VI at La Jolla Village

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Angelica Boyles and Eryn Kane conducted an unannounced Case Management visit to follow up on a resident death reported to Community Care Licensing (CCL). LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit to Ellen Blys, Care Center Administrator. CCL received notification of Resident #1's death (R1) on 9/18/26. [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] On 9/18/26 R1 was found on the sidewalk by facility staff who initiated CPR. Staff promptly called for emergency services who pronounced R1 deceased. During today's visit, LPAs conducted a file review. The facility is currently awaiting the death certificate and will forward to the Department once received. At this time, LPAs observed no immediate health or safety concerns and no deficiencies were cited during today's visit. Additional visits and follow-up may be necessary for complete review of this incident based on additional information from the Death Certificate once obtained. An exit interview was conducted with Ellen Blys, Care Center Administrator to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Sep 21, 2026

Allegation investigated: Staff did not provide reasonable accommodation

Licensing Program Analyst (LPA) Natasha Persaud conducted a telephone visit to conclude the complaint investigation. LPA spoke with Executive Director, Stephanie Boudreau. During the investigation, records were reviewed, and interviews were conducted with staff and resident. It was alleged that staff did not provide reasonable accommodation. It was reported Resident #1 (R1) was not allowed to self-park in the facility's parking garage structure. The facility uses LAZ parking management company services and has valet attendants on site. All resident and visitor cars are parked by the attendants due to safety reasons. The residents have assigned parking spots to make it easier for valet attendants to locate their car for prompt service. Only staff are allowed to self park. The Executive Director (ED) stated the decision to eliminate self-parking was implemented in September of 2014. Residents were notified of the change on 7/11/2014 indicating the change will be effective as of 09/01/14. R1 was previously provided with a garage door remote and returned the remote without any objections to the change. However, as of 09/02/14, R1 has had objections and would like to self park. Continued on LIC 9099C. Unsubstantiated R1 reported they have a disabled placard, along with an assigned disabled parking spot, but not allowed to self park. The ED explained R1's request has been denied multiple times due to safety reasons and facility policy. Staff interviews revealed residents can call up to 15 minutes prior to needing their vehicle and the attendants will have them promptly brought to the front of the building. On 07/31/26, LPA observed the parking attendants using their radios to communicate with one another for safety. The attendants also honked the horn on the vehicle as turning the corners to alert the other attendants. The residents are not trained to professionally navigate the parking structure with narrow turns. LPA also cross reported to building code enforcement. In addition, ADA compliance is regulated for city owned buildings. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were emailed to Executive Director, Stephanie Boudreau.the state’s words, verbatim · CDSS document, Aug 4, 2026 · control 08-AS-20260724154741

Allegation investigated: Staff did not provide a resident with a bedroom Staff did not ensure resident was provided privacy

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to commence a complaint investigation. LPA identified herself and discussed the allegations mentioned above with Director of Resident Services, Syril Jones. LPA spoke with Executive Director, Stephanie Boudreau via telephone, while at the facility. During the investigation, LPA briefly toured the facility, requested records, and interviewed staff and residents. It was alleged staff did not provide a resident with a bedroom and staff did not ensure resident was provided privacy. It was reported that Resident #1 (R1) has been sleeping in a recliner in one of the memory care unit’s activity rooms due to a flood in another resident's room. The Care Center Administrator (CCA) explained Resident #2 (R2)’s room endured the flood, not R1’s room. However, R2 was relocated to R1’s room. R1 was removed from their private room and placed in one of their activity room’s that has glass doors/windows that was kept open, exposing R1. R1 was not accorded with dignity or privacy with direct care. R1 has been in the activity room for approximately three (3) or more weeks. Everyone visiting and walking by is able to observe R1 sleeping on the recliner. Continued on LIC 9099C. Substantiated On 07/20/26, LPA observed R1 asleep on the recliner in the activity room, with the glass doors wide open. R1’s belongings were not in the activity room with R1. LPA requested privacy for R1 when providing direct care until the issue was resolved. Therefore, staff asked another staff to obtain a privacy shade to assist with privacy for R1 during direct care. Prior to LPA requesting privacy, the facility was not using any privacy shades to protect R1’s privacy and dignity. Staff interviews confirmed R1 was moved from their room twice (2) due to repairs, not related to their unit. Staff also confirmed the flood was not in R1’s room, but in R2’s room. Instead of moving R2 to another private room, once affected by the flood the CCA relocated R1 to an activity room and gave R2, R1’s private bedroom. R1 was not accorded with dignity or privacy with direct care or their own personal bedroom. The CCA's interview revealed they believed it was appropriate to move R1 out of their private room due to R1 preferring to sleep in a recliner. On 07/21/26, both residents were relocated to their own private rooms. Based on observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations were found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Director of Resident Services, Syril Jones whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jul 31, 2026 · control 08-AS-20260719082836

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(2)(B) · Plan of correction due date: Aug 28, 2026

Personal Accommodations and Services. Living accommodations...shall be related to the facility's function. The facility shall...and privacy for the residents ...in the facility. No room commonly used for other purposes shall be used as a sleeping room for any resident. This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not ensure that 1 out of 545 [R1] residents were provided with a bedroom. R1 was made to sleep in the activity room, which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 31, 2026

Plan of correction: Executive Director (ED) stated R1 was relocated back to their private room on 07/21/26. In addition, vendor training will provided to staff in memory care unit regarding Personal Accommodations and Services. Proof of training due by POC due date. This is an amended version of the original report created on 07/31/26

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Aug 28, 2026

Additional Personal Rights of Residents in Privately Operated Facilities. To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications...and meetings of resident and family groups. This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not ensure that 1 out of 545 [R1] residents were provided privacy. R1 was made to sleep in the activity room with no privacy with direct care, which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 31, 2026

Plan of correction: Executive Director (ED) stated R1 was relocated back to their private room on 07/21/26. In addition, vendor training will provided to staff in memory care unit regarding Personal Rights. Proof of training due by POC due date. This is an amended version of the original report created on 07/31/26.

Allegation investigated: Facility had low water pressure

Licensing Program Analyst (LPA), Natasha Persaud conducted a telephone visit to conclude the complaint investigation. LPA discussed the allegation mentioned above with Executive Director, Stephanie Boudreau. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged that the facility had low water pressure. It was reported that the South Tower 20th and 21st floor had low residual water pressure. It also stated the supply did not provide a residual water pressure of at least fifteen (15) pounds per square inch. The facility obtained a professional plumbing company to test the water pressure. The professional plumbing company stated that the Uniform Plumbing Code (UPC) has to say on required residual pressure; 15 psi is the minimum residual pressure required at any plumbing fixture. The “Flow” referred to is not “Residual pressure”. Continued on LIC 9099C. Unsubstantiated Based on the definition in the UPC code book the static pressure that was recorded “is the residual pressure” because it is pressure present after allowance has been made for friction loss, head, meter, and other losses that occur as water makes it way from the source to the plumbing fixture. According to the pressures measured at the facility they had well above 15 psi at each fixture. The flow rate of the water as the fixture is on, can vary depending on the make, model and built in design of the shower head and valve from the manufacturer. The facility provided proof of tested water pressure for multiple units, which were complaint to UPC. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were emailed to Executive Director, Stephanie Boudreau.the state’s words, verbatim · CDSS document, Jul 21, 2026 · control 08-AS-20250724141308

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. LPA was greeted and allowed entry into the facility and conducted the visit with Executive Director, Stephanie Boudreau. LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured at 113-116 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. There was an indoor pool, on the Independent Living side of the facility, which was locked. Per the Executive Director, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Executive Director, Stephanie Boudreau to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jul 20, 2026

Allegation investigated: Lack of supervision resulting in financial abuse

Licensing Program Analyst (LPA), Natasha Persaud conducted a telephone visit to conclude the complaint investigation regarding the above mentioned allegation. LPA discussed the allegation with Executive Director, Stephanie Boudreau. During the investigation, records were reviewed and interviews were conducted with staff, residents and outside sources. It was alleged lack of supervision resulting in financial abuse. It was reported Staff #1 (S1) stole $2880.00 from Resident #1 (R1). R1’s Physician’s Report dated 03/27/25 indicated R1 had a Major Neurocognitive Disorder and was unable to manage their own cash resources. An outside source that manages R1’s money, discovered a check was made out to S1 by R1. A review of the Guardian Background Check System reflected S1 was associated to the Home Care Agency (HCA) and the facility. S1 was employed by the HCA and outsourced to R1 at the facility to provide one on one care. The HCA obtained signatures from R1 and S1 for comparison and it was determined the check was forged by S1. An outside source confirmed S1 cashed the check on 04/24/25 and stated it was earned for providing care. Continued on LIC 9099C. Unsubstantiated Evidence also revealed S1 was working outside of their scheduled hours. S1’s employer, reimbursed R1. S1 was terminated from employment with the HCA. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were emailed to Executive Director, Stephanie Boudreau.the state’s words, verbatim · CDSS document, Feb 20, 2026 · control 08-AS-20250708162806

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on three (3) incidents reported to Community Care Licensing (CCL). LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Director of Resident Services Syril Jones. Note, LPA did step out for lunch from 12:25-1:25pm. Report 1: CCL received an Incident Report on 11/13/25 in which it was reported that a resident (identified as R1) had notified staff of a fall in their independent living apartment. Emergency services were contacted and R1 was assisted back into their wheelchair and was not transferred to the hospital. It was noted in the report that the day previous (11/6/25), R1 had a fall and was taken to the hospital and returned same day with several injuries. Per the report, after the second fall, R1 was advised of having a 1:1 caregiver due to the recent frequency of falls. Report 2: CCL received an Incident Report on 12/2/25 in which it was reported that a resident (identified as R2) reported pain to their side on 11/26/25. Emergency services were contacted and R2 was taken to the hospital where two (2) rib fractures were found. The report notes that R2 had a fall the day prior 11/25/25 and emergency services were called but R2 was not taken to the hospital. R2's responsible party and primary care provider were notified. Report 3: CCL received an Incident Report on 12/29/25 in which it was reported that on 12/23/25, a resident (identified as R3) was taken to the hospital by their family member due to back pain. There, it was found that R3 had compression fractures to two (2) vertebrae. Per the report, R3 returned to the facility same day. [Continued on LIC 809-C] [Continued from LIC 809] During today's visit, LPA conducted interviews and health and safety visits with R1, R2, and R3, as well as consultation with Director of Resident Services Jones. Interviews did not reveal any licensing or regulatory concerns. Regarding R1, they are currently residing in the facility's SNF (Skilled Nursing Facility) to meet higher level care needs for a health condition unrelated to this incident. Per staff interviews, R1 and their responsible party have been advised of options to meet needs as R1 is no longer suitable for independent living, whether it be transitioning to the facility's Assisted Living (AL) area or remaining in Independent Living with a private 1:1 24/7 caregiver. File review of R1's records show care meeting attempts by the facility with R1 and communications with R1's responsible party post falls. Records also revealed the facility conducted updated assessments and care plans. Records also noted R1 had begun private caregiving services 11/14/25 but discontinued them 12/8/25. R1's updated physician's report (11/21/25) note R1 to be independent in Activities of Daily Living (ADLs). Regarding R2, per interviews, it was revealed that R2 had declined transfer to the hospital by the paramedics after their initial fall, and staff promptly contacted emergency services once R2 notified them of a change in condition, thus there was no delay of medical attention by the facility. Regarding R3, per staff and resident interviews, R3 had no recent falls around the time of the incident. LPA observed no immediate health and/or safety concerns during the visit. No Deficiencies were cited during the visit as facility staff responded appropriately to each of the incidents reported. An exit interview was conducted with Executive Director Stephanie Boudreau to whom a copy of this report was provided. Their signature below confirms receipt of this document.the state’s words, verbatim · CDSS document, Jan 12, 2026

Allegation investigated: Facility staff violated residents personal rights

Licensing Program Analyst (LPA)Tiffany Holmes contacted the facility to deliver findings for a complaint investigation via tele-virtual. LPA identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Amy Patterson, Associate Executive Director. During the investigation, LPA toured the facility, conducted interviews and completed a records review. It was alleged that the facility staff violated residents personal rights. Interviews revealed that that if the residents do not chose a selected home care agency(ies) that the facility staff want them to choose, then they get threatened. Interviews revealed by the staff at the facility by doing this it does not allow the residents to choose an unbias option that includes variation in hourly costs or agencies. Interviews with residents stated they have not been threatened and that they have been given the choice to choose their own home care servicer. Interviews revealed the residents don't feel intimidated by the staff at the facility and that they in fact feel comfortable. Interviews revealed that it is the resident’s right to be able to choose which home care agency they want with the options available to them. Interviews revealed there haven't been any complaints from residents regarding not being able to choose their own home care agency. An unsubstantiated finding means that while the allegation may have validity, there is not enough evidence to conclude that the alleged violation occurred.Therefore, this allegation is deemed unsubstantiated An exit interview was conducted with Amy Patterson,Associate Executive Director, who received a copy of this report, and the Licensee Appeal Rights (9058 03/22) at the conclusion of the visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 24, 2025 · control 08-AS-20250611162024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Associate Executive Director Amy Patterson. Additionally, LPA briefly spoke with Executive Director Stephanie Boudreau to inform them of the purpose of their visit. Community Care Licensing received an Incident Report on 9/30/25 in which it was reported that a small fire broke out in the facility's laundry room on 9/27/25. Per the report, a pillowcase became stuck in the flatiron machine and the friction resulted in the pillowcase catching on fire. Laundry room staff were able to extinguish the fire as security and engineering staff arrived. Per the report, the fire department arrived on scene and ensured the fire was put out and the area safe. Per the report, the fire was contained to the laundry room and no impact to residents occurred. During today's visit, LPA conducted a visit to the laundry room where the fire took place and interviewed staff present that day. LPA observed the machine and surrounding area to be remediated and in good repair. No Deficiencies were cited during the visit as facility staff reacted appropriately to the situation. An exit interview was conducted with Associate Executive Director Patterson to whom a copy of this report was provided. Their signature below confirms receipt of this document.the state’s words, verbatim · CDSS document, Oct 2, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to the facility. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Associate Executive Director (AED) Amy Patterson. On today's date, LPA delivered an Immediate Exclusion letter for Staff 1. AED stated they understood the reason for its issuance. No deficiencies were cited during the visit. An exit interview was conducted with AED Patterson to whom a copy of this report, the Immediate Exclusion Letter for S1, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Sep 12, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced visit to complete the Annual Inspection partially conducted on July 31, 2025. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) Stephanie Boudreau and Associate Executive Director (AED) Amy Patterson. The facility's license shows a maximum capacity of 783 non-ambulatory residents. Additionally, the facility is approved for 25 hospice waivers. During today’s inspection there were 522 residents in care. During today's visit, LPA inspected the North Tower building and Care Center. The areas inspected today were clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms inspected contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. The facility has a water fountain fixture at the front entrance as well as another in front of the dining area at the North Tower. A Deficiency is being cited per Title 22 regulations and noted on the attached LIC 809D. In addition, a Civil Penalty is being assessed for a Zero Tolerance Violation regarding Accessible Bodies of Water and are noted on the attached LIC 421IM in the amount of $500. Additionally, LPA conducted file review. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. Last fire drill conducted with staff was on 7/24/25. One Deficiency was cited during today's visit for the accessible fountains. An exit interview was conducted with Executive Director Boudreau to whom a copy of this report was provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 14, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arian Golbakhsh and Licensing Program Manager (LPM) Sabel Martinez conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA and LPM were welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) Stephanie Boudreau. The facility's license shows a maximum capacity of 783 non-ambulatory residents. Additionally, the facility is approved for 25 hospice waivers. During today’s inspection there were 523 residents in care. LPA, LPM, and ED Boudreau toured the interior and exterior of the main floor and inspected common areas as well as a sample of resident units in the South Tower. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms inspected contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink in a unit on the 20th floor read at 108.3F.. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were stored in areas inaccessible to residents. [Continued on LIC 809-C] [Continued from LIC 809] No toxic chemicals or poisons were accessible to clients. Centrally stored medication for the Independent Living Residents were labeled, as required, and stored in locked areas. An indoor pool exists on the premises. LPA and LPM observed the pool to have three (3) secured entryways with electronic key access. Per ED Boudreau, only eligible residents who have been assessed may have access to the pool. Per ED Boudreau, no firearms or ammunition are kept at the facility. Fire extinguishers were serviced within the last 12 months. Required licensing postings were observed in visible areas of the facility. LPA and LPM interviewed 2 staff and 3 clients, and interviews did not reveal any licensing or regulatory concerns. Due to time constraints, an additional visit on a subsequent date is required to complete the annual inspection. No deficiencies were cited during today's visit. An exit interview was conducted with Executive Director Boudreau to whom a copy of this report was provided. Their signature below confirms receipt of this document.the state’s words, verbatim · CDSS document, Jul 31, 2025

Type of visit: Case Management - Other

Licensing Program Manager (LPM) Sabel Martinez and Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit. They introduced themselves and disclosed the purpose of the visit to Executive Director Stephanie Boudreau. During the visit, an amended report was delivered and report signatures were secured. An exit interview was conducted with Executive Director Boudreau, to whom a copy of this report, and Licensee Rights (LIC 9058), were provided via email. An email read receipt confirms the documents were received.the state’s words, verbatim · CDSS document, Jul 31, 2025

Allegation investigated: Unlawful eviction

On June 4, 2025, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to present investigative findings. Upon arrival, LPA was greeted by Associate Executive Director, Amy Patterson, to whom she introduced herself and explained the purpose of the visit. The Department investigated the complaint allegation listed above. The investigation comprised a facility tour, multiple interviews, and a thorough review of relevant records. Background of the Complaint On May 5, 2025, Community Care Licensing (CCL) received a complaint alleging unlawful eviction. Specifically, it was alleged that on April 27, 2025, when the hospital attempted to discharge Resident (R1) back to the facility, the staff initially refused to accept R1 back into their independent living apartment. (Continue at LIC9099C) Unsubstantiated (Continue from LIC 9099) A Confidential Names List (LIC 811) was provided to identify the resident. A review of R1’s physician’s report from January 2025 and facility assessments indicated that R1 was considered fully independent and capable of making their own decisions. Detailed Findings A comprehensive review of R1’s medical records, hospital discharge instructions, and facility records revealed that R1 sustained a serious head injury after a fall in January 2025. Due to R1’s change in condition and heightened fall risk, R1 was discharged from the skilled nursing facility back to their apartment under a revised service care plan designed to meet their needs. This plan included 24/7 care and supervision, along with physical therapy to aid in regaining strength and mobility. R1 agreed to hire a private duty aide (caregiver) to assist with all activities of daily living (ADLs), including dressing, bathing, and transfers, to ensure their health and safety. Interviews with R1, facility staff, and external sources confirmed that on April 4, 2025, staff were informed that R1 had canceled the services from the 24/7 caregiver agency effective April 3, 2025, as they no longer required assistance with ADLs. However, multiple interviews indicated that R1 did not officially notify staff as required by the admission agreement, which mandates that residents provide an updated physician’s report following hospitalization or changes in condition. R1 failed to provide such documentation to confirm that they were no longer a fall risk requiring 24/7 care and supervision with ADLs. Observations from staff and external sources consistently indicated that R1 still needed assistance with their ADLs. To ensure R1's health and safety, staff reestablished the 24/7 caregiver agency promptly and continued to provide necessary services. On April 25, 2025, R1 experienced a change in condition and was readmitted to the hospital via 911 emergency services. Consequently, staff discontinued services from the 24/7 caregiver agency while R1 remained hospitalized. (continue at LIC9099C) (Continue from LIC9099C) On April 27, 2025, when staff were informed by hospital personnel that R1 was being discharged back to their apartment, they communicated the need for the 24/7 agency to provide a caregiver at the facility on short notice. Approximately an hour later, after confirming that R1’s Power of Attorney (POA) had secured caregiver services on April 26, 2025, staff contacted the hospital to arrange for facility staff to follow up with R1 upon arrival. Interviews confirmed that R1’s POA did not notify facility staff about the arrangements for R1’s discharge and the secured caregiver agency. Conclusion Based on the investigation, which included observations, interviews with key staff and external sources, and a review of relevant resident records, there was insufficient evidence to support the allegation of unlawful eviction. The evidence confirmed that R1 returned to their apartment on April 27, 2025, under 24/7 care and supervision. Facility staff would continue to monitor R1’s condition through health and safety checks as required by Title 22 regulations. Therefore, this allegation is deemed unsubstantiated. An unsubstantiated finding means that while the allegation may have validity, there is not enough evidence to conclude that the alleged violation occurred. An exit interview was conducted with Associated Executive Director Amy Patterson, who was provided with a copy of this report, the Confidential Names List (LIC 811), and the Licensee Appeal Rights (9058 03/22) at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jun 4, 2025 · control 08-AS-20250505110228

Allegation investigated: Staff violated resident's privacy.

On June 4, 2025, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to present investigative findings. Upon arrival, LPA was greeted by Associate Executive Director Amy Patterson, to whom she introduced herself and explained the purpose of the visit. The Department conducted an investigation into the complaint allegation listed above, which included a facility tour, multiple interviews, and a thorough review of relevant records. Background of the Complaint On May 22, 2025, Community Care Licensing (CCL) received a complaint alleging that staff violated a resident's privacy. Specifically, it was alleged that on May 16, 2025, facility staff knocked on R1's door and, upon receiving no answer, entered without R1's knowledge or consent. Furthermore, on May 19, 2025, facility staff called 911, leading law enforcement to conduct a wellness check on R1. A Confidential Names List (LIC 811) was provided to identify the resident. (Continue at LIC9099C) Unsubstantiated (continue from LIC9099) A review of R1’s most recent physician’s report from January 2025 and facility assessments indicated that R1 was considered fully independent and capable of making their own decisions. Investigation Findings A detailed review of R1’s medical records, hospital discharge instructions, and facility records revealed that R1 sustained a serious head injury from a fall in January 2025. Due to a change in condition and increased fall risk, R1 was discharged from the skilled nursing facility back to their apartment under a revised service care plan. This plan included 24/7 care and supervision, as well as physical therapy to aid in regaining strength and mobility. R1 agreed to retain a private duty aide (caregiver) to assist with activities of daily living (ADLs), such as dressing, bathing, and transfers, ensuring R1's health and safety. R1 was also subject to health and safety checks by facility staff to monitor any changes in condition, including daily check-ins with the private duty aide agency. This protocol was established by the facility for all residents, in compliance with Title 22 regulations, Division 6, Chapter 8, Article 08, which mandates regular observation of residents for changes in functioning and appropriate assistance when needed. The regulation (87466, Observation of the Resident) specifically outlines that the licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observations reveal unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or physical health condition are observed, the licensee must ensure that such changes are documented and brought to the attention of the resident's physician and responsible person. During interviews with staff and external sources, it was reported that access to R1’s apartment was being denied, preventing staff from conducting the required wellness checks. On May 16, 2025, facility staff knocked on the door, and when there was no answer, they announced themselves and entered to conduct the wellness check. Staff expressed concern that, despite multiple attempts to gain access, the 24/7 caregivers were instructed not to open the door to facility staff. On May 19, 2025, facility staff sought assistance by calling 911, prompting law enforcement to conduct the wellness check. (Continue at LIC9099C) (continue from LIC9099C) Staff stated during multiple interviews that during instances when the caregiver on duty did not open the door, staff announced themselves and entered R1’s apartment. In all cases, R1 was aware of the visits and had granted permission for the wellness checks. Conclusion Based on the investigation results, which included observations, interviews with key staff and external sources, and a review of pertinent resident records, there was insufficient evidence to support the allegation that staff violated R1’s privacy by entering the apartment after knocking and announcing themselves. Therefore, this allegation is deemed unsubstantiated. An unsubstantiated finding means that while the allegation may have validity, there is not enough evidence to conclude that the alleged violation occurred. An exit interview was conducted with Associate Executive Director Amy Patterson, who received a copy of this report, the Confidential Names List (LIC 811), and the Licensee Appeal Rights (9058 03/22) at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jun 4, 2025 · control 08-AS-20250522091750

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted a case management visit to deliver an amended report. LPA met with Executive Director, Stephanie Boudreau, and informed her of the purpose of the visit. Today's visit is to deliver an amended report from complaint visit conducted on 2/28/2025. The amended report was reviewed with Executive Director, Stephanie Boudreau and signatures were obtained. An exit interview was conducted, Appeal Rights (LIC 9058 03/22) along with a copy of this report was provided to Boudreau at the end of the visit.the state’s words, verbatim · CDSS document, Mar 3, 2025

Allegation investigated: Staff did not provide a comfortable room temperature for resident resulting in injury

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA was greeted by Executive Director Stephanie Boudreau, to whom she identified herself and explained the purpose of the visit. The Department investigated the above-listed complaint allegation. The investigation included a facility tour, multiple interviews, and a detailed review of relevant records. On February 3, 2025, Community Care Licensing (CCL) received a complaint alleging that facility staff failed to maintain a comfortable temperature for Resident 1 (R1), resulting in injury. [A Confidential Names List (LIC 811) was provided to staff to identify the resident.] (Continue at LIC9099C) Unsubstantiated (Continue from LIC9099) It was alleged that on January 18, 2025, R1 experienced an unwitnessed fall in their apartment due to sleep deprivation caused by cold temperatures. Specifically, it was claimed that lack of sleep led to low blood pressure and dizziness, causing R1 to fall in the bathroom during the night. As a result, R1 sustained a traumatic left subdural hematoma. On January 25, 2025, R1 was transferred to a skilled nursing facility for continued treatment and recovery. On February 7, 2025, R1 was discharged back to their independent living apartment under 24/7 care and supervision due to a change in condition. R1 required assistance with all activities of daily living and was determined to be a high fall risk due to the recent fall, poor balance, general weakness, and low blood pressure. On February 10, 2025, LPA visited R1’s apartment and observed it to be clean and free of odors. Two thermostats were present, including one inside R1’s bedroom. The bedroom thermostat displayed a temperature of 81°F, set at 75°F. However, R1 preferred using the thermostat in “manual mode” instead of “auto mode” meaning the heat remained on beyond the set temperature. Conversely, if R1 turned off the unit and forgot to turn it back on, the temperature could drop below their desired comfort level. Facility maintenance recommends keeping thermostats in “auto mode” for optimal efficiency. During the visit, LPA noted the apartment felt very warm. According to Title 22 regulations, the temperature was within the required range (68 - 85°F). The second thermostat, located in the main living room, displayed 76°F, aligning with the standard home temperature range of 68 - 76°F. [Note: Each apartment in the facility has its own HVAC unit, and thermostats are located inside individual units, allowing residents full control over their room temperature settings.] During the visit, R1 pointed to the vent and indicated that cold air was coming through. However, LPA observed a vent deflector (a transparent cover directing airflow upwards) to prevent direct airflow. LPA did not feel cold air coming through the vent. During the visit, R1 was in bed under blankets and stated they still felt cold, with cold hands to the touch. Interviews with R1’s private caregivers consistently indicated that the apartment temperature was comfortable and, at times, too warm. A review of caregivers’ daily care notes for February 2025 showed that R1 had asked caregivers on several ocassions to turn off the heat because they felt too warm. The caregiver present during the visit confirmed they had no concerns about the apartment’s temperature but acknowledged that R1 continued to feel cold. (continue at LIC9099C) (continue from LIC9099C) On August 27, 2024, CCL had previously investigated and delivered unsubstantiated findings regarding the same allegation. Interviews with facility management and the director of engineering revealed that the facility had been addressing R1’s concerns since November 13, 2023. In response, facility maintenance replaced the thermostats twice in November and December 2023 because R1 believed they were old and inaccurate. Additionally, at R1 requested the thermostats to be relocated twice in December 2023 and January 2024. Maintenance also checked and replaced the apartment vents. On April 8, 2024, R1 hired an independent HVAC consultant to investigate the heating and airflow in their apartment. The consultant reported placing sensors inside the apartment. The readings showed no issues with room temperature. The sensors monitored temperatures continuously for several days, both during the day and night. The consultant’s findings aligned with studies conducted by the facility’s engineers and maintenance staff. Additionally, interviews with multiple residents living on the same floor near R1’s apartment did not reveal any HVAC-related complaints. A review of R1’s medical records disclosed a significant list of medical conditions, including recurring urinary tract infections (UTIs), sleep disorder, Raynaud’s syndrome, primary anemia, osteoarthritis (left hip and both knees), gait difficulty, weight loss, obstructive sleep apnea, primary insomnia, chronic weakness, and acute cough. Medical notes indicated that symptoms associated with these conditions include low blood pressure, dizziness, and feeling cold. For instance: • Raynaud’s disease causes areas such as fingers and toes to feel numb and cold. • Primary anemia, particularly iron deficiency anemia, can cause constant cold sensations due to poor blood circulation and oxygen distribution, leading to cold hands and feet, even in warm environments. Based on the results of the investigation, which consisted of observations, interviews with key staff and outside sources, and a review of pertinent resident records there was insufficient evidence to support the allegation that staff did not provide a comfortable room temperature for R1 resulting in injury. (continue at LIC9099C) (Continue from LIC9099C) Therefore, this allegation is unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence that the alleged violation occurred. An exit interview was conducted with Executive Director Stephanie Boudreau, who was provided with a copy of this report, the Confidential Names List (LIC 811), and the Licensee Appeal Rights (9058 03/22) at the conclusion of the visit.the state’s words, verbatim · CDSS document, Feb 28, 2025 · control 08-AS-20250203115111

Allegation investigated: Staff threatened a resident with eviction

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA was greeted by Executive Director Stephanie Boudreau, to whom she identified herself and explained the purpose of the visit. The Department investigated the above-listed complaint allegation. The investigation included a facility tour, multiple interviews, and a detailed review of relevant records. On February 11, 2025, Community Care Licensing (CCL) received a complaint alleging that facility staff threatened Resident 1 (R1) with eviction, [A Confidential Names List (LIC 811) was provided to staff to identify the resident.] (Continue at LIC9099C) ****This is an amended LIC9099**** Unsubstantiated continue from LIC9099 The complaint specifically alleged that staff repeatedly threatened R1, stating that if they continued to complain about the cold temperature in their room, they would be transferred to a skilled nursing facility and their apartment would be sold. However, interviews with outside sources did not provide details regarding when or how these threats occurred. Additionally, outside sources stated that they were unaware of R1 being verbally or informally served with an eviction notice. During an interview conducted on February 10, 2025, R1 did not express any concerns regarding eviction. R1 stated that on January 18, 2025, they experienced an unwitnessed fall in their apartment, which resulted in a traumatic left subdural hematoma. On January 25, 2025, R1 was transferred to a skilled nursing facility for continued treatment and recovery. On February 7, 2025, R1 was discharged back to their independent living apartment under 24/7 care and supervision due to a change in condition. On February 12, 2025, a care plan meeting was held with R1 to discuss their current needs. It was determined that R1 required assistance with all activities of daily living and was considered a high fall risk due to their recent fall, poor balance, general weakness, and low blood pressure. During this meeting, R1 agreed with the care plan and acknowledged the need for assistance to continue residing in their independent living apartment. R1 also stated that the care plan included physical, occupational, and speech therapies to help regain independence. Multiple interviews with key staff and outside sources consistently denied the allegation, stating they had never witnessed or heard of any staff member threatening R1 with eviction. On the contrary, interviewees indicated that the staff’s primary focus was to develop and implement a comprehensive service care plan to ensure R1’s health and safety while remaining in their independent living apartment were met. Based on the results of the investigation, which consisted of observations, interviews with key staff and outside sources, and a review of pertinent resident records there was insufficient evidence to support the allegation that staff threatened R1 with eviction. (Continue at LIC9099C) (continue from LIC9099C) Therefore, this allegation is unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence that the alleged violation occurred. An exit interview was conducted with Executive Director Stephanie Boudreau, who was provided with a copy of this report, the Confidential Names List (LIC 811), and the Licensee Appeal Rights (9058 03/22) at the conclusion of the visit.the state’s words, verbatim · CDSS document, Feb 28, 2025 · control 08-AS-20250211003115

Allegation investigated: Staff did not meet the needs of residents in care Staff did not accord dignity to residents in care Staff did not maintain the facility in good sanitary condition

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced complaint visit to open a complaint investigation. While at the facility LPA investigated and delivered findings regarding the above-mentioned allegations. LPA identified herself and was granted entry by Executive Director, Stephanie Boudreau. LPA stated the purpose of the visit and reviewed and delivered the findings of the complaint with Boudreau. The Department’s investigation consisted of interviews with staff and a detailed review of relevant records pertinent to this investigation. On December 11, 2024, it was alleged that the staff did not meet the needs of residents in care, staff did not accord dignity to residents in care and staff did not maintain the facility in good sanitary condition. Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained from staff interviews and records review, we have found that the complaint was unfounded. (continue at LIC9099C) Unfounded (continue from LIC9099) An unfounded determination means that the allegation was false, could not have happened, and/or is without a reasonable basis. The allegations were not pertinent to this licensed facility. The Department will be cross-reporting this complaint to the appropriate agency for follow-up. The report was discussed, and an exit interview was conducted with Executive Director, Boudreau, to whom a copy of this report along with Licensee/Appeal Rights (LIC9058 03/22) was provided at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Dec 13, 2024 · control 08-AS-20241211085525

Allegation investigated: Facility staff threatened resident Facility staff confiscated resident’s personal property Staff did not provide reasonable accommodations per physician’s orders

This is an amended report originally signed on 10/18/2024. Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA was greeted by Associate Executive Director, Amy Patterson to whom she identified herself and discussed the purpose of the visit. The Department investigated the above-listed complaint allegations. The investigation consisted of a tour of the facility, multiple interviews, and review of records, including medical records. On November 17, 2023, Community Care Licensing (CCL) received a complaint alleging that facility staff threatened resident (R1), [a LIC 811 Confidential Names List was provided to staff to identify the resident]. It was specifically alleged that on July 11, 2014, facility staff threatened R1 when they ordered valet parking only and took away their self-parking status. (continue at LIC9099C) Unsubstantiated Continue from LIC9099 During interviews with outside sources, it was indicated that the implementation of the valet-only policy change violated the terms of R1’s Continuing Care Residency Agreement (CCRA). A review of R1’s CCRA indicated that R1 executed and signed the residency agreement on December 31, 2011, and moved in to live in the community on January 5, 2012. On page 4 of the CCRA, section 2.1.9, stated the following regarding resident parking, “One car per home may be kept at the Community, provided you have a valid driver's license, insurance, and a currently registered automobile…. Provider may require some or all parking to be on a valet basis”. In addition, a review of the resident handbook, page 24 indicated the following, “We may require some or all resident parking to be on a valet basis. Currently, we permit you to decide whether you prefer to valet park or self-park your automobile." Interviews with facility staff indicated that on July 11, 2014, (2.5 years after R1 moved in), a formal memorandum was distributed to all the self-parkers including R1 informing them of the transition to valet parking only effective September 1, 2014. A review of the memorandum indicated no violations of Title 22 regulations regarding proper notification to residents regarding changes that affect the community. At the time of the change, 24 residents were utilizing self-parking, including R1, the remaining 500+ residents did not self-park. Interviews with other residents who self-parked did not disclose any concerns. During staff interviews, it was indicated that initially, R1 returned their garage door remote without any objections. On September 2, 2014, R1 requested for valet to park their vehicle in space 216 to have easy access. Although there were no allowances for assigned spaces due to limited garage space, the facility agreed to accommodate R1’s request. R1 agreed not to drive their vehicle out of the garage on their own. In addition, on March 27, 2015, R1 requested a standing reservation to have their vehicle ready at the east entrance each day at the same time. This would avoid R1 needing to call ahead like all the other residents. The facility accommodated R1’s request for a standing reservation. In March 2016, R1 requested valet to stop bringing their vehicle to the east entrance. Despite several discussions with R1 regarding not adhering to the parking policy, R1 continued to drive their vehicle out of the garage. In addition, during staff interviews, it was indicated that R1 was observed driving in the wrong direction in paths marked for one-way traffic. During an interview, the facility administrator explained that when the community was in fill-up mode and occupancy was low, they were able to allow residents to self-park their vehicles. (Continue at LIC9099C) Continue from LIC9099C However, the residency agreements and handbooks notified residents that valet parking would be required in the future when the number of vehicles reached a critical mass in the garage. The garage was designed for valet parking and the community always intended for all parking to be “valet”. During a tour of the parking garage, conducted on July 29, 2024, it was observed tight spaces, one-way driving paths, narrow turns, and vehicles were double and/or triple parked to accommodate the necessary number of vehicles. During an interview, the facility administrator explained that when the community reached maximum occupancy levels, the number of vehicles in the garage was over capacity as well and it made self-parking unmanageable and unsafe for both the residents and staff. R1 objected to valet parking, refused to comply, and continued to drive their vehicle out of the garage contrary to community parking policy and safety rules. On July 29, 2024, during an interview, R1 admitted driving the wrong way in the garage stating that the valet attendants were also driving the wrong way. Based on the information obtained from observations, records reviewed which included available correspondence between R1 and facility staff, and interviews conducted there was insufficient evidence to indicate that staff threatened R1. It was also alleged that facility staff confiscated resident’s personal property. It was specifically alleged that on September 16, 2016, valet staff moved R1’s vehicle from the regular parking space #216 to #223B. On August 25, 2016, R1 was provided with notice that facility staff would be taking further actions if R1 continued to drive their vehicle out of the garage. Between August 29 – September 13, 2016, R1 continued to retrieve and drive their vehicle out of the garage. On September 15, 2016, the facility staff issued a final notice to R1 that if they did not agree to comply with the parking policy, they would need to take immediate action to protect the safety of other residents and staff. Space #223B was designated as a tandem space. Tandem parking is when two people share two parking spaces, and only one space is in front of the other. This means that someone is parking behind you (or vice-versa) and one car needs to move into the spot first, then the second lines up behind it. The vehicle parked in space #223A was in front of R1’s vehicle which prevented R1 from driving the vehicle out of the garage on his own. R1 had the 2nd set of keys for their vehicle and continued to have access to retrieve personal belongings in and out of their vehicle. However, to be able to drive out of the garage, R1 would need to use valet service. (continue from LIC9099C) (continue from LIC9099C) On July 29, 2024, during a tour of the garage, it was confirmed that the distance between both spaces was approximately 15 feet apart. Based on observations and the information obtained during interviews with R1 and staff, there was insufficient evidence to corroborate the allegation that staff confiscated R1’s vehicle as they continued to have access. Lastly, it was alleged that staff did not provide reasonable accommodations per physician’s orders. It was specifically alleged that R1 was denied a reasonable accommodation to self-park due to a chronic medical condition. On January 11, 2024, R1 provided a note from a nurse practitioner stating, “Please consider this a prescription request for resident to have special accommodation to self-park be restored per R1's prior arrangement, next to the garage elevator on the P1 self-parking level.” The note further stated that, “R1 believes their medical condition is aggravated by the frequent seat adjustments by the valet parking attendants”. In addition, a physician’s note dated May 11, 2024, was also provided that stated, R1 seeking self-parking medical accommodation for a chronic medical condition that is a long-term issue. A detailed review of R1’s medical records, including the initial medical certification prior to admission (dated November 9, 2011,) service care plan for 2023 and 2024, resident annual self-evaluations from 2015 – 2024, annual resident appraisals from 2015 – 2024, disclosed no official diagnosis of the chronic medical condition. During interviews with R1 and with staff, it was indicated that the medical certification on file with the facility was from 2011 which indicated no primary or secondary diagnosis. Staff indicated the medical certification had not been updated because there had not been any changes in R1’s medical condition. On August 8, 2024, R1 provided an updated physician’s report with a primary diagnosis as “acupuncture and anti-inflammatory”, which R1 indicated to be treatments for their chronic medical diagnosis. Further review of R1's medical records did not provide a history of the chronic medical diagnosis as an official diagnosis for a long-term chronic medical condition claimed to be caused by the frequent seat adjustments by the valet parking attendants. (continue from LIC9099C) (Continue from LIC9099C) R1’s request for reasonable accommodation was denied due to the high level of safety risks involved in allowing residents to drive in and out of the underground parking garage that utilizes the tandem parking system that has been managed by a 7/24 professional and independent parking management company since 2005. In addition, facility management had serious safety concerns about allowing R1 to drive in the parking garage given their history of refusing to follow the marked flow of traffic signs. During interviews, it was indicated that R1 was observed driving opposite direction of the flow of traffic despite the visibly marked arrows. The Health and Safety Code, section 1569.269(a)(16), includes regulations that require facilities to take into consideration the health and safety of other residents in the community. The regulation states, that residents of residential care facilities for the elderly shall have the following rights, to reasonable accommodation of individual needs and preferences in all aspects of life in the facility, except when the health or safety of the individual or other residents would be endangered. For safety reasons, facility management decided not to allow any resident to drive including R1. Furthermore, facility management offered and put into place several procedures to accommodate R1’s medical concerns such as ensuring valet parking staff returned the seat to the preset setting by pressing the program button for seat adjustments. In addition, the facility offered to have ongoing discussions with the valet staff about the importance of resetting the driver's seat in R1’s vehicle when the valet exits the vehicle. The facility building management consistently asked every valet to be reminded to double-check R1’s vehicle when they exit the vehicle. The valet attendants also programmed R1’s vehicle car seat so that each of the three (3) “reset seat” buttons automatically adjusts the seat to R1’s personal settings. Facility staff also suggested to R1 that they visually take the time to check the seat before they sit down. (continue on LIC9099C) (Continue from LIC9099C) On September 4, 2024, R1’s physician provided a signed statement stating that the reasonable accommodations provided by the facility addressed R1’s medical condition. During interviews, this information was verified with outside sources. During the investigation, it was revealed that Resident 1 (R1) had an ongoing dispute with the facility regarding R1’s contractual right to self-park their vehicle. This dispute led R1 to file a lawsuit against the facility, resulting in a temporary injunction order that was subsequently lifted. R1 later voluntarily dismissed the legal action. The Department’s Continuing Care Contracts Bureau (CCCB) reviewed the contractual dispute and determined that the facility was not in violation when it implemented a policy requiring all residents to utilize valet parking. Based on the results of the investigation, which consisted of observations, interviews with staff, outside sources, and review of resident and facility records there was insufficient evidence to support the allegations listed in this report. Therefore, these allegations were unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence that the alleged violation occurred. An exit interview was conducted with Associate Executive Director, Amy Patterson, to whom a copy of this report, Confidential Names List (LIC 811), and Licensee Appeal Rights (9058) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 18, 2024 · control 08-AS-20231117103051

Allegation investigated: Staff did not maintain a comfortable temperature for resident Staff did not meet resident's dietary needs Staff charged resident for services not rendered

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA was greeted by Executive Director, Stephanie Boudreau to whom she identified herself and discussed the purpose of the visit. The Department investigated the above-listed complaint allegations. The investigation consisted of a tour of the facility, multiple interviews, and a detailed review of relevant records, including medical records and other relevant evidence pertinent to this investigation. On April 16, 2024, Community Care Licensing (CCL) received a complaint alleging that facility staff did not maintain a comfortable temperature for resident (R1), [a LIC 811 Confidential Names List was provided to staff to identify the resident]. It was specifically alleged that the temperature in R1’s apartment was freezing (62-65 °F) because there was airflow coming through the front door from the hallway and that the facility’s heating, ventilation, and air conditioning systems (HVAC) blew cold air inside their apartment. (continue at LIC9099C) Unsubstantiated (Continue from LIC9099) On April 18, 2024, a tour of the facility was conducted, and the apartment was observed to be clean and free from odors. There were two thermostats on the walls, one located inside R1’s bedroom. This thermostat was originally located in the hallway (middle section of the apartment). At the request of R1, facility staff relocated the thermostat inside R1's bedroom. The thermostat indicated the room temperature was 76 °F (degrees Fahrenheit), the temperature was set at 76°F. (The average room temperature in most homes falls between 68–76°F). Per Title 22 regulations the temperature should be within 68-85 °F. LPA noticed that R1 had multiple room thermometers inside their room on top of the dressers, and nightstands, all the room thermometers indicated the temperature to be between 74-76 °F. The 2nd wall thermostat was located in the living room and was observed with a room temperature reading of 78°F, the temperature was set at 77°F. In addition to the wall thermostat, LPA observed multiple room thermometers located on top of furniture in various places in the living room and dining room, the temperature readings ranged between 74-76°F. Note: LPA also observed that R1 had a room thermometer on their hands with a room temperature reading of 76°F. [Note: Every apartment in the facility was equipped with its HVAC unit and the thermostats are located inside each apartment unit. The residents have complete control of setting the thermostat temperature to meet their needs.] LPA observed there was blue painter's tape around the entry door. R1 stated that they felt a draft coming through the door from the hallway and that was the reason they had placed the tape around the perimeter of the door to block the air from blowing into the apartment from the hallway. R1 asked the LPA to feel the draft, but the LPA was not able to feel any draft coming through the door when the door was closed. However, a draft could be felt coming through the door from the hallway as you open the door and when the door was wide open. The temperature in the hallway was comfortable for the LPA. LPA did not feel any air blowing outside in the hallway. R1 stated that at nighttime, is when they felt a draft as if a plane was flying inside the apartment. LPA conducted a brief interview with the housekeeper who was present during the visit and indicated they had no concerns with the temperature inside R1’s apartment. Interviews with facility management and the director of engineering indicated that the facility had been working with R1 in addressing their concerns since they reported the problem on November 13, 2023. Facility maintenance replaced the thermostats twice in November and December 2023 because R1 stated they were old and were not accurate. (Continue at LIC9099C) (Continue from LIC9099C) In addition, R1 requested the thermostats to be relocated twice as well in December 2023 and in January 2024. Maintenance checked and replaced the vents inside their apartment and adjusted the vent louvres located in the hallway to point away from their entry door. Maintenance staff replaced the weather stripping of the entry door and tested it to ensure no air was coming through the door by placing a big blower directly outside the door. On April 8, 2024, R1 hired an independent HVAC consultant to conduct a study and investigate the heating and airflow issues in their apartment. Per an interview with the independent consultant, the project consisted of doing an initial document review, site inspection, preliminary analysis, and consultation with R1. The consultant said that they placed sensors inside the apartment, outside on the terrace, and in the hallway and the readings of the sensors did not detect or disclose any problems with the room temperature. The sensors were placed for several days continuously which monitored the temperature during the day as well as at night. The independent consultant’s findings were consistent with the studies conducted by the facility’s engineers and the maintenance staff. Interviews with multiple residents living on the same floor near R1’s apartment did not disclose any problems with their HVAC. Based on observations, interviews, and records reviewed, there was insufficient evidence that facility staff did not maintain a comfortable temperature in R1’s apartment. It was also alleged that staff did not meet residents’ dietary needs. This allegation was previously investigated by CCL on August 8, 2022. A review of R1's residential agreement indicated that the provider would accommodate customary and reasonable special diets that are prescribed by a physician. A review of R1's Physician's Report dated April 23, 2024, indicated that R1 is allergic to dairy, eggs, and whey. A review of R1's medical records did not disclose any other changes in R1’s diet that required modifications ordered by R1’s physician. There were no records showing that the doctor prescribed any modifications based on medical necessity. Interviews were conducted with residents, including the Chair of the Residents’ Counsel. Residents interviewed indicated that modified diets were available for residents who needed them, including alternative meals for residents with allergies. Resident interviews also indicated that given the diverse population of the residents in care, the facility made every effort to please residents, however, some residents will enjoy certain items, whereas others will not. (Continue at LIC9099C) (Continue from LIC9099C) A detailed review of restaurant menus for April 2024 and observations of the lunch service at the facility during the visit conducted on April 18, 2024, indicated that the residents had a choice of four (4) appetizers to choose from, including two (2) soups and two (2) salads. The main entrée had nine (9) different choices to choose from, including a variety of proteins, including chicken, salmon, lobster, ham, crabs, and hamburgers. Based on interviews, observations, and records reviewed, there was insufficient evidence that the facility failed to adhere to the resident's dietary needs. It was also alleged that staff charged R1 for services not rendered. It was specifically alleged that R1 was charged over $30,000 for food service and they do not eat any meals provided by the facility. R1 stated that they have food allergies and prefer to cook their meals. R1 stated they calculated the amount overcharged by taking the average cost of a meal $25 and multiplying it by the days they have not eaten at the facility. A review of the residency agreement signed by R1 indicated that on October 25, 2016, a memorandum was sent to all residents informing them of the meal plan changes. Effective November 1, 2016, all Independent Living residents will be moved to the “one meal a day” plan. Every month, each Independent Living unit will receive a resident meal allowance equivalent to the number of days in that month (i.e., November = 30 meal allowance; December = 31 meal allowance). The meal allowance will be doubled for those units occupied by two residents. At the time of the meal, you may decide if that meal will be deducted from your meal allowance or charged to your account. It was also indicated that if you did not fully utilize your monthly meal allowance, a credit of $5.50 per unused meal would be applied to the resident’s account at the end of that month and would appear on the following month’s statement. A review of R1's billing statements from (January 2023 - March 2024) showed that R1 received the correct meal credits for each month. R1 stated they do not eat the food provided by the facility because they prefer eating organic food. R1 resides in independent living and can make choices regarding what meals to eat and not eat. R1's medical records and facility assessments confirmed that R1 was independent and was able to make personal choices of which meals to eat to meet their dietary restrictions as well as opt not to eat at the facility and receive the agreed upon meal credit. Based on records reviewed and interviews conducted there was insufficient evidence that facility staff charged R1 for services not rendered. (Continue from LIC9099C) (Continue from LIC9099C) Based on the results of the investigation, which consisted of observations, interviews with key staff and outside sources, and review of pertinent resident and facility records there was insufficient evidence to support the allegations listed in this report. Therefore, these allegations are unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence that the alleged violation occurred. An exit interview was conducted with Executive Director, Stephanie Boudreau, to whom a copy of this report, Confidential Names List (LIC 811), and Licensee Appeal Rights (9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 27, 2024 · control 08-AS-20240416094242

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Annual visit. LPA met with Director of Resident Services, Syril Nelson, and we discussed the purpose of the visit. Executive Director, Stephanie Boudreau is the certified administrator for the facility, and her Administrator's Certificate expires on January 25, 2025. The facility file was reviewed prior to the visit. According to the facility’s license, the facility has a maximum capacity of 783 non-ambulatory elderly residents; age 60 and above. Dementia approved for 23 with delayed egress. The facility is approved for a 25-hospice waiver. The facility was assessed by touring it inside and out. LPA inspected for compliance with safety, maintenance, and operational requirements. LPA interviewed staff, residents in assisted and independent living as well as general conversation with residents in the memory support unit. The facility is separated into three (3) distinct areas, South Tower, North Tower, and the Care Center. LPA briefly interacted with residents in care. All facility staff observed by the LPA have a current criminal record clearance. Nelson stated there are no firearms stored on the premises. The no firearm policy is strictly adhered to. There were five (5) complete dining areas available for all residents. There were at least 2 days of perishable food, and at least 7 days of non-perishable food present, all safely stored in two (2) of the dining areas inspected. Cooking/dining equipment and utensils were present. (continue at LIC809C) (continue from LIC809) There is a facility pool, and LPA toured the area with Nelson. Access to the pool is restricted by way of a key fob and the three (3) doors were secured during the LPA's visit. LPA tested one of the exit doors equipped with a delayed egress door and confirmed working properly. There were a total of four (4) delayed egress exit doors. There were a total of 11 fire extinguishers inspected that had been serviced in February 2024. Today's inspection consisted of parts of South Tower, Assisted Living, and the Care Center. The hot water temperature was measured by maintenance once a month. LPA observed smoke alarms were present in each room. The appliances in the resident rooms were in working order. Each room observed was clean, sanitary, and in good operating condition. It was also observed pull cords in each of the residents' rooms. All bathrooms inspected had grab bars installed by the toilets and shower areas. Cleaning supplies for the housekeeping staff were secured in the housekeeping closet. The signal system was tested in the presence of Nelson; staff responded in less than one (5) minutes. Some of the residents also utilize a pendant that can be worn to request staff assistance in emergencies. The pendant was also tested in the presence of Nelson, and staff responded in less than one (1) minute. Medications were labeled, as required and stored in locked areas. LPA observed several medication carts that were locked and secured. In independent living, all residents keep their medication locked in a medication cabinet. Keys to the medication cabinets were kept and controlled by appropriate staff with responsibility for medication management. All required postings were observed in the facility in assisted living. LPA interviewed staff and reviewed multiple staff and resident records/files. LPA interviews did not raise any licensing concerns. The files that LPA reviewed contained the required documents. Confidential records were stored in locked areas. Facility staff conducted an emergency drill on May 20, 2024, LPA verified that emergency drills were conducted at least quarterly in some cases every two (2) months. Fire drills were conducted each month. The facility updated its disaster and emergency preparedness plan on May 10, 2024. Liability insurance was current, expiration date 12/31/2024. No violations were observed during the visit. During the visit, an exit interview was conducted with the Director of Resident Services, Syril Nelson, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 21, 2024

Allegation investigated: Licensee did not follow the terms of the admission agreement

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA was greeted by Executive Director, Stephanie Boudreau to whom she identified herself and discussed the purpose of the visit. The Department investigated the above-listed complaint allegation. The investigation consisted of a tour of the facility, multiple interviews with staff, residents, and outside sources, and records review. On November 16, 2023, Community Care Licensing (CCL) received a complaint alleging that the facility did not follow the terms of the admission agreement. It was specifically alleged that after being discharged from the hospital, resident (R1) [a LIC 811 Confidential Names List was provided to staff to identify the resident] was not allowed back into their apartment located in the independent living venue of the community. Continue at LIC9099C Unfounded Continue from LIC9099 A review of facility and medical records indicated that on August 28, 2023, R1 tripped on carpet and fell in their apartment. R1 received immediate medical attention and was transported to the hospital by emergency personnel. A review of R1’s medical reports indicated that R1 sustained a severe thumb fracture. R1 was admitted to the hospital for orthopedic hand surgery and was placed into a thumb spica splint. The medical report indicated that R1 showed behaviors with elements of paranoia and dementia. On August 30, 2023, according to the medical report, R1 was discharged with non-weight-bearing instructions on the right thumb and to keep the dressings and splint clean, dry, and intact. A review of the care conference report that took place before discharge with R1, R1's responsible party, and the assigned care manager stated that R1 would require 7/24 care in their independent living apartment after rehabilitation services were provided in skilled nursing aka “Care Center” located in the community. During the care conference, R1 was informed of what was required for them to be discharged back to their independent living apartment when there was a change in condition. Facility management informed R1, as stated in the admissions agreement signed on January 18, 2021, that they would need to have 24-hour caregivers and adhere to the safety precautions required to be in place due to R1’s fall risk condition and cognitive status. Facility management also informed R1 of the option to move out of the facility to another community and that a list of facilities would be provided to assist with finding another community. R1 and R1’s responsible party declined the moving out option and opted for R1 to stay at the care center until further medical evaluations were completed to establish if R1 could return to independent living. During interviews with facility staff, it was indicated that R1 and R1’s responsible party were offered a copy of the "resident rights" but declined acceptance. An interview with R1 confirmed their understanding of their care service plan while living in the care center. In addition, during an interview, R1 confirmed that the facility would hold their apartment while they remained in the care center and that they could access their apartment as needed to obtain any necessary items as long as they were assisted by facility staff. During the investigation, it was determined that the R1 entered into a continuing care residency agreement at the community on January 18.2021. The agreement stipulated that upon transfer to the care center after a hospital stay, the monthly fee would continue to apply if the resident intended to return to the apartment. Continue at LIC9099C Continue from LIC9099 Based on the results of the investigation, which consisted of observations, interviews with key staff, R1, and outside sources, and a review of pertinent resident and facility records there was no evidence found to support the allegation listed in this report. The Department has found that the complaint allegation was unfounded, meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Executive Director, Stephanie Boudreau, to whom a copy of this report, Confidential Names List (LIC 811), and Licensee Appeal Rights (9058 01/16) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Nov 30, 2023 · control 08-AS-20231116081523