shift on 03/20/25. Facility notified R1s physician, LTCO and responsible party regarding this incident. Facility Nurse checked R1 for any injurers on 03/21/25 morning and none were present. SOC341 also indicating that during facility’s internal investigation, S2 ad S3 denied any wrongdoings and provided their written statements however S1 resigned from their position. Department conducted interviews with resident ,R1 and staff (S2,S3, S4) during today's visit. At this time, this incident is under review and department will do follow up if warranted. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, Mar 27, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Talwinder Bains arrived on 11/12/24 to conduct the annual inspection. LPA met with administrator, Miriam Faris and explained the purpose of today's visit. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed medications of five (5) residents comparing with physician orders and find no errors. LPA reviewed five (5) residents and five (5) staff files and found all required documents. LPA and administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguishers were last serviced on 11/27/23 and were ready for emergency use. Hot water temperature was observed to be 110-112 degrees F, which is within the regulation range of 105-120 degree. Inside temperature was 72-74 degree F. Facility was clean and well organized. All required postings were observed. Facility is conducting quarterly fire and disaster drill as required. No deficiencies were observed or cited per Title 22, CCR Regulations during this visit. Exit interview conducted and copy of this report was provided to administrator.the state’s words, verbatim · CDSS document, Nov 12, 2024

Allegation investigated: Facility did not follow resident's contract. Facility is serving food to residents that is not of quality. Facility did not issue a refund to a resident in care.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 07/31/24 to deliver complaint findings for above allegations. LPA met with Executive Assistant, Ellaina Canady and explained the purpose of the visit. The department conducted records review ,facility observations and interviews to investigate the complaint. **Report continued on LIC9099-C** Unfounded **Report continued from 9099.... Allegation- Facility did not follow resident's contract. Facility did not issue a refund to a resident in care.-UNFOUNDED The Department conducted record review, facility’s observations, staff and resident’s interviews to investigate these allegations. Record review indicated that resident, R1 moved in to the facility on 05/09/24 and the admission agreement was signed by facility Administrator, Miriam Faris and R1s responsible party (RP) on 05/07/24. Per admission agreement, monthly charges were agreed at $6695/monthly. RP paid $5062.55 (prorated rate for May 2024) and full month payment of $6695 for June 2024. It was also noted that per signed admissions agreement, RP was required to provide a 30 days notice to move out of the facility. R1 moved out of the facility on 06/16/24. RP gave 30 days notice to facility on 06/20/24. Four (4) Staff interviews conducted on 07/18/24 indicated that R1s care needs were providing per their Needs and Service plan. From all this gathered information, it has been concluded that RP did not provide 30 days ‘move out’ notice for R1 per admission agreement, therefore the facility does not owe a refund to R1 and RP. Additionally, facility staff followed R1s care needs based on R1’s need and service plan. Based on all this information, these allegations were found to be UNFOUNDED. Allegation- Facility is serving food to residents that is not of quality. UNFOUNDED The Department conducted record review, facility’s observations, staff, and resident’s interviews to investigate these allegations. During facility observation on 07/18/24, it was observed during meal service that facility was providing quality food to residents and staff were supportive to resident’s dietary needs. Record review indicated that facility provides choice of different foods with daily menu and substitute /alternate items are also available during meals. Four (4) Staff interviews conducted on 07/18/24 indicated that facility was meets residents dietary needs and offer quality food on daily basis. Four (4) residents interviews conducted on 07/18/24 reflected that facility’s meal services were fine and they enjoy their daily meals. Residents expressed their satisfaction with quality of the food that is served and did not report any concerns. Based on gathered information, this allegation was found to be UNFOUNDED. Based on the investigation, the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, Jul 31, 2024 · control 59-AS-20240715093209

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 07/31/2024 to conduct a case management visit and met with Executive Assistant, Ellaina Canady and explained the purpose of the visit. The facility submitted a completed Unusual Incident/Injury Report (LIC624) on/around 07/22/24 regarding 1 missing bottle out of 3 bottles of Oxycodone (narcotic) for resident, R1 (hospice care) during pm med count on 07/20/24. IR stated that, on 7/20/24 Med Manager notified ED that during PM narcotic count a bottle of oxycodone was missing for R1, Prior to 2pm count on 07/20/24, R1 had 3 bottles of oxycodone. Sacramento County Sheriff’s Department was notified on 07/22/24 regarding this incident. Facility also notified CCLD, R1s physician, responsible party, hospice agency and other agencies as required. Facility launched their internal investigation and did the through search for this missing medication. During today's visit LPA interviewed 2 staff members and requested documents related to incident which facility will send to LPA via email by 08/02/24. This case is under review and Department will follow up as warranted. 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, Jul 31, 2024

Allegation investigated: Facility staff did not safeguard resident's belongings.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 05/29/24 to deliver complaint findings for above allegation. LPA met with Executive Assistant, Ellaina Canady and explained the purpose of the visit. The department conducted records review ,facility observations and interviews to investigate the complaint. **Report continued on LIC9099-C** Unfounded ***Report continued from 9099..... Allegation- Facility staff did not safeguard resident's belongings ---Unfounded The Department conducted (4) four staff (4) four residents’ interviews, facility’s observations, and record review to investigate this allegation. From the records review, it has been revealed that the facility has a record of some of R1’s personal belongings which is documented on the R1’s Inventory Form and located in R1’s facility file. R1 did not list anything in that form and refused to list their personal belongings upon admission dated 04/29/22. R1 was discharged from the facility on 01/09/24. During the department facility visit, facility was able to find some of the missing items for R1 as listed in the complaint. R1 was contacted to make arrangements to pick up items from facility. Four (4) Residents interviews indicated that there were no issues with their personal belongings and facility is safeguarding them. Four (4) Staff interviews indicated that they were no issues with resident’s personal belongings and staff assist residents if they were missing any items to locate them or report to their managers if needed. Based on all this information, this allegation is found to be Unfounded. Based on the investigation, the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, May 29, 2024 · control 59-AS-20240502105253

Allegation investigated: Staff mismanaged resident medication.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 03/07/24 to deliver complaint findings for above allegation. LPA met with administrator Miriam Faris and explained the purpose of the visit. The department conducted records review ,facility observations and interviews to investigate the complaint. **Report continued on LIC9099-C** Unsubstantiated **Report continued from 9099...... Allegation- Staff mismanaged resident medication. Based on the department's investigation, including facility observations, record review, and interviews with staff and residents, it has been concluded that the allegation made against the facility regarding medication administration is unsubstantiated. The interviews with both staff and residents indicated that medications were being given to resident, R1 on time, and the facility maintained proper logs and documentation for all medications according to physician's orders. Residents interviews confirmed that they were receiving their scheduled medications in a timely manner, and the staff were not mismanaging their medications. Therefore, the allegation is determined to be without basis or evidence and is therefore considered Unsubstantiated. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No citations were issued today per CCR, Title 22 Regulations. . Exit meeting conducted with administrator. A copy of this report has been provided to the facility.the state’s words, verbatim · CDSS document, Mar 7, 2024 · control 59-AS-20240206091615