Alta Vista Senior Living

Type of visit: Required - 1 Year

On 10/01/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA was greeted and granted entry by Destiny Quijada, Activities Director, where LPA explained the purpose of the visit. The facility has an approved fire clearance for ten (10) residents that are bedridden with an approved hospice waiver for (15). The administrator was not at the facility at the time the inspection was conducted. Below are the observations made during today's visit: The facility was observed to be clean, with the passageways being from of obstructions. The food supply was sufficient as there was a 2 day supply of perishable food items and a 7 day supply of non perishable food items. The chemicals, and other hazardous items were observed to be locked and inaccessible to residents in care. The resident bedrooms were observed to have the required furniture such as bed, chair, chest of drawers,night stands and light. The bathrooms were observed to have grab bars, with pull cords and the signal system was tested and observed to be operable, in addition residents are provided with pendants . The hot water temperature was tested in randomly selected resident bathrooms and found to be within regulatory limits of 113.8 degrees Fahrenheit. The medications are stored in a locked medication room inside medication carts. The fire extinguishers were last serviced 05/18/25. The last emergency disaster drill was conducted on 09/15/25. There are no known guns or ammunition on the premises. There are no pools or bodies of water observed at the facility. The facility annual fees were observed to have been paid. The facility is in possession of valid liability insurance that expires on 04/20/26, and the governing body was observed to be in good standing. Records review: Per the Guardian personnel roster all staff present at the facility were observed to have obtained criminal record clearance and to be associated to the facility. The Executive Director Jennifer was observed to have a valid administrator's certification with a certificate that expires on 03/21/27, as well as CPR certification that expires on 11/06/25. However a records review of four (4) staff files revealed the files are incomplete, as there are records missing such as criminal record statement, proof of 20 hours of completed training and health screening report. Additionally LPA observed for there to not be proof of valid CPR certification. Deficiency cited. Resident files were observed to have updated medical assessments, appraisals and admissions agreements. The facility is to submit an updated emergency disaster plan LIC610E, by 5pm on 10/6/25. Based on today's inspection the deficiencies are being cited in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). on the attached 809D. An immediate civil penalty of $250 is being assessed due to a repeated violation within a 12 month period. An exit interview was conducted and a copy of this report, LIC809D, LIC421FC, LIC9098-Proof of Corrections form, and appeal rights were reviewed and provided to Destiny Quijada, Activities Director.the state’s words, verbatim · CDSS document, Oct 1, 2025

Allegation investigated: Staff did not keep facility free of insects.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent visit to continue to investigate the allegation listed above, and to deliver the findings. The LPA arrived at the facility and spoke with Destiny Quijada, Activities Director (AD). The LPA explained the reason for the visit. On 09/24/2024, Licensing Program Analyst (LPA), Javina George, conducted an unannounced visit to the facility to initiate the investigation into the allegation listed above. LPA met with Executive Director Jennifer Gephart and informed her of the purpose of LPAs visit. LPA conducted a tour of the interior/exterior areas of the facility, conducted a review of records, obtained and requested copies of pertinent documentation. On 04/26/2025, LPA Sandra Urena interviewed staff, and residents and obtained copies of pertinent documents relevant to the investigation, and conducted a tour of the facility at 1:15 p.m. Continues on LIC 9099C... Substantiated Staff did not keep facility free of insects. On the allegation that staff did not keep facility free of insects, it is the concern of the Reporting Party (RP) that the facility is doing nothing about the bed bug issue and believes it has been a problem for months. On 09/19/2024, LPA George conducted an interview with the RP who stated that R1 sits in their bedroom chair and picks off the bugs off their arms. Furthermore, LPA George conducted a facility visit on 09/24/2024 and was unable to inspect the rooms due to not having access to the rooms due to being treated for bed bugs. On 04/26/2025, LPA Urena interviewed the Resident Services Director (RSD) about the bug infestation. The interview revealed that the facility did experience a bug infestation problem in September of 2024. The infestation was taken care as follows: By relocating the residents to vacant rooms, removing residents’ clothes and linens (bagging the clothes and linens, treating them with heat, then washing them), and treating the rooms with heat for 48 eight hours followed by spraying the rooms with bug spray. The rooms were aired out for at least 24 hours before residents were allowed to return. Record review of at least two exterminator and pest control companies’ invoices revealed that the facility has kept up with monthly pest control services to prevent re-infestation. Residents’ interviews revealed that they have not experienced bug problems since last year when the rooms were treated. Staff interviews revealed that they were aware of the bug infestation. LPA Urena was unable to interview R1. Based on the information obtained through interviews, observation and record review, the allegation that staff did not keep the facility free of insects was confirmed. Therefore, the allegation is deemed Substantiated at this time. Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 6, the following deficiencies were observed and cited (9099-D) during the visit. Citations were issued. Exit Interview was conducted. A copy of the report and Appeal Rights were issued. Staff did not safeguard resident's personal belongings. On the allegation that the staff do not safeguard resident’s personal belongings, it is the concern of the Reporting Party (RP) that some R1’s articles of clothing are missing, per the RP, only one item of clothing was identified by R1, and was unable to identify any additional items. To investigate the allegation, LPA Urena conducted staff and residents’ interviews. The residents’ interviews revealed that they have not experienced personal belongings missing from their room. The residents stated that if they leave any items in the clothing pockets (e.g. reading glasses) when the clothes get taken to get washed, staff always return the items. The staff interviews revealed that sometimes residents may forget personal belongings when they are in common areas of the facility, if the staff notices right away and know who the item belongs to, they rerun the item to the resident, if not, they give it to the med tech. The LPA interviewed the housekeeping and laundry staff and asked if residents’ clothing could be getting misplaced during the wash and not returned to the original resident. The housekeeping staff and laundry staff stated that the laundry (clothes and linens) get collected from each of the residents’ room in a laundry basket. The clothes and linens are then washed individually per resident. Residents’ clothes are never mixed in the wash and dry cycle. The staff puts the residents’ clothes and linens back in the hamper and return it to the residents’ rooms. When asked if they were aware that residents were alleging that articles of clothing were missing, they said they were not aware. Facility was not able to locate R1’s Client /Resident Personal Property and Valuables(LIC 621). LPA Urena was unable to interview R1. Based on the information obtained through interviews and record review, and although the allegation may be valid, and may have happened, there is not sufficient evidence to confirm if the personal belongings are not being safeguarded by staff. Therefore, the allegation is deemed Unsubstantiated at this time. Pg. 3 Staff are not bathing a resident in care. On the allegation that the staff are not bathing a resident in care, it is the concern of the Reporting Party (RP) that R1 is not getting showers 2 times a week. To investigate the allegation, LPA Urena interviewed staff, residents in care and reviewed pertinent records. The residents’ interviews revealed that they do receive assistance with showers as needed, and at least two times a week, or more if requested or needed. Showers can be either in the a.m. (usually after breakfast or lunch) and/or in the p.m. shift after 2:00 p.m. The interview with the RSD revealed that the residents’ families can choose during the initial admission/registration process the preferred time frame (AM/PM) for a shower. Furthermore, the residents, and families can request additional bathing times if needed. The RSD stated that R1 was receiving assistance with showers. The interview with staff revealed that the staff make notations in the facility’s End of Shift Report (ESR) where staff document if the residents refuse a shower, reason for refusal and if resident had a shower. LPA Urena reviewed the ESR for 09/22024. The record review revealed that the ESR is a document that includes the names of the staff who provide the showers, names of residents, residents’ room number, an area for comments, etc. The record review indicated that R1 was being assisted with showers, and at least in two occasions R1 refused showers. Review of the Physician’s Report and the resident’s Assessment indicate that R1 did not need assistance with bathing. The LPA was unable to interview R1. Based on the information obtained through interviews and record review, the staff was assisting R1 with showers, and R1 did not need assistance with bathing. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview was conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 27, 2025 · control 18-AS-20240919115403

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 2, 2025

CCR 87303(a) Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times...safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by. Based on interviews and records review, the licensee failed to comply with the section cited above as bed bugs were observed by multiple residents in multiple bedrooms, which poses a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 27, 2025

Plan of correction: POC: The Administrator agreed to review section cited and provide a statement of understanding on how ensure that the facility will be kept free of pest to LPA Urena via email by 05/02/2025.The Licensee contracted a fumigation exterminator company, and the bug infestation was cleared.

Allegation investigated: Staff does not prevent resident from threatening another resident.

On 04/27/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted a subsequent unannounced visit to further investigate and deliver findings for the above-named allegation. LPA met with Activities Director, Destiny Quijada, and the purpose of the visit was discussed. LPA was granted access into the facility. The investigation consisted of the following: On 10/09/24, the department conducted a review of records, and requested and obtained copies of pertinent documentation, and conducted a tour of the entire facility. On 04/26/25, the department conducted interviews with staff #1-#5 (S1-S5), attempted to interview resident #1 (R1), and interviewed residents #2-#9 (R2-R9). The department requested and received the following documents: staff roster, resident roster, Residence and Care Agreement, Identification and Emergency Information, Physician’s Report, Needs and Services Plan and facility notes for R2. Furthermore, the department conducted a tour of the facility. Continued on LIC 9099-C Unsubstantiated On 04/27/25, the department received the following documents: Face Sheet, Identification and Emergency Information, Physician's Report, Preplacement Appraisal Information, Needs and Services Plans for R1. The investigation revealed the following: Allegation: Staff does not prevent resident from threatening another resident. It is being alleged that a resident has been threatened several times by another resident. It is also alleged that the resident attempted to report the issue to a manager, but nothing has been done about these incidents. On 04/26/25, between 10:25 AM and 12:00 PM, the department interviewed S1-S5. Based on interviews conducted, 3 out of 5 staff interviewed denied the allegation, and 2 out of 5 staff interviewed did not know of the allegation happening. 5 out of 5 staff interviewed stated that the facility ensures that all residents feel and are safe and comfortable in the facility. On 04/26/25, between 01:10 PM and 02:40 PM, the department attempted to interview R1 and interviewed R2-R9. Based on interviews conducted, 4 out of 8 residents interviewed stated that no resident has threatened another resident in the facility, and 4 out of 8 residents interviewed stated that they don’t know of a resident being threatened by another resident in the facility. The department was unable to interview R1 for an answer. 8 out of 8 residents interviewed stated that no resident has ever threatened them, and the department was unable to interview R1 for an answer. 7 out of 8 residents interviewed stated that they feel safe and comfortable in this facility, and 1 out of 8 residents interviewed stated that they did not feel safe and comfortable at this facility. The department was unable to interview R1 to get an answer. Based on interviews, a review of records and observation, the above allegation is found to be Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited during this visit. An exit interview was conducted with Activities Director, Destiny Quijada, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 27, 2025 · control 18-AS-20240930113845

Allegation investigated: Resident sustained unexplained injuries while in care. Residents are left in soiled diapers for extended period of time.

On 04/27/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted a subsequent unannounced visit to further investigate and deliver findings for the above-named allegations. LPA met with Activities Director, Destiny Quijada, and the purpose of the visit was discussed. LPA was granted access into the facility. The investigation consisted of the following: On 12/30/21, the department conducted a review of records and requested and obtained copies of pertinent documentation. On 04/26/25, the department conducted interviews with staff #1-#5 (S1-S5), and resident #1-#8 (R1-R8). The department requested and received the following documents: staff roster, and resident roster. Furthermore, the department conducted a tour of the facility. Continued on LIC 9099-C Unsubstantiated The investigation revealed the following: Allegation: Resident sustained unexplained injuries while in care. It is being alleged that a resident sustained some skin tears, possibly done when staff tried to reposition the resident. On 04/26/25, between 10:25 AM and 12:00 PM the department interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed were not aware of the allegation. 5 out of 5 staff interviewed stated that all clients are treated with care, patience, dignity and respect. On 04/26/25, between 01:10 PM and 02:40 PM, the department interviewed R1-R8. Based on interviews conducted, 8 out of 8 residents interviewed did not know of a resident sustaining unxexplained injuries while in care. 8 out of 8 residents interviewed stated that facility staff is providing them with the necessary care and supervision. 8 out of 8 residents interviewed stated that they are satisfied with the services being provided to them. Based on interviews, a review of records, and observation, the above allegation is found to be Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Allegation: Residents are left in soiled diapers for extended period of time. It is being alleged that a resident was found drenched in urine and that they had not been checked on since the night before. On 04/26/25, between 10:25 AM and 12:00 PM, the department interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed stated did not know of a resident being left in soiled diapers for an extended period of time. 4 out of 5 staff interviewed stated residents are changed every 4 hours and as needed, and 1 out of 5 staff interviewed stated they did not know how often residents were changed. On 04/26/25, between 01:10 PM and 02:40 PM, the department interviewed R1-R8. Based on interviews conducted, 7 out of 8 residents interviewed stated they did not know of a resident being left in a soiled diaper for an extended period of time, and 1 out of 8 residents stated they have been left in a soiled diaper for an extended period of time. Continued on LIC 9099-C 7 out of 8 residents interviewed stated that they are changed when they need to be changed, and 1 out of 8 residents interviewed stated they are not changed when they need to be changed. 7 out of 8 residents interviewed stated that their daily needs are being met, and 1 out of 8 residents interviewed stated that their daily needs are sometimes met. 8 out of 8 residents interviewed stated that they are satisfied with the services being provided to them. Based on interviews, file review and observation, the above allegation is found to be Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited during this visit. An exit interview was conducted with Activities Director, Destiny Quijada, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 27, 2025 · control 08-AS-20211223102726

Allegation investigated: Neglect / Lack of Care and Supervision Resident's wound has not recovered due to staff neglect Staff do not ensure that resident's dietary needs are met Insufficient staffing to meet the needs of residents in care Staff did not keep the resident's room free from odor Staff did not keep resident's room clean Staff did not safeguard resident's personal items

On April 18, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced and met with Executive Director, Jennifer Gephart. LPA explained the reason for the visit was to provide findings for the complaint investigation. On November 30, 2022, Community Care Licensing received a complaint alleging Neglect / Lack of Care and Supervision, resident's wound has not recovered due to staff neglect, staff do not ensure that resident's dietary needs are met, insufficient staffing to meet the needs of residents in care, staff did not keep the resident's room free from odor, staff did not keep resident's room clean, staff did not safeguard resident's personal items. During the investigation LPA’s conducted interviews, record reviews, and made observations. Regarding the allegation that Neglect/Lack of Care and Supervision it was reported that Resident Number 1 (R1) had an unwitnessed fall and was sent to the Emergency Room (ER) at Tri-City Medical Center. Information obtained from interview with attending physician Dr. Bonomo advised that a Cat Scan (computed axial tomography) (CT) did not reveal any head injuries only a minor laceration to R1’s ear lobe. Unsubstantiated Regarding the allegation staff do not ensure that resident's dietary needs are met, it was reported that staff put food in front of the residents and leave them slumped over alone to eat. It was stated that R1 required assistance with eating. It was further reported that R1 has lost a significant amount of weight (approximately 30 to 50 lbs.) since being placed at the facility. Information obtained from interviews with facility staff advised that R1 does eat well balanced meals and can feed themselves. It was advised that R1 may need assistance with certain foods, but there are no documented plans regarding eating assistance in R1’s service plan. Interviews with additional residents indicated that there were no noted concerns with ensuring their dietary needs were met, they do not have any concerns regarding dietary needs being met to at this time. A review of the records confirmed R1 is able to eat with her hands but may require assistance if utensils are needed. Additional information obtained from observations revealed that R1 was able to eat without assistance. A review of the records did not corroborate that any significant amount of weight was lost the information obtained from a review of R1’s weight records confirmed a loss of six pounds from the time of admissions to discharge date on 05/21/2023. Regarding the allegation the facility has insufficient staffing to meet the needs of residents in care, it was reported that staffing has been a consistent issue and the reason that most of R1’s needs do not get met. Information obtained from interviews with Administrator, Jennifer Gephart advised that the facility guidelines for staff meeting the needs of residents in care is to follow the resident’s plan of care upon admissions and to conduct an assessment. Interviews with additional staff indicated that R1 was receiving Hospice services and nurses were at the facility two to three times a week to attend to the needs of R1. A review of the records confirmed that R1 was receiving services through Cabrillo Hospice agency; narrative charting, nurses sign in sheets, and other documents were obtained. Interviews with additional staff indicated that the care staff are continuously training on personal rights care and supervision, and that staff are scheduled per each shirt to provide adequate care and supervision. Additionally, residents are encouraged to visit their primary physicians annually. Documents provided and reviewed on site to confirm this. Addition interview with administrator, Jennifer indicted that staff are continuously receiving training on personal rights, and the care and supervision of residents in care. Interviews with additional residents indicated that there are sufficient staff to meet their needs, and that there are all ways enough staff from the Med-tech to the nurses. The nurses are usually moving about there were no reported concerns. Information obtained from records reviewed included staff schedules and confirm adequate staff are scheduled per shift. No noted concerns document currently. Regarding the allegation staff did not keep the resident's room clean and free from odor it was reported that R1’s room had an unpleasant smell, the baseboards were covered with a sticky brown substance, and that R1’s room had piles of dirty laundry. Information obtained from interview with Administrator advised that the facilities policy on housekeeping and how the residents’ rooms are maintained is that the house keeping is scheduled daily from 6:00am to 6:00pm. There are three house keepers, and each work daily or as needed. A review of the house keeping scheduled corroborated the information. Interviews with additional staff indicated that housekeeping and how the residents’ rooms are maintained is through the housekeeping team. Information obtained from interviews with additional staff indicated that caregivers inform the housekeeper staff if there is an additional need and they will clean it. Additional information stated that caregivers do not usually clean the residents’ rooms that is what the housekeepers are for. Interview with R1 was not possible currently. Interviews with additional residents indicated they are happy with the housekeeping and how their rooms are maintained. Additional information obtained from resident interviews stated that there are no noted concerns with how their rooms are kept clean. Regarding the allegation staff did not safeguard resident's personal items, it was reported that another resident was observed coming in and out of R1’s room without permission. Information obtained from interviews with facility staff advised that facility’s policy on safeguarding personal property that the residents are responsible for the safeguarding of their own personal items and property. Interviews with additional staff indicated that the facility encourages residents not to have anything of value, if so, there are lock boxes in the respective living units. Observations confirmed facility had security cameras in place, safety lock boxes if requested in living units, and doors can be locked. Interviews with additional staff stated that each resident living unit has a lock on the door and each room is equipped with a lockbox if requested. Interviews with additional residents indicated that there were no noted concerns with the safeguarding of their personal items. Based on LPA's inability to interview pertinent parties, interviews, record reviews, and observations there is not enough information to support the listed allegations. Therefore, these allegations have been determined unsubstantiated. An allegation finding of unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of this report was provided to Executive Director, Jennifer Gephart. Regarding the allegation staff did not keep the resident's room clean and free from odor it was reported that R1’s room had an unpleasant smell, the baseboards were covered with a sticky brown substance, and that R1’s room had piles of dirty laundry. Information obtained from interview with Administrator advised that the facilities policy on housekeeping and how the residents’ rooms are maintained is that the house keeping is scheduled daily from 6:00am to 6:00pm. There are three house keepers, and each work daily or as needed. A review of the house keeping scheduled corroborated the information. Interviews with additional staff stated that housekeeping and how the residents’ rooms are maintained is through the housekeeping team. Additional information obtained stated that caregivers advise the housekeeping staff if there is an additional need and they will clean it. Additional information stated that caregivers do not usually clean the residents’ rooms that is what the housekeepers are for. Interviews with additional residents indicated that they are happy with the housekeeping and how the residents’ rooms are maintained. Additional information obtained from resident interviews stated that there are no noted concerns with how their rooms are kept clean. Regarding the allegation staff did not safeguard resident's personal items, it was reported that another resident was observed coming in and out of R1’s room without permission. Information obtained from interviews with facility staff advised that facility’s policy on safeguarding personal property that the residents are responsible for the safeguarding of their own personal items and property. The facility encourages residents not to have anything of value, if so, they have a lock box in the respective living units. Observations confirmed facility had security cameras in place, safety lock boxes if requested in living units, and doors can be locked. Interviews with additional staff stated that each resident living unit has a lock on the door and each room is equipped with a lockbox if requested. Interviews with additional residents indicated that there were no noted concerns with the safeguarding of their personal items. Additional information obtained from interviews with Executive Director Diane Domingo advised that a conference call with R1’s family, and the family agreed to the service plan. Information obtained from interviews with the Hospice Nurse advised that R1 had behavioral problems and is easily agitated and that the Hospice Nurses maintain a record of R1’s progress and treatment of overall health. Further information obtained from observations revealed that R1 appeared to look well and was well cared for. Information obtained does not support the allegation. Regarding the allegation Resident's wound has not recovered due to staff neglect, it was reported that R1 has a wound located on their hip. It was reported that the wound has not healed in over one year. Information obtained from interviews with Administrator, advised that Hospice nurses were treating R1’s wounds and monitoring R1’s general health. The wound was initially observed by Hospice who completes the full body assessment during showers, a review of the records corroborated this Information obtained from an interview with a Hospice Nurse advised that the facility staff maintain a record of R1’s progress and treatment of their overall health. There was not sufficient evidence to support that R1’s wounds did not recover due to staff neglect. A review of the records revealed that the Hospice Nurses were at the facility two to three times a week to attend to R1's wound. Regarding the allegation staff do not ensure that resident's dietary needs are met, it was reported that staff put food in front of the residents and leave them slumped over alone to eat. It was stated that R1 required assistance with eating. It was further reported that R1 has lost a significant amount of weight (approximately 30 to 50 lbs.) since being placed at the facility. Information obtained from interviews with facility staff advised that R1 does eat well balanced meals and can feed themselves. It was advised that R1 may need assistance with certain foods, but there are no documented plans regarding eating assistance in R1’s service plan. Interview with Resident was not possible at this time. Interviews with additional residents indicated that there were no concerns with dietary needs being met. A review of the records confirmed R1 is able to eat with her hands but may require assistance if utensils are needed. Additional information obtained from observations revealed that R1 was able to eat without assistance. A review of R1's weight records did not reveal any significant amount of weight loss. Information obtained did not support this allegation.the state’s words, verbatim · CDSS document, Apr 18, 2025 · control 18-AS-20221130130504

Allegation investigated: Unlawful eviction

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial complaint visit was conducted on 07/03/2024 by LPAs Venus Mixson and Kathleen Banrasavong and a subsequent complaint visit was conducted on 04/12/2025 by LPA M. Arroyo. On today’s visit, LPA Arroyo met with Memory Care Director, Beatrice Soliven. Entrance interview. During the initial visit on 07/03/2024, LPAs Mixson and Banrasavong toured the facility and requested and received pertinent documents. On 04/12/2025, LPA Arroyo conducted interviews with one staff, conducted a plant tour starting at 9:20am, and conducted a resident file review and obtained copies of pertinent documents. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that facility issued an unlawful eviction notice to Resident #1 (R1) in December 2023 and again in January 2024, citing nonpayment as the reason for eviction. Records reviewed and interviews conducted revealed that R1 had a Power of Attorney (POA) who was responsible for paying R1’s living expenses at the facility. However, due to the POA’s inability to make payments, the facility issued eviction notices to both R1 and the POA. Interviews with staff confirmed that the eviction notices were issued due to nonpayment. Staff stated that they attempted to contact R1’s POA multiple times without receiving a response resulting in eviction notice. Additionally, the facility proceeded to search for an alternative placement for R1 after issuing eviction notice. Furthermore, law enforcement had an approved Eviction Restoration Notice authorizing the removal of R1 from the facility on July 3, 2024. Based on the information obtained and reviewed during the investigation, the Department found insufficient evidence to support the allegation of “unlawful eviction.” Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy provided.the state’s words, verbatim · CDSS document, Apr 13, 2025 · control 18-AS-20240625154351

Allegation investigated: Staff did not manage resident's care needs while in care Staff handled resident in a rough manner Staff did not follow resident's special diet Staff left resident slumped over in their wheelchair for extended time periods

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to continue the investigation for the allegations listed above. Upon arrival, the LPA met Memory Care Director, Beatrice Soliven and explained the reason for the visit. Entrance interview. The initial complaint visit was conducted on 02/07/2024 by LPA Venus Mixson and a subsequent visit was conducted on 04/12/2025 by LPA M. Arroyo. On 02/07/2024, LPA Mixson toured the facility, interviewed the Executive Director, made observations, and requested and received pertinent documentation. On 04/12/2025, LPA Arroyo conducted interviews with three staff and five residents, conducted a plant tour starting at 9:20am, observed residents in dining room and common areas, conducted a medication review on five randomly selected residents, and conducted a resident file review and obtained copies of pertinent documents relevant to the investigation. During today’s visit, the LPA conducted an interview with one staff. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that staff did not manage resident's care needs while in care. It was reported that R1 was not being provided with pain medication or hygiene care by the facility staff. Records reviewed and staff interviews revealed that facility staff provided R1 with showers twice a week. Upon R1’s admission to hospice care, the care plan was updated to include showers twice weekly, provided by the hospice nurse. According to the hospice care plan dated 01/07/2024, the hospice nurse was responsible for assisting R1 with hygiene, personal care, homemaking tasks, and providing showers twice per week. A review of the hospice flow sheet showed that R1 received either a shower or a bed bath from the hospice nurse on 01/08/2024, 01/15/2024, and 01/17/2024, indicating that the hospice team was not consistently following the care plan regarding hygiene and bathing. Interviews with facility staff also revealed that aspirin is typically prescribed as a routine medication rather than on a PRN (as-needed) basis. Staff stated that R1 was administered aspirin daily with morning medications until their doctor ordered the discontinuation of most medications, including pain medications, due to R1's difficulty swallowing. At that point, R1 was transitioned to comfort medications. The care plan further stated that the hospice nurse was responsible for assisting with pain and symptom management, assessing vital signs during each visit, and reporting any unrelieved pain despite rest and prescribed medications. Additionally, documentation from an outside agency / hospice notes dated 01/08/2024 indicated that R1 showed no signs of pain or distress during the hospice nurse’s visit. Furthermore, interviews with five out of five residents revealed no concerns regarding the administration of their daily medications. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff did not manage resident’s care needs while in care”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that staff handled resident in a rough manner. It was reported that staff were observed grabbing Resident 1 (R1) roughly while providing care. Interviews conducted with staff revealed that no residents had reported being handled inappropriately or too roughly while receiving assistance. Additionally, staff stated that residents regularly communicate with their family members, and no complaints have been received from families regarding rough handling. Interviews conducted with residents indicated that they had not observed staff handling other residents roughly, nor did they feel that staff were too rough when assisting them. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Residents further stated that staff are nice, polite, and courteous when responding to requests for assistance. Furthermore, five out of five residents interviewed reported no concerns about living at the facility. Based on the information obtained, the Department has insufficient evidence to support the allegation of “staff handles resident in a rough manner”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that staff did not follow resident's special diet. It was reported that R1 was unable to swallow, resulting in solid food and vomit remaining in R1’s mouth. It was further reported that R1 should not have been given solid food due to the risk of choking. Records reviewed and staff interviews conducted revealed that R1 had a tendency to pocket food and medications. According to a facsimile provided, staff were in regular communication with R1’s primary care physician (PCP) and reported any changes in R1’s condition. On 07/20/2023, the facsimile shows that facility staff reported R1’s food and medication pocketing behavior, which led the PCP to update care orders on 07/21/2023 to crush medications and modify R1’s diet to mechanical soft. Staff continued to communicate changes in R1’s condition with the PCP, as evidenced in a facsimile dated 01/02/2024, in which staff reported that R1 was no longer able to retain food or fluids and continued to vomit. On 01/05/2024, staff reported that R1 was still vomiting and unable to keep down food or fluids, despite the PCP’s updated order on 01/03/2024 to administer two (2) Ensure nutritional drinks five (5) times daily. Interviews with staff confirmed that R1 was assisted with feeding on a daily basis. Staff closely monitored R1 while eating, observing for signs of choking, as R1 frequently struggled with swallowing. Furthermore, staff maintained consistent communication with R1’s physician and followed medical orders as they were received. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff did not follow resident’s special diet”. Therefore, this allegation is deemed Unsubstantiated at this time. It was further alleged that staff left resident slumped over in their wheelchair for extended time periods. It was reported that R1 was left slumped over in their wheelchair by the dining table for extended periods, up to eight (8) hours. Interviews conducted with staff revealed that residents are escorted to the dining room for meals each day unless they are able to get there independently. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Staff stated that residents typically participate in activities after breakfast until lunchtime. Following lunch, residents are returned to their rooms to nap or rest until dinner, which is served a few hours later. Staff further explained that most residents in the memory care unit are incontinent and are therefore checked at least every couple of hours to ensure they are dry and to reposition them as needed. Interviews also indicated that when residents are taken back to their rooms, they are not left sitting in their wheelchairs. Instead, they are transferred to either their beds or recliner chairs to allow them to rest and relieve pressure on their backs and bottoms. Additionally, during a visit conducted on 04/12/2025, the LPA observed residents being returned to their rooms and appropriately transferred to their beds for rest. Based on the information obtained, the Department has insufficient evidence to support the allegation of “staff left resident slumped over in their wheelchair for extended time periods”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy provided.the state’s words, verbatim · CDSS document, Apr 13, 2025 · control 18-AS-20240131123229

Allegation investigated: Staff do not safeguard resident's personal belongings Staff do not ensure resident’s room is free of tripping hazards

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA met with Business Office Manager Monica Flores, where the LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of observations, interviews with staff members and residents, and a review of records. On December 17, 2024, Community Care Licensing received a complaint alleging staff do not safeguard resident's personal belongings and staff do not ensure resident’s room is free of tripping hazards. In regards to the allegation that staff do not safeguard resident’s poperty, it was reported that Resident #1’s (R1) room was being entered by R2 in the middle of the night. R2 would enter and take drinks and snacks from R1. Continued on 9099-C. Unsubstantiated Information obtained from interview with Administrator stated they were aware of R2 wondering the halls, but it was not reported R2 entered resident’s rooms and took their belongings. It was advised that due to the concern, the facility began to monitor R2 more closely and redirected R2 back to their room. Information obtained from additional staff interviews corroborated the information and stated there were no concerns advised regarding theft of R1’s belongings. Information obtained from Interview with R1 revealed they reported the concerns to their family, but could not remember if the concerns were relayed to facility staff. Information obtained from R2 did not corroborate the allegation. It was stated that R2 denied entering other residents room and taking their belongings. LPA conducted a record review and could not find any incidents regarding R2 entering rooms of other residents. Pertaining to the allegation that staff do not ensure resident’s room is free of tripping hazards, it was reported that the facility had uneven floors in the living room, bathroom, and entrance of the resident rooms, which caused R1 to fall. Information obtained from interview with Administrator stated there were no issues with the floor being uneven or other hazards which caused falls. It was advised that the floor was updated due to wear and tear, but not because of foundational issues. Information obtained from staff interviews corroborated the information. Information obtained from interview with R1 indicated that they did not observe uneven floors or have issues with the flooring. Additional interviews were conducted and there were no concerns advised regarding the facility. During a visit to the facility, LPA observed eight rooms, including the noted areas of concern and R1’s room. LPA did not observe any abnormalities on the floors that would be considered uneven or hazardous. Pertinent documentation was reviewed and although there were falls reported, they were not due to hazards. Based on observation, record review, client, and staff interviews, the allegations that the facility did not safeguard resident’s personal belongings and staff do not ensure resident’s room is free of tripping hazards, are Unsubstantiated. A finding that the complaint is unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided to Business Office Manager Monica Flores.the state’s words, verbatim · CDSS document, Feb 21, 2025 · control 18-AS-20241217105224

Allegation investigated: Staff did not ensure the hot water is working properly

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegation. LPA met with Executive Director, Jennifer Gephart who was informed of the purpose of the visit. During the visit, LPA conducted interviews, documented observations/conducted a walk through, and conducted records review. It was alleged that “Staff did not ensure the hot water is working properly”. It was alleged that on 01/07/2025, the facility did not have hot water for a couple hours. LPA conducted (4) resident interviews, which revealed conflicting information. (2) of (4) residents reported not having hot water in their apartment, which has since been resolved. (2) of (4) residents stated they have always had hot water in their apartment. Unsubstantiated LPA conducted (5) staff interviews, which revealed that around the facility did not have hot water for a few hours during the morning. Staff revealed the hot water came back on the same day after restarting the water heater. Staff revealed there is no issue with the hot water presently. During today’s visit, LPA conducted a tour of the facility and checked the hot water temperature in the kitchen, first and second floor. The kitchen has a reading of 120.3F with a hot water sign above the sink that is designated for staff use only. Room 106 on the first floor was checked hot water which read at 113.7F. Room 218 was read for hot water at 115.1F. Therefore, the allegation that the facility does not have hot water is unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 14, 2025 · control 18-AS-20250107090937

Allegation investigated: Staff did not ensure that the facility was in good repair Staff did not provide a safe environment.

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegations listed above. LPA met with Jennifer Gephart, Executive Director and explained the purpose of the visit and the elements of the allegations. The allegations were investigated, and the investigation consisted of observations, interviews and records review. On 07/09/2024 Community Care Licensing received a complaint alleging that staff did not ensure that the facility was in good repair and that staff did not provide a safe environment. Regarding the allegation of staff did not ensure that the facility was in good repair. It was alleged that there were two gates that were disabled/out of service, which poses a safety risk since anyone can enter or leave the facility. On 07/12/24 the initial complaint visit was conducted, and LPA observed for there to be 2 gates in the back of the property. However, only one was observed to be out of service. Both of the gates required a code to enter, however the electronic/locking function was disabled and would not engage, on the gate that is facing towards the facility garage. Substantiated As a result, LPA observed for facility staff to be utilizing a red and black band that was adjusted with a silver clamp to hold the band in place that would assist with keeping the gate closed. Per interview with the Business Office Manager the facility was in the process of getting quotes to repair the gate. LPA requested copies of the quotes but were not received. LPA followed up on 07/16/24 in regards to the status of the gate repair, and was informed that the facility was still in the process of obtaining quotes. On 09/30/24 LPA conducted a follow up visit and observed for the gate to have been repaired and the code entry mechanism to be functioning properly. Based on observation and interviews the allegation of staff did not ensure the facility was in good repair is substantiated. Staff did not provide a safe environment. It was alleged that a door in memory care was not functioning properly (locking) as the locked door was to assist with preventing memory care residents from leaving out of the designated areas, and the electronic function was not working on the door. LPA observed for said door to be working properly at the time that the visit was conducted on 07/12/24. However, through further investigation of a conducted records review revealed that on 06/27/24 Resident #1 (R1) was able to successfully exit out of the facility. Local law enforcement had to respond to the facility and was able to successfully locate R1 in another building. R1 was said to have entered into the bedroom of another resident and walked out onto their patio, walked down the pathway and exit through the gate that was disarmed and not functioning/locking properly. Per an interview with Memory Care Director Jenna Lazaga R1 did not obtain any injuries and as a result the eloping incident the facility implemented two-hour safety checks. Based on interviews and records review the allegation of staff did not provide a safe environment is substantiated. An allegation that is substantiated means a finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted and a copy of this report, appeal rights, LIC811-confidential names list and LIC9098-Proof of corrections form was reviewed and provided to Executive Director Jennifer Gephart.the state’s words, verbatim · CDSS document, Oct 9, 2024 · control 18-AS-20240709091545

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 23, 2024

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: the licensee did not ensure that the facility gate was in good repair, which posed a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 9, 2024

Plan of correction: There is no POC due at this time, as the gate was officially repaired on 09/27/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Oct 23, 2024

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by the licensee did not ensure that the premises was maintained in safe and healthful environment. Which posed a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 9, 2024

Plan of correction: The licensee agrees to conduct an inservice on elopment and, safety checks. Proof of POC is to be submitted to the department by 5pm on the due date indicated.

Allegation investigated: Staff did not ensure the facility elevator is in good repair.

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegations listed above. LPA met with Jennifer Gephart, Executive Director and explained the purpose of the visit and the elements of the allegations. The allegation was investigated, and the investigation consisted of observations interviews and records review. On 10/03/2024 Community Care Licensing received a complaint alleging that Staff did not ensure the facility elevator is in good repair. LPA conducted an interview with Business Office Manager Monica Flores that revealed that one of the facility elevators was recently in operable due to it being retagged by the state. Per Monica there are inspections conducted on a monthly basis. During a recent inspection it was discovered that the outlet and light/lamp fixtures were identified as not operable. LPA conducted a records review which revealed that the facility was informed 1 year ago that the elevator mdoel required a new outlet and light fixture, while another part was being installed. As a result the elevator was red tagged and was prohibited from being used. Based on records review the allegation of staff did not ensure the elevator is in good repair is substantiated. Substantiated A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Note that during today's visit LPA verified that the elevator is in working order. The elevator was observed to be fully illuminated and there was no signs observed prohibiting use of the elevator. An exit interview was conducted and a copy of this report, 9099D, and appeal rights were provided to Jennifer Gephart, Executive Director.the state’s words, verbatim · CDSS document, Oct 9, 2024 · control 18-AS-20241003120638

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 9, 2024

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: the licensee did not ensure that the elevator was in good repair, which posed a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 9, 2024

Plan of correction: There is no POC at this time, as the elevator was officially repaired on 09/13/24.

Type of visit: Required - 1 Year

On 10/09/24 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA was greeted and granted entry by Executive Director Jennifer Gephart where LPA explained the purpose of the visit. The facility has an approved fire clearance to accept and retain 10 residents that are bedridden with an approved hospice waiver for (15), there is currently 14 residents receiving hospice services. LPA conducted a tour of the facility, below is a summary of what was observed. The facility is a two story structure; the first floor consists of facility's assisted living and memory care with delayed egress. There is an activity room, lounge area and dining room located on the first floor. The second floor will service assisted living residents, and also contains a medication room, theater room, beauty salon, and an activity room. The bathrooms were observed to have grab bars, with pull cords and the signal system was tested and observed to be operable. The hot water temperature was tested in resident bathrooms and found to be within regulatory limits of 106.7 degrees Fahrenheit. Medications were observed to be labeled and in a locked place that is inaccessible to residents. The facility is utilizing an electronic medication authorization record tracking system. The smoke/carbon monoxide detectors were tested and observed to be operable. The facility fire/safety inspection was completed on 07/10/24. The last emergency disaster drill was conducted on 5/24/24, deficiency cited as drills are to be conducted on a quarterly basis and should have been completed in September 2024. The facility was observed to have fully charged fire extinguishers throughout the facility, that were serviced in May 2024. There are no known guns or ammunition on the premises. There are no pools or bodies of water observed at the facility. The outdoor and indoor passageways are free from obstructions. Food supply: the facility was observed to have a 2 day supply of perishable food items and a 7 day supply of non perishable food items which meets the requirements Records review: All staff present at the facility were observed to have obtained criminal record clearance and to be associated to the facility. The Executive Director Jennifer was observed to have a valid administrator's certification. Further records review revealed that the facility does not have a staff that is CPR certified working during each shift. Deficiency cited. Resident files were observed to have medical assessments, admissions agreements and personal rights. The facility was observed to have the required postings such as Long Term Care Ombudsman Poster, CCL complaint poster, personal rights, and license. The facility was observed to not have proof of valid liability insurance, deficiency cited. Based on today's inspection the deficiencies are being cited in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). on the attached 809D. An exit interview was conducted and a copy of this report, LIC809D, LIC9098-Proof of Corrections form, and appeal rights were reviewed and provided to Jennifer Gephart, Executive Director.the state’s words, verbatim · CDSS document, Oct 9, 2024