Sunrise at La Costa

Allegation investigated: Staff obtained outside services for the resident without prior authorization Staff did not properly supervise the resident Staff did not get resident appraisal updated

Licensing Program Analyst (LPA) Becky Kennedy conducted an unannounced complaint visit to the facility to deliver findings on the above allegations. LPA was granted entry to the facility after identifying herself. LPA met with Jennifer Ortega, Executive Director and explained the purpose of the visit The Department’s investigation consisted of review of facility records, outside source records, and interviews of facility staff and outside sources. The allegations in this complaint all involve Resident 1 (R1). The investigation revealed R1’s mental wellbeing was of some concern prior to admission, including a period of psychiatric hospitalization about a month prior to admission. The initial assessment for R1 noted a mood of sadness and the facility staff would encourage R1 to express their feelings and concerns during mood changes Unsubstantiated R1’s physician’s report noted R1 was depressed but was not suicidal. The physician determined that R1 could leave the facility without supervision. About five months after admission R1 was overheard talking with a suicide prevention hotline. The facility staff contacted R1’s responsible party who was unavailable to assist in obtaining an assessment of R1's needs. The facility contacted the Psychiatric Emergency Response Team (PERT), and after the PERT assessment R1 was transported to a hospital for evaluation. Two days after the PERT assessment the resident was released from the hospital without being admitted for in-patient psychiatric services. The discharge documentation had a note signed by the physician stating R1 “is not suicidal”. Twenty-five days later R! was brought into the facility accompanied by an outside individual who reported that R1 was walking into traffic. The following day facility staff conducted a Suicide Risk Assessment regarding R1. Although R1 denied being suicidal, or having a plan, R1’s behavior of walking in the street without an apparent concern for their safety was noted. After the assessment, and noting the very concerning behavior, facility staff determined that a one-to-one companion was needed to keep R1 safe. An email was sent on a Monday to inform R1’s responsible party of the requirement for a one-to-one companion. Facility staff told R1’s responsible party that they had until Friday to hire a companion. On Wednesday facility staff hired a companion. Interviews revealed that the facility’s practice would be to use facility staff as one-to-one companions until outside staff could be secured. R1 is responsible for the cost of these services. It was alleged that facility staff obtained outside services for the resident without prior authorization. Residential Care Facilities for the Elderly (RCFE) are required to follow Title 22, Division 6 Chapter 8 regulations. Section 87466-Observation of the Resident states 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 observation reveals unmet needs.” A review of the admission agreement signed by R1’s responsible party states that “the community will revaluate resident’s needs to determine which service level is appropriate... The fee charged will be based upon the Service Level provided.” The community determined that R1 needed additional services and arranged for those serviced to be provided. Not the admission agreement, nor the RCFE regulations require that prior authorization is required. This allegation is Unsubstantiated. It was further alleged that facility staff did not properly supervise the resident. The investigation revealed that R1’s initial physician’s report stated that R1 could leave the facility without supervision. Until the incident when R1 was found to be acting unsafe in traffic, the facility had no reason to supervise R1 outside of the community. This allegation is Unsubstantiated. It was further alleged that facility staff did not get resident appraisal updated. The investigation revealed that the day after the incident where R1 was unsafe in traffic, a Suicide Risk Assessment was completed to address the area of concern regarding R1. This allegation is Unsubstantiated. Based on the evidence obtained during the complaint investigation, the above allegations are UNSUBSTANTIATED, meaning the preponderance of evidence standard was not met to prove a violation occurred. An exit interview was conducted with Jennifer Ortega, Executive Director; a copy of this report and Licensee's Rights (LIC9058) were provided.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 08-AS-20221005150217

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Jennifer Ortega, Executive Director. This facility serves one hundred and twenty (120) residents 60 and above; all may be non-ambulatory and fifteen (15) may be bedridden. There is an approved hospice waiver for fifteen (15). During today’s inspection there were 89 residents in care. LPA was accompanied by Executive Director (ED) Jennifer Ortega during a tour of the facility. A tour of the facility was conducted which included a sample of resident units, the dining area, recreation rooms, and food storage areas. Signal systems are in place and operational. PPE supplies are onsite. Passageways were free from obstructions. According to ED, Ortega, there are no weapons and/or ammunition stored on the premises. There are no pools or bodies of water on the premises. Facility does feature delayed egress doors as well as a locked perimeter in Terrace level (Reminiscence Unit). Each resident had clean and sufficient bed linens. All extra linens, towels, and washcloths are stored in resident's individual rooms. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars and anti slip floors. Hot water temperature in residents’ bathrooms were compliant. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. (Continued on LIC809-C) (Continued from LIC 809) Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed room not assessable to residents. Centrally stored medications were properly stored and locked in carts/cabinets. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions. Staff records review verified that all staff records were complete and compliant. Resident records were reviewed and confirmed compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. An exit interview was conducted with ED, Ortega, to whom copies of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. Their signature on this form acknowledges receipt and a copy of the report was given to ED, Ortega.the state’s words, verbatim · CDSS document, Nov 4, 2025

Allegation investigated: Staff are not providing resident with assitance with activities of daily living Staff are not administrating medication as prescribed

Licensing Program Analyst (LPA) Iby Strong made an unannounced visit to open an investigation on the above mentioned allegations. LPA identified herself and disclosed the purpose of her visit. LPA met with Executive Director Jennifer Ortega and discussed the basic elements of the complaint According to allegations, Resident 1 (R1) did not get assistance with activities of daily living and R1 did not receive medication as prescribed. During the visit, LPA Strong was able to establish that Resident 1 (R1) is not and was not a resident of this facility. Therefore the complaint is unfounded. An exit interview was conducted and a copy of Licensee's Rights along with a copy of this report was provided to Executive Director Jennifer Ortega. Unfoundedthe state’s words, verbatim · CDSS document, Oct 7, 2025 · control 08-AS-20250930090346

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Hannah Rodgers conducted an unannounced case management visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Jennifer Ortega. The facility self-reported an incident that occurred on June 1, 2025, and June 2, 2025, involving Resident #1 (R1), Resident #2 (R2), and Staff #1 (S1) [See LIC811 Confidential Name List for identification of select person identifiers used in this report]. The incident report indicated on June 1, 2025, S1 was rough with R1, by grabbing and pulling on both of R1’s wrists in order to get them out of their wheelchair. It was also reported that on June 2, 2025, S1 was witnessed pushing R2’s walker into R2’s knees after R2 would not comply with standing up as S1 had instructed. S1 was placed on suspension and their last day worked was June 2, 2025. S1 was officially terminated by the facility on June 3, 2025. During today’s visit, LPA briefly toured the facility, observed residents in care, reviewed and obtained copies of facility records, and interviewed staff and residents. Interviews with internal sources revealed that S1 was seen being rough R1 and R2 primarily during transfers. LPA attempted to interview R1 and R2, but due to their baseline memory loss, each was unable to be qualified as a reliable historian for this case. Review of R1’s physician’s report dated July 26, 2024, and R2’s physician's report dated June 18, 2025, revealed that both R1 and R2 have a primary diagnosis of Alzheimer's Disease, and both require assistance with all Activities of Daily Living (ADLs) except for feeding themselves. [CONTINUED ON LIC809-C] Review of S1’s Performance Counseling & Improvement Plan for Corrective Action signed and dated June 6, 2025, revealed that S1 did not follow the policy/company rule of abuse or neglect of a resident and was terminated as a result. One deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). An exit interview was conducted with Executive Director Ortega, to whom a copy of this report, LIC 809-C, LIC 809-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.the state’s words, verbatim · CDSS document, Sep 5, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Sep 5, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: "(a)...residents... shall have all of the following personal rights: (8) To be free from neglect...punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse." This requirement was not met, as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as two (2) out of eighty-nine (89) residents were not free from neglect, punishment, and/or physical abuse by S1, which posed a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 5, 2025

Plan of correction: Licensee terminated S1's employment on 6/3/2025 as a result of the incidents with R1 and R2. Licensee provided proof of S1's termination. The deficiency was cleared during LPA's visit.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Hannah Rodgers conducted an unannounced case management visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Jennifer Ortega. The facility self-reported an incident that occurred on August 11, 2025, involving Resident #1 (R1) reporting missing $900 from their bedroom [See LIC811 Confidential Name List for identification of select person identifiers used in this report]. During today’s visit, LPA briefly toured the facility, observed residents in care, reviewed and obtained copies of facility records, and interviewed staff and residents. There were no deficiencies cited during today's visit. However, this incident may require further follow-up visits. An exit interview was conducted with Executive Director Jennifer Ortega, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to.the state’s words, verbatim · CDSS document, Sep 5, 2025

Allegation investigated: Neglect/lack of supervision resulted in a resident-on-resident altercation

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced visit to initiate and deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Jennifer Ortega. On March 6, 2025, it was alleged that Neglect/Lack of Supervision resulted in a resident-on-resident altercation. It was alleged that Resident #1 (R1) hit Resident #2 (R2) in the back twice while getting onto the elevator at the facility [See LIC811 Confidential Name List for identification of select person identifiers used in this report]. The Department’s investigation consisted of an unannounced facility visit, records review, and staff, resident, and outside source interviews. [Continued on LIC9099-C] Unsubstantiated Record review revealed that on March 4, 2025, the Executive Director of the facility self-reported this witnessed incident to the Department. Per record review and staff interviews, on March 2, 2025, at approximately 2:20 PM, R2 was receiving assistance from Staff #1 (S1) getting off the elevator with their walker. R1 was in their electric wheelchair waiting to exit the elevator when they got frustrated with the amount of time R2 was taking to exit so they slapped R2 in the back open handed twice. During this incident S1, while assisting R2, asked R1 to be patient as R1 was vocalizing their frustration. Once R1 hit R2, S1 immediately intervened and separated the two residents. Per interview, the two residents were exiting the elevator to attend an activity. While both residents still attended the activity, staff ensured they sat on opposite sides of the room and supervised the two residents during the activity. The residents did not interact after the altercation. Per staff interviews, S1 assessed R2 for injuries and inquired about how they were doing. R1 was then interviewed by Staff #2 (S2) to which they admitted to hitting R1. R2 was interviewed shortly after but could not recall the incident due to baseline memory loss. Record review and interviews revealed that local law enforcement was notified, and the facility notified the appropriate parties of the witnessed incident between R1 and R2. Review of R1’s medical assessment records dated September 29, 2023, revealed that R1 had a diagnosis of arthritis, was not confused or disorientated, and did not exhibit inappropriate or aggressive behaviors. Review of R1’s individual service plan report did not reveal any specialized observation requirements. Staff interviews revealed this incident was R1’s first physical incident with another resident. Review of R2’s individual service plan report dated December 17, 2024, revealed R2 needs a one person assist with mobility to escort them to meals and activities. Interview with S1 verified this need for R2 and thus explained their presence for the altercation between R1 and R2. Based on interviews and records review, the investigation did not yield a preponderance of evidence to conclude that the facility’s neglect/lack of supervision resulted in a resident-on-resident altercation. Based on the foregoing, the allegation is unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director Ortega, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 08-AS-20250306150642

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Hannah Rodgers conducted a Case Management - Incident visit. LPA identified themselves and met with Executive Director Jennifer Ortega, to discuss the purpose of the visit. The facility self reported an incident that occurred on February 18, 2025 involving Resident #1(R1), Resident #2(R2), Resident #3(R3), Resident #4(R4) and Staff #1(S1) [See LIC811 Confidential Name List for identification of select person identifiers used in this report]. The incident report indicated S1 was rough with R1, R2, R3, and R4 while providing care. S1 was placed on suspension and their last day worked was February 18, 2025. S1 officially resigned from the facility February 25, 2025. LPA conducted interviews with residents and staff. Staff interviews provided conflicting information. Per interviews, S1 was designated to the memory care floor primarily on the right wing. Per staff interviews, the right wing is challenging as there are eight residents who require total assistance with transfers from and to wheelchairs, including R1, R2, R3, and R4. LPA attempted to interview R1, R2, R3, R4, and a sample of their floor mates, but due to their baseline memory loss, each was unable to be qualified as a reliable historian for this case. Interview with S1 did not reveal they had been rough with residents and denied the allegations. Based on interviews and records review, there did not yield a preponderance of evidence to conclude that S1 was rough with residents. No deficiencies were cited during the visit. An exit interview was conducted with Executive Director Ortega, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 12, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Amy Rodgers and Angelica Boyles, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPAs were granted entry into the facility by Evelyn Franco, Wellness Nurse. LPAs identified themselves and stated the purpose of the inspection. This facility serves one hundred and twenty (120) residents 60 and above; all may be non-ambulatory and fifteen (15) may be bedridden. LPAs were accompanied by Interim Executive Director (IED) Jennifer Ortega during a tour of the facility. A tour of the facility was conducted which included a sample of resident units, the dining area, recreation rooms, and food storage areas. Signal systems are in place and operational. PPE supplies are onsite. Passageways were free from obstructions. According to IED, Ortega, there are no weapons and/or ammunition stored on the premises. There are no pools or bodies of water on the premises. Facility does feature delayed egress doors as well as a locked perimeter in Terrace level (Reminiscence Unit). Each resident had clean and sufficient bed linens. All extra linens, towels, and washcloths are stored in resident's individual rooms. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars and anti slip floors. Hot water temperature in residents’ bathrooms were compliant. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed room not assessable to residents. Centrally stored medications were properly stored and locked in carts/cabinets. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions. Staff records review verified that all staff records were complete and compliant. Resident records were reviewed and confirmed compliant. LPAs reviewed the theft and loss policy and procedures. LPAs conducted a thorough review of In-service training procedures. Transportation procedures are compliant. LPAs observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. An exit interview was conducted with IED, Ortega, to whom copies of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. Their signature on this form acknowledges receipt and a copy of the report was given to IED, Ortega.the state’s words, verbatim · CDSS document, Oct 30, 2024

Allegation investigated: Staff did not safeguard resident's personal belongings.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver investigation findings. LPA was granted entry into the facility and met with Executive Director (ED) Arguero Hernandez , to whom she disclosed the reason for the visit. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA observation, records review and interviews with facility staff and outside sources. According to records review a LIC621 (Resident Personal Property and Valuables Inventory) was in R1's facility file however, the document was not completed. According to interviews with R1's responsible party (RP) the Licensee did not present the LIC621 document at time of move in or during contractual presentation. Therefore, no residential personal property and valuables were inventoried at time of move in. (Continued on 9099C) Unsubstantiated (Continued from 9099) ED Arguero Hernandez tour showed that while R1 did have a myriad of bags in their room, the RP claims they are not the bags or items R1 brought into the facility at time of move in. During the 9/27/2024 tour LPA Rodgers accompanied by S1 and R1 looked through items in closet and discovered a few pieces of possible gold jewelry along with cosmetic jewelry. LPA Rodgers advised ED Arguero Hernandez to speak with R1's RP and encourage the RP to take home R1's the more valuable items for safe keeping. Police report (dated 7/16/24 and 7/23/24) can not confirm or deny any items were taken from R1’s room. An OS1 was interviewed and was able to confirm they had no concerns about theft of residents belongs. According to the facility’s running Theft and Loss Records: There was no mention of any missing items reported over the last 12 months with the exception of R1's belongings. Based on evidence obtained from interviews, observations and records reviewed, no corroborating evidence was obtained to indicate the facility failed to safeguard a client’s belongings. Based on the Department's investigation there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with ED Arguero Hernandez to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) will be provided at the conclusion of today's visit.the state’s words, verbatim · CDSS document, Sep 27, 2024 · control 08-AS-20240822162042

Allegation investigated: Licensee did not issue resident’s authorized representative a timely refund.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver investigation findings. LPA was granted entry into the facility and met with Executive Director Arguero Hernandez, to whom she disclosed the reason for the visit. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA observation, records review and interviews with facility staff and outside sources. On 8/27/2024 it was alleged that the Licensee did not provide Resident 1’s (R1’s) Responsible Party (RP) a full refund after the death of a resident. A records review revealed R1’s RP was issued a full refund of the original pre-paid rent within 15 days the removal of all personal belongs belonging of R1. The full refund was issued on 5/7/2024. The records also indicate an automatic ACH withdrawal was also made on 5/6/2024 from R1’s personal account. Further records reviewed as well as interview with S1 indicates there was an accounting oversight from the licensee and an additional refund was issued 8/23/2024 to R1’s RP. (continued on 9099-C) Unsubstantiated (Continued from 9099) Interviews conducted with Responsible Party and the ED Arguero Hernandez, as well as a facility records review revealed the facility issued the RP a refund in an amount meeting the Department’s mandate. Based on the Department's investigation there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director Arguero Hernandez to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) will be provided at the conclusion of today's visit.the state’s words, verbatim · CDSS document, Sep 27, 2024 · control 08-AS-20240827140738

Allegation investigated: Licensee did not make available for public viewing a licensing report from the preceding 12 months.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Marlen Arguero-Hernandez. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, records review, and LPA observations. It was alleged that the Licensee did not make available for public viewing a licensing report from the preceding 12 months. LPA observations, corroborated by staff interview and records review, revealed that public licensing reports and/or information regarding how to obtain them, were not made available to residents and visitors. LPA directly observed the concierge station and required postings during two (2) unannounced facility visits; LPA did not observe any Licensing reports or signs informing of how to view a report. Interview with front desk staff revealed admissions that staff did not know what a Licensing report was, nor where to locate the reports from the preceding 12 months. Staff were unable to locate a sign or instructions on how to obtain a Licensing report. (Continued on LIC9099-C p.2) Substantiated (Continued from LIC9099 p.1) Staff interview and LPA observations further revealed that a sign informing the public regarding Licensing reports existed at the facility, but had been taken down at an unknown time and placed in an office, away from public view. Based on interviews, records review, and LPA observations, the preponderance of evidence has been met that alleged violation occurred and is therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Executive Director Marlen Arguero-Hernandez, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from LIC9099 p.1) Staff interviews were also inconsistent regarding the facility's policy on moving furniture; some staff informed that moving resident furniture was against facility policy due to liability reasons. Other staff informed that this policy did not exist, and that the required furniture should have been moved. Staff interviews and records review further revealed that the staff member who moved R1's bed into the temporary room was disciplined for the action. No records were found to corroborate that a facility policy existed restricting staff from moving resident furniture. Records and interviews did not produce evidence to confirm which furniture was moved into R1's temporary room. LPA directly observed the unfurnished room in question; the lighting was ambient from the bathroom only; no ceiling light existed in the room. Outside sources interviewed did not have observations and/or were not able to recall which furniture existed in R1's temporary room during the timeframe of complaint. R1 passed away in June 2023 and was not able to be interviewed for the investigation. It was alleged that the Licensee did not provide a Resident 1 (R1) with basic laundry service. Staff interview revealed that laundry was completed according to a weekly schedule, and evening caregivers were responsible for putting resident laundry out, to be picked up by laundry staff the next morning. Staff interview further revealed that R1 had significant incontinence issues, which resulted in their clothing needing to be changed more frequently. Review of facility records corroborated staff statements that R1's personal laundry was washed each Friday by caregiving staff, and R1's linens and towels were washed on Mondays by housekeeping staff. Records also revealed that between January - March 2023, 11 additional loads of R1's laundry were washed outside of R1's regular wash day, as needed. Outside sources interviewed had not observed R1 in dirty, mismatched, or missing clothing, nor had they observed R1's closet to be void of clothing or an overflowing laundry basket. R1 passed away in June 2023 and was not able to be interviewed for the investigation. It was alleged that the Licensee did not employ a full-time activities director, as required based on capacity. Staff interviews revealed that while the activities director position was vacant during the timeframe of complaint, temporary staff were put in place to perform the duties until a permanent staff member was identified. (Continued on LIC9099-C p.3) (Continued from LIC9099-C p.2) Records review corroborated staff statements; schedules and personnel records showed that a combination of 3 staff members were assigned to the activities director position from December 2022 to April 2023. It was alleged that the Licensee did not provide a responsible person a written report of an incident which threatened a resident’s welfare within seven days. Review of Department and facility records revealed that the incident in question occurred on 6/3/23 and the responsible person was notified by staff regarding the incident via phone. Records review further revealed that the Licensee emailed the incident report to the responsible party on 6/7/23, four (4) days after the incident occurred. The evidence shows that the Licensee provided the incident report within the required timeframe. It was alleged that the Licensee did not provide a responsible person copies of resident’s general care records within two business days. Staff interview revealed that the Executive Director acknowledged the records request the day it was made and started the process. Staff interview further revealed that records requests were provided after the corporate legal team affirmed it. Staff interview, corroborated by records review, showed that the request was made by the responsible person on 6/14/23 and acknowledged by the Executive Director. Records review further showed that the records were sent to the responsible person on 6/20/23. The evidence shows that the facility started the records request immediately to produce the records, and they were provided to the responsible person. Based on interviews, direct LPA observations and records review, the investigation did not yield sufficient evidence to conclude that Licensee did not provide resident with required bedroom furniture, Licensee did not provide resident with basic laundry service, Licensee did not employ a full-time activities director, as required based on capacity, Licensee did not provide a responsible person a written report of an incident which threatened a resident’s welfare within seven days, and Licensee did not provide a responsible person copies of resident’s general care records within two business days. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director Marlen Arguero-Hernandez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 29, 2024 · control 08-AS-20230710094552

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.38(a) · Plan of correction due date: Mar 29, 2024

Each residential care facility for the elderly shall place in a conspicuous place copies of all licensing reports issued by the department within the preceding 12 months, and all licensing reports issued by the department resulting from the most recent annual visit of the department to the facility. This requirement was not met, as evidenced by: Based on interviews, records review and observations, Licensee did not place copies of all licensing reports within the preceding 12 months in a conspicuous location. This posed a potential health and safety risk to 91 of 91 persons in care.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: During a facility visit on 3/13/24, Executive Director immediately posted a sign regarding obtaining Licensing reports at the concierge desks. Executive Director provided proof that in-service training had been started, and confirmed that all additional concierge staff would be trained by 3/29/24.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Interim Executive Director (IED), Thais Andrade Souza, after identifying themselves and stating the purpose of the inspection. This facility serves one hundred and twenty (120) residents 60 and above; all may be non-ambulatory and fifteen (15) may be bedridden. LPA was accompanied by IED, Souza during a tour of the facility. A tour of the facility was conducted which included a sample of resident units, the dining area, recreation rooms, and food storage areas. Signal systems are in place and operational. PPE supplies are onsite. Passageways were free from obstructions. According to IED, Souza, there are no weapons and/or ammunition stored on the premises. There are no pools or bodies of water on the premises. Facility does feature delayed egress doors as well as a locked perimeter in Terrace level (Renaissance Unit). Each resident had clean and sufficient bed linens. All extra linens towels, and washcloths are stored in locked closet. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars and anti slip floors. Hot water temperature in residents’ bathrooms were compliant. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed room not assessable to residents. Centrally stored medications were properly stored and locked in carts/cabinets. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions. Staff records review verified that all staff records were complete and compliant. Resident records were reviewed and confirmed compliant. LPA reviewed the theft and loss policy and procedures. LPA conducted a thorough review of In-service training procedures. Transportation procedures are compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. An exit interview was conducted with IED, Souza, to whom copies of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. Their signature on this form acknowledges receipt and a copy of the report was given to IED, Souza.the state’s words, verbatim · CDSS document, Nov 27, 2023