Sungarden Terrace

Allegation investigated: Licensee did not meet reporting requirements related to scabies incident.

icensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the findings in the above-mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Administrator During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, and outside sources. On 2/13/26, the department received a complaint alleging the Licensee did not meet reporting requirements related to scabies incident. Staff 1 (S1) stated that while they monitored the resident’s condition, no report was made to Community Care Licensing (CCL) within the required timeframe. (Continue on LIC9099C) Substantiated (Continue LIC9099) Staff 2 (S2) acknowledged awareness of R1’s symptoms and confirmed that no verbal or written report was submitted to CCLD. S2 explained that they believed a report was only required once a formal diagnosis was confirmed, rather than at the onset of symptoms or suspicion of a communicable condition. A review of records indicated that the facility did not submit an LIC 624 or any other type of required report to Community Care Licensing. Under communicable disease guidelines used by Community Care Licensing and County Department Public Heath, scabies is classified as a communicable disease, and even one suspected case in a facility is treated as a potential outbreak due to ease of spread. Facilities are expected to report, isolate appropriately, and implement control measures. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and are 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 Susan O'Shaughnessy, Administrator,, 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 29, 2026 · control 08-AS-20260213115042

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: May 29, 2026

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require.. (2) Occurrences, such as epidemic outbreaks, poisonings,. which threaten the welfare, safety or health of residents .. shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met, as evidenced by: Licensee did not follow reporting requirements for 1 of 44 residents. This posted a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2026

Plan of correction: Administrator agrees to complete a training with an outside source and provide proof of completion, which was completed prior to the POC date of today.

Allegation investigated: Licensee did not give resident medication as prescribed.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Susan O'Shaugnessy. The Complainant alleged that Licensee did not give a resident medication as prescribed. Specifically, they claimed that facility staff in practice did not give Resident #1 (R1) their ABH (a compound of Ativan, Benadryl, Haldol) topical gel at the required frequency called for in R1’s hospice physician’s orders. [See LIC811 Confidential Names List for a description of R1.] CCLD’s investigation involved multiple unannounced facility tours/welfare checks, review of relevant facility and hospice care records on R1, and interviews of pertinent facility staff and outside sources. [CONTINUED ON LIC 9099, 1 of 2] Substantiated [CONTINUED FROM LIC 9099] R1 was not interviewed for this case because they had moved out of the facility by the date CCLD received the complaint, and then R1 passed away under hospice care, from their Alzheimer’s Disease, just two days later. Multiple family members unanimously reported that R1 could not be meaningfully interviewed during their final days. LPA reviewed the hospice medication orders regarding R1’s ABH gel, which were signed and in Licensee’s possession, and the facility’s Medication Administration Records (MARs) on R1, showing when staff applied the ABH gel to R1’s skin, in practice. Together, these documents showed: From 03/20/2026 through 03/31/2026, facility staff wrote in the MAR that the ABH gel should be applied to R1’s skin “every 8 hrs. routinely or every 4 hrs. as needed,” when in reality, R1’s hospice doctor had ordered the ABH gel to be given every 8 hours routinely, and additionally up to once every 4 hours as needed. In practice, staff applied the ABH gel to R1’s skin 2 times on 03/20/26, 1 time on 03/21/26, 2 times on 03/22/2026, 1 time on 03/25/2026, 1 time on 03/26/2026, 1 time on 01/29/2026, and 2 times on 03/31/2026. There were 26 missed routine doses of the ABH gel between 03/20/2026 and 03/31/2026. Then from 04/01/2026 through R1’s move-out on 04/04/2026, facility staff wrote in the MAR that the ABH gel should be applied to R1’s skin “every 4 hours routinely topical for agitation,” consistent with a changed/updated hospice order executed around that time. However, in practice, staff applied the ABH gel to R1’s skin 1 time on 04/03/2026 and 2 times on 04/04/2026. There were thus 18 missed routine doses of the ABH gel between 04/01/2026 and R1’s physical move-out around midday on 04/04/2026. Review of R1’s hospice agency’s visit records showed multiple of their nurses wrote that facility staff were not giving R1 their ABH cream as ordered, despite their giving corrective instruction. LPA’s interviews of multiple facility medication technicians showed they lacked clarity and consensus on the matter, and corroborated that the ABH gel was not given to R1 exactly as it was prescribed during the complaint period. Manager interview showed that during the complaint period, there was an unplanned staffing vacancy at the Resident Services Director (RSD) role, and there was no licensed nurse or pharmacist active on the staff roster. (This point is already being addressed in a separate Annual Inspection report.) The RSD is ordinarily the facility’s lead clinician who oversees the facility’s medication management program. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] Based on records and interviews, a preponderance of evidence exists to show that Licensee did not give a resident medication as prescribed. The allegation is therefore Substantiated, and one (1) deficiency was cited for it per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Administrator Susan O'Shaugnessy, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. [CONTINUED FROM LIC 9099-A] The Complainant said S1 and S2 then speedily pushed R1 forward in their wheelchair to their bathroom (located inside R1’s bedroom) without the footrests in place, causing R1’s feet to fold and drag behind them on the floor. R1 was not interviewed for this case because they had moved out of the facility by the date CCLD received the complaint, and then R1 passed away under hospice care, from their Alzheimer’s Disease, just two days later. Multiple family members unanimously reported that R1 could not be meaningfully interviewed during their final days. According to R1’s LIC602 Physician’s Report and Licensee’s preplacement appraisal documents, and corroborated by interviews of staff and outside sources: A few weeks before R1 moved into the memory care unit at Sungarden Terrace, R1 had a fall at their own home that resulted in a “displaced transverse fracture of right patella” (i.e., kneecap) and “other abnormalities of gait/mobility,” for which R1 underwent surgery. While living at the facility, R1’s dementia was pronounced, they were usually disorientated, were non-ambulatory status, were wheelchair-dependent and frail, wore incontinence products, and relied on staff to help them with mobility, transferring, and toileting, among other tasks. Hospice agency records further showed that R1 had been admitted to hospice care on 03/16/2026 for “Alzheimer’s disease” and “severe protein-calorie malnutrition,” that R1 “remained confused and agitated,” and that R1 was experiencing “delirium after anesthesia for [their] knee surgery.” The Complainant provided the names of multiple outside visitors [Person #1 (P1), Person #2 (P2), Person #3 (P3), and Person #4 (P4)] who allegedly witnessed the 04/04/2026 transferring incident. LPA contacted each of these persons for interview. P1 said R1’s transfer was too “abrupt” and “fast,” and that R1’s feet dragged on the floor as S1/S2 wheeled R1 to their bedroom. P1 said S1 and S2 were similarly rough with R1 in the bathroom, as they transferred R1 on and off the toilet. P2 said S1 and S2 “seemed rough” in the way they “wrenched” R1 out of the living room recliner chair, but also acknowledged that R1 was non-alert, “deadweight,” and “hunched over” on this date. P2 recalled R1 expressing to the caregivers their desire to go use the bathroom, prior to the transfer. P2, who was very knowledgeable about R1’s care needs, explained that it was appropriate that staff purposely removed R1’s wheelchair footrests, since they presented more of a hazard than help to R1, given R1’s hallucinating and repeated attempts at pedaling themselves or standing up with the footrests still in the way. [CONTINUED ON LIC 9099-C, 2 of 3] [CONTINUED FROM LIC 9099-C, 1 of 3] P3 said R1 was mumbling during the incident and that S1 and S2 were “a bit rough” during the transfer, but P3 also did not fully commit to saying that the transfer was objectionable. P4, meanwhile, did not respond to LPA’s multiple interview requests. In their own separate interviews about the incident: S1 and S2 each told LPA that they worked together to transfer R1 from living room couch chair to wheelchair, in a coordinated fashion. They reported R1 on this date could not fully bear their own body weight. They both denied seeing R1 being resistant leading up to the transfer. They both said they each stood opposite each other on R1’s sides and lifted R1 from under their armpits and by grabbing the waistband of R1’s pants (rather than R1’s hands, elbows, or lower arms). They both denied being rough in lifting R1 up; they said the speed of the transfer was reasonable given that R1 could not help with their own legs. They both denied dropping R1 roughly into the seat of their wheelchair. They both explained that wheelchair footrests were intentionally not used for R1, due to their presence increasing the likelihood of injury to R1, considering R1’s known pattern of behavior. They both denied seeing R1’s feet drag on the floor as they wheeled R1 to and from their bedroom. LPA also separately interviewed 2 of 2 other staff who witnessed the transfer, Staff #3 (S3) and Staff #4 (S4), who both closely corroborated the points S1 and S2 had explained above. Inside the bathroom itself, S1 and S2 continued to provide two-person assistance to R1. They both denied transferring R1 roughly on and off the toilet. Another staff member was present for a portion of the time in the bathroom, and they denied seeing any rough transfers there, either. LPA reviewed pertinent surveillance camera footage of the incident, which per CCLD requirements, depicted only common areas and hallways and featured video only, with no-audio component. There was a supporting post/column in the memory care living room which obstructed part of the camera’s view on R1. However, according to the footage: There was no clear visible evidence that R1 physically resisted staff leading up to the transfer. S1 and S2 positioned themselves on each side of R1. S1 and S2 bent their knees, paused, and worked together to lift R1 in coordinated fashion. R1 was deadweight. S1 and S2’s first exertion was not successful, and they immediately lowered R1 back to the seat of the chair. On the second exertion, they were able to lift R1 up and transfer R1 to their nearby wheelchair. During this second exertion, S3 even briefly reached in to assist, but by then the transfer was mostly complete. The available footage did not clearly indicate that either S1 or S2 had grabbed R1’s elbow or forearm area. Once in the wheelchair, R1 remained leaning/bent over forward with a hunched back, unable to sit upright, and appearing minimally-alert. [CONTINUED ON LIC 9099-C, 3 of 3] [CONTINUED FROM LIC 9099-C, 2 of 3] R1’s legs looked thin and atrophied on camera. As S2 rolled R1 in their wheelchair to their room, they did so by walking the wheelchair backwards, with S1 walking behind them. There was no indication that R1’s feet meaningfully dragged on the floor during this transit from the living room to their room. A few minutes later, S1 rolled R1 in their wheelchair from their room back to the living room. This time, S1 pushed the wheelchair in a forward direction, but there was still no indication that R1’s feet meaningfully dragged on the floor. Based on records and interviews, a preponderance of evidence does not exist to show that Licensee’s staff handled R1 in an rough manner, considering the overall context of R1’s physical and mental state during the incident. The allegation is therefore Unsubstantiated, and no deficiency was cited for it. An exit interview was conducted with Administrator Susan O'Shaugnessy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 08-AS-20260408093545

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 23, 2026

87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not assist 1 of 46 residents (R1) with self-administered medications as needed/prescribed, which posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: As of the date of deficiency issuance, R1 had passed away from natural causes. Per manager interview, Licensee continues to search for a replacement RSD. In the meantime, Licensee has arranged with Ron’s Pharmacy to hire a consultant pharmacist and/or nurse to perform a review of the facility’s medication management program and procedures, scheduled to occur the first week of May 2026. Licensee agreed during this time to also have this licensed professional conduct a medication training in-service for the facility’s current med techs, and to E-mail the training sign in sheet to LPA, by the POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite deficiencies identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Susan O'Shaugnessy. Facility internal incident reports and progress notes, combined with hospice visit records and interviews of managers and outside sources, aligned to show: Resident #1’s (R1’s) terminal/admitting hospice diagnoses were “unspecified severe protein-calorie malnutrition” and “Alzheimer’s disease with late onset.” [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] R1 had an unwitnessed fall inside their bedroom on the evening of 03/31/2026, after which facility staff phoned R1’s responsible person (RP) and hospice agency. Per hospice notes, facility staff reported to hospice personnel that R1’s left elbow following the fall had redness, swelling, and pain with movement. A hospice nurse visited and assessed R1 that same evening, writing, “[R1’s] left elbow noted to be significantly swollen, red, warm to touch, and tender compared to right elbow…pain evidenced by grimacing and guarding left elbow.” The hospice nurse stated to facility staff that they believed R1’s left arm to have a fracture and recommended that R1 be sent to the hospital. However, R1’s responsible person did not want R1 sent to the hospital. Licensee deferred to the RP and did not call 911 for R1, which is still required when there is a medical emergency not directly related to the expected course of the resident’s terminal illness. (Per regulation, Licensees are required to call 911 in these situations. If a resident and their RP still refuse transport to the hospital, then they should do so directly to the first responders, after those first responders have evaluated the resident on scene and provided their own recommendations). [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Licensee’s own internal written policy titled “Medical Emergency” states, “The Administrator or caregivers are not required to obtain permission from the family/responsible party before summoning emergency medical services.” R1 remained at the facility through 04/04/2026, during which time Licensee did not seek or arrange for mobile X-ray to be performed on R1’s arm. R1 then passed away at home on 04/10/2026. Per the hospice agency, R1’s cause of death was “Alzheimer’s Dementia.” Licensee also did not submit an LIC624 Incident Report (or equivalent written report) to CCLD or R1’s RP, describing R1’s fall and symptoms. (Regulation requires such a written report to be submitted to both CCLD and the RP within seven days of incident occurrence.) Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). Plans of Correction were jointly developed with the Licensee. LPA also provided Technical Assistance regarding CCLD’s interpretation of a resident’s right to privacy (refer to the LIC 9102-TA page). An exit interview was conducted with Administrator Susan O'Shaugnessy, to whom a copy of this report, the LIC 809-D page, the LIC9102-TA page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 23, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87469(c)(3) · Plan of correction due date: May 23, 2026

87469 Advanced Directives and Requests Regarding Resuscitative Measures: “(c)(3) Specifically for a terminally ill resident that is receiving hospice services…For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).” This requirement was not met, as evidenced by: Based on records and interviews, when 1 of 45 residents (R1), who was receiving hospice services, experienced a medical emergency not directly related to the expected course of their terminal illness, Licensee did not immediately telephone emergency response (9-1-1) for them. This posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Licensee agreed to conduct in-service retraining for current staff on Licensee’s existing “Medical Emergency” written policy and regulations CCR 87465 and 87469. (The texts of these regulations were provided to the administrator during today’s visit.) Licensee agreed to E-mail a copy of the training sign-in to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Apr 30, 2026

87211 Reporting Requirements: “(a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified…(D) Any incident which threatens the welfare, safety or health of any resident…” This requirement was not met, as evidenced by: Based on records and interviews, 1 of 45 residents (R1) experienced an incident which threatened their welfare and/or health, and Licensee did not submit a written report to the licensing agency and the resident’s responsible person within seven days. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: During today’s visit, LPA provided the facility administrator training on LIC624 Incident Reports and the full text of CCR 87211. Licensee agreed to write an LIC624 Incident Report describing their current knowledge regarding R1’s fall on 03/31/2026, and to E-mail a copy of this to both R1’s RP and CCLD (CCLASCPSanDiegoRO@dss.ca.gov), bcc’ing LPA on both E-mails, by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Dang Nguyen made an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrative Assistant Jasmine Ybarra. LPA then met with Administrator Susan O’Shaughnessy, who arrived shortly after. According to the facility’s license, the facility has a maximum capacity for one-hundred-ten (110) residents, of whom all may be ambulatory or non-ambulatory, and up to ten (10) may be bedridden. Also, up to twenty (20) of the residents may be under hospice care at any given time. Per LPA observation, LIC602 Physician’s Reports, and manager interviews: During today’s inspection, there were a total of forty-nine (49) residents in care, of whom thirty-four (34) were non-ambulatory, and one (1) was bedridden. Also, eight (8) of the residents were under hospice care. The facility’s license and fire clearance allowed for the use of locked perimeter doors in the memory care unit, and such doors were compliant with this stipulation. LPA reviewed records for multiple residents and multiple staff. LPA interviewed multiple staff. LPA, accompanied by the administrator, also toured the interior and exterior of the facility, and inspected all common areas and multiple resident rooms. 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 working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was complaint at 75 F. [CONTINUED ON LIC 809-C, 1 of 2] [CONTINUED FROM LIC 809] Where tested, hot water temperature at taps accessible to residents were compliant. Appliances to preserve perishable food were also all compliant in temperature: Main Walk-In Refrigerator was 37.7 F. Main Walk-In Freezer was 0 F. The Medication Room Refrigerator was also complaint in temperature. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. No fireplaces or pools (or similar bodies of water) were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Fire detection system, carbon monoxide detectors, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguishers were serviced within the last twelve (12) months. Required licensing postings were observed in visible areas of the facility. Fire/disaster drills were performed at required intervals. Licensee presented proof of current business liability insurance. During a review of records, LPA observed, and manager interview confirmed: For 1 of 5 sampled residents [Resident #1 (R1)] Licensee did not possess proof/documentation that the resident had a negative tuberculosis test result or chest X-ray, as was required to be on file before the resident’s move in. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] For 4 of 5 sampled residents [Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5)], Licensee did not have as part of the resident’s record the name, address, and telephone number of a dentist to be called in an emergency, as required. For R2, Licensee also did not have as part of resident’s record the name, address, and telephone number of a physician to be called in an emergency, as required. Licensee did not have proof/documentation that within the last twelve (12) months, they held a meeting/conference with the responsible person and other appropriate parties for 5 of 5 sampled residents (R1 through R5), for the purpose of reviewing and updating the resident’s written record of care / care plan, as was required. [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809-C, 1 of 2] Licensee did not possess an LIC610E Emergency and Disaster Plan that met current regulatory requirements. Licensee also did not possess documentation demonstrating that either a consultant pharmacist or nurse had reviewed the facility’s medication management program and procedures at least twice per year, which is a requirement for residential care facilities for the elderly licensed to provide care for 16 or more persons. Three (3) deficiencies were cited per California Code of Regulations, Title 22, and two (2) deficiencies were cited per California Health and Safety Code (refer to the attached LIC809-D pages). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Administrator Susan O’Shaughnessy, to whom a copy of this report, the LIC 809-D pages, and the LIC811 Confidential Names List were provided during today’s visit.the state’s words, verbatim · CDSS document, Mar 27, 2026

Allegation investigated: Resident sustained a broken arm while in care

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Administrator Susan O'Shaughnessy. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. It was alleged that resident sustained a broken arm while in care. Interviews revealed on 08/12/2025 Resident 1 (R1) was in the memory care unit. Interviews revealed there were two staff on the overnight shift a caregiver and a med tech who was training a new staff. Interviews revealed while Staff 1 (S1) the med tech and trainee were upstairs, S2 (the caregiver) was downstairs covering the memory care unit. Interviews revealed that staff are supposed to do rounds every 2 hours. Interviews revealed that according to camera footage in the facility that S2 rounds began at 11:11pm, another was conducted at 3:49am and 5:28am. Interviews revealed it was at 5:28 am on 08/13/2025 that S2 conducted their rounds and observed that R1had an unwitnessed fall and was on the floor with a dried bowel movement (BM) on the side of them. Substantiated Interviews revealed that S2 called S1 on the walkie talkie told them about the incident. Camera footage showed S1 arrived at the room at 5:31am, then S1 called the lead med tech @5:37am to inform them of the incident. Interviews revealed the lead med tech told them not to move the resident, grab R1s medical book, to call 911 and call the hospital to let them know R1 was coming and that they needed a sitter. Interviews revealed that S1 relayed the message of not moving R1 to S2. Interviews revealed S1 went to the front of the facility to grab the book and make the call to 911. Interviews revealed when S1 returned to the R1s room, S1 observed R1 had been moved, showered and was dressed. Interviews revealed that camera footage shows S2 requesting towels from another staff despite R1 showing complaints of pain while their shoulder was popped out. Interviews revealed the company policy states that rounds are to be conducted every 2 hours. It also states in the event of a witnessed or unwitnessed fall, where a resident is expressing pain, the resident must not be moved and 911 must be called immediately. EMS personnel arrived on scene at 6:03 am and took R1 to the hospital. Records reviewed revealed R1 was diagnosed with resident sustained a right humerus fracture and a small subdural hematoma. (The report shows resident suffered a right fracture humerus back in January 2025 as well and at that time they were treated non surgically) and R1 was discharged to a skilled nursing facility from the hospital. Interviews revealed the staff were written up for their actions on 08/13/2026. Interviews revealed that S1 quit after their write up and S2 was terminated on 08/20/2025 due to failure to conduct resident rounds every two hours, as required. Video footage indicated rounds were completed at 11:11 pm., 3:49 am., and 5:28 am., falling short of the mandated schedule. Improper handling of a resident following an unwitnessed fall. Despite the resident expressing pain and showing signs of a displaced shoulder, S2 proceeded to move, shower, and dress resident prior to EMT arrival and failure to adhere to emergency protocol. (The Company policy clearly states that in the event of a witnessed or unwitnessed fall accompanied by pain, the resident must not be moved and 911 must be called immediately. These actions represent a serious breach of our standards of care and safety protocols and compromise the well-being of our residents). Based on interviews, and records review, the allegation is valid, and the preponderance of the evidence has been met. An exit interview was conducted with Susan O'Shaughnessy, 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 19, 2026 · control 08-AS-20250917154616

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 2, 2026

Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not ensure that R1 was provided care and supervision, which posed an immediate health, safety, and personal rights risk to 1 (R1) of 41 residents in care.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: Licensee agrees to schedule an in-service training on the topics of care and supervision and protocols for staff by an outside source.Licensee will send proof of training, training materials and sign in sheet to CCL by POC due date of 04/02/2026

Allegation investigated: The facility did not provide enough staff for adequate resident care. Unqualified Facility staff administered medications to residents

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Administrator Susan O'Shaughnessy. On 9/4/25 it was alleged that the Licensee did not provide enough staff for adequate resident care. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Interviews were conducted with three staff members, three residents, and three outside sources. All staff reported that staffing assignments are posted daily and coverage is sufficient to meet resident needs, including assistance with ADLs, medication administration, and timely call-light response. (Continued on LIC9099C) Unsubstantiated (Continued from LIC9099C 3 of 3) MARs reviewed showed medications administered as prescribed, with no discrepancies noted. Incident and complaint logs for the past six months contained no substantiated reports of medication errors or unqualified staff administering medications. LPA observations during the visit confirmed that medications were stored securely in locked cabinets and carts, and medication passes were conducted by staff wearing name badges indicating their role. No unqualified staff were observed handling medications. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Susan O'Shaughnessy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from LIC9099 2 of 3) Residents confirmed that care is provided as scheduled, call-light response is prompt, and no delays have impacted their safety or comfort. Outside sources, including a family member, hospice nurse, and ombudsman, stated they observed adequate staff presence and timely care delivery, with no concerns regarding staffing adequacy. Records reviewed included staffing schedules, timecards, call-light response reports, resident service plans, medication administration records, and incident logs for the past six months. Documentation showed scheduled coverage consistent with resident needs and no substantiated complaints related to staffing. LPA observations during the visit confirmed staff were present and actively assisting residents with ADLs and mobility. Call-light spot checks demonstrated responses within three to six minutes, and no unattended residents or signs of unmet care needs were observed. On 9/4/25 it was alleged that unqualified facility staff administered medications to the residents. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Interviews were conducted with three staff members, three residents, and three outside sources. All staff interviewed stated that only trained and authorized personnel administer medications, and confirmed they have completed required medication training per facility policy and Title 22 requirements. Staff reported that medication administration is documented in the Medication Administration Record (MAR) and overseen by supervisory staff. Residents interviewed stated they receive medications on time and have not observed or experienced untrained staff giving medications. Outside sources, including a family member, hospice nurse, and ombudsman, reported no concerns regarding medication administration practices and confirmed that medications appear to be managed appropriately. Records reviewed included staff training logs, medication competency checklists, medication technician certificates, MARs, and facility policies on medication administration. Documentation confirmed that staff assigned to medication duties have completed required training and competency evaluations in accordance with regulations.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 08-AS-20250904133832

Allegation investigated: Facility does not have hot water. Staff do not provide residents with a comfortable temperature. The facility does not provide quality food.

Licensing Program Analyst (LPA) Amy Domingo made an unannounced visit to conduct an investigation on the above-mentioned allegations. LPA met with Executive Director Susan O'Shaughnessy and discussed the basic elements of the complaint. The Department’s investigation consisted of staff, resident, outside source interview s and a facility tour. On January 28, 2026, Community Care Licensing (CCL) received a complaint alleging that the Facility does not have hot water. During the visit, the LPA tested hot water temperatures in resident bathrooms and kitchen areas using a calibrated thermometer. Regulations requires that hot water in resident-use fixtures be maintained between 105°F and 120°F to ensure comfort and safety. Observations showed hot water temperatures measured at 100 degrees Fahrenheit, which is within the regulatory range. Faucets were functioning properly, and residents were observed using sinks and showers without difficulty. No signs of plumbing malfunction were noted. A review of facility maintenance logs indicated that water heaters were serviced on a regular basis and were operational. No documented complaints regarding lack of hot water were found in communication logs or grievance records. Facility policies on environmental safety and maintenance were current and consistent with Title 22 and Health & Safety Code requirements. Unsubstantiated (Continued from LIC9099 2 of 3) Two staff members were interviewed. Both staff stated that hot water is available throughout the facility and confirmed that temperatures are checked regularly during housekeeping and maintenance rounds. Staff reported that any plumbing issues are addressed immediately and documented in the maintenance log. Two residents were interviewed; both reported that they have access to hot water for bathing and hand washing and stated they have not experienced any issues with water temperature. Two outside sources, were interviewed, both stated they have not observed any problems with hot water during visits and reported that residents appear to have access to functioning bathrooms and showers. Outside sources noted that the facility communicates promptly if maintenance is needed, and the nurse confirmed that the environment meets health and safety standards. On January 28, 2026, Community Care Licensing (CCL) received a complaint alleging that the Staff do not provide residents with a comfortable temperature. Interview with Staff 1 (S1) confirmed measures have been taken, such as insulated draperies, offering of different room accommodations, offering individual room heaters and extra blankets, as well as timely responses to requests of modifying residents room temperature to make residents feel more comfortable in their room. During the visit, the LPA observed the facility’s indoor temperature and confirmed readings within the range required by Title 22 regulations requires that facilities maintain a comfortable temperature for residents, generally between 68°F and 85°F. Observations showed the thermostat set at 74 degree Fahrenheit and functioning properly. Residents were observed wearing appropriate clothing, and no signs of discomfort were noted. A review of facility records, including maintenance logs and temperature checks, indicated that the heating and cooling systems were serviced on a regular basis and were operational. No documented complaints regarding uncomfortable temperatures were found in the communication logs or grievance records. Facility policies on environmental comfort and maintenance were current and consistent with Title 22 and Health & Safety Code requirements. Two staff members were interviewed. Both staff stated that the facility maintains the thermostat within the required range and adjusts temperatures based on resident feedback. Staff reported that residents are encouraged to use personal fans or blankets if they prefer a different temperature and that any concerns are addressed promptly. Two residents were interviewed; both reported that the temperature in the facility is comfortable and stated they have not experienced issues with heating or cooling. Residents confirmed that staff respond quickly to any requests for adjustments. Two outside sources were interviewed. Both stated they have not observed any issues with temperature during visits and reported that residents appear comfortable. The family member noted that the facility communicates promptly if maintenance is needed, and the nurse confirmed that the environment meets health and safety standards. (Continued from LIC9099 3 of 3) On January 28, 2026, Community Care Licensing (CCL) received a complaint alleging that the facility does not provide quality food. During the visit, the LPA observed a scheduled meal service and reviewed posted menus. Observations showed the menu aligned with these required regulations listing balanced offerings and noting alternatives for residents with preferences or dietary restrictions. Meals appeared palatable and were served at appropriate temperatures, and staff were observed following sanitary practices. The dining environment was orderly, with residents receiving assistance as needed and opportunities to request substitutions. A review of facility records indicated that menus were planned in advance and reflected seasonal diets. Kitchen temperature logs and maintenance records showed refrigerator and hot holding equipment within safe ranges, and staff training files documented completed in-services on safe food handling, sanitation, and resident nutrition consistent with Title 22 expectations Communication logs and grievance records did not reflect a pattern of complaints about food quality. The facility’s policies on food service and sanitation were current and consistent with Health & Safety standards for safe meal preparation and service. Two staff members were interviewed. The food service supervisor stated that menus are developed to meet nutritional guidelines, with daily alternatives available, and that resident feedback is solicited and incorporated through suggestion sheets and resident council input. The caregiver interviewed reported that staff assist residents during meals, monitor intake, and promptly address concerns and provide substitutions, adjusting portions, or offering alternate textures for residents with chewing/swallowing needs. Both staff denied systemic issues with food quality and described routine temperature checks and cleanliness practices. Two residents were interviewed; both reported the food as generally satisfactory, noting that meals are varied and substitutions are available upon request. One resident shared that they prefer milder seasoning and that staff consistently accommodate this preference; the other resident stated portion sizes are adequate and that they have not experienced problems with the freshness or temperature of meals. Two outside sources, were interviewed. Outside source 1 (OS1) reported no ongoing concerns with food quality and observed that the facility communicates about diet changes and accommodates preferences. Outside source 2 (OS2) stated the meals observed were consistent with a balanced diet and reported that residents appeared to tolerate and accept the food well, with staff responsive to dietary needs and hydration prompts. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Susan O'Shaughnessy Administrator, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 08-AS-20260128102314

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management - Incident visit. LPA was welcomed by Susan O'Shaughnessy, the Director of Marketing and Admissions, and discussed the purpose of the visit. Today's visit was in response to an Incident Report (LIC624) that the licensee self submitted to the CCLD San Diego Regional Office. According to the LIC624, on 8/21/24, Resident #1 (R1) was involved in an incident where a Staff 1 (S1) had a physical altercation with R1. The video shows R1 and S1 hitting and pushing each other. R1 falls to the ground and crawls on the floor until they can get up, while S1 watched and does not assist R1. R1 is seen on the video wiping blood from their hand. R1 tries to stop the bleeding with a tissue, while they bend over to wipe the blood from the floor. Staff 2 (S2) came to the memory care unit, where they saw the cut on R1's hand and applied aid. R1 was taken to the emergency room, where the resident received four stitches.The facility did not notify R1's responsible party of the incident. During today’s visit, LPA performed a facility tour, welfare check, collected records, observed R1, and interviewed staff. (Continued on LIC809C) (Continued from LIC809) Two (2) deficiencies were cited per California Health and Safety Code (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Administrator. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiencies are being cited on the attached LIC809D. An immediate Civil penalty of $500 was assessed during today's visit for the facility's: To be free from punishment, humiliation, intimidation, abuse, or other actions, and the licensee shall provide for and encourage all personnel to report observations or evidence of such abuse. An exit interview was conducted with Administrator, to whom a copy of this report, the LIC809-D, the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 25, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Sep 8, 2025

To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met, as evidenced by: Interviews and records review for 1 of 44 residents This poses an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Aug 25, 2025

Plan of correction: LPA and facility administration jointly agreed to have all staff in serviced regarding Resident Rights by 9/8/25

From the deficiency page — Deficiency type: Type A · Section cited: CCR87413(a)(3) · Plan of correction due date: Sep 8, 2025

Residents in all residential care facilities for the elderly shall have all of the following personal rights: The licensee shall provide for and encourage all personnel to report observations or evidence of such abuse, exploitation or prejudice. This requirement was not met, as evidenced by interviews and records review for 1 of 44 residents. This poses an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Aug 25, 2025

Plan of correction: LPA and facility administration jointly agreed to have all staff in serviced regarding Personnel Reporting requirements by 9/8/25

Allegation investigated: Staff neglected residents care needs Licensee did not uphold visitor policy. Staff took away residents cell phone.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Administrator Susan O'Shaughnessy. Department’s investigation consisted of staff and resident interviews, interviews with outside sources and LPA observations in the memory care area of the facility. On June 20, 2025, Community Care Licensing (CCL) received a complaint alleging that staff neglected the care needs of Resident #1 (R1). More specifically R1 has lost a lot of weight recently and was itching. Hospice records indicated R1 has diagnoses including dementia, lung mass, and congestive heart failure, with documented periods of agitation and refusal of care. During the visit, LPA observed R1 being offered multiple food options and staff encouraging them to eat. R1 declined some items but accepted others, but ate very little. No visible signs of itching were observed. Interviews with outside sources and LPA observations reveal staff were attentive and present. (Continued on LIC9099) Unsubstantiated (Continued from LIC9099) It was also alleged that the licensee did not uphold the facility’s visitor policy. Interviews with an outside source revealed that two visitors attempted to visit R1 while appearing intoxicated. Staff spoke with the visitors and requested that they contact R1’s responsible person. The visitors subsequently left the facility. LPA interviews confirmed that visits on later dates did occur, during which the reporting party was able to enter the facility without issue, and the visits went well. It was also alleged that staff took away R1’s cell phone. LPA interview with reporting party was unclear if facility took the phone and stated it was unclear who took it. A review of R1's inventory at move-in did not list a cell phone, and both R1's responsible person confirmed R1 no longer has a phone due to their inability to use it. No documentation or credible evidence was found to support the claim that the facility removed or withheld a cell phone. Based on interviews, and LPA observations there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Susan O'Shaughnessy, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were providedthe state’s words, verbatim · CDSS document, Aug 18, 2025 · control 08-AS-20250620154824

Allegation investigated: Facility did not maintain a comfortable temperature for a resident in care.

Licensing Program Analyst (LPA) Amy Rodgers made an unannounced visit to conduct an investigation on the above-mentioned allegation. LPA met with Executive Director Susan O'Shaughnessy and discussed the basic elements of the complaint. The Department’s investigation consisted of staff and resident interviews and a facility tour. On May 5, 2025, Community Care Licensing (CCL) received a complaint alleging that R1's room and the entire facility were very cold. An interview with Resident #1 (R1) confirmed they cannot control their room's temperature. Direct observation in R1's room reflected a temperature of 76 degrees. Interview with the Executive Director and R1 confirmed measures have been taken, such as insulated draperies, offering of different room accommodations, offering individual room heaters and extra blankets, as well as timely responses to requests of modifying R1's room temperature to make R1 feel more comfortable in his room. (Coninued on LIC9099) Unsubstantiated (Continued from LIC9099) Interviews with residents revealed some residents have experienced uncomfortable temperature in their rooms However, the front desk responds to requests to adjust the temperature throughout the day and night. During a facility tour, LPA observed individual thermometers in the hallway near R1's room to reflect a temperature range of 76-78 degrees. Temperatures throughout the common area averaged temperature range of 75-78 degrees. Based on interviews, and LPA observations there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Susan O'Shaughnessy, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were providedthe state’s words, verbatim · CDSS document, May 12, 2025 · control 08-AS-20250506094003

Allegation investigated: Licensee staff did not take steps to prevent the spread of a communicable disease. Licensee staff does not ensure residents receive adequate medical treatment.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to conduct a complaint investigation and deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Administrator Susan O'Shaughnessy. On April 14, 2025, Community Care Licensing (CCL) received a complaint alleging that licensee staff did not take steps to prevent the spread of a communicable disease and licensee staff does not ensure residents receive adequate medical treatment. The Department’s investigation consisted of staff and resident interviews, interviews with outside sources, and a facility tour of common areas and resident rooms in the memory care area of the facility. Regarding the allegation, licensee staff did not take steps to prevent the spread of a communicable disease. More specifically, residents were experiencing scabies symptoms in February 2025 and continued to exhibit symptoms of scabies in April 2025. (Continued on LIC 9099) Unsubstantiated (Continued form 9099) Staff interviews revealed that they have not witnessed other residents itching in a manner that would make them suspicious of Scabies. Staff interview revealed that facility staff enacted infection control protocols upon receiving notice of a possible Scabies case at the facility. Staff interview revealed that all staff were briefed and trained on infection control protocols and management was made aware of any potential scabies case as soon as it was observed. Staff interview revealed that they have been thoroughly cleaning, sanitizing and changing the sheets daily in the suspected room as utilizing PPE during the time frame of the complaint. Staff interviews further reveal the linens and clothing are being properly laundered or disinfected. The Administrator did confirm that the facility had not reached outbreak status for Scabies during the time frame of the complaint. Regarding the second allegation, licensee staff does not ensure residents receive adequate medical treatment. More specifically, from February 2025 to April 2025 Resident #1(R1) has had no visible improvements. Staff and outside source interviews reveal that the treatment for C1 was being followed as prescribed. Staff members interviewed consistently described the administration instructions of the medication in question. Interview with outside sources reveal no concerns or knowledge of errors regarding medication administration. They also reveal the facility has been in communication with the responsible party as well as working with medical agencies on C1's behalf. Staff interview further revealed that the official notification protocol was not enacted because an outbreak had not been determined, but staff were provided information on scabies symptoms. Outside source interview revealed no concerns regarding the Licensee's infection control notification protocols. Records review did not show that the Licensee has failed to report confirmed outbreaks to necessary parties and agencies when required. Based on interviews, direct LPA observations and records review, and outside source interviews a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator Susan O'Shaughnessy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 17, 2025 · control 08-AS-20250414103911

Allegation investigated: Staff does not provide a comfortable room temperature for resident.

Licensing Program Analyst (LPA) Amy Rodgers conducted a facility visit to open a complaint and deliver findings. LPA gained access to the facility, identified herself and met with Administrator Susan O'Shaughnessy to whom was explained the purpose of the visit. The Department’s investigation consisted of staff and resident interviews and a facility tour. On February 12, 2025, 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 heat does not run long enough to maintain a comfortable temperature in R1’s apartment. (continue at LIC9099C) (Continued form LIC 9099) Unsubstantiated (Continued form LIC 9099) An Interview conducted with the Executive Director revealed that the building is heated through a central heating system and the residents cannot control the temperature of their rooms. An interview conducted with Resident #1 (R1) also corroborated they have no control of the temperature, heating or air conditioning in their room. The interview with R1 also revealed no issues with their heating in the common areas of the facility. A CCL annual inspection was conducted on February 7, 2025 and it was noted common area hallway temperatures to be 78 degrees, 77 degrees, 79 degrees, and 75 degrees. An interview conducted with residents revealed they have not had any issues with the temperature being comfortable in their rooms and front desk responds to requests to adjust the temperature throughout the day and night. An interview with front desk employee confirms they tour the facility in the morning at 8am and re-set the thermostats throughout the building to 71 degrees, said thermostats control the halls as well as the individual rooms. The front desk employees are responsible to also set the thermostats to 78 degrees at night. During a facility tour LPA observed individual thermometers in the hallway located near R1's room to reflect a temperature range of 76-78 degrees and the individual room ranged from 72-77 degrees. Direct observation in R1's room reflected a temperature of 72 degrees. Interview with the Administrator and R1 confirmed measures are being taken, such as insulated drapery's, different room accommodations, and extra blankets to make R1 feel more comfortable in his room. Based upon the information obtained during the investigation it is determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the violation occurred and is therefore UNSUBSTANTIATED. An exit interview was conducted with Administrator O'Shaughnessy whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights. (LIC9058 3/22).the state’s words, verbatim · CDSS document, Feb 13, 2025 · control 08-AS-20250212142931

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Angelica Boyles and Arian Golbakhsh made an unannounced visit to conduct the required annual Inspection. LPAs were granted entry into the facility by Administrator Susan O'Shaughnessy, after identifying themselves and stating the purpose of the inspection. The facility serves 110 elderly residents, age 60 and above, all whom may be non-ambulatory. Approved for ten (10) bedridden residents. The facility is approved for locked perimeter. LPAs were accompanied by Administrator Susan O'Shaughnessy for a tour of the facility which included the outside areas and a sample of resident units, the dining area, and recreation rooms. Exterior and interior passageways were free from obstructions. Pull cords are present and easily assessable to residents. Resident and facility room temperatures were within a comfortable and compliant range. Each resident had clean and sufficient bed linens, towels, and washcloths. 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. Hot water temperature in residents’ bathrooms were compliant. Facility has a two day supply of perishable and a seven day supply of nonperishable food items. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closet. The medication carts were locked and medications were labeled and kept in compliance with label instructions. [Continued on 809-C] [Continued from 809] LPAs interviewed staff and clients. LPAs reviewed multiple staff and client files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPAs also conducted a review of In-service training procedures. There are large designated activity rooms and gathering areas throughout facility. At the time of visit, LPAs observed two different group activities in which many residents were participating. LPAs observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No deficiencies were sited at the time of visit. A final exit interview and a copy of this report was provided to Administrator Susan O’Shaughnessy whose signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Feb 7, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers were granted entry into the facility Administrator Susan O'Shaughnessy, after identifying herself and stating the purpose of the inspection. The facility serves 110 elderly residents, age 60 and above, all whom may be non-ambulatory. Approved for ten (10) may be bedridden. The facility is approved for locked perimeter. LPA was accompanied by Care Supervisor Claudia Munoz, for a tour of the facility which was conducted inside and out and included a sample of resident units, the dining area and recreation rooms. Exterior and interior passageways were free from obstructions. Pull cords are present and easily assessable to residents. Resident and facility room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens, towels, and washcloths. 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. Hot water temperature in residents’ bathrooms were compliant. [Continued on 809-C] [Continued from 809] Facility has a two-day supply of perishable 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. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closet. The medication carts were locked and medications were labeled and kept in compliance with label instructions. LPA interview confirmed the licensee provides assistance in meeting medical and dental needs. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA also conducted a review of In-service training procedures. There are large designated activity rooms throughout facility as well as gathering areas throughout the facility. At the time of visit, LPA observed two different large group activities in which many residents were participating. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No deficiencies were sited at the time of visit. A final exit interview and a copy of this report and Licensee/Appeal Rights - LIC 9058 (rev. 01/16), were provided to , Administrator O’Shaughnessy . whose signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Feb 23, 2024