Knolls West Assisted Living

Type of visit: Required - 1 Year

On 6/04/2026 at 09:05 AM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Assistant Administrator (AA) Janeth Gonzalez and was granted entry to the facility. The facility is a thirty two (32) bedrooms with thirty two (32) bathroom facility with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of sixty four (64) non-ambulatory and seventeen (17) hospice care and the current census is fifty four (54) residents. LPA was accompanied by AA to conduct a general overall inspection, which included, but was not limited to the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathroom to be at 111 degrees F at Room #20 113.3 degrees F at room#3 and 109 degrees F at room #18 . The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire alarms was serviced by TRL system on 5/30/2026. Seven (7) fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, labor laws, and the disaster plan were posted in a common area. LPA observed that the emergency phone numbers are not posted in a location visible for both staff and resident. Technical violation issued. ***Continuation in LIC809C *** Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Room with the resident’s medications locked. LPA observed complete first aid kit at the facility. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. Care & Supervision: The facility has an Assistant Administrator present in the facility with enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care. Record Review: LPA reviewed four (4) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA observed resident files reviewed were complete. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that staff #3(S3) do not have an updated CPR. Deficiency issued. Medications/Medication Administration Record (MAR) were audited, no issues observed. Based on the observations made during today’s visit, one (1) deficiency and a technical violation were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report LIC809, LIC809C, LIC809D, LIC9102 forms and Appeal rights were discussed and provided to Assistant Administrator Janeth Gonzalez.the state’s words, verbatim · CDSS document, Jun 4, 2026

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On 5/4/2026 at 11:15 AM, Licensing Program Analyst (LPA) Eldin Serrano conducted an unannounced case management visit to the facility to follow up on Client #1 (C1)'s death which occurred on 4/29/2026. LPA met with the Assistant Administrator Janeth Gonzalez. LPA spoke with the Assistant Administrator Janeth Gonzalez to obtain additional information regarding the death. LPA reviewed C1’s facility file. LPA requested copies of the following documents: Client ID/emergency information, admission's agreement, physician's report, client care plan/individual services and support plan, centrally stored medication log, and special incident report/death report. The Department is requesting a copy of C1's death certificate and police report once it becomes available. Further investigation may be required depending on the cause of death. No deficiencies were cited during the visit. An exit interview was conducted where this report was discussed and provided to Assistant Administrator Janeth Gonzalez.the state’s words, verbatim · CDSS document, May 4, 2026

Type of visit: Case Management - Other

On 5/4/2026 Licensing Program Analyst (LPA) Eldin Serrano arrived to the facility to deliver findings on an amended report (LIC 9099) regarding complaint control number 56-AS-20260403115257the state’s words, verbatim · CDSS document, May 4, 2026

Allegation investigated: Staff do not respond to residents' requests for assistance. Staff are not following universal precautions to prevent the spread of infectious disease. Staff do not treat residents with respect.

***This is an amendment**** On 4/13/2026 at 9:20 AM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to amend and deliver the findings of the above allegations. LPA Serrano met with Assistant Administrator Janeth Gonzalez to explain the purpose of the visit. The investigation consisted of file review, interviews with facility staff and residents as well as facility observation. Allegation #1: Staff do not respond to residents' requests for assistance. – Based on interviews with staff and residents, all of them confirmed that staff respond to residents’ requests for assistance in a timely manner when they pull the call light button. The allegation cannot be substantiated. *** Continuation in LIC9099C *** Unsubstantiated Allegation #2: Staff are not following universal precautions to prevent the spread of infectious disease. - Based on interviews with residents and staff, all parties reported that universal precautions were consistently followed to prevent the spread of infectious diseases. Resident #1 (R1) was evaluated by an external provider, who determined that R1 had shingles after another resident had already been placed in the same room. Facility staff are not medical professionals and relied on external assessments. Both residents are under quarantine. The allegation cannot be substantiated. Allegation #3: Staff do not treat residents with respect. – Interviews with staff and residents indicated that staff treat residents respectfully. When behavioral issues arise, staff use communication and redirection techniques to de-escalate the situation. There was no evidence that residents were placed in time-out for inappropriate behavior. Therefore, this allegation is unsubstantiated. Information received during investigation LPA did not find evidence to corroborate the allegations. Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where this report, LIC9099 and LIC9099C were discussed and provided to Janeth Gonzalez.the state’s words, verbatim · CDSS document, Apr 13, 2026 · control 56-AS-20260403115257

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(6) · Plan of correction due date: Apr 20, 2026

Title 22, Division 6 Chapter 8 Article 08 87465 Incidental Medical and Dental Care (6)When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidence by: Based on LPAs observations, record review the facility did not comply with the section cited above by not ensuring that the medication records were accurately maintained by staff when compared to medication given, which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 13, 2026

Plan of correction: The Licensee shall retrain staff on medication management training conducted by a medical professional. Training documentation shall include the name of the trainer, names of staff with signatures, that attended the training.

Allegation investigated: Residents sustained multiple bedsores due to staff neglect Facility staff did not meet residents’ hygiene needs Facility staff did not ensure residents had clean bed linens Facility staff did not ensure residents had clean clothing Facility staff did not meet residents’ grooming needs Facility staff served residents food of poor quality Facility staff withheld food from residents Facility staff were not trained on procedures regarding medications before dispensing medications Facility staff spoke inappropriately to residents

On 02/23/2026 at 9:40AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility to deliver findings for the above allegations. LPA met with Assistant Admnistrator, Janeth Gonzalez, introduced self and stated the purpose of the visit. It is alleged that residents sustained multiple bedsores due to staff neglect. LPA conducted interviews with residents and staff. Resident 1 (R1) no longer resides at the facility and was unable to be interviewed. Record review confirmed R1 left the facility on 01.23/2024. LPA interviewed a relative of R1 who stated that they did not have any concerns with the care that was provided to R1 and denied the allegation. Interviews with staff revealed they currently have no residents with bedsores. Based on interviews conducted with the relative of R1 and staff, and a review of records, the allegation is UNSUBSTANTIATED. It is alleged that facility staff did not meet residents' hygiene needs. LPA conducted interviews with residents and staff. Residents stated that staff assist them with their hygiene needs when needed and denied that staff do not meet their hygiene needs. LPA interviewed staff and staff denied the allegation. Based on interviews Unsubstantiated conducted with residents and staff, this allegation is UNSUBSTANTIATED. It is alleged that facility staff did not ensure residents had clean bed linens. LPA observed a sufficient amount of clean bed linens in the storage room. LPA conducted a tour of resident bedrooms and observed clean linen on each of their beds. LPA interviewed staff and staff denied the allegation. LPA interviewed residents and residents denied the allegation. It is alleged that facility staff did not ensure residents had clean clothing. LPA observed residents clothing to be clean and in good condition. LPA interviewed staff and staff denied the allegation, stating that residents' clothes are changed when appropriate. LPA interviewed residents and residents denied the allegation. Based on observation and interview, the allegation is UNSUBSTANTIATED. It is alleged that facility staff did not meet residents' grooming needs. LPA interviewed residents and residents stated that staff assist with their grooming needs. Residents denied the allegation. LPA interviewed staff and staff stated that residents are assisted with their needs by staff or a professional. Staff denied the allegation. Based on interview and observation, the allegation is UNSUBSTANTIATED. It is alleged that facility staff served residents food of poor quality. LPA conducted a tour of the facility's kitchen and pantry. LPA observed the food to be varied and of good quality. LPA interviewed staff and residents. Both staff and residents denied the allegation. Based on interview and observation, the allegation is UNSUBSTANTIATED. It is alleged that facility staff withheld food from residents. LPA interviewed residents and residents denied the allegation. LPA interviewed staff and staff stated that food is always available to residents. Staff denied the allegation. Based on interview, the allegation is UNSUBSTANTIATED. It is alleged that facility staff were not trained on procedures regarding medications before dispensing medications. LPA interviewed staff. Staff stated that only staff that are trained in medication procedures can administer medications. Staff denied the allegation. Based on interviews, the allegation is UNSUBSTANTIATED. It is alleged that staff spoke inappropriately to residents. LPA interviewed residents and stated that have not witnessed staff speaking inappropriately to residents. Residents denied the allegation. LPA interviewed staff and staff denied witnessing the allegation. Based on interviews, the allegation is UNSUBSTANTIATED. An UNSUBSTANTIATED complaint is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where this report LIC9099 and LIC9099C were discussed and copies were provided to Assistant Administrator, Janeth Gonzalez.the state’s words, verbatim · CDSS document, Feb 23, 2026 · control 56-AS-20240126083631

Allegation investigated: Staff did not ensure residents were fed

On 12/17/2025 at 9:05 AM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to investigate and deliver the findings of the above allegation. LPA Serrano met with Assistant Administrator Janeth Gonzalez to explain the purpose of the visit. The investigation consisted of file review, interviews with facility staff and residents as well as facility observation. Allegation: Staff did not ensure residents were fed. – Based on information received during staff and resident’s interviews, 5 out of 5 staff stated that the facility staff feed all the residents in care. They further stated that there are always staff helping with the feeding and if a staff member cannot work that day, another staff from different shifts or office personnel will cover. 5 out of 5 residents stated that they are always fed in the facility 3 times a day and a snack. Some residents that cannot come to the dining table, the staff will go to their rooms and serve them their meals. LPA observed that the facility has more than enough supply of perishable and non-perishable food for the residents in care. LPA was unable to corroborate the allegation. ******continuation on LIC9099C******* Unsubstantiated Information received during investigation LPA did not find evidence to corroborate the allegations. Based on the evidence, the allegations mentioned above is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where this report, LIC9099 was discussed and provided to Assistant Administrator Janeth Gonzalez.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 56-AS-20251212162254

Type of visit: Required - 1 Year

On 8/08/2025 at 09:10 AM, Licensing Program Analysts (LPAs) Eldin Serrano and Magda Malcore made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPAs met with Administrator Terronsay Whaley and was granted entry to the facility. The facility is a thirty two (32) bedrooms with thirty two (32) bathroom facility with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of sixty four (64) non-ambulatory and seventeen (17) hospice care and the current census is fifty two (52) residents. LPAs was accompanied by Staff #5 to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPAs inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs observed sufficient furniture and lighting throughout the facility. LPAs measured and observed the water temperatures in the bathroom to be at 105 degrees F at Room #26. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, labor laws, and the disaster plan were posted in a common area. ***Continuation in LIC809C *** Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Room with the resident’s medications locked. LPAs observed complete first aid kit and first aid book at the facility. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. Care & Supervision: The facility has an Administrator present in the facility with enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care. Record Review: LPAs reviewed five (5) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPAs observed resident files reviewed were complete. LPAs reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications/Medication Administration Record (MAR) were audited, no issues observed. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report LIC809 and LIC809C forms were discussed and provided to Administrator Terronsay Whaley .the state’s words, verbatim · CDSS document, Aug 8, 2025

Allegation investigated: Staff does not ensure resident is provided meal service in a timely manner. Staff does not ensure medications are dispensed as prescribed for resident in care.

On 12/09/2024 at 9:20 AM, Licensing Program Analyst (LPA) Eldin Serrano conducted an unannounced visit to the facility to commence a complaint investigation. LPA Serrano was greeted and granted entrance by a staff member and LPA Serrano met with the administrator Terronsay Whaley. LPA Serrano identified himself and discussed the purpose of the visit and the elements of the allegations with administrator Whaley. LPA Serrano conducted a quick tour of the facility, interviewed staff, and obtained facility records. Regarding allegation "Staff does not ensure resident is provided meal service in a timely manner." LPA Serrano reviewed facility documents and conducted interview with the administrator. Per resident's roster review and interviews conducted, LPA Serrano determined Resident #1 (R1) does not live at this facility. LPA was able to verify that R1 lives at another facility nextdoor that is a skilled nursing facility (Knolls West Post Acute) that resembles the name of this facility and shared the same address. ***Continuation in LIC9099C*** Unfounded Regarding allegation “Staff does not ensure medications are dispensed as prescribed for resident in care.” LPA Serrano reviewed facility documents and conducted interviews with relevant parties. Per documents (resident's roster) review and interviews conducted, LPA Serrano determined Resident #1 (R1) lives at another facility. During the visit today, 12/09/2024 LPA Serrano was able to verify that R1 lives at another facility nextdoor that is a skilled nursing facility (Knolls West Post Acute) that resembles the name of this facility and shared the same address. . Therefore, Staff does not ensure resident is provided meal service in a timely manner.(Allegation #1) and Staff does not ensure medications are dispensed as prescribed for resident in care. (Allegation #2) are UNFOUNDED. This agency has investigated the complaint allegations. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with administrator Terronsay Whaley and a copy of this report, LIC9099 was discussed and provided.the state’s words, verbatim · CDSS document, Dec 9, 2024 · control 56-AS-20241204160217

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Michelle Echeverria and Lavette Farlow made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs met with Administrator, Terronsay Whaley and caregiver, Janeth Gonzalez and were granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) licensed capacity for (64), current census (51). The facility has (32) apartment bedrooms with bathrooms included, reception area, office with medication room, employee room, laundry room, media room, theater room, activities room, kitchen, dining room and an outdoor shaded area with seating. LPAs were accompanied by the Administrator and caregiver to conduct a general overall inspection, which included, but was not limited to the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature 76, 74, and 75 degrees fahrenheit. Water temperature measured at 110, 111.1, 110.2, 110.9, 109.8 and 106.8 degrees fahrenheit. LPAs inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating fire extinguishers, smoke detectors, signal alarms and carbon monoxide alarms. Posters such as personal rights, CCL complaint poster, CCL license, ombudsman, and facility sketch were posted in a common area. LPAs observed the Emergency Disaster Plan last reviewed/updated on 3/20/23 on the old form. Technical violation issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for residents/staff files. Medications were kept in Med-Room inaccessible to residents. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed (5) residents files for admission agreements, physician reports, and needs and services plans. LPA also reviewed (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications were not audited due to time management. The facility last conducted a fire drill on 04/10/2024. No deficiencies and one technical violation were cited during this visit. An exit interview was conducted, and this report LIC809, LIC809C and LIC9102TV were discussed and provided to Administrator, Terronsay Whaley.the state’s words, verbatim · CDSS document, Aug 22, 2024