Lo-Har Senior Living

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Staff did not assist resident in making a medical appointment

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to open a complaint investigation and to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Yolonda Torres, Clinical Director. On 04/15/2026 it was alleged "Staff did not assist resident in making a medical appointment." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "Staff did not assist resident in making a medical appointment", it was alleged when a friend of a resident at the facility tried to havethe resident sign for a medical appointment, staff stopped the resident from signing. (Continued on LIC9099C, Page 2) Unsubstantiated (Continued from LIC9099, Page 1) Staff interviews revealed that staff provide medical visits for residents through a mobile doctor who visits the facility on a weekly to biweekly basis. Staff 1 (S1) stated that Resident 1 (R1) is not allowed to sign documents or make financial or medical decisions. S1 noted that R1 sees the mobile doctor on a biweekly basis. S1 told the LPA that they are afraid that R1 could become a victim of financial abuse or worse if they were to sign documents provided by visitors without the POA or responsible party present. Outside Source interviews revealed that R1 has been receiving medical appointments through the facility. Outside Source 1 (OS1) Confirmed they are able to see R1's progress notes and medications through an online charting system. Additionally, OS1 stated they are in communication with the facility twice a week about R1's condition and progress. This corroborates staff interviews. OS1 stated they have no concerns about the facility's ability to provide care for R1 and noted to the LPA that since having moved in, R1's condition has improved greatly. Records review revealed that R1 has been seen by the mobile doctor during the period of the complaint per the progress notes dated, 03/20/2026, 04/01/2026, 04/09/2026. Review of the progress note dated 03/20/2026 stated and confirmed that R1 is "forgetful, unable to concentrate, and unable to make appropriate medical or financial decisions independently." This corroborates outside source and staff interviews. Based on interviews 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 Yolonda Torres, Clinical Director and Executive director Andy Chin, 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-20260415123800

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Correia conducted a Case Management visit to check on the health and safety of the Residents in care. LPA Correia was greeted by Caregiver Bishop, identified herself, was granted entrance, and met with Clinical (CD) Director Torres and disclosed the purpose of the visit.. During today's visit, the LPA Correia toured the facility, briefly spoke to Residents in care, and secured records. There were no immediate health or safety concerns observed during the visit. An exit interview was conducted with CD Torres, to whom a copy of this report, and Licensee Rights (LIC 9058), will be provided at conclusion of the visit.the state’s words, verbatim · CDSS document, Feb 23, 2026

Allegation investigated: Staff did not meet resident's personal hygiene needs

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings in the above-mentioned allegation. LPA met with Clinical Director Yolanda Torrez and discussed the purpose of the visit. Community Care Licensing (CCL) received a complaint alleging staff were not assisting Resident 1 (R1) with hygiene. During the investigation, the Department conducted observations, collected records and conducted interviews. According to records collected, R1 began to refuse care in October of 2025, leading to multiple rashes. Records also revealed that R1 was prescribed medical ointment to treat such rashes. Interview with staff revealed that R1 would decline showers or sponge baths more than they would accept. Interviews also revealed that facility reported such issues to R1’s responsible party and medical provider. Lastly, additional information found revealed that R1 would also reject assistance at medical facilities. Based on interviews and observations there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Clinical Director, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 6, 2026 · control 08-AS-20251030101817

Allegation investigated: Lack of supervision resulted in client-on-client altercation.

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 Jonathan Wheeler and Clinical Director Yolie Torres. On 12/12/25 it was alleged that lack of supervision resulted in a client-on-client altercation when Resident 1 (R1) accused Resident 2 (R2) of hitting them. The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff, residents, outside sources, and records review. Staff interviews revealed that Resident 1 (R1) suffered from hallucinations and had not made allegations against anyone like this before, however R1 has experienced paranoia in the past about things happening to them such as their food being poisoned. Staff members interviewed unanimously informed that R2 had never been accused of physically hurting anyone and that they tended to stay to themselves. The facility conducted an internal investigation and found no corroboration that the incident occurred or that there was a supervision issue at night in the memory care building R1 and R2 live in. (Continued on LIC9099 p.2) Unsubstantiated (Continued from LIC9099 p.1) Both Wellness Coordinators (supervisors) were working the NOC shift during the timeframe of incident. No witnesses or injuries were found in the internal investigation, and Resident 2 (R2) denied touching R1 or getting up in the middle of the night, as accused. Staff noted that the accusation was also inconsistent with R2's typical behaviors. Both residents reside in the facility's Memory Care building. Resident interviews did not corroborate the allegation, as R1 refused to speak about the situation to LPA during interview. R1 did not confirm that they made the allegation about someone hurting them when asked. R2 was aware that R1 accused them of hurting them, but stated that they did not. R2 informed that they try to stay away from R1 and do not engage with them. Outside source interviews did not corroborate the allegation. An outside advocacy agency staff (OS1) familiar with the facility informed that they did not have concerns about the facility's supervision of residents. OS1 advised having visited the facility and speaking with the residents, none of whom have expressed concern about staff supervision. OS1 stated that the staff properly addressed the situation when the allegation was made. OS1 had not seen any resident care needs go unmet related to supervision. A second outside source familiar with the allegation informed that no physical marks or injuries were observed on R1 when the allegation was made, and that no specific date or time was advised regarding when the event occurred. There were no witnesses to the alleged incident. Records review revealed facility progress notes detailing the accusation, the facility's internal investigation, and required reporting. The "Physician's Report for Residential Care Facilities for the Elderly (RCFE)" for both residents showed that both residents suffered from cognitive impairments, and that neither resident had behaviors of aggression. Preplacement Appraisals for both residents indicated that the residents tended to say to themselves. During and unannounced facility visit LPA walked the property twice. LPA observed caregivers, housekeepers, and maintenance staff walking around the facility. LPA observed caregivers engage with residents and ask how they were doing, as well as provide assistance with Activities of Daily Living (ADLs). LPA observed staff in all buildings where residents were residing throughout the visit. 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 Clinical Director Yolie Torres, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 08-AS-20251212115648

Allegation investigated: Licensee is not ensuring that resident's are provided clean and comfortable beds.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to initiate an investigations in the above-mentioned allegation. LPA met with Clinical Director Yolanda Torrez and discussed the purpose of the visit. Community Care Licensing (CCL) received a complaint alleging resident beds are not clean and have urine soaked stains. During the investigation, LPA Strong conducted a facility inspection. During the inspection LPA observed three resident beds that had plastic liners, under the liners the beds had brown and orange stains. Additionally, one of the mattressed was falling apart and was being held together with the bed cover. Based on observations, a preponderance of evidence exists to support the allegations. A deficiencies is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Cinical Director Yolanda Torres, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to. Substantiated It was also alleged that facility staff were making residents suffer by forcing them to wash and cut their hair to deal with the lice. Interview with resident did not reveal that staff forced resident to cut their hair. Additionally, there were not interviews to corroborate that residents were suffering for being treated for lice. Interview with an outside source could not corroborate that residents were being forced to treat for lice. Based on interviews, and observations there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Clinical Director, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 17, 2025 · control 08-AS-20251014123627

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(3)(A) · Plan of correction due date: Oct 31, 2025

87307(3)(A) …. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. This requirement was not met as in evidence: Based on observations, the licensee did not provide 3 of 68 residents in care clean and comfortable mattresses that pose a possible health risk to persons in care.the state’s words, verbatim · CDSS document, Oct 17, 2025

Plan of correction: Licensee agrees to replace the mattresses by POC date and provide proof of such to LPA via email.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Clinical Director Yolanda Torres. According to the facility’s license, the facility has a maximum capacity of 68 residents of which 41 may be non-ambulatory with a hospice waiver for 10. The facility is comprised of 6 stand-alone buildings, with two memory care areas both approved for secured perimeter. LPA toured the interior and exterior of the facility and inspected multiple rooms. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Water temperature in residents rooms were measured all between 105 degrees F to 119 degrees F. There are no bodies of water present. A few mattresses required replacing and Clinical Director agrees to have them replaced. LPA toured and observed the commercial kitchen and walk-in refrigerator. The kitchen was clean, organized and sanitary. Cooking/dining equipment and utensils were present. There was sufficient perishable food and at least two weeks worth of non-perishable food. LPA observed multiple medication carts and first aids were complete and readily accessible. Medications were labeled, as required, and stored in locked medication carts. Resident records contained the required documentation. Staff records contained the required documentation. LPA reviewed care staff first aid refresher training's within the facility training system. Per Clinical Director, no firearms or ammunition are kept at the facility. Fire extinguishers were readily accessible in each cottage and have been serviced within the last year. No deficiencies were cited on todays visit. An exit interview was conducted with Clinical Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to during the visit.the state’s words, verbatim · CDSS document, Oct 17, 2025

Allegation investigated: Lack of supervision resulted in injury Neglect resulted in pressure injuries Facility retained resident with a higher level of care needs Staff did not address resident's change in condition while in care Staff did not ensure that resident stayed hydrated while in care Staff did respond to requests for assistance by resident in a timely manner Staff did not ensure that resident had clean clothing Staff did not ensure that resident's hygiene needs were met Staff did not ensure that resident's toileting needs were met.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings on the above-mentioned allegations. LPA met with Clinical Director Yolanda Torres and Director Jonathan Wheeler and discussed the purpose of the visit. On February 9, 2023, Community Care Licensing (CCL) received the following complaint allegations regarding Resident 1’s (R1) care received. During the investigation LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. Resident 1’s records collected revealed R1 is a diagnosed with a mild- cognitive impairment, has a history of skin breakdowns, can follow instruction and is able to use a walker for mobility. Additional records revealed R1 was only at the facility for a total of eight days. According to the first allegation, on the fourth day of stay, R1 sustained an unwitnessed fall which resulted in bruising. Interviews with staff did not reveal any information to corroborate that R1 was not treated for unwitnessed fall. Interview with residents present during the time of the incident revealed that facility staff respond to residents timely. Unsubstantiated R1’s Physician Report established that R1 does not require continuous monitoring or continuous bed care According to the second allegation, neglect to R1 resulted in multiple stage 1 and stage 2 pressure injuries to genital area and ankle. Facility records revealed R1 was admitted with a quarter size scab to the ankle. Records also revealed that R1 has a history of skin breakdown prior to admission. Staff interviews did not reveal any information to corroborate that R1 was neglected resulting in pressure injuries. The third allegation states facility retained R1 who required a higher level of care. Records collected revealed facility conducted a pre-admission appraisal and found R1 to be at facility’s level of care available. Physician report dated January 16, 2023, did not show any restricted or prohibited diagnosis. Interview with staff revealed there were no issues with the level of care required by R1. According to the fourth allegation, the facility did not address R1’s ten-pound weight loss while in care. Records were unable to confirm R1 lost the weight during the eight day stay at the facility. Interview with staff could not corroborate that R1 was not monitored or R1’s changes were not identified during R1’s stay. According to the fifth allegation, R1 was not given enough fluids resulting in dehydration. Interview with multiple staff revealed residents are given water or juice throughout the day in addition to the beverage with their meals. Interview with other residents reveal residents are provided with numerous drinks throughout the day. There were no records documenting R1 as dehydrated. The sixth allegation states facility staff were not responding timely to call button. Interview with staff could not establish that facility was not responding timely to call button. Records collected could not establish facility staff were not responding timely to residents in need. Interview with residents revealed that they are assisted within a few minutes of requesting assistance. The seventh allegation states R1 was not provided with any clean clothing. Interview with laundry staff revealed that laundry is done regularly and there is one full time employee conducting laundry service. Interview with residents revealed that they do have full laundry service. LPA Strong observed laundry service and confirmed such information. According to the eighth allegation, R1 was only fully showered one time during R1’s stay. Interview with staff revealed that residents also receive sponge baths as well as showers. Interview with residents established that facility staff provide residents with bi-weekly showers or sponge baths depending on resident. Interview with staff could not establish that facility staff only provided R1 with one shower during stay. Lastly is was alleged that R1 was not assisted with toileting needs. Interview with staff could not establish that R1 was not assisted with toileting. Interview with residents established that they are changed frequently or assisted to the restroom when requested. There were no records available to corroborate allegation. Based on interviews, records available and observations there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Clinical Director Yolanda Torres and Director Jonathan Wheeler to whom a copy of this report, and the Licensee/Appeal Rights were provided.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 08-AS-20230209083323

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management visit to follow-up on multiple incidents reported to Community Care Licensing. LPA met with Clinical Director Yolanda Torres and Director Jonathan Wheeler and discussed the purpose of the visit. Community Care Licensing received an incident report on 9/16/2025 in which it was reported that Resident #1s (R1) and Staff 1 (S1) had a verbal altercation. Interview with Clinical Director established that S1 denied the allegations. Statement from Staff 2 (S2) established that S2 observed S1 cursing at R1. LPA was unable to interview R1 as they are no longer present at the facility due to increased psychiatric behaviors. Additionally, on 9/16/2025, CCL received an LIC624, Unusual Incident Report regarding R2 being issued the incorrect medication. According to report, R2 was issued a lower dose of a medication than they are prescribed and the error was reported to all required entities. R2's Physician Report established they require medication management. Clinical Director stated there were no adverse reactions to medication. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. On today's date, one deficiency was issued for medication administration. An exit interview was conducted with Clinical Director to whom a copy of their appeal rights, 809-D, LIC811, and this report were provided to.the state’s words, verbatim · CDSS document, Sep 25, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 24, 2025

87465 (a):(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as in evidence: Based on interviews the licensee did not assist resident with self-administratrion of medication in 1 of 66 persons in care R1 which posed a potential Safety, risk to persons in care.”the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: Licesee states facility staff will conduct re-medication technician training and will provide such proof to LPA by POC date.

Allegation investigated: Resident sustained injury when transferred. Staff did not assist resident with incontinence care. Staff did not meet residents' dietary needs.

Licensing Program Analyst (LPA) Iby Strong contacted facility via telephone to deliver findings in the above-mentioned allegations. LPA spoke with Clinical Director Yolanda Torres and discussed the purpose of the call. On February 8, 2022, Community Care Licensing (CCL) received a complaint alleging Resident (R1) sustained a bruise when transferred, staff did not assist R1 with incontinence care and staff did not meet R1’s dietary needs. During the investigation, the Department conducted interviews, and reviewed facility records. According to the first allegation, on February 4, 2022, R1 complained of discomfort while being transferred from wheelchair and R1 was observed to have a hand shaped bruised on their left side.Interview with outside source could not establish that facility staff caused bruise to R1. Interview with other residents revealed they were not in any discomfort when being transferred or cared for by staff. Interview with staff present during that time revealed that internal investigation of allegation yielded no results. Unsubstantiated It was also alleged that R1 was not assisted with incontinence care during the night. Records collected revealed that as of January 11, 2022, R1 returned from a brief hospital stay with a noted higher level of care. Records show R1’s care plan was updated, and staff were reminded that R1 needed more assistance. Interview with residents revealed that they had no issues with the care being provided by staff. Interview with outside source could not corroborate R1 was not receiving incontinence assistance at night. Lastly it was alleged that R1 was not being provided with prescribed dietary shake. Records collected revealed R1 was prescribed dietary shake as of January 24, 2022, and records show R1 began receiving such shake daily as of January 25, 2022. Interview with staff present during this time revealed R1 was regularly receiving shakes and there was one incident of the prescription not arriving on time due to delivery error. Interview with outside source could not confirm R1 did not receive shakes. Based on interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Clinical Director, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) emailed to.the state’s words, verbatim · CDSS document, Sep 10, 2025 · control 08-AS-20220208135238

Allegation investigated: Facility is not returning representative communication attempts.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to initiate a complaint investigation on the above-mentioned allegations. LPA met Clinical Director Yolanda Torres and discussed the purpose of the visit. According to the allegation on July 31, 2025, during an undisclosed period, the facility did not return resident representatives telephone calls or email communication. On today’s date, LPA Strong conducted a facility inspection and dialed the facility telephones with no issues. Additionally, interview with staff revealed there have been no email communications missed from any outside sources. Interviews with outside source established the email address being used was for an employee no longer present at the facility. Based on interviews, and observations there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Clinical Director, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 1, 2025 · control 08-AS-20250731110422

Allegation investigated: Physical abuse that resulted in serious injury.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Clinical Director Yolanda Torres. On May 15, 2023, Community Care Licensing (CCL) received a complaint alleging Staff 1 (S1) physically assaulted Resident 1 (R1) (R1 – see LIC811 Confidential Names List) which resulted in a fractured nose. Physician’s Report dated March 6, 2023, confirmed R1 was diagnosed with a major neurocognitive disorder and has aggressive behaviors. R1’s Individual Service Assessment dated December 21, 2021, also established that R1 required encouragement, reassurance or interventions regarding mental status. Details of the allegation state that on May 13, 2023, at approximately 10:06pm, S1 struck R1 in the face, resulting in a fractured nose and a black eye. Interview with multiple staff revealed that earlier on that date, S1 had ordered pizza for the staff and R1 had asked for a piece. S1 proceeded to deny R1 any of their food and R1 became verbally aggressive. Substantiated Interview with S2 revealed that at around 10pm, R1 proceeded to ask S1 for pizza again, and S1 declined his request. At this time R1 became more verbally aggressive and S1 clocked out of their shift and went outside. According to Staff 2, minutes later, S1 came back into the building and told S2, “I hit him”, referring to R1. Interview with lead MedTech revealed that S1 told MedTech that R1 hit S1 so S1 hit them back. On May 14, 2023, emergency personnel interviewed S1 who revealed that during the incident, R1 swung at S1, S1 dodged the attempted hit then struck R1 with an open right hand to the nose in self-defense, which cause R1 to fall to the floor. Medical records collected revealed that on May 14, 2023, R1 was admitted to hospital due to facial trauma and diagnosed with a nasal fracture. On June 1, 2023, S1 was interviewed by the Department. S1 stated that they were being assaulted by R1, and in self-defense put out right arm, which cause R1 to hit nose on S1’s arm. Interview with another resident revealed that S1 has a history of verbal outbursts towards residents in care. Based on interviews conducted, review of records, including outside sources records, a preponderance of evidence exists to support the allegation that staff assaulted resident in care, resulting in serious injury. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). The Department has determined this violation resulted in injuries to the resident in care. An immediate Civil Penalty is being charged and is noted as a duplicate violation within 12 months, therefore it is assessed as $1,000 on the LIC421IM. Currently, per Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of Community Care Licensing Division. An exit interview was conducted with Clinical Director Yolanda Torres, and a Plan of Correction was jointly developed. A copy of this report, LIC811, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Clinical Director Yolanda Torres, signature on this form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 1, 2025 · control 08-AS-20230515112520

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

87468.2 a)... All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: 8)To be free from verbal, mental, physical, or sexual abuse. This requirement was not met as in evidence: Based on interviews and records collected the licensee did not protect R1 from physical abused in 1 of 57 residents in care which posed an immediate Safety risk to persons in carethe state’s words, verbatim · CDSS document, Aug 1, 2025

Plan of correction: Licensee had a personal rights training in May of 2025. Due to duplicate violation within 12 month, POC considered cleared.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management visit to follow-up on two incidents reported to Community Care Licensing. LPA met with Clinical Director Yolanda Torres and discussed the purpose of the visit. Community Care Licensing received a SOC341 on 5/25/25 in which it was reported that Resident #1s (R1) was being treated roughly by Staff 1 (S1). According to interview with Clinical Director, an internal investigation was conducted and S1 was placed on a corrective action plan but no abuse to R1 was found. Additionally, on 7/1/2025, the Department received an incident report stating Resident 2 (R2) did not receive their prescribed medication and suffered no adverse results. According to Clinical Director, all staff have been retrained on medication management and managerial staff will be conducting random medication audits and shadowing of staff. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. No deficiencies were cited during today’s visit. An exit interview was conducted with Clinical Director. The Licensee was provided a copy of their appeal rights (LIC9058 03/22), LIC811, this report and their signature on this form, acknowledges receipt of these rights.the state’s words, verbatim · CDSS document, Aug 1, 2025

Allegation investigated: Neglect resulted in hospitalization Staff did not provide adequate supervision to residents in care Staff did not meet resident's laundry needs Facility had no food service director

Licensing Program Analyst (LPA) Amy Rodgers met with Executive Director Jonathan Wheeler, to deliver findings on the above-mentioned allegation. LPA identified herself and disclosed the purpose of her visit, and conducted the meeting via phone call. The Department’s investigation consisted of an unannounced facility visit, records review, and staff, resident, and outside source interviews. On June 20, 2023, Community Care Licensing (CCL) received a complaint alleging that Neglect resulted in hospitalization and staff did not provide adequate supervision to the resident in care. More specifically, resident #1(R1) is allowed to sit outside for hours with no supervision, which led to hospitalization.[See LIC811 Confidential Name List to identify select person identifiers used in this report]. (Continued on 9099-C) Unsubstantiated (Continued from 9099) Resident #1 (R1) 's physician report dated July 22, 2023, indicates that R1 uses a wheelchair for mobility and exhibits wandering behavior. However, a review of records and department observations confirmed that R1 can self-propel their wheelchair and navigate the facility grounds independently. Records review of an outside medical provider revealed that the licensee staff appropriately notified R1's medical provider of a change of condition. The medical provider responded for evaluation and determined that a hospital visit was unnecessary. Interviews with staff indicated that staffing was based on residents' acuity levels. Medication Technicians (Med Techs) on each shift were an extra person to assist when needed. Additionally, the facility used an Agency/Registry staff to help assist in the recommended staffing numbers. Regarding the allegation, the facility had no food service director. More specifically, there is no dietary person at the facility, and they do not know if there is emergency food and water as per the regulations. Annual inspections conducted by the department reveal that there are emergency food and water supplies at the facility. Interviews and records review confirm that the Licensee employs one designated person responsible for food planning, preparation, and service. Regarding the allegation, the staff did not meet the residents' laundry needs. More specifically, clothes were not cleaned on time. Interviews with staff reveal that staff usually wash and fold laundry on the NOC shift. Interviews with staff also reveal that they are aware of the laundry service needs and are hiring additional staff. However, the department did not observe residents wearing soiled clothing. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Jonathan Wheeler, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail. A reply E-mail or read receipt confirmation was requested from Executive Director Wheeler upon receipt of documentsthe state’s words, verbatim · CDSS document, Jul 21, 2025 · control 08-AS-20230620122813

Allegation investigated: Staff do not provide residents with housekeeping Staff do not properly launder resident’s clothing Staff do not safeguard resident's belongings Staff do not meet residents’ dietary needs

LPM II Donna Teutschel conducted a telephone conference with Administrator, Johnathan Wheeler, who was not the administrator at the time this complaint was filed.. A review was conducted of the allegations listed and the investigative details available.to date. The Department is unable to prove or disprove the allegations and the findings are determined to be Unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 7, 2025 · control 08-AS-20230206145343

Allegation investigated: Staff did not assist resident with incontinence care

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to initiate an investigation on the above-mentioned allegation. LPA met Clinical Director Yolanda Torres and discussed the purpose of the visit. On June 19, 2025, Community Care Licensing (CCL) received a complaint alleging that on an unknown date, an unidentified staff refused to provide Resident 1 (R1) with incontinence care assistance as it was not their jo. R1’s Physician Report states R1 is depressed, is able to groom, feed and toilet independently but is incontinent. During the investigation, LPA Strong conducted interviews, and reviewed facility records. According to interview with R1, R1 had a bladder accident, R1 pressed their call button, and an unknown staff arrived, this staff expressed to R1 that incontinence care for R1 was not their job but proceed to provide R1 with assistance and fresh clothes and bedding. Unsubstantiated R1 stated that they reported the incident to Wellness Coordinator and the said staff was terminated. Interview with Wellness Coordinator revealed that such incident was not reported to them. Interview with Clinical Director revealed that there have been no known incidents between staff and residents and no staff have been terminated recently due to interactions with residents. Interview with other residents could not confirm the incident. Interview with outside source could not establish the incident occurred. Based on interviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Clinical Director to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 26, 2025 · control 08-AS-20250619082145

Allegation investigated: Facility staff are not meeting resident needs. Physical plant violation. Personal Rights violation

.LPM II Donna Teutschel conducted a telephone conference with Clinical Director, Yolanda Torres. Both Clinical Director, Yolanda Torres, and Administrator, Jonathan Wheeler, are new to the facility. A review was conducted of the allegation listed and investigative details available.to date. The Department is unable to prove or disprove the allegation and the findings are determined to be Unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 25, 2025 · control 08-AS-20220218122343

Allegation investigated: Insufficent staffing to meet residents needs

LPM II Donna Teutschel conducted a telephone conference with Clinical Director, Yolanda Torres. Both Clinical Director, Yolanda Torres, and Administrator, Jonathan Wheeler, are new to the facility. A review was conducted of the allegation listed and investigative details available.to date. The Department is unable to prove or disprove the allegation and the findings are determined to be Unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 25, 2025 · control 08-AS-20221020104531

Allegation investigated: Facility did not ensure client was treated with dignity.

LPM II Donna Teutschel conducted a telephone conference with Clinical Director, Yolanda Torres. Both the Clinical Director, Yolanda Torres, and Administrator, Jonathan Wheeler, are new to the facility. Details of the allegation found that 2 residents, R1 and R2, who had previously shared a room had an altercation where R1 retrieved a mop out of the facility trash which upset R2 and R2 spontaneously slapped R1. R1 and R2 had been roommates are no longer. No staff engligence was determined. A further review was conducted of the allegation listed and investigative details available.to date. The Department is unable to prove or disprove the allegation and the findings are determined to be Unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 25, 2025 · control 08-AS-20221121154125

Allegation investigated: Staff did not ensure resident's heigene needs were met. Staff had inappropriate interaction with residents. Staff handled resident in a rough manner

LPM II RA Donna Teutschel conducted a telephone conference with clinical Director, Yolanda Torres..Both clinical director, Yolanda Torres, and Administrator Jonathan Wheeler are new to the facility. A review was conducted of the allegations listed above and investigative details available.to date. The Department is unable to prove or disprove these allegations as there were no additional interviews to support the allegations and the findings are determined to be Unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 25, 2025 · control 08-AS-20240614175101

Allegation investigated: Residents in care sustained unexplained injuries Staff conduct inimicable. Lack of supervision resulted in resident left on the floor for an extended amount of time. Staff yelled at residents in care Staff did not follow physician's special diet orders. Facility was unsanitary

LPM II Donna Teutschel conducted a telephone conference with Clinical Director, Yolanda Torres. both the Clinical director, Yolanda Torres, and the Administrator, Jonathan Wheeler, are new to the facility. A review was conducted of the allegations listed and investigative details available.to date which do not corroborate allegations and lack details necessary.. The Department is unable to prove or disprove any of the allegations and the findings are determined to be Unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 25, 2025 · control 08-AS-20230516142516

Allegation investigated: Staff do not meet residents dietary needs Staff do not provide resident with laundry service Staff do not provide resident with housekeeping service

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to continue an investigation on the above-mentioned allegations. LPA met with Clinical Director Yolanda Torres and discussed the purpose of the visit. Executive Director Jonathan Wheeler arrived shortly after. On March 25, 2025, Community Care Licensing (CCL) received a complaint alleging facility staff did not meet Resident 1’s (R1) dietary needs, staff did not provide R1 with laundry services and staff did not provide R1 with housekeeping services. During the investigation, LPA Strong conducted interviews, and reviewed facility records. According to R1’s Physician report dated February 7, 2024, R1 can follow instruction, can communicate need, is able to feed self and is ambulatory. R1’s Service Plan from February 22, 2024, states R1 will be offered choices in food menu and will be provided a No Added Salt diett, and changes show that as of March 30, 2025, states R1 is to have a Renal Diet. Unsubstantiated Interview with Dietary Director established that R1, received their special diet since move in but would often refuse the food or not eat it. Interview with an outside source established that R1 would often leave the facility with responsible party and return with fast food. On April 3, 2025, LPA Strong observed an untouched plate of food in R1’s room with grilled chicken and vegetables, as well as boxes of processed snacks and cereals. It was also alleged that R1 did not receive assistance with laundry and housekeeping. Interview with outside source revealed that R1 would often take clothes to responsible party’s home to complete laundry. Interview with staff revealed R1 did not allow staff to enter room to collect laundry for service or to allow staff to conduct a thorough cleaning of room. Interview with R1 corroborated that R1 did not allow staff in room and R1 preferred to do own housekeeping. Based on interviews, and record reviews the preponderance of evidence was not met to prove alleged violations, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Jonathan Wheeler, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 16, 2025 · control 08-AS-20250325131432

Allegation investigated: Staff did not seek medical attention for a resident in care. Staff did not ensure that a resident in care was fed. Staff did not ensure that residents are given water. Staff did not ensure facility was free of malodors

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to continue an investigation on the above-mentioned allegations. LPA met with Clinical Director Yolanda Torres and discussed the purpose of the visit. Executive Director Jonathan Wheeler arrived shortly after. On April 2, 2025, Community Care Licensing (CCL) received a complaint alleging staff did not seek medical attention for R1, staff did not ensure R1 was fed, staff did not provide multiple residents water and did not ensure facility bedding was free of odors. During the investigation, LPA Strong conducted interviews, and reviewed facility records. According to the first allegation, on an undisclosed date, Resident 1 (R1) was observed to be having gastrointestinal issues, including vomiting and diarrhea for over two days and staff did not provide R1 with medical care. Interviews conducted with an outside source established that R1 has an ongoing- medical conditional resulting in regular diarrhea and vomiting. Records collected revealed that as of March 24, 2025, R1 received medical labs from primary care provider due to diarrhea. Unsubstantiated Records also show that as of March 31, 2025, R1 was prescribed medication and warm liquids to assist with gastrointestinal issues. Based on this information, facility had active communication with R1’s medical provider. The second allegations states that on a undisclosed date, R1 had not eaten for two days. Records collected revealed that R1 refused meals on March 13, 2025. Interview with multiple staff revealed that R1 did not like to eat and would often skips meals. Interview with an outside source established that R1 did have access to protein shakes as needed. The third allegation states that Resident 2 (R2) had not been given water for two days. Interview with an outside source revealed that R2 was having regular bowel and bladder movements which did not make outside source believe water was being withheld. Interview with staff established that R2 enjoyed eating and drinking and would communicate needs often. LPA Strong also observed multiple water coolers throughout the facility available for resident use. Lastly, it was alleged that facility bedding was not washed correctly, resulting in urine odors. During today’s date, LPA Strong did not notice any malodors in resident rooms or bedding. Interview with staff established that staff were unaware of clean bedding having any remaining malodors. Interview with outside sources could not corroborate that facility bedding had malodors. Based on interviews, and record reviews the preponderance of evidence was not met to prove alleged violations, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Jonathan Wheeler, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 16, 2025 · control 08-AS-20250402110241

Allegation investigated: Neglect/Lack of Supervision resulting in serious bodily injury

Licensing Program Analysts (LPA) Iby Strong and Hannah Rodgers conducted an unannounced visit to deliver findings in the above complaint allegation. LPAs identified themselves and discussed the purpose of the visit with Executive Director Jonathan Wheeler. On December 2, 2024, Community Care Licensing (CCL) received a complaint alleging Neglect/Lack of Supervision resulting in serious bodily injury to Resident 1 (R1). Physician’s Report dated September 26, 2024, states R1 is diagnosed with mild neurocognitive impairment, was ambulatory and heath is in fair status. Facility records also show R1 moved into the facility on October 07, 2024. Unsubstantiated During the investigation, the Department collected pertinent resident records, outside source records and conducted various interviews. According to details of the allegation, on or around November 26, 2024, R1 was not receiving the proper level of care which resulted in multiple falls and a fractured leg. Records collected revealed that R1 was diagnosed with a fractured leg prior to R1’s move into the facility and was actively receiving physical therapy for such injury from an outside source agency. Records also confirmed R1 was receiving medical care for pre-existing injury as early as October 11, 2024, only four days after moving in. Interviews with multiple staff confirmed that as of December 10, 2024, R1 had had a change in condition which had caused multiple falls, but no injuries were observed or reported. Interview with an outside source established that facility was providing multiple status check for R1 throughout the day. Based on a review of pertinent records and interviews, the preponderance of the evidence standard was not met to prove neglect/lack of supervision resulting in serious bodily injury. An exit interview was conducted with Executive Director Jonathan Wheeler, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 29, 2025 · control 08-AS-20241202144844

Allegation investigated: Neglect resulted in a Stage 4 (four) pressure injury Staff did not meet resident’s incontinence care needs

Licensing Program Analysts (LPA) Iby Strong and Hannah Rodgers conducted an unannounced visit to deliver findings in the above complaint allegations. LPAs identified themselves and discussed the purpose of the visit with Executive Director Jonathan Wheeler. On August 2, 2022, Community Care Licensing (CCL) received a complaint alleging staff neglect of Resident 1 (R1) (R1 – see LIC811 Confidential Names List) resulted in a Stage 4 (four) pressure injury and staff did not meet R1’s incontinence care needs. Physician’s Report dated September 27, 2019, confirmed R1 was diagnosed with Multiple Sclerosis (MS) and had a bladder/bowel impairment. R1’s Individual Service Assessment dated February 10, 2022, also established that R1 had a history of skin breakdown and a record of yeast rashes in groin area. The assessment also stated that R1 will receive physical assistance with bathing two times per week and staff will monitor R1 for skin redness, openings, or abnormalities. Lastly, the assessment revealed that R1 was receiving urinary catheter care from an outside source agency. Substantiated According to the first allegation, on July 30, 2022, R1 was observed to have a Stage 4 (four) pressure ulcer on the left buttocks while being treated for an unrelated urinary catheter issue. Based on staff statements, on July 30, 2022, Staff 1 (S1), Staff 2 (S2) and Staff 3 (S3) were walking the facility patio when S1 observed a catheter bag on the ground. S1 and S2 believed the bag belonged to R1 and proceeded to R1’s room, where it was found that R1 was missing such catheter bag. R1 explained to staff that the catheter had been leaking but was unaware the bag was missing. Staff proceeded to contact outside source agency that provided catheter care and was instructed to contact emergency personnel for assistance. According to S1, prior to emergency personnel arriving, S1 and S2 cleaned/wiped R1’s groin area and whole body, while not observing any irregularities with skin. Medical records collected revealed once R1 arrived at hospital, it was found that R1 had a Stage 4 (four) gangrenous pressure ulcer to left buttocks. According to interview with Administrator, no staff was aware that R1 had developed a pressure injury. Interview with multiple staff revealed that R1 was known to be refusing care since May of 2022 and care records corroborated such information. Interview with Administrator confirmed that Administrator was aware of R1 refusing care and did not take action to prevent such issues. It was also alleged that R1 was not assisted with incontinence care for bowel movements. Interviews with multiple staff revealed that R1 was refusing bowel incontinence care from staff. Records collected revealed that as of May 25, 2022, R1 had a change in condition, and required assistance with activities of daily living (ADSL), was bed bound, and forgetful. Documentation shows that these changes were also documented on June 8, 2022, and July 15, 2022, with additional information that R1 was defecating in bed, wheelchair, and shower. Interview with S1 revealed that R1 was denying staff from entering room and often hiding feces throughout the shared cottage. Administrator could not provide documentation that such changes and behaviors were reported to R1’s Physician and/or family. Based on staff and outside source interviews conducted, review of records, including outside sources records, a preponderance of evidence exists to support the allegation that staff neglect of R1 resulted in a Stage 4 (four) pressure injury and staff did not meet R1’s incontinence care needs. The allegations are therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). The Department has determined this violation resulted in injuries to the resident in care. An immediate Civil Penalty of $500.00 is charged and is noted on the LIC421IM. Currently, per Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of Community Care Licensing Division. An exit interview was conducted with Executive Director Jonathan Wheeler, and a Plan of Correction was jointly developed. A copy of this report, LIC811, LIC 9099-Cx2, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Executive Director Jonathan Wheeler, signature on this form confirms receipt of documents. According to the first allegation, on July 30, 2022, R1 was believed to have a leaking and malfunctioning urinary catheter for two days and facility staff did not seek medical attention for R1. According to records collected, R1 was receiving urinary catheter care from an outside source agency. Interviews with staff revealed that on July 30, 2022, Staff 1(S1), Staff 2 (S2) and Staff 3 (S3) were walking the facility patio when S1 observed a catheter bag on the ground. S1 and S2 believed the bag belonged to R1 and proceeded to R1’s room, where it was found that R1 was missing such catheter bag, R1 explained to staff that catheter had been leaking but was unaware the bag was missing. Staff proceeded to contact outside source agency that provides catheter care and was instructed to contact emergency personnel for assistance. R1 was taken by emergency personnel on the same date of incident. Records collected revealed that R1 had a visit by outside source agency medical professional and had a urinary catheter change on July 29, 2022. It was also alleged that as of July 30, 2022, facility licensee knowingly retained a resident with a prohibited condition Stage 4 (four) pressure ulcer without an exception from the Department. Interview with S1 and S2 established that care staff were unaware of R1’s pressure injury. Interview with Administrator revealed R1 has refused care since May 2022, and had not allowed staff to provide care or make observations of resident’s physical conditions. Records collected did not confirm R1 was diagnosed with pressure injury until July 30, 2022. Interview with outside source medical professional revealed that a pressure injury on R1 had not been observed during regular care or reported by R1. Based on interviews, and record reviews the preponderance of evidence standard has not been met, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Jonathan Wheeler, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 29, 2025 · control 08-AS-20220802160403

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: May 30, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ...residents in privately operated residential care facilities for the elderly shall have ...the following personal rights:(8) To be free from neglect. This requirement was not met as evidence by: Based on interviews and record reviews the licensee did not protect resident from neglect in 1 of 67 persons in care (R1) which posed an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: Licensee will provide staff with a vendorized traiing in regards to self neglect and skin assessments. Licensee will provide proof of training scheduled within 24 hours.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(a)(1)(C) · Plan of correction due date: Jun 13, 2025

87625 Managed Incontinence (a)The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following....: (1).... managed with any of the following: (C) A program of scheduled toileting at regular intervals. Based on interviews and record reviews the licensee did not provide resident with managed incontince program in 1 of 67 persons in care (R1) which posed an potential health risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: Licensee will provide staff with a vendorized training in regards to incontinence care.

Allegation investigated: Physical abuse to resident by facility staff resulted in serious bodily injuries.

Licensing Program Analysts (LPA) Iby Strong and Hannah Rodgers conducted an unannounced visit to deliver findings in the above complaint allegation. LPAs identified themselves and discussed the purpose of the visit with Executive Director Jonathan Wheeler. On December 13, 2023, Community Care Licensing (CCL) received a complaint alleging physical abuse to Resident 1 (R1) by facility staff resulted in serious bodily injuries. Physician’s Report dated November 14, 2023, states R1 is diagnosed with mild neurocognitive impairment and is ambulatory. Facility records also show R1 moved into the facility on November 17, 2023. Unsubstantiated During the investigation, the Department collected pertinent resident records, outside source records and conducted various interviews. According to details of the allegation, R1 reported that on December 11, 2023, Staff 1(S1) lifted and threw R1 during an emergency evacuation at the facility causing fractures to multiple ribs. Medical records confirmed that on December 12, 2023, R1 was diagnosed with fractured ribs. Interview with S1 revealed that S1 did not assist R1 in the evacuation on December 11, 2023, and S1 was focused in extinguishing the fire in a residents’ room. Interview with Staff 2, who was also present on the date of the incident, revealed R1 was not assisted out of the facility as R1 is ambulatory. Records collected revealed that R1 was later found with a fire lighter and cardboard on the date of the fire and was considered a suspect of arson to the facility. During further interviews it was found that on December 9, 2023, R1 had an outburst where R1 urinated on the floor of the facility, destroyed holiday decoration and hit Staff 3 (S3) and Staff 4 (S4). Interview with S3 and S4 revealed R1 slapped S3 and punched S4; attempts of S4 to intervene in further violence on S3 and residents, resulted in S4 and R1 slipping on the urine-soaked floor, causing S4 to fall on top R1. S4 believes the fall may have caused R1’s fractured ribs. After the incident, S3 and S4 assessed R1 for injuries and R1 reported to be fine. Records collected confirmed R1 has assaulted multiple staff and destroyed facility property. Interview with an outside medical source established that facility attempted to protect R1 from self and others and injuries may have not been an act of abuse. Further interviews revealed that R1 has a history of chest pain, and according to Staff 5 (S5), R1 reported having chest pain as of December 6, 2023. Interview with R1 established that R1 believed their ribs were injured as of the first incident on December 9, 2023. Based on a review of pertinent records and interviews, the preponderance of the evidence standard was not met to prove physical abuse to resident by facility staff resulted in serious bodily injuries. An exit interview was conducted with Executive Director Jonathan Wheeler, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 29, 2025 · control 08-AS-20231212085832

Allegation investigated: Neglect and/or Lack of supervision resulted in resident-on-resident altercation with injury.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Executive Director Jonathan Wheeler. On December 24, 2024, Community Care Licensing (CCL) received a complaint alleging staff neglect and/or lack of supervision resulted in resident-on-resident altercation with injury. Allegation states that on December 23, 2024, Resident 1 (R1) and Resident 2 (R2) had a physical altercation that resulted in swelling to the head and laceration to R1. Physician’s Report dated September 18, 2024, states R1 is diagnosed with a major neurocognitive disorder and does not require continuous bed care. R2’s Physician Report dated September 18, 2024, shows R2 is considered confused and disoriented but has no aggressive behaviors. R1 care records show R1 has a history of verbal and physical aggression with other residents but no history with R2. Unsubstantiated During the investigation, through record reviews, and interviews, the Department established the following sequence of events. Based on staff statements, on December 23, 2024, at or around 4pm, R1 was heard calling R2 derogatory names then R2 hit R1 in the face, which resulted in a cut and bruising to R1’s face. According to multiple staff, R1 and R2 were separated and R1 was provided first aid while emergency personnel arrived. At this time, R1 was taken to receive medical care and R2 was sent to a psychiatric hold for a safety evaluation. While both residents were away, Wellness Coordinator requested R1 and R2’s Primary Care Provider to re-evaluate both resident’s medications but such changes were denied. On the same night of the incident, both R1 and R2 were discharged back to the facility. On this date, there were three staff present to intervene in the incident, provide first aid and contact emergency personnel. According to outside source records, on this date R1 was diagnosed with an abrasion to the forehead and contusion of the forehead. The investigation also found that on December 24, 2024, at or around 4pm, R1 was heard calling R2 the same derogatory names and R2 hit R1 in the face multiple times. Staff present established that the altercation was heard, and multiple staff assisted in separating the two residents. On this date, emergency personnel were contacted but only medical assistance arrived. R1 was then taken to receive medical care. Outside source records collected revealed that this incident resulted in R1 having a cut to the scalp as well as a hematoma, but no fractures were found. According to interview with the Wellness Coordinator R1 and R2’s rooms are now in different parts of the same building; their meals are served in different locations and there is additional supervision to both residents. R2 has since received medication to assist with agitation. Based on a review of pertinent records and interviews, the preponderance of the evidence standard was not met to prove staff neglect and/or lack of supervision resulted in resident-on-resident altercation with injury. An exit interview was conducted with Executive Director Jonathan Wheeler, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 21, 2025 · control 08-AS-20241224160823

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Wellness Coordinator Jenna Purnell, and Executive Director Jonathan Wheeler and discussed the purpose of the visit. Community Care Licensing received an incident report on 12/18/24 in which it was reported that Resident #1s (R1) prescribed as-needed medication went missing from the facility. According to records and interviews on 12/9/24 Staff 1 (S1) accepted a delivery of Medication 1 (M1) from a courier. On 12/16/24, Wellness Coordinator was informed that M1 was missing from medication room. Interviews established that R1's medication on-hand was sufficient to provide R1 with medication without missing a dose. It was also revealed that incident was reported to medical provider, pharmacy and another government agency. Interview with R1 corroborated that R1 has not missed medication. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. No deficiencies were cited during today’s visit. An exit interview was conducted with Executive Director Jonathan Wheeler. The Licensee was provided a copy of their appeal rights (LIC9058 03/22), LIC811, this report and their signature on this form, acknowledges receipt of these rights.the state’s words, verbatim · CDSS document, Jan 2, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Wellness Coordinator Jenna Purnell, and Clinical Director Yolanda Torres we discussed the purpose of the visit. Community Care Licensing received an incident report on 10/29/24 in which it was reported that Resident #1 (R1) eloped from the facility on 10/29/24. R1 was found by responsible party. Per interviews the licensee followed absentee notification plan as necessary. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. No deficiencies were cited during today’s visit. An exit interview was conducted with Wellness Coordinator Jenna Purnell, and Clinical Director Yolanda Torres. The Licensee was provided a copy of their appeal rights (LIC9058 03/22), LIC811, this report and their signature on this form, acknowledges receipt of these rights.the state’s words, verbatim · CDSS document, Nov 20, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Iby Strong and Hannah Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Jonathan Wheeler. According to the facility’s license, the facility has a maximum capacity of 68 residents, of whom 41 may be non-ambulatory. LPAs toured the interior and exterior of the facility and inspected each room. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. One shower valve within the cottages was not in working condition, and multiple sinks were not draining. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, as required, and stored in inaccessible areas. No pool or body of water is present. Per Executive Director, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit were observes and readily accessible. Resident records reviewed had required documentation. Staff records reviewed contained required documentation. One deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D) An exit interview was conducted with Executive Director , to whom a copy of this report,LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided tothe state’s words, verbatim · CDSS document, Oct 25, 2024

Allegation investigated: Lack of supervision resulted in a resident on resident altercation

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to initiate a complaint investigation on the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit with Business Office Manager Amanda Pepin. Clinical Director Yolanda Torres arrived shortly after. On September 27, 2024, Community Care Licensing (CCL) received a complaint alleging lack of supervision resulted in Resident 1 (R1) hitting Resident 2 (R2) resulting in a bruise on the face to R2. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to R2’s Physician Report, R2 is diagnosed with a major neurocognitive disorder but can communicate need. R1’s Physical Report shows that R2 has a major neurocognitive disorder and has inappropriate/aggressive behaviors. Unsubstantiated According to interview with R2, R1 hit R2 while sitting in the common area. Interview with R2 corroborated that R2 hit R1 after R1 called R2 derogatory names. Interview with staff present revealed R1 and R2 have not had previous instance of disagreements or violent behaviors with each other. Interview with staff present on the date of the incident revealed that staff were feet away from residents when the incident occurred. Interview with outside source revealed that this was an isolated incident. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Business Office Manager Amanda Pepin and Clinical Director Yolanda Torres, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 3, 2024 · control 08-AS-20240927162433

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Business Office Manager Amanda Pepin and Clinical Director Yolanda Torres, and we discussed the purpose of the visit. Community Care Licensing received an incident report on 9/23/4 in which it was reported that Resident #1 (R1) went absent without official leave (AWOL) from the facility on 9/21/24. According to records, R1 was observed leaving with an outside source vendor at 1:45pm, at 2:15pm the facility received a phone call from emergency personnel explaining R1 had been found away from the facility. According to interview with Staff present on the date of the incident, staff did not recognize R1 as a resident of the facility and did not prevent R1 from leaving the locked memory care unit. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. A deficiency is being cited for California Health and Safety Code. An exit interview was conducted with Business Office Manager Amanda Pepin and Clinical Director Yolanda Torres who was also provided a copy of their appeal rights (LIC9058 03/22), LIC811, LIC809 D and this report were provided to.the state’s words, verbatim · CDSS document, Oct 3, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312 · Plan of correction due date: Oct 10, 2024

1569.312 Basic Service Requirement Every facility required to be licensed under this chapter shall provide at least the following basic services: (d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement was not met as in evidence in: Based on interviews and records reviewed the licensee did not know the whereabouts of R1 which posed a potential Safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 3, 2024

Plan of correction: Licensee has changed the door codes, locks and added addtional signage to prevent residents from leaving. Plan of correction has been cleared as of today's date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management Visit to cite a deficiency which was identified during a separate complaint investigation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Business Office Manager Amanda Pepin and Clinical Director Yolanda Torres. On today's date, LPA Strong reviewed records. According to records reviewed, Resident 1 (R1) was assaulted by Resident 2 on September 24, 2024. According to interviews and records reviewed, licensee did not report incident to Community Care Licensing or the Long Term Care Ombudsman. Based on records reviewed and interviews a deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). An exit interview was conducted with Business Office Manager Amanda Pepin and Clinical Director Yolanda Torres. A copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to her during today’s visit.the state’s words, verbatim · CDSS document, Oct 3, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Oct 31, 2024

(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met as in evidence in: Based on interviews and records reviewed the licensee did not report abuse to R1 which posed a Safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 3, 2024

Plan of correction: Licensee agrees to provide abuse reporting AND written reporting training to all staff at facility by date and provide LPA with proof of such.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Iby Strong conducted a plan of correction visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Business Office Manager Amanda Pepin-Laphen. The purpose of the visit was to issue LIC421FC for ongoing civil penalties. On 5/17/24, the licensee was issued a duplicate deficiency for a violation in California Code of Regulations Section 87411(c)(1) originally issued on 11/3/23 . As of yesterday, 5/21/24, Executive Director provided LPA with proof of correction. Based on such information, a civil penalty of $100 per day from 5/18/24 until 5/21/24 was assessed. An exit interview was conducted with Business Manager Amanda Pepin-Laphen, whose signature below confirms receipt of a copy of this report, the LIC421FC, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, May 22, 2024

Allegation investigated: Licensee did not ensure staff were trained

-Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings in the above-mentioned allegation. LPA met with Executive Director Jared Green and discussed the purpose of the visit.-On April 9, 2024, Community Care Licensing (CCL) received a complaint licensee did not ensure staff were trained. -During investigation, LPA Strong collected pertinent facility documentation and conducted interviews. According to allegation, multiple staff are not trained on first aid and cardiopulmonary resuscitation (CPR). Records collected revealed three out of sixteen care staff have current first aid training. Records also revealed that sixteen out of sixteen staff have CPR training. Interview with staff revealed they were unaware first aid training was not current. -Based on records reviewed and interviews, a preponderance of evidence exists to support the allegations. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). Additionally, a civil penalty is being issued due to duplicate citation within 12 months. An exit interview was conducted with Executive Director Jared Green to whom a copy of this report, LIC 9099-C, LIC 9099-D,421FC, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to. Substantiated It was also alleged that staff did not provide residents with a safe environment from R1, R2 and R3. Interviews with staff revealed that such residents had not had behaviors that injured any of the other residents. Records reviewed did not reveal any information to corroborate that these residents had had threatening behaviors. Outside source interviews did not reveal any corroborating information. Additionally, it was alleged that staff did not prevent residents from smoking in non-smoking areas of facility. Interview with staff revealed that residents have been found smoking in the non-smoking areas of the facility. Staff revealed that residents are reminded of smoking areas, but they cannot be physically forced them to move. Interviews with residents revealed that residents are often reminded where smoking areas are. Also, it was alleged that facility had mold in the vents and walls were damaged. On May 8, 2024, LPA Strong conducted a facility inspection and did not observe any damaged walls or mold in the vents. Interview with Maintenance Director revealed that maintenance workers are continuously working on the facility. Interview with staff did not reveal any information to corroborate this allegation. Lastly, it was alleged that facility staff did not maintain a comfortable temperature for residents. On May 8, 2024, LPA Strong also reviewed the facility temperatures, noting that the indoor temperatures for the main lodge was 70 degrees Fahrenheit and each cottage ranged from 70-75 degrees Fahrenheit. Interview with Maintenance Director revealed that they can control the facilities temperatures via mobile device. Interviews with outside sources did not reveal any information to corroborate allegation. Based on LPA's interviews, and record reviews 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 Jared Green, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 17, 2024 · control 08-AS-20240409092642

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: May 29, 2024

87411 Personnel Requirements(c) All RCFE staff who assist residents with personal activities of daily living ..(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on records reviewed the licensee did not provide first aid training to 13 of 16 staff which poses a potential health and safety risk to 56 persons in care.the state’s words, verbatim · CDSS document, May 17, 2024

Plan of correction: Licensee agrees to provide training to care staff, will provide proof of training to LPA.

Allegation investigated: Staff did not respond to communications from resident's representative in a timely/appropriate manner.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings in the above-mentioned allegation. LPA met with Executive Director Jared Green and discussed the purpose of the visit. On April 29, 2024, Community Care Licensing (CCL) received a complaint alleging staff did not respond to communications from resident's representative in a timely/appropriate manner. During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to allegation, for a three-month period from April 29, 2024, resident’s representative did not receive appropriate communications from facility after calling phone number as well as leaving multiple voicemails. Records collected revealed R1 is legally blind and requires assistance with telephone calls. On May 6, 2024, LPA Strong attempted to contact the facility two times and the telephone was not answered in an appropriate manner, and the first call was disconnected. Substantiated LPA Strong attempted two phone numbers provided to responsible party by facility staff and both numbers went directly to facility main line. Interviews with staff revealed that facility does have a voicemail system, and telephones in each room do not receive incoming calls. Based on interviews, and records reviewed, a preponderance of evidence exists to support the allegations. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Jared Green, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to. It was also alleged R1 was not allowed to leave the facility unassisted. Based on R1 Physicians Report dated September 27, 2023, R1 is not able to leave facility unassisted. Interview with staff revealed R1 has not had any family or friends present to assist R1 in going out into the community. Interview with outside source confirmed it is not safe for R1 to be allowed to leave unassisted. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation are unsubstantiated. An exit interview was conducted with Executive Director Jared Green, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 17, 2024 · control 08-AS-20240429142934

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(9) · Plan of correction due date: May 31, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents...shall have... the following personal rights:(9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement was not met as evidence in; Based on observations and interviews the licensee did not communicate with representatives promptly and appropriately in 1 of 65 persons in care [R1] which posed a potential Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 17, 2024

Plan of correction: Licensee agrees to provide staff with customer service training and working phones by 5/31/2024.

Allegation investigated: Staff did not allow resident to contact emergency personnel.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Executive Director Jared Green. On April 30, 2024, Community Care Licensing (CCL) received a complaint alleging Resident 1 (R1) was not allowed to contact emergency personnel. During the investigation, LPA Strong conducted interviews, and reviewed facility records. According to allegations, R1 has not been allowed to contact emergency personnel. According to R1’s Physician Report, R1 is diagnosed with a major neurocognitive disorder, is not allowed to leave facility unassisted and has wandering behavior. According to staff interviews, R1 continuously contacts emergency personnel from personal cell phone. Staff revealed they have not limited resident from using cell phone. Interview with outside source revealed they have limited R1’s access to emergency personnel. Unsubstantiated Outside source also revealed facility does not have any history in limiting resident from contacting emergency personnel. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation are unsubstantiated. An exit interview was conducted with Executive Director Jared Green, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 17, 2024 · control 08-AS-20240430110741

Type of visit: POC

Licensing Program Analyst (LPA) Rebecca Ruiz conducted a plan of correction visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Interim Wellness Director Jenna Purnell. LPA met with Administrator Jared Green. The purpose of the visit was to verify if the deficiencies issued on 3/29/2024 had been corrected. On 3/29/2024, the licensee was issued multiple deficiencies with a correction due date of 4/29/2024. As of today’s date, 5/6/2024, the licensee has not submitted proof of correction to the Department. During today’s visit, LPA Ruiz observed residents in care and spoke with Administrator and Interim Wellness Director. Per Administrator and Interim Wellness Director, the report that LPA Ruiz provided the previous Wellness Director on 3/29/2024 was not provided to the Administrator, and both individuals were not aware of the POC due date. Additionally, the previous Wellness Director's last day working at the facility was 4/15/2024. LPA Ruiz provided Administrator with an LIC178 and granted a POC due date extension for the deficiencies cited on 3/29/2024. The new POC due date is 5/31/2024. An exit interview was conducted with Interim Wellness Director Jenna Purnell and Administrator Jared Green, whose signature below confirms receipt of a copy of this report, the LIC178, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, May 6, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Executive Director Jared Green, and we discussed the purpose of the visit. Community Care Licensing received an incident report on 4/15/24 in which it was reported that Resident #1 (R1) went absent without official leave (AWOL) from the facility on 4/13/24. R1 was found by emergency responders and returned to facility. Per records reviewed licensee followed absentee notification plan as necessary. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. LPA Strong observed auditory alarm installed in the memory care cottage. No deficiencies were cited during today’s visit. An exit interview was conducted with Medication Technician Anastasia Hanna who was also provided a copy of their appeal rights (LIC9058 03/22), LIC811, this report and their signature on this form, acknowledges receipt of these rights.the state’s words, verbatim · CDSS document, Apr 19, 2024

Allegation investigated: Licensee did not employ an adequate number of direct care staff to support resident care needs Facility was malodorous Facility was not kept clean Staff did not meet residents’ incontinence needs Staff did not meet residents’ hygiene needs Staff did not follow physician’s order

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Business Office Manager Amanda Pepin and Wellness Director Rosa Barajas. During today's visit, LPA collected facility records. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the Licensee did not employ an adequate number of direct care staff to support resident care needs, the facility was malodorous, facility was not kept clean, staff did not meet residents’ incontinence needs, staff did not meet residents’ hygiene needs, and staff did not follow physician’s order. Continued on LIC9099-C page… Substantiated Review of Resident 1’s (R1) medical assessment records dated May 2021, revealed that R1 had a diagnosis of dementia, was confused and disoriented, was non-ambulatory, used a wheelchair, had bladder incontinence, had limited ability to communicate needs, and was unable to follow directions. R1 also required staff assistance with medication administration, bathing, dressing, grooming, feeding, transferring, and toileting care and had a physician prescribed diet. The Department attempted to interview R1 but the interview did not reveal any relevant information due to R1’s cognitive impairment and non-verbal state. Interviews with staff and review of R1’s needs and service plan dated 2021 revealed that R1 required multiple staff to lift, transfer, and shower. Staff disclosed during interviews that staff were unable to request assistance from other staff while caring for any residents who required more than one person due to staffing level. Staff interviews revealed that some staff would refuse to shower R1 due to not having enough staff to lift R1. Interviews revealed that staff had falsified shower logs to falsely indicate that they had showered residents. Outside source interviews revealed that on multiple occasions, R1 was observed in soiled clothing or in the same clothing over several days. Interviews with outside sources revealed that R1 was observed to be wearing soiled briefs and clothing on multiple occasions. Interviews with staff and outside sources and review of R1’s updated medical assessment and hospital discharge paperwork dated January 2023 revealed that R1 required staff assistance with oxygen administration through the use of a nasal cannula after being discharged from the hospital at the end of January 2023. Staff interviews revealed that R1 would occasionally pull the nasal cannula down and interviews with staff and outside sources revealed that R1 had been observed with the nasal cannula pulled away from their nose on several occasions. Review of R1’s needs and service plan dated 2021 revealed that staff were instructed to check on R1 “frequently” during the day and night, but the document did not specify a time period between checks or the number of checks to be conducted during a 24-hour day. Interviews with outside sources revealed that on more than one occasion, outside sources were unable to locate staff to provide direct care to residents. Outside source interviews alleged that staff were not available to assist residents, including R1, or did not respond to calls for resident care assistance for more than 30 minutes. Continued on LIC9099-C page… Onsite visits to the facility by the Department in January, February, and May of 2023 revealed that the facility lobby and resident rooms smelled of urine. During an onsite visit in February 2023, resident rooms were observed by the Department to be messy with clothing cluttered around the room, trashcans that contained soiled incontinence briefs, and bags of laundry piled outside of resident rooms. Evidence obtained during outside source interviews supported the allegation that R1’s room was observed to be cluttered and smelled of urine or other foul odors and that the facility smelled of urine and was not kept clean. Interviews with facility management stated that housekeeping staff were supposed to clean resident rooms two to three times a week and caregivers were responsible for disposing of soiled briefs daily. However, interviews with staff disclosed difficulties with meeting the care needs for residents and completing additional tasks such as laundry and housekeeping during their shifts due to workload and number of residents requiring care. Review of the staff schedule for December 2022 revealed that approximately 4 staff were scheduled per 8-hour shift, with each staff member responsible for a different section of the facility or assigned as the medication technician for the entire facility. Interviews with facility management and staff stated that caregivers were responsible for collecting, washing, and returning residents’ clothing on a rotating schedule in addition to assisting residents with care needs. During interviews, staff voiced concerns that they were unable to meet the needs of residents due to the workload, staffing level, facility layout, and the number of residents needing care at the same time. Staff stated that during meals, kitchen staff were asked to supervise residents in the dining room while caregivers assisted residents with meals in their rooms. Interviews revealed caregivers were not able to assist all of the residents who required assistance with feeding due to workload. Interviews raised concerns that staff were unable to assist all residents who required feeding assistance and that those residents would be unable to eat food without assistance. Additionally, interviews with staff brought up concerns that staff could not track residents’ meal intake or determine if residents were finishing meals or losing weight. Interviews with staff revealed that R1 required assistance with eating meals and would eat all meals in R1’s room. Continued on LIC9099-C page… Evidence collected during staff interviews revealed that staff believed that R1 had not been assisted with meals and that meals were only being delivered to R1’s room. Staff voiced concerns that R1 had lost weight but there were no reports that R1 was finishing smaller portions of food or refusing meals. Hospital records show that R1 was diagnosed with acute hypoxic respiratory failure and aspiration pneumonia with sepsis while at the hospital in January 2023. The Department has investigated the above-mentioned allegations and based on interviews, records reviewed, and Department observations, the preponderance of the evidence has been met, therefore, these allegations are deemed substantiated. The following deficiencies are cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D pages. A civil penalty in the amount of $500 is being assessed per Health and Safety Code 1569.49(c)(1), for a violation that the Department determined resulted in the hospitalization of R1. The Wellness Director was informed that determination of civil penalties under Health and Safety Code Section 1569.49 are pending and under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted with Wellness Director Rosa Barajas, whose signature below confirms receipt of a copy of this report, and LIC421IM, and the Licensee Appeal Rights (LIC9058 3/22). R1’s care was overseen by a non-profit agency who provided R1 with a physician and arranged R1’s medical appointments and transportation for medical care. Interviews revealed that on 1/9/2023, Staff 1 (S1) contacted the Wellness Director after S1 observed that R1 had a change of condition that resulted in R1 having difficulty eating. After being notified by S1, the Wellness Director contacted the non-profit agency to have R1 seen by their physician. R1 was seen by the physician the same day who sent R1 to the hospital where R1 was diagnosed with acute hypoxic respiratory failure, aspiration, sepsis, and pneumonia. R1 remained in the hospital for 10 days and was discharged back to the facility on 1/19/2023. When asked why R1 was not transported to the hospital from the facility when staff observed R1’s change in condition on 1/9/2023, the Wellness Director stated that the non-profit organization physicians were responsible for assessing and determining the necessary care for R1. Interviews confirmed that the Wellness Director, S1, or any other facility staff did not call 911 or emergency services for R1 on 1/9/2023. Once R1’s change in condition was observed, the Wellness Director arranged for R1 to be assessed by their physician on the same day. Interviews with facility staff revealed that staff are instructed to conduct status checks on residents every two hours which included assisting residents with meals and turning any bedridden residents like R1. During interviews, staff voiced concerns that they were unable to meet the needs of residents due to the workload, staffing level, facility layout, and number of residents needing care at the same time. Despite not calling emergency services for R1 once the change in condition was observed, the facility ensured that R1 was seen by medical providers and received medical care for the change in condition on the same day it was noted. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Wellness Director Rosa Barajas, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).the state’s words, verbatim · CDSS document, Mar 29, 2024 · control 08-AS-20230123095916

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87611(e) · Plan of correction due date: Apr 29, 2024

87611 General Requirements for Allowable Health Conditions (e) … the licensee shall ensure that the resident is cared for in accordance with the physician’s orders and that the resident’s medical needs are met. This requirement has not been met as evidenced by: Based on interviews and records review, the licensee did not ensure that R1’s physician’s order for assistance with feeding and oxygen use was followed, resulting in hospitalization for R1. This posed an immediate health risk to R1.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: R1 no longer resides at the facility or receiving care from the facility. The Wellness Director is currently implementing in-service training for following physician's orders for care and medications. The Wellness Director will submit copies of staff sign in sheet for physician's order training to the Department by POC due date of 4/29/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 29, 2024

87411 Personnel Requirements – General (a) facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement has not been met as evidenced by: Based on interviews and records reviewed, the licensee did not comply with the above section as staff were not able to meet resident care needs. This poses a potential health risk to 64 of 64 residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: Wellness Director is currently reassessing residents and their care plans to determine necessary staff levels. Staff have also been hired and Wellness Director is currently interviewing new hires. Wellness Director will submit a list of staff hired in March and April 2024 and will submit copies of updated staffing schedule for April 2024 to the Departmentby POC due date of 4/29/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 29, 2024

87303 Maintenance and Operation (a) the facility shall be clean, safe, sanitary, and in good repair at all times… This requirement has not been met as evidenced by: Based on observation and interviews, the licensee did not comply with the section above as the facility was observed to be cluttered and dirty on multiple occasions. This poses a potential health risk to 64 of 64 residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: Staff have also been hired and Wellness Director is currently interviewing new hires. The Wellness Director will conduct refresher housekeeping training and implement a housekeeping log for resident rooms and submit copy of training sign in sheet and housekeeping log to the Department by POC due date of 4/29/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(f)(5) · Plan of correction due date: Apr 29, 2024

87303(f)(5) Maintenance and Operation (f)(5) Solid waste… shall be maintained in a clean and sanitary condition. This requirement has not been met as evidenced by: Based on observation and interviews, the licensee did not comply with the above section as soiled incontinence briefs were not emptied frequently enough to prevent odors. This poses a potential health risk to 64 of 64 residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: Staff have also been hired and Wellness Director is currently interviewing new hires. The Wellness Director will conduct refresher housekeeping training and implement a housekeeping log for resident rooms and submit copy of training sign in sheet and housekeeping log to the Department by POC due date of 4/29/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Apr 29, 2024

87625 Managed Incontinence (b)… the licensee shall be responsible for… (3) ensuring that incontinent residents are kept clean and dry. This requirement has not been met as evidenced by: Based on interviews and records review, the licensee did not comply with the section above as R1 was not assisted with incontinence services to remain clean and dry. This poses a potential health risk to 64 of 64 residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: Staff have also been hired and Wellness Director is currently interviewing new hires. Wellness Director will conduct an inservice training for staff on incontinence care and submit sign in sheets to the Department by POC due date of 4/29/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Apr 29, 2024

87464 Basic Services (f)(4) Personal assistance and care as needed by the resident… with those activities of daily living such as… bathing… This requirement has not been met as evidenced by: Based on interviews and records review, the licensee did not comply with the above section as R1 was not assisted with bathing services as needed. This poses a potential personal rights risk to 64 of 64 residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: Staff have also been hired and Wellness Director is currently interviewing new hires. The Wellness Director will be conducting an inservice training on the physical requirements of caregiving and providing assistance with ADLs to residents. Wellness Director will submit sign in sheets to the Department by POC due date of 4/29/2024.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to deliver an amended LIC9099 report. LPA was greeted by, identified herself to, and explained the purpose of the visit with Wellness Director Rosa Barajas. During today’s visit, LPA obtained Baraja’s signature on the amended complaint report dated 1/27/2023. An exit interview was conducted with Wellness Director Rosa Barajas, 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, Mar 29, 2024

Allegation investigated: Staff falsified medication records Medication is not being issued as prescribed

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings on the above-mentioned complaint allegations. LPA identified herself and discussed the purpose of the visit with Business Office Manager Amanda Pepin. On March 7, 2024, Community Care Licensing (CCL) received a complaint that staff did not issue Resident 1 (R1) R1 medications as prescribed staff and falsified (R1) medication records. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to allegation, On February 29, 2024, R1 was admitted to the hospital, and it was observed that R1 did not have traces of prescribed medication in their blood work. According to an interview with staff, R1 takes medication regularly, has not declined medication and R1 has not been observed spitting medication out. Interview with Executive Director did not reveal any information to corroborate R1 was declining medication. Unsubstantiated Interview with an outside source confirmed R1 does not have a history of declining medication. Records collected did not corroborate that resident did not take medication. It was also alleged that staff entered R1’s medication into the medication administration records as administered when R1 was not at the facility. Interview with staff revealed that computer has a special code that identifies when medication is issued with a number 0 and not issued with a number 8. Records reviewed verified R1 was not at the facility starting February 29, 2024, and a number 8 was entered into those records. LPA Strong also observed two medication administrations had been edited by staff. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Business Office Manager to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 26, 2024 · control 08-AS-20240307152027

Allegation investigated: Unlawful Eviction

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to initiate a complaint investigation on the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit with Executive Director Jared Green. On March 4, 2024, Community Care Licensing (CCL) received a complaint alleging Resident 1 (R1) was not allowed to return home after hospital stay.During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to allegation, on February 28, 2024, R1 was admitted to hospital and on March 4, 2024, an unknown care staff member told hospital staff that R1 was not to return to facility. Interviews with staff revealed that staff were told that R1 was issued a 30-day eviction notice and such information was communicated to the hospital. Records collected revealed R1 did return to the facility on March 7, 2024. Interview with Administrator revealed that he was communicating with the hospital about R1’s stability prior to returning to facility. Unsubstantiated Based on LPA's interviews, and record reviews 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 Jared Green, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were providedthe state’s words, verbatim · CDSS document, Mar 11, 2024 · control 08-AS-20240304113239

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Executive Director Jared Green, and we discussed the purpose of the visit. Community Care Licensing received a phone call and voicemail on 3/10/24 in which it was reported that Resident #1 (R1) went absent without official leave (AWOL) from the facility on 3/10/24. R1 was found by emergency responders and taken to local emergency room. Per records reviewed licensee followed absentee notification plan as necessary. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. No deficiencies were cited during today’s visit. An exit interview was conducted with Executive Director Jared Green. The Licensee was provided a copy of their appeal rights (LIC9058 03/22), LIC811, this report and their signature on this form, acknowledges receipt of these rights.the state’s words, verbatim · CDSS document, Mar 11, 2024

Allegation investigated: Residents were not being assisted with activities of daily living.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to initiate a complaint investigation on the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit with Executive Director Jared Green. On February 7, 2024, Community Care Licensing (CCL) received a complaint alleging Resident 1 (R1) was not assisted with daily dressing. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation, conducted interviews and made observations. Based on Resident 1 (R1) Physician’s Report dated August 8, 2023, R1 is diagnosed with Parkinson’s disease and tremors. According to R1’s care plan R1 requires assistance with dressing and other activities of daily living. Interview with outside source revealed that R1 was not wearing pants on an outing where the temperature was about 50 degrees Fahrenheit. Interview with R1 revealed R1 does not ask for assistance in dressing due to being denied by staff multiple times. Substantiated On today’s visit, LPA Strong observed multiple residents waiting for caregiver assistance, but no caregivers were available to provide assistance. Interview with residents revealed they have not received grooming assistance in multiple days. Based on observations, interviews, and records reviewed, a preponderance of evidence exists to support the allegations. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Jared Green, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.the state’s words, verbatim · CDSS document, Feb 14, 2024 · control 08-AS-20240207161427

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Feb 28, 2024

87464 Basic Services (f)Basic services shall at a minimum include:(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing. These requirements were not met as evidence by:Based on interviews and observations the licensee did not provide basic services in 3 of 62 persons in care ([R1/R2/R3]) which posed a potential Health risk to persons in care.the state’s words, verbatim · CDSS document, Feb 14, 2024

Plan of correction: Licensee agrees to provided outside training for Parkinsons residents and activities of daily living by 2/28/2024.

Allegation investigated: Staff did not follow resident's care plan

Licensing Program Analyst (LPA) Tiffany Holmesconducted an unannounced visit to deliver findings for the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit with Jenna Purnell, Wellness Director. On December. 22, 2023, Community Care Licensing (CCL) received a complaint alleging staff did did not follow resident's care plan. During the investigation, LPA Holmes collected pertinent resident records as well as facility documentation and conducted interviews. Interviews revealed that the resident has been livng at the facility since 08/01/2015. The care plans that were observed were completed on 12/12/2021 and again it was updated on 11/07/2023. Based on the two care plans observed, Resident 1(R1) did not have anything written or documented stating that they have a Do Not Resuscitate (DNR). Interviews with staff revealed R1 has no had a DNR on any of their care plans. Interviews with staff revealed they do not recall any documentation being provided to them from the family or from St. Pauls Pace. There is no information to corroborate the allegation. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Jenna Purnell, Wellness Director , to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 23, 2024 · control 08-AS-20231222092615

Allegation investigated: Lack of supervision resulting in serious bodily injury Facility staffing is insufficient to meet resident's needs

Licensing Program Analyst Becky Kennedy concluded the investigation which began on 7/14/2021. LPA Kennedy made an unannounced visit to the above facility today and met with MedTech, Karriem Jones. LPA advised Mr. Jones of the reason for today's visit and delivered the investigation findings on the above allegations. It was alleged that a lack of supervision resulted in serious bodily injury to Resident 1 (R1), and that the facility staffing was insufficient to meet the resident’s needs. The investigation into the above allegations consisted of observations, interviews with residents, staff, outside sources, records reviews, and tour of the interior and exterior facility. The investigation revealed that on 4-2-2021 R1 was in the dining area of the facility and got up from their wheelchair holding a bowl. As R1 attempted to walk across the dining room R1 fell. Unsubstantiated Two caregivers were in the dining room at the time of R1’s fall, and two additional staff members responded to assess R1. Facility staff called 911 as R1 reported being in pain. R1 was taken by ambulance to the hospital where R1 was diagnosed with a hip fracture. Interviews with R1, staff and outside sources revealed that R1 is prone to falls due to both a medical condition and a temperament such that R1 is resistant to efforts intended to discourage R1 from attempting to walk and other fall mitigation efforts. The facility provided R1 with a pendant to alert staff when they need assistance and fall alert mats were placed near R1’s bed and chair. R1 lost the pendant and disabled the fall alert mats. Due to R1’s vulnerability to falling, staff member check on R1 every 30 minutes. Staffing the facility has been a concern since the COVID-19 pandemic. The facility had ongoing hiring efforts to replace staff that resigned. Although at the time of the incident staffing was not at pre-pandemic levels, interviews with staff and outside sources revealed that staff worked hard to meet all resident’s needs. R1’s fall was not due to either inadequate staffing or a lack of care and supervision. Based on observation and statements from internal and external sources including R1, the investigative findings are unsubstantiated. An exit interview was conducted and a copy of this report, and appeal rights were given to Karriem Jones.the state’s words, verbatim · CDSS document, Jan 5, 2024 · control 08-AS-20210712083444

Allegation investigated: Staff did not assist resident with feeding

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings for the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit with Executive Director Jared Green. On December 7, 2023, Community Care Licensing (CCL) received a complaint alleging staff did not assist Resident 1 (R1) with feedings. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. Based on Resident 1 (R1) Physician’s Report dated August 8, 2023, R1 is diagnosed with Parkinson’s disease with psychosis, hallucinations, and tremors. According to R1’s care plan nutrition and eating section, R1 uses adaptive utensils for his tremors and request double food portions. Interview with staff revealed R1 has not requested assistance with eating from most staff but one. Unsubstantiated Interview with Staff 1 (S1) revealed R1 has requested assistance with eating from S1, S1 has assisted R1, R1 will eat a small portion then R1 will state that was enough assistance and continue eating on their own. Interview with R1 revealed R1’s increased frustration with disease progression but no information to corroborate allegation. Interview with outside source did not reveal any corroborating evidence to prove staff have denied R1 with assistance. Based on LPA's interviews, and record reviews 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 Jared Green, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 2, 2024 · control 08-AS-20231207154555

Allegation investigated: Staff neglect resulted in a resident sustaining a bedsore Staff did not provide a resident with an appropriate living arrangement Staff did not prevent a resident from causing harm to another resident Staff did not properly report an incident involving a resident

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings for the above-mentioned allegations. LPA identified herself and discussed the purpose of the visit with Wellness Director Jenna Purnell. On November 14, 2023, Community Care Licensing (CCL) received a complaint alleging neglect to Resident 1 (R1) resulted in R1 sustaining a bedsore, staff did not provide Resident 2 (R2) with an appropriate living arrangement, staff did not prevent Resident 3 (R3) from causing harm to Resident 4 (R4) and Staff did not properly report an incident to R4’s responsible party. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. Based on Resident 1 (R1) Physician’s Report dated October 27, 2022, R1 is confused/disoriented and is non-ambulatory. According to interviews with staff, R1 is actively receiving Home Health visits for Stage II pressure ulcer. Unsubstantiated Interview with outside source verified that R1 is receiving such care. Interview with outside source also revealed that they did not believe that R1 was neglected, rather that the facility established wound care with medical provider in a timely manner. Records and interviewed also revealed that R1 Stage II pressure ulcer has healed due to proper care of wound. It was also alleged that R2 was forced to sleep on the living room couch and their bed was given to another resident. Interview with staff revealed that R2 preferred to sleep on living room couch and multiple staff attempts to redirect resident but resulted in resident returning to couch. Interviews also revealed R2’s bed was not given to another resident, rather, another resident slept in R2’s bed when it was not in use. Interview with outside source revealed that R2 was given the right to a safe and comfortable accommodation. Additionally, it was alleged that staff did not prevent R3 from harming R4. According to interviews with Staff 1 (S1) and Staff 2 (S2) on November 2, 2023, staff observed R3 having an emotional outburst that resulted in R4 being pushed by R3 and R4 sustaining a skin tear on the back of the hand. Interviews also revealed R4 was given first aid. Interview with outside source established that there were no concerns regarding the supervision and care of R3 as well as R4 are receiving. Lastly, it was alleged that R4’s responsible party was not notified of R4’s injury after altercation with R3. According to S2, S2 contacted the responsible party by telephone on the date of the incident. LPA Strong also observed a signed incident report created by S2 that documented S2 contacting the reporting party. Interview with outside source established that responsible party did not receive a phone call regarding such incident. Based on LPA's interviews, observations, record reviews and conflicting statements there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Wellness Director Jenna Purnell to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 08-AS-20231114135318

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Iby Strong conducted a Case Management Visit on today’s date. LPA met with Wellness Director Jenna Purnell and discussed the purpose of the visit. On 12/11/2023 the RO received notification from the Licensee that the facility had a fire. There are six (6) buildings on the property. The fire was reported to occur in Building B, room 8. According to staff present, at approximately 8:45am, the facility fire alarms went off. Staff immediately evacuated 20 of the residents residing in this building. All 20 residents of this building were accounted for and were brought to the adjacent buildings on the property. Local fire and police arrived. Local fire department provided all clear of fire at approximately 1:00 PM. During today's visit, LPA conducted a health and safety check on the residents in care and observed the room where the fire took place. The room was clean and damaged furnishings have been replaced. No deficiencies were cited or observed on this date. An exit interview was conducted. The Licensee will be provided a copy of the Licensee/Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Dec 12, 2023

Allegation investigated: Medication was not issued as prescribed.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings in the above-mentioned allegation. LPA met with Executive Director Jared Green and discussed the purpose of the visit. On February 6, 2023, Community Care Licensing (CCL) received a complaint alleging licensee was not issuing medication as prescribed. During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to allegation, licensee did not order medication timely and medication was not distributed according to prescription. Additionally, on November 14, 2023, CCL received additional information alleging that medication is not being issued as prescribed as medication has been found on the floor of residents rooms. Substantiated Interviews revealed that staff have found medication on the facility floor multiple times within the last six months. Interviews also revealed that staff did not receive medication order from pharmacy for Resident 1 (R1) until a few days after it was prescribed. During facility inspection on 11/20/23, LPA Strong observed three resident rooms with medication on the floor. Interviews revealed that staff could not confirm which resident the medication belonged to. Outside source interviews corroborated that residents have not received medications as prescribed. Based on interviews, and records reviewed, a preponderance of evidence exists to support the allegations. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Jared Green, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.the state’s words, verbatim · CDSS document, Nov 20, 2023 · control 08-AS-20230206145343

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Dec 27, 2023

87465 Incidental Medical and Dental Care (c)(2)Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on interviews and observations licensee did not issue medication as prescribed in five of 65 persons in care which posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Nov 20, 2023

Plan of correction: Licensee agrees to conduct vendorized training to staff by December 20, 2023 and provide proof of scheduled training by December 4, 2023.